Manitoba

a. mbudsman

March 11,2019

750 - 500 Portage Avenue
Winnipeg, MB R3C 3X1
Telephone: 204-982-9130
Toll Free in Manitoba: 1-800-665-0531
Fax: 204-942-7803
E-mail: ombudsma@ombudsman.mb.ca
www.ombudsman.mb.ca

500 avo Portage, Piece 750
Winnipeg, MB R3C 3X1
Telephone: 204-982-9130
Sans frais au Manitoba: 1-800-665-0531
Telecopieur: 204-942-7803
Courriel : ombudsma@ombudsman.mb.ca
www.ombudsman.mb.ca

The Honourable Margaret Wiebe
Chief Judge
Provincial Court of Manitoba
5th Floor - 408 York Avenue
Winnipeg, MB R3C OP9

Our files: 2014-0553,0554,0555
& 2015-0122
Recommendations
re Inquest Report for Brian Lloyd Sinclair

Dear Chief Judge Wiebe:
As you are aware, it is the practice of my office to follow up on inquest recommendations when
they relate to a provincial department, agency or municipality.
I am writing to advise you of the results of the inquiries made by my office concerning the
inquest report recommendations into the death of Mr. Brian Lloyd Sinclair. The December 9,
2014 inquest report ofthe Honourable Judge Timothy J. Preston was issued on December 12,
2014.
BACKGROUND
The inquest report detailed the circumstances of Brian Lloyd Sinclair's death. Mr. Sinclair died
on September 21,2008, at age 45, in the Emergency Department (ED) at the Health Sciences
Centre (HSC).
Many hours earlier, Mr. Sinclair had attended at an inner city primary health care facility (the
Health Action Centre or HAC) complaining of abdominal pain and problems with his Foley
urinary catheter. He was assessed by a physician, provided a letter from the physician and told to
give the letter to the Health Sciences Centre Emergency Department (HSC ED) staff when he
arrived there.
At the HSC ED, Mr. Sinclair spoke to the Triage Aide at the ED reception desk and waited. He
did not receive assessment or treatment for the next 34 hours, until discovered by another visitor
in the ED. Thus, Mr. Sinclair had passed away in the waiting room of the HSC ED, hours prior
to when HSC staff discovered he was dead.

 The 63 recommendations made by the Honourable Judge Preston were noteworthy, in light of
the circumstances of Mr. Sinclair's death. In the course of our monitoring efforts, we
communicated with Manitoba Justice and Manitoba Health, Seniors and Active Living
(MHSAL).
By its most recent letter dated January 25,2019, MHSAL advised that of the 63
recommendations, 55 recommendations have been completed and eight are not completed. Of
the eight recommendations that are not completed, seven are partially completed and only one
recommendation remains open. Regarding the one recommendation that is open
(Recommendation #22), MHSAL indicated it is unable to provide a timeline for completion, due
to the operational status of the newly created Shared Health, the organization tasked with the
recommendation.
RESPONSE TO INQUEST RECOMMENDATIONS
Below are the 63 recommendations
MHSAL have addressed them:
Recommendation

and detailed summaries of how Manitoba Justice and

#1

That the Office of Public Trustee and the RHAs review their policies and procedures
ensure the primary care giver and service providers of any Committee of the Public
Trustee are made aware of the Committeeship.

to

MANITOBA JUSTICE: ... When the Public Guardian and Trustee (PGT) is appointed as
committee under The Mental Health Act, steps are taken to notify a variety of agencies
and services of the appointment and the extent of the PGT's role in managing the affairs
of the client. There is a delegation of a variety of responsibilities involving the needs of
each client, to the regional health authority (RHA) where that client resides .... In
addition, the PGT contacts Manitoba Health to ensure the involvement of the PGT as
committee can be included in the individual's health record. The PGT advises that the
delegation made by the PGT to a RHA continues to be appropriate and forms one
element of the communication strategy required to support the client.

MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure primary care provider notification of committeeship status.

