Man's death at Pukatawagan nursing station, 3 days after calling for help, sparks federal review

A 48-year-old Cree man who called the nursing station in a northern Manitoba community with an urgent medical situationdied after waiting three days to be seen, prompting aformal federal government patient safety review.

"If those nurses could've seen him right away, or if somebody could see him and send him out, that guy could've been still alive today," said Marcel Caribou, the brother-in-law ofMurdock Colomb, who died in Mathias Colomb Cree Nation in April.

Colomblived with Marcel's brother,Lawrence, and Lawrence's partner, Judy Caribou.

OnFriday, April 8,Colomb was coughing, complaining of not feeling well and had swollen legs and feet, Judy said.

Currently, due to staffing shortages and the COVID-19 pandemic, community members on First Nations typically haveto callnursing stations to be triaged, unless it's an emergency.

Judy said she called the nursing station late that Friday afternoon andhanded Colombthe phone, tellinghim to say it was an emergency.

At the time she called, hisfeet were "all puffed up with water," she said.She asked him if he said during the call that it was an emergency.

"He said yes [and] they told him, 'come Monday morning.'"

On Monday, Judy's daughter drove Colomb to the nursing station as soon as it opened.

Judy said they called later to say he would bemedevacedto Winnipeg, more than 700 kilometres to the south.

But before that could happen, the nursing station called back.

"They said that his heart stopped twice. That's when we went to the nursing [station]. They were trying to revive him but he couldn't make it," Judysaid.

The family is still waiting on a medical examiner's report for his cause of death, but believe the medical system failed him.

"That guy was dying. At least somebody could've went and checked," said Marcel Caribou.

Colomb, whowas employed with Mathias Colomb Cree Nation'spublic works department,is now being remembered by family and friends as a friendly, kind, hard-working outdoorsman.

He was active and had no obvioushealth ailments and took no medications, said Judy.

Nursing shortage

The chief of Mathias Colomb Cree Nation, which has an on-reservepopulation of around 2,300people, said she can't comment on Murdock Colomb's case, but saysthe nursing station is under a lot of pressure.

"We have a shortage of nurses right nowthat's why everybody has to phone in," said Chief Lorna Bighetty.

She'd like to see walk-ins available at nursing stations without calling ahead, as was the case before the COVID-19 pandemic, butsaid the staffing needs to be in place.

Indigenous Services Canada spokesperson Maddy Warlow said a new policy to improve access to primary care on-reserve wasissued in June, and the department is working with community leaders and front-line staff on its implementation.

The department is working to "address the shortage situation and ensure safe care and services," Warlow said in awritten statement.

People with non-emergent and non-urgent issues are encouraged to seek care during regular nursing station hours, which are9 a.m. to 5 p.m. If several people are seeking care at the same time, they'retriaged and seen based on the severity of their illness or injury, wroteWarlow.

Health-care workers, including nurses, are also on-call overnight, she said.

A formal patient safety review into Murdock Colomb's case will be co-led by the First Nations and Inuit Health Branch Nursing Directorate, along with anexternal review team ofnurses, community members, physicians, the First Nation Inuit Health Branch leads and educators,the spokesperson said.

The team willreview Colomb'scare and medical records,in order to make quality improvement recommendations to government and provide his familywith answers,wrote Warlow.

"The health and well-being of Indigenous Peoples and communities is a high priority for our government, and our thoughts are with the family for their loss," she wrote.

Concerns about access to care

A young mother in Pukatawagan said she too had trouble accessing appropriatecare at the nursing station.

Cassandra Cook brought her three-year-old daughter, Cassidy Bighetty, to the nursing station three times between March and April for a growing, softsore on the top of her head.

"[I] felt helpless, like I couldn't do anything for her," said Cook.

Each time, she said her daughter wasassessed and sent home once with Tylenol, another time with antibiotics.

"That's when I said, 'Good enough,' and then waited until child tax [payments]and got my kids ready and jumped the train" to The Pas, more than 200 kilometres to the south,she said, where she wasimmediately seen atSt. Anthony's General Hospital.

"At first they said it was an abscess and the antibiotics that she was given wouldn't help at all, and that it was a good thing we brought her out. [It] would've just got worse," she said.

Two days later, Cassidy went forsurgery to drain the area of fluid. The area has healed and she's happy now, her mother said.

Cook said a local leader is working with her and the nursing station to review her daughter's experience.

"The way I see it is, for years now, they wait until somebody's really sick or their infection gets worse before they send that person out" of the community for care, she said.

"Especially when it was a child, they should've sent her out the first time they seen her."

Pukatawagan man's death sparks federal patient safety review

2 years ago

Duration 1:58

A 48-year-old Cree man who called the nursing station in Mathias Colomb Cree Nation with an urgent medical situation died three days later, without getting the care that he needed.