Sask. patient not consulted by SHA after critical incident, ombudsman

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A Saskatchewan man’s perspective was not sought by the provincial health authority after a followup surgery to remove a chunk of surgical equipment left in his lung.

That’s according to the ombudsman’s annual report tabled on Thursday, giving an overview of the incident while highlighting measures the Saskatchewan Health Authority (SHA) has since adopted after the man’s family complained.

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According to the report, the man went in for surgery to treat lung cancer. After the initial surgery, it was determined that a “piece of equipment” approximately one centimetre in size “broke off in his lung,” read the report, which added that a followup surgery to remove it resulted in the man losing “a significant portion” of his lung.

“He was never the same after these procedures, struggling to manage both his health and household,” read the report.

A critical incident review (CIR) was conducted by the SHA but at no time was the patient asked for his perspective, nor was he offered any information on the outcome of the review.

A “critical incident” is defined in part as “a serious adverse health event” while receiving care at a provincial centre. The accidental incident is further described as serious and undesired — resulting in death, disability, harm, an unexpected stay in a health centre, etc. — and does not stem from a patient’s underlying health issues.

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Months later, the man did receive a draft letter related to the CIR, but it contained little information. More than a year later, the man received a formal letter about the review. Over that timeline, the ombudsman reported, “the family had lost trust in the SHA.”

Before the family could report this experience to the provincial ombudsman, the man passed away.

An investigation found that the SHA did not report the incident within 60 days to the Ministry of Health, as is mandated by legislation. The report also noted a variance across the province in how CIRs are conducted.

“The treatment of this patient and his family was not in accordance with the principles of administrative fairness,” read the report.

In response, the SHA has brought in new guidelines, reporting templates, disclosure policy, and new work standards for CIRs.

A letter of apology was given to the man’s family, outlining what was done and what will be done going forward. The SHA said it will also “embed the principles of patient and family centred care” into new CIRs and develop a mechanism to make sure legislative timelines are met.

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