The MHSAL "Communication of Public Committeeship Status" Policy addresses this
recommendation, requiring each RHA, the Selkirk Mental Health Centre (SMHC) and
Health Corporations to have policies that set out a process for communicating a public
committeeship status of a person to the primary care and service providers, ensuring
providers' awareness.

2

 Recommendation #2
That Winnipeg Regional Health Authority (WRHA) Home Care review its policies and
procedures to ensure that Home Care updates service providers concerning any
hospitalization of their clients.
MHSAL: RHAs and MHSAL have undertaken policy reviews. RHA policies and
procedures that have been updated and implemented, will ensure service providers are
provided information regarding hospitalization of clients.

This response applies to this recommendation and recommendations 3, 4 and 5. MHSAL
and RHAs assessed the recommendation against the 28 current MHSAL Home Care
policies, as well as RHA operational policies, procedures and guidelines. A policy gap
was identified in two areas - (i) information sharing at points of transition of care and (ii)
the policy on Home Care Service was suspended or withdrawn. RHAs undertook policy
and procedures development to address these gaps.
The establishment of provincial policy to set expectation(s) for RHAs to have a policy is
not yet finalized. Draft provincial policies are completed but finalization is pending the
future state of MHSAL, to ensure alignment for policy oversight, going forward. This
work is contingent on the operational status of Shared Health (SH).
Recommendation #3
That WRHA Home Care review its policies and procedures to ensure that each service
provider is made aware of the specific care plan for each Committee.
MHSAL: RHAs and MHSAL have undertaken policy reviews. RHAs have policies and
procedures that have been implemented, which will ensure service providers are aware of
client care plans.
MHSAL repeats the last paragraph of its response under Recommendation#2

here.

Recommendation #4
That WRHA review its policies and procedures to ensure that when a medical service is put
on hold, suspended or withdrawn from any client for any reason, that there is an alternate
plan in place or that the hold be reviewed on a regular basis.
MHSAL: RHAs and MHSAL have undertaken policy reviews. RHAs have policies and
procedures that have been implemented, which will ensure service providers are aware of
changes to client care plans.
MHSAL repeats the last paragraph of its response under Recommendation#2

here.

3

 Recommendation

#5

That WRHA Home Care reviews its policies and procedures to ensure the provision to
service providers of relevant background information of their vulnerable clients.
MHSAL: RHAs and MHSAL have undertaken policy reviews. RHAs have policies and
procedures that have been implemented, which will ensure care providers are aware of
relevant information of home care vulnerable clients.
MHSAL repeats the last paragraph of its response under Recommendation#2
Recommendation

here.

#6

That the RHAs and the Office of the Public Trustee continue to review the feasibility of
compatible electronic charting of all relevant medical information for clients of the Public
Trustee.
MANITOBA JUSTICE: ... With respect to health and medical records, the PGT has no
greater entitlement to health information than would have been available to the client. In
most situations, the PGT does not need access to a client's health records. When medical
information is required, the PGT will request it from the health provider in a manner
similar to how the client would have made a request. In that context, implementing the
recommendation that consideration be given to develop some form of shared database
amongst RHA, MHSAL and PGT would be problematic from a records management and
privacy perspective.

MHSAL: An Information Communication Technology (lCT) study had been undertaken
to assess the feasibility of compatible electronic charting of all relevant medical
information for clients of the Public Trustee. The feasibility study addressed all ICT
recommendations from the Brian Sinclair Inquest, identifying that an investment of
$300M ongoing operating costs and approximately $50M one-time cost would be
required to accomplish the recommendations. Further, the assessment identified that the
existing ICT capital plan will address, over time, the majority ofICT inquest
recommendations.
Consequentially, the ICT plan will be sustained, ensuring, over time, all ICT issues
identified in the Brian Sinclair inquest recommendations are addressed.
Recommendation

#7

That the Office of the Public Trustee and the RHAs review their policies and procedures
ensure that when a patient is a Committee of the Public Trustee, the patient's
Committeeship status is clearly flagged on that patient's medical chart.

to

MANITOBA JUSTICE: ... The discussions with the WRHA and MHSAL have explored
the possibility of changing how and when the involvement of the PGT as committee is
4

 communicated to each of those organizations and health service providers generally. The
PGT is supportive of changes which lead to better communication and is prepared to
make any changes necessary to PGT processes, procedures or systems that are required to
accommodate changes made by RHAs and!or MHSAL.
MHSAL: The ICT feasibility assessment determined that the flagging of Public Trustee
committeeship status is not presently in scope in the ICT plan. Further, it has been
determined that the absence of this flag, poses the most material risk to RHAs being able
to assure information communication across service entities (relative to committeeship
status) and upholding the RHAs responsibilities therein.
As such, a recommendation to government will be forthcoming proposing specific one
time and ongoing operating investments in an ICT solution to mitigate this ongoing risk.
Recommendation #8
That the RHAs review the feasibility of electronic charting for all their facilities.
MHSAL: An ICT study had been undertaken to assess the feasibility of electronic
charting for all in .scope facilities. The existing ICT capital plan will address, over time,
electronic patient record deployment and eChart across all in scope facilities. The
financial investment required to achieve this recommendation'sooner is not feasible.
Furthermore, MHSAL indicated that its response to recommendation 6, 2nd paragraph (page 4)
also applies to this'recommendation.
Recommendation #9
That the protocol that requires primary care physicians sending patients to an Emergency
Department (ED), to notify the ED in advance by phone, be maintained - including
verification of whether a letter has been given to a client to present to the ED staff.
MHSAL: Assessments have been undertaken, affirming that the requirements established
by the College of Physicians and Surgeons of Manitoba remain in place and are
requirements of physician practice. The College of Physicians and Surgeons of Manitoba
(CPSM) has practice standards! guidelines in place that guide the communication process
between primary care physicians and Emergency Departments (EDs).
Recommendation #10
That the RHAs continue to review their policies and procedures to examine the feasibility
of letters from primary care physicians to EDs being sent electronically.
MHSAL: In the fall of2016, the Health Senior Leadership Council limited the scope of
this recommendation to only those individuals under the public trustee. An assessment of
policies and procedures were undertaken, identifying that the limiting enabler in doing
this function is the absence of identification of individuals who are committees. This
5

 recommendation is not feasible in the absence of the implementation of the ICT solution
proposed in recommendation 7.
Recommendation #11
That WRHA review its policies and procedures to ensure that primary care facilities
develop a uniform protocol for the transportation of clients with mobility or cognitive
challenges to other health care facilities.
MHSAL: In the fall of2016, the Health Senior Leadership Council limited the scope of
this recommendation to only those individuals under the public trustee. A review of RHA
current practices, degree of risk presented by this issue, implications on RHA operations
and alignment with RHA mandates occurred. MHSAL and RHA policies have been
developed.
Operational governance roles are of particular question with the establishment of Shared
Health (SH), thus some operational governance policies previously held by MHSAL may
move to SH. Thus, the implementation of the policies is contingent on the operational
status of SH.
Recommendation #12
That all RHAs review their policies and procedures to ensure that vulnerable persons,
including persons with mobility issues, are assisted by staff with the triage process
immediately upon their arrival at an ED.
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
The MHSAL policy "Emergency Department Registration, Triage and Waiting Room
Monitoring Policy" was implemented in August 2016. It required all regions to have
policies and protocols in place, in response to a variety of policy gaps identified through
the inquest (recommendations 12, 15, 17, 19 and 33). RHAs were audited on compliance
with the policy in January 2017.
Recommendation #13
That paper triage lists at any ED be eliminated and that each presenting person's
information be entered electronically into a hospital registration system upon first point of
contact by ED staff.
MHSAL: Paper triage has been eliminated in EDs; policies have been developed and
audited, entrenching this requirement. Registering the patient, at the first point of contact,
is incongruent with the national triage standards to triage first. The objectives of the
policies developed establish the intent to do both triage and registration simultaneously.
The ability to electronically register patients at first point of contact is further limited at
6

 in scope facilities by ICT and infrastructure. The deployment of Emergency Department
Information System (EDIS) has addressed ICT requirements. The infrastructure
assessment completed has identified the highest risk sites for this issue and proposes risk
mitigation on these sites through safety and security (see recommendation 14 and 24).

