Critical incidents: Provincial report details deaths and misdiagnoses while in care

A personal home care patient suffers second-degree burns to their lower limbs after the legs were dangled over the side of the bed on a baseboard heater.

A home care client living with dementia in an assisted living facility dies after not receiving nursing services.

A suicidal client with known mental health issues is taken to a mental health centre by family members, who express concern their loved one was going to take their own life. The client commits suicide four days after being discharged from hospital.

• 'Critical incidents' uncovered in Manitoba pathologist's work
• Infant received 10 times more morphine than normal

The incidents are just three of 38 unintended critical cases highlighted in Manitoba Health's latest critical incident report.

The two-page quarterly report from Manitoba Health provides few details about the incidents but classifies them all as major or fatal. As a result, they were reported to the Minister of Health as critical incidents.

The latest report, which doesn't name the health care facilities where incidents happened, outlines serious events from Jan. 1 to March 31, 2016.

Other incidents in the report:

• A patient was admitted with flu-like symptoms and held in hospital. The next day, bloodwork done the next day, showing a Streptococcus A infection. The patient died three days later. 
• Another patient was admitted with flu-like symptoms and dehydration, was rehydrated and sent home 12 hours later. Two days later, the patient's family called an ambulance; the patient died later that day. 
• A patient had a myocardial perfusion scan despite a doctor knowing the patient had low blood pressure before the test. During the procedure, the patient's blood pressure continued to drop and while it did slightly improve, the patient experienced sudden weakness and an even further drop in blood pressure before dying in the inpatient unit.
• A patient did not receive required thyroid medication during two months in hospital. A pharmacist discovered the issue when reviewing patient discharge medications. Bloodwork showed "profound" hypothyroidism.
• Doctors referred a patient with an initial diagnosis of adenocarcinoma for treatment, but the diagnosis wasn't communicated to a second site. Ineffective treatment was given and caused irreversible renal damage.
• A patient living in a personal care home died after a co-resident pulled out the patient's feeding tube.
• A student who had consent to be in a room with a patient during a diagnostic imaging procedure started inflating a medical balloon on a tube quickly instead of slowly. The patient experienced extreme pain as a result. The discomfort continued after being discharged and bled. A CT scan later showed perforation of the pelvic pouch.

There were 10 deaths reported among the 38 critical incidents.

Read the complete report from Manitoba Health online.