Judge says medical system failed baby in Manitoba

WINNIPEG — A judge says an overloaded and outdated medical system — not uncommon in northern communities — failed a Manitoba infant girl who died two months after she was born.

Drianna Ross died of an infection in November 2011 because information was not passed on from a remote nursing station to a hospital in Thompson, ineffective drugs were given and “the seriousness of her condition was not recognized in a timely way,” Judge Don Slough wrote in an inquest report released Tuesday.

“There is no doubt that the provision of health care in the north is challenging,” he said in the report.

Tweet This Click to share quote on Twitter: "There is no doubt that the provision of health care in the north is challenging," he said in the report.

“The co-operation between (health) agencies, in collaboration with First Nations communities, must expand in its scope, with the goal of ensuring that residents of some of Manitoba’s most disadvantaged communities have access to the quality health care that is the right of all Canadians.”

The inquest was told that Drianna was born healthy in Thompson General Hospital and returned with her parents to God’s Lake Narrows, a remote fly-in community of about 1,300 people.

When she was two months old, her parents contacted the community’s nursing station repeatedly over three days about their daughter’s high fever.

There is a doctor in the community on weekdays, but the inquest was told the physician’s workload is very high, so Drianna was treated by an inexperienced nurse who had not learned protocols for infants with high fever.

Eventually, the girl was flown to the Thompson hospital, diagnosed with pneumonia and placed on antibiotics.

The inquest was told Drianna died from a bacterial infection called methicillin-resistant staphylococcus aureus, or MRSA, a condition that would not be addressed by the antibiotics she was given.

“It appears that information regarding Drianna Ross’s treatment and high fever over the last few days while she was in God’s Lake Narrows … was not included in the material sent to Thompson General Hospital,” Slough’s report says.

Tweet This Click to share quote on Twitter: "It appears that information regarding Drianna Ross's treatment and high fever over the last few days while she was in God's Lake Narrows … was not included in the material sent to Thompson General Hospital," Slough's report says.

It also says the nurse who took care of Drianna in Thompson was inexperienced, lacked specialized pediatric training and felt “overwhelmed” with his workload the night Drianna arrived.

The report points to problems Slough said are common in northern communities — overworked and inexperienced health-care professionals, outdated technology that forces doctors and nurses to rely on paper copies instead of electronic records, and an acceptance of MRSA and other infections as commonplace.

“Social factors, such as crowded households, busy and cramped facilities (e.g. nursing stations) contribute to the prevalence and spread of MRSA,” Slough wrote.

“In my view, the acceptance of MRSA as a fact of life in northern communities cannot be tolerated.”

The report makes a long list of recommendations that include better training, updated equipment and a greater use of nurse practitioners, who have more training and authority than other nurses.