A patient who died waiting for care in a hallway at Winnipeg’s Health Sciences Centre was not transferred to a monitored bed due to lack of available space in the emergency department, according to a critical incident review into what could have prevented his death. 

That review, released on Friday, was conducted after a patient died at HSC’s emergency medical services arrivals hallway on Feb. 27, about an hour after arriving at the hospital by ambulance.

He was assessed upon arrival, but his condition deteriorated and staff were unable to revive him, the report says.

His death was declared a critical incident, which is defined by the province as a case where people have suffered “serious and unintended harm” while receiving health care.

The review found that “patient flow challenges” prevented the man from being put into a monitored bed, which is a bed with a heart monitor attached, noting that the hospital was dealing with twice its usual number of critically ill or injured patients at the time. 

This spike in admissions around the time the man arrived at the hospital exacerbated pre-existing challenges in the emergency department’s capacity, according to the report.

HSC — the largest hospital in Manitoba — has opened up six more medicine beds recently to help with overcrowding issues, and is planning to open up six more this summer depending on staffing, said Dr. Shawn Young, the chief operating officer at Health Sciences Centre, at a Friday morning news conference held to address the report.

The opening of a new treatment clinic for minor injuries this summer should also help people get more timely care, he said. 

Ideally, the hospital would open more ER beds, but staffing presents a challenge, he said.

“Would I love to open 30 beds? For sure, but would I be able to staff them? Absolutely not.”

Baseline staffing no longer adequate: nurses union

The critical incident report said staffing was near baseline at the time of the patient’s death.

However, the president of the Manitoba Nurses Union says baseline staffing is no longer adequate for HSC’s emergency department, and patient outflow needs to be more efficient.

“We are in such trouble in our health-care system when it comes to being able to move patients through our system,” Darlene Jackson told CBC News on Friday.

Nurses who were working when the man died said both the emergency room and the waiting room were completely full, according to Jackson.

“It was an incredibly busy day … They had bottlenecking, which means that they had patients backed up, waiting to be seen, because of their admitted patients in their emergency department,” she said.

Manitoba’s largest centre for trauma patients needs more monitored beds, said Jackson. She said the man who died waiting for care also clearly needed a bed in the emergency department, and not a stretcher in the hallway where nurses could not see him.

“They need to look at how they move [admitted] patients out of that department and how they get them up to those beds on the units in a timely fashion, that allows them to actually get more patients in,” said Jackson.

“I look at it as a big knot that you have to find the right end to pull to start unraveling.”

Kinew criticizes PC health cuts

Issues in emergency departments are “more acute and at times dangerous than baseline staffing permits,” union representative Brandi Johnson said in a statement.

While more monitored beds are needed, the need to boost staffing is even more pressing, she said.

That call for more health-care staff was echoed by Manitoba NDP Leader Wab Kinew, who held a press conference Friday at the legislature in response to the review.

Kinew says the Progressive Conservative government has not invested in health-care enough, and criticized cuts made to the health-care budget since 2016.

Health Sciences Centre is one of three Winnipeg hospitals that has an emergency room. In 2017, the provincial government announced three other emergency rooms would be converted to urgent care centres or community clinics.

But Jennifer Cumpsty, the executive director of acute care services at Health Science Centre, said the hospital has also made some recent changes to improve the flow of patients out of the emergency room and into other departments so that patients waiting for care can be seen by a doctor sooner.

For example, if the emergency department is experiencing a surge, an email blast will go out to all departments asking if they can help get patients transferred out of the ER more quickly to create extra space, rather than putting that responsibility solely on the ER, Cumpsty said at Friday morning’s news conference.

“We’ve had everybody coming down if needed. We’ve had managers come down and get reports because their own staff are too busy or they’re trying to turn over the room or move patients,” she said. 

“That’s kind of the shift that we’ve been seeing, especially over the last couple months, is that everybody understands that we all own this.”