Paper triage was eliminated across Manitoba following direction to do so within 3
months of the release of the inquest recommendations on December 12,2014. RHAs
were required to report to MHSAL, confirming they had eliminated paper triage methods
and RHAs reported compliance with the direction.
Recommendation

#14

That RHAs review the floor plan of all EDs to ensure that no persons in the ED waiting
room requiring medical care face away from the triage desk.
MHSAL: Floor plans reviewed. Infrastructure assessments completed. Future
infrastructure recommendations are coming forward to address high-risk sites which
cannot meet this recommendation and recommendation 24, based on existing ED layout
and infrastructure.
All rural emergency departments with greater than 10,000 visits per year have made
accommodations to ensure that persons in the waiting rooms can be seen at the triage
desk, predominantly the addition of CCTV cameras. As this work is ongoing and longterm, a time line cannot be estimated.
Recommendation

#15

That RHAs review their policies and procedures
rooms are awakened at regular intervals.

to ensure that persons in ED waiting

MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
In addition, the department repeated its response to recommendation #12, per the second
paragraph in blue text under that recommendation.
Recommendation

#16

That the RHAs review t~e feasibility of secondary traumatic

stress training for all ED staff.

MHSAL: Assessment of existing activities in place and RHA investments required to
attain this recommendation, have occurred. Training standards will be imbedded into
operational and governance policy to be implemented and audited on a go forward basis.

7

 The following training is available across regions: Vicarious trauma training is provided
to all RHAs. Additionally, Northern Regional Health Authority (NRHA) provides online
psychological First Aid for all ED staff to complete.
Recommendation #17
That the RHAs review their policies and procedures to ensure that staff intervenes when a
person is vomiting in an ED.
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
Recommendation #18
That the RHAs review their policies and procedures with respect to interview notes taken
on behalf of hospital Administration after the occurrence of critical incidents, with a view
to having the notes dated and initialed or otherwise authenticated by the interviewee.
MHSAL: Policy analysis and feasibility assessment was conducted, determining that this
recommendation is incongruent with critical incident policy and legislation, and is not
feasible.

The Critical Incident Reporting and Management Policy provides direction to regional
health authorities and provincial organizations with respect to critical incident reporting,
investigation, disclosure and recording, and notification to the Minister in accordance
with the legislation. The review detelmined that undertaking this recommendation would
be incongruent with this policy.
Recommendation #19
That the RHAs review handover policies in the ED to ensure that the oncoming triage and
reassessment nurses are fully briefed on the status of persons present in the waiting room.
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
In addition, the department repeated its response to recommendation #12, per the second
paragraph in blue text under that recommendation.

8

 Recommendation #20
That all RHAs review the feasibility of a security presence at the entrance to an ED.
MHSAL: A feasibility assessment was undertaken by all RHAs, identifying that to
address this recommendation, an investment of approximately $4.SM ongoing operating
would be required for all in scope facilities. The relative risks necessitating a 2417
security presence at in scope EDs have not materialized, and as such, this has been
determined to not be feasible or required at this time.
Recommendation #21
That ED Security staff receive training in the areas of substance abuse and dealing with
persons with physical or mental challenges.
MHSAL: Assessment of existing activities in place and RHA investments required to
attain this recommendation have occurred. Training standards will be imbedded into
operational and governance policy to be implemented and audited on a go forward basis.
Recommendation #22
That all RHAs review the feasibility of implementing the recommendations of the Brian
Sinclair Critical Incident Review Committee.
MHSAL: This recommendation was determined to be redundant of most other
recommendations with the exception of the RHA development of role descriptions for all
Emergency Department (ED) staff, presently underway. Shared Health Manitoba (SH)
will also playa role in establishing the standards for education and roles of ED staff
provincially.
Accordingly, actions associated with this recommendation are contingent on the
operational status of SH, which is undertaking provincial oversight including the
development of standardized job descriptions. A timeline for this work cannot be
estimated at this time.
Recommendation #23
That all RHAs review the feasibility of the presence of a Community Support Worker for
EDs, where deemed appropriate.
MHSAL: Feasibility assessment was undertaken, identifying that an ongoing operating
investment of approximately $3.34M per annum would be required. Recommendations
on pursuit of this investment have been deferred, awaiting outcomes of the Health System
Sustainability and Innovation Review (HSIR), aka KPMG Report, and ED Wait Times
Task Force recommendations.

9

 Recommendation #24
That all RHAs review the feasibility of creating a distinct pre-triage area for EDs, where
deemed appropriate.
MHSAL: Infrastructure assessments have been completed. Future infrastructure
recommendations are being worked on, to address high-risk sites that cannot meet this
recommendation and recommendation 14, based on existing ED layout and infrastructure.
Recommendation #25
That all RHAs review the feasibility of replicating the HSC ED front-end procedures
throughout the system, where deemed appropriate.
MHSAL: Given the variation in infrastructure, leT and staffing at all in scope EDs, this
recommendation has been determined not feasible.
Recommendation #26
That the RHAs continue to review, create and implement long-term strategies for the
recruitment and retention of nurses.
MHSAL: Evidentiary documentation has been compiled provincially and for each RHA
on existing strategies for mid and long term nursing recruitment.
The review resulted in identifying multiple strategies in place across regions, including
but not limited to the Nursing recruitment and retention fund, relocation assistance,
refresher programs, various education grants, various mentorship programs, and regional
implementation of the "Grow your own" program.
Recommendation #27
That the RHAs continue to review a rotation of roles and hours of work for ED Nurses in
an effort to reduce fatigue.
MHSAL: The regions review and adjust staffing rotations and hours of work in
emergency departments, on an annual basis and more frequently as part of regular
operational planning. RHAs have submitted evidentiary documentation confirming that
these activities occur annually and as part of regular operational planning processes.
Recommendation #28
That RHAs, health care site Directors, Nurse Directors and Manitoba Nurses Union
(MNU) representatives continue to convene ongoing meetings focused on an
interdisciplinary, integrated health care model for Emergency Medicine.

10

 MHSAL: All RHAs, with the exception of Northern Regional Health Authority (NRHA),
have submitted responses indicating that ongoing interdisciplinary meetings on integrated
health care for Emergency Room (ER) Medicine services occur regularly. Follow up with
NRHA will occur.

Recommendation #29
That the WRHA review the feasibility of establishing Transition Centres for vulnerable
patients discharged from urban EDs, where deemed appropriate.
MHSAL: Health System Leadership Council (HSLC) directed an alternate solution be
implemented, as transitional housing for homeless individuals is not within the mandate
of the health care system. RHAs were directed to identify processes by which the RHAs
engage with social support I homelessness service entities within each RHA. Evidentiary
documents from each RHA, addressing the matter, have been submitted accordingly.
Recommendation #30
That the RHAs identify staffing demands in all EDs and strategically plan to supply
adequate staffing for all EDs.
MHSAL: The regions regularly review and identify staffing demands in emergency
departments, on both an annual basis and as part of regular operational planning. RHAs
have submitted evidentiary documentation confirming that these reviews occur annually
and as part of operational planning processes.
Evidentiary documentation reviewed included: RHA's daily assessments of staffing
ratios and scheduling. The assessments included ensuring hours of work are compliant to
existing collective agreements.
Recommendation #31
That an ongoing review of staffing ratios for all EDs be undertaken by all RHAs, to match
supply to demand.
MHSAL: The regions regularly review and identify staffing ratios for all EDs to ensure
the supply of staff matches the demand for them. RHAs have submitted evidentiary
documentation indicating that these reviews occur annually and more frequently as part
of regular operational planning processes.
Recommendation #32
That the RHA Directors, Site Directors, ED Directors and the Ministry of Health review
the feasibility of strategic planning to implement accountability structures, including
measurement and reporting systems.

11

 MHSAL: A feasibility review has been completed. The province and the regions follow a
framework that sets out processes for strengthening the accountability of the health
system. The framework document is available at:
http://www.gov.mb.ca/hcalthirhaJdocs/ahsa2009·rulf
In satisfaction of this recommendation, the province and regions have developed
evidentiary documentation, outlining how accountability processes occur regularly.
Recommendation #33
That the RHAs review the feasibility of creating a region-wide Overcapacity Protocol, such
as the Alberta Overcapacity Plan, where deemed appropriate.
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
In addition, the department repeated its response to recommendation # 12, per the second
paragraph in blue text under that recommendation.
Recommendation #34
That the RHAs review the feasibility of providing on-site diagnostic equipment in EDs,
where deemed appropriate.
MHSAL: An assessment of the operational requirements of RHAs, at in scope facilities
(necessitating increased on-site diagnostic equipment) was conducted. The assessment
concluded that current diagnostic equipment available at in scope facilities, is sufficient
for patient and provider requirements.
Recommendation #35
That the RHAs review the feasibility of a seven-day workweek for the office of the Home
Care Coordinator.
MHSAL: This recommendation was incorporated into Home Care review &
recommendations. It will be addressed by actions determined through the home care
review. This recommendation will be further addressed through Shared Health / RHA
Clinical Services planning, and is accordingly contingent on the operational status of
Shared Health.
Recommendation #36
That the relevant utilization representative(s) meet with the Ministry of Health, Housing
and Healthy Living representatives to continue to review bed registry and guidelines for
transfers and discharge of patients from hospitals, including the feasibility of a seven-day
workweek.

12

 MHSAL: It has been determined that the Ministry of Housing does not have a role to play
in the long-term clinical care and associated housing of patients. WRHA has
implemented a 7-day workweek for utilization managers. It has been determined that this
requirement is not warranted in facilities outside of Winnipeg.
Discharge guidelines have been reviewed by RHAs and will be further informed by
standards developed by SH. Shared Health will also review and propose
recommendations on bed registries provincially. Accordingly, this recommendation is
contingent on the operational status of Shared Health.
Recommendation #37
That RHAs review the feasibility of the implementation of the delivery of primary care,
after-hours, urgent services, where deemed appropriate.
MHSAL: Evidentiary documentation has been prepared demonstrating the current and
planned actions of the province and RHAs in satisfaction of this recommendation.
The following have been undertaken to achieve after hours service delivery of primary
care:
•
•

•

In 2014, the CPSM issued a policy statement to all physicians, which outlined
practice coverage of physicians for after hours and vacation.
As part of the Doctors Manitoba Agreement, physicians employed or contracted
by a RHA are required to follow specific duties as outlined in a "Job Description
for General Practitioner Physicians". Among several duties related to timely
access to primary care, physicians are required to participate in after-hours
services.
MHSAL has undertaken numerous steps to increase system and provider capacity
that will improve and increase access overall and at the time patients want! need
it, such as supporting provider groups to implement Advanced Access, adding
resources to support interprofessional practice, the opening of eight Access
Centres in Winnipeg and the creation of My Health Teams.

Recommendation #38
That the WRHA review the feasibility of community health care facilities with integrated
models of care.
MHSAL: Evidentiary documentation has been prepared, demonstrating that the current
and planned actions of the province and RHAs are in satisfaction of this recommendation.
Feasibility assessments reviewed the need for consistency in access to primary care
across the province and, the readiness of regional and primary care provider assessment
for establishing integrated models of care. Progress has been made on the implementation
of the Primary Care Strategic Plan, to address:

13

 •

•

•
•

Primary care capacity planning - a robust planning process with the regional,
primary care and provincial representatives in its second year. This process
identifies gaps in primary care and potential solutions, to stabilize primary care.
Enrollment at a home clinic, to identify Manitobans that have a regular primary
care provider. As of December 1, 2017, 62% of Manitobans have been officially
enrolled.
There are Primary Care Networks operational in three regional health authorities
in Manitoba.
40 new inter-professional team members have been hired to work with Fee-forService (FFS) physicians, to increase access to primary care and enable
physicians to spend more time with patients, to meet their medical needs.

MHSAL was further investigating access to improved primary care services. Efforts
to improve coordination between primary care providers and sites, other health and
social services to meet patients' needs through information sharing, referral pathways
and service inventories are currently underway.
Recommendation #39
That RHAs continue to review the feasibility of incorporating more Nurse Practitioner
positions in EDs, where deemed appropriate.
MHSAL: Feasibility assessments were undertaken. RHAs have an indication of where
Nurse Practitioners (NPs) are in place and where they could be in place, in future, if
supply ofNPs is available. MHSAL recommended a deferral of further work on this
recommendation, to align with clinical services models and NP placement determination,
in correlation with the Clinical Services Planning report (CSP report) and KPMG reports.
Recommendation #40
That RHAs review the. feasibility of recruiting and retaining Hospitalists, where deemed
appropriate.
MHSAL: Shared Health Manitoba will further assess this issue in congruence with
recommendations of the Provincial and Clinical Services plan and Health Sustainability
Innovation Review.
Recommendation #41
That RHAs review the feasibility of the implementation of "one way consults" from the ED
to the hospital ward, where deemed appropriate.
MHSAL: Provincial Medical Leadership Council (PMLC) has advised that this is not
feasible. However, processes to improve consultation and admission from the ED will be
further assessed following operational status of Shared Health.

14

 Recommendation #42
That the RHAs review the feasibility of hiring and retaining Physician Assistants to work
in EDs, where deemed appropriate.
MHSAL: Actions on this recommendation were deferred pending the outcomes of
KPMG report, Clinical Services Planning report (CSP report) and emergency task force
report. The KPMG report titled "Health System Sustainability and Innovation Review"
was released in full on May 31, 2018. Further action on this recommendation is
contingent on the operational status of Shared Health.
Recommendation #43
That the RHAs review the feasibility of creating a process to establish a deadline for
admitting a "boarded" ED patient to a hospital bed, where deemed appropriate.
MHSAL: Similar to recommendation 41, processes to improve consultation and
admission from the ED will be further assessed, following operational status of Shared
Health.
Recommendation #44
That the RHAs create a Hospital Length-Of-Stay Reduction Committee to monitor and
optimize patient flow in RHA hospitals.
MHSAL: All RHAs have flow committees that consider issues of length of stay. In
addition, issues of length of stay and flow optimization will be further considered by SH
to establish provincial benchmarks for RHAs to adhere to. The establishment of
provincial benchmarks for flow will occur in conjunction with the SH-Ied clinical
services planning, the completion date of which is unknown.
Recommendation #45
That the WRHA engage in strategic planning with the Ministry of Health and Manitoba
Housing for the funding and construction of more long term care facilities.
MHSAL: MHSAL developed a 10-year Personal Care Home (PCH) plan, and presented
it to the Health System Leadership Committee (HSLC), who accepted the plan as
satisfactory evidentiary documentation for this recommendation.
In 2016, the government announced a commitment for the establishment of 1200
additional peH beds and the completion date for this is unknown.
Recommendation #46
That WRHA continue pursuing the feasibility of the recruitment and retention of more
Nurse Practitioner services in personal care homes.
15

 MHSAL: Feasibility assessments were undertaken. RHAs have an indication of where
Nurse Practitioners (NPs) are in place, and where they could be in place in the future-if
the supply ofNPs becomes available. MHSAL recommended a deferral of further work
on this recommendation, pending the operational status of Shared Health.
Recommendation #47
That the RHAs review the feasibility of the creation of a single electronic health record
accessible to all health care facilities.
MHSAL: An ICT study had been undertaken to assess the feasibility of electronic
charting for all in scope facilities. The existing ICT capital plan will address, over time,
electronic patient record deployment and eChart across all in scope facilities. The
financial investment required to achieve this recommendation sooner is not feasible.
In addition, the department advised that its response to recommendation 6 (i.e. that an investment
of $300M ongoing operating costs and approximately $50M one-time cost would be required to
accomplish the recommendation) applies to this recommendation.
Recommendation #48
That the Ministry of Health and the RHAs review the feasibility of the expansion of
Primary Care Networks.
MHSAL