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 The nurse at the federal government-run clinic, the only source of
emergency care in this remote indigenous community, told the
officers the 37-year-old could sober up in jail, according to
testimony at a 2018 inquest. Minutes after leaving the clinic, the
police sped back. Matawapit had no pulse and could not be revived.
At the inquest, the nurse testified that in sending Matawapit on to
jail, she had been following a standard protocol for intoxicated
patients in the northern reserves. Government officials testified
there was no such thing.
The coroner found that in the nearly six years between the death and
the inquest, there was no evidence of any formal review of the case
“or any learning from the events of that evening” akin to typical
procedures in hospitals or emergency rooms. Matawapit’s death,
attributed to heart disease, likely would have passed under the
radar but for the fact that she died in police custody, which made
the inquest mandatory.
Over at least nine years, the Canadian federal government has not
consistently tracked, let alone investigated, poor outcomes at
clinics on indigenous reserves, according to a Reuters analysis of
documents, including internal reports and meeting notes obtained
through public records requests.
Record-keeping on deaths and other critical incidents at the
clinics, which provide basic and emergency care to about 115,000
people, has been erratic and fragmented, Reuters found. The
incidents often are detailed in separate provincial computer
systems, when they are tracked or reported at all.
As a result, there is no way for the federal government to know how
often patients die or suffer injury at the clinics or how that
compares to the rest of the Canadian health system.
The federal government’s First Nations and Inuit Health Branch (FNIHB),
which funds 79 clinics and manages 50 of them, is hampered in
identifying potentially harmful patterns and preventing future
mistakes, documents and interviews with medical experts indicate.
Whether turning away apparently intoxicated patients in the northern
reserves – described in the coroner’s verdict as the “northern
protocol”- has been a widespread practice is difficult to say.
Reuters was able to find one other similar death, detailed in
Manitoba police records, that occurred five months after Matawapit’s.
The federal government enacted a policy saying it was “not
appropriate” to hold intoxicated patients in - but only after last
year’s inquest brought the issue to light.
Reuters' findings come as the country is in the midst of a public
reckoning with the legacy of settler colonization, a hotter issue
today than in nations such as the United States and Australia where
European settlers also displaced local peoples.
With an indigenous population that is growing and gaining political
clout, Prime Minster Justin Trudeau came to power in 2015 promising
"reconciliation" with aboriginal people. Reduced to a minority
government in this week's election, he needs the support of other
parties to govern and will face pressure from the left to address
poverty, poor housing and health problems that are especially acute
on remote reserves.
It will not be an easy task. Even reviewing critical health care
incidents could be a challenge because of the multiple jurisdictions
and providers involved, said Michael Green, a professor at Queen’s
University who was once chief of staff at a small northern hospital
that often received patients from clinics in indigenous communities.
But “without review, there's no opportunity to learn and make the
system safer for everybody," he said.
Staff at FNIHB, part of Indigenous Services Canada, say they strive
to provide the best possible care and have been working on a
replacement reporting system, slated to roll out next year.
The effort, which documents show began in 2014, has been planned
behind closed doors and has not previously been reported, although
pilot programs are running in Manitoba and Alberta.
Documents reviewed by Reuters indicate the system is designed to
provide national case tracking and a consistent process for
investigating and following up on cases.
Robin Buckland, executive director of primary healthcare at FNIHB,
said the current system is “not a bad policy” but the agency is
working to build an environment in which staff members can learn.
“It’s taken a long time,” she said. “But we want it to be right, and
we want to implement it well.”
Reuters was not able to reach the nurses involved in treatment
described in this story.
“We truly believe that nurses are working hard to deliver the best
health care possible, under difficult work conditions,” said Debi
Daviau, president of the Professional Institute of the Public
Service of Canada, which represents permanent staff nurses and other
civil servants.
‘SECOND-CLASS CITIZENS’
For years, indigenous communities have complained about poor
treatment on remote reserves, which are often hundreds of miles from
top-tier or specialized medical services in major cities. Matawapit
died in a community more than 300 km (186 miles) from the nearest
major highway.
For a map of reserves see:
https://graphics.
reuters.com/CANADA-HEALTH-NURSINGSTATIONS/
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These federally funded clinics, usually called nursing stations,
struggle to retain nurses, often filling gaps with the help of
private staffing agencies.
Services there need more government scrutiny, not less, some critics
say.
“We are treating members of the First Nations communities as
second-class citizens,” said Emily Hill, a senior staff lawyer with
Aboriginal Legal Services, which represented the Matawapit family at
the inquest. “This is a large government health service. You would
expect there to be layers of oversight and accountability.”
Documents reviewed by Reuters show FNIHB staffers have repeatedly
called for a modern reporting system for poor or unexpected
outcomes.
The FNIHB started to track critical incidents in 2006. By 2010,
however, a federal audit found that “monitoring and analysis at both
the national and regional level is not occurring.”
Four years later, a FNIHB working group said that a common national
policy was needed with “clear processes for reporting and tracking"
incidents, according to meeting notes reviewed by Reuters.
In 2016, an internal report by a member of the working group looked
at how other public organizations, including federal prisons,
reviewed outcomes. Every policy was found to be more "robust" than
the one at FNIHB.
The report, reviewed by Reuters, said that while some patient safety
incidents had been recorded in a national database between 2006 and
2014, regions had stopped using it because of the difficulty in
collecting data.
Federal policy focused mainly on nurses’ well-being, not patients’,
the report said.
The nurse at the Matawapit inquest illustrated that point,
testifying that a debriefing after the patient's death was geared
“more to how we were feeling as opposed to what we did."
A SIMILAR DEATH
On November 28, 2012, the Royal Canadian Mounted Police in God’s
Lake Narrows, Manitoba, responded to a report that Tracy Okemow, 31,
was drinking and threatening suicide. Police found her next to two
empty pill bottles labeled “metformin," a diabetes drug, according
to a police review of the incident seen by Reuters. She agreed to go
to the local nursing station.
The nurses told officers they had consulted with a doctor off the
reserve who felt her “consumption of medication was not of concern
and she could be incarcerated until sober,” according to the police
report.
Okemow spent the night in jail. A witness later told police that she
seemed to be in agony. In the morning, she was flown to a Winnipeg
hospital, where she died the next day of metformin toxicity, the
report said.
There was no inquest or federal inquiry. “In the case of Ms. Okemow,
the death occurred outside of a federally operated facility –
therefore FNIHB did not undertake a formal review,” Indigenous
Services Canada said in a statement.
Off reserve, healthcare is under provincial jurisdiction.
‘THEY BRUSH US OFF’
The federal government has reviewed some patient deaths, often after
they draw media attention. Documents reviewed by Reuters show
officials have found serious systemic problems, including nurses who
are stretched thin and do not always appreciate the seriousness of
patients’ symptoms.
After two children died from complications of strep infections in
2014, an internal review looked at a “sampling” of young people who
had died, and called for better recruitment and retention of nurses,
as well as more physician services.
A 2018 review looked at a 15-month-old toddler seen on a Saturday
night for a seizure and infections. The nurse on duty did not
consult a doctor, and the child died the next day. The report called
for better oversight of nurses, as well as changes to shifts and
staffing to address fatigue.
FNIHB’s Buckland said the agency is working to improve hiring and
retention amid a global shortage of healthcare workers.
In Manitoba, the family of Tyson McKay is suing the federal
government, alleging that the 32-year-old man died of a heart attack
31 hours after visiting a clinic complaining of chest pain in 2015.
The suit alleges the nurse did not perform the appropriate tests
that could have diagnosed his condition.
In a court filing, the government said a staffing agency was
responsible for ensuring the nurse was qualified. The staffing
agency defended its care and referred questions to the government.
Kelvin McKay, Tyson’s 41-year-old brother, has been going to the
clinics since childhood. He said he sees a pattern.
“Nurses come in and out of our community, and they fail to take the
time to get to know our people, and they think we come in with fake
illnesses. They brush us off. And that’s not how it’s supposed to
be.”
(Additional reporting by Rod Nickel in Winnipeg; Editing by Denny
Thomas and Julie Marquis)
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