Two babies died when emergency air transport wasn’t available to take them to the Children’s Hospital in Winnipeg near the tail end of 2018, according to Manitoba Health’s latest critical incident report.
The report, released Thursday, says one of the babies was sent to Children’s Hospital in unstable condition by ground ambulance because air transport was not available.
The report says the baby had a heart attack upon arrival at the hospital.
The infant was admitted to the pediatric intensive care unit, but intubation was difficult and the baby died after treatment was later withdrawn.
The other baby, who was in unstable condition after a premature birth, was taken to Children’s Hospital by ground ambulance when Lifeflight air ambulance declined, according to the report.
The infant underwent surgery for bowel obstruction the same day but died the next day.
The critical incident report lists 30 critical incidents — including seven deaths — reported from Oct. 1 to Dec. 31, 2018.
The reports, released every three months, do not provide information that would identify patients or say where the incidents occurred.
In one incident a patient suffered cardiac arrest after coming to the emergency room with chest pain. The patient was to be transferred by STARS air ambulance, but the report says STARS arrived almost two hours later without a doctor on board.
The report says STARS staff were at first not able to intubate the patient, and later decided to take them by ground ambulance, but the patient died on arrival to the transfer destination.
Another reported incident saw a resident choke and die during a meal.
While the patient was supposed to be supervised during mealtimes, the report says that information hadn’t been “consistently communicated to the entire care team.”
In another incident, a patient who had gone to the emergency room with an acute medical condition died after being discharged home with follow-up to community services.
The report says “the opportunity to immediately consult expert medical services … was not realized” in that case.
In another incident, described by the report not as a death but as a major incident, a personal care home resident was pushed to the ground by another resident and fractured a hip. The resident died two days later, according to the report.
The report also includes a misdiagnosis that led to an unnecessary surgical procedure, a medication miscalculation that led to an overdose, and one case where a patient underwent an invasive procedure mistakenly.