The review is in, and it points to complex systemic and human factors as to why residents of a Humboldt care home were exposed to carbon monoxide late last year.
On June 24, the Saskatoon Health Region (SHR) released "A review on Carbon Monoxide Exposure in St. Mary's Villa Long Term Care Facility, December 26, 2010."
The Boxing Day emergency resulted in 24 Villa residents, five employees, and two visiting family members undergoing assessment and treatment for exposure to the colourless, odourless gas.
It also resulted in the deaths of three Villa residents - an 89-year-old male resident, and two female residents, aged 94 and 98 - between December 26 and January 26.
While each resident had a number of significant underlying medical conditions, it is believed exposure to carbon monoxide was a contributing factor in each of these deaths, a news release issued by the SHR stated.
"The immediate infrastructure issues at St. Mary's Villa that resulted in the exposure have been addressed, but it is our responsibility and commitment to find out why the exposure occurred, what could have been done to prevent it, and how we can prevent an exposure from ever happening again not only in our health-care facilities, but in health-care facilities everywhere," said Maura Davies, president and CEO of the SHR.
The review found that many complex systemic and human factors played a role into why the carbon monoxide exposure occurred and how it was managed:
The carbon monoxide leak was not caused by one single issue with the boiler, but a combination of factors that culminated in a loss of draft and the subsequent carbon monoxide leak.
The complexity of carbon monoxide gas and its characteristics make it difficult to detect and its symptoms can be confused with many other common illnesses.
Just prior to the exposure, the Villa experienced a noro-virus outbreak that gave staff reason to initially think the symptoms they and some residents were experiencing were related to that outbreak.
The exposure occurred during the height of the Christmas holiday season, the festivities of which can leave individuals more tired than usual.
The review also points to a need for system-wide improvements in a number of areas, including the inspection of mechanical systems, laboratory testing capabilities in all acute care facilities, rules for activation of Region Incident Command, and the redevelopment of integrated fire and carbon monoxide systems across the SHR, the news release states.
The review outlines the chronology of events relating to the exposure at the Villa, prepared as part of an investigation conducted by the SHR. As well, it includes evidence and advice from a number of other internal and external reports completed since the exposure, including reports from SaskPower, March Consulting and Associates, an independent engineering firm, a multi-agency debriefing report, and an epidemiology report prepared by the SHR Public Health Services.
The result is a series of findings and recommendations for system-wide improvements in the SHR.
In the news release, the SHR states that it is acting progressively to improve standards and ensure energy systems are properly sized and easy to operate. This means not only replacing boilers, but taking steps to increase efficiency so the system operates following best practices. This progressive approach will allow the SHR to address system issues and implement a redesign that fits the environment.
A Request for Proposal for the redevelopment has been issued and it is expected the project will be complete in the coming months, while continuing to keep the facility warm and safe.
"We are absolutely committed to studying and examining this incident in the long term," said Shan Landry, vice president Community Services with the SHR. "As a health region, we want to ensure that the lessons learned from this tragedy are shared with our provincial and federal partners to improve safety and reduce the risk of exposure to carbon monoxide in all health care facilities."
"We again offer our sincerest sympathies to the families and loved ones of the three individuals that passed away, and our deepest regret to the residents, visitors, staff, physicians and volunteers who were directly affected by the carbon monoxide leak," said Davies. "We are committed to taking steps to ensure this type of incident does not happen again.
"I also want to acknowledge the heroic efforts of our staff that night. Despite suffering from the effects of CO exposure they put the residents' safety and well-being first and prevented further exposure. We are grateful for their efforts," said Davies.
The SHR expressed thanks to all those who participated in interviews for its investigation and review, and all of the external organizations who attended the Villa on December 26 and prepared reports, including the Humboldt Fire Department, Humboldt and District Ambulance Service, Prax Air, the Saskatchewan Ministry of Health, SaskEnergy, PHH Arc Environmental Ltd. and Johnson Controls.
The full report is available at www.saskatoonhealthregion.ca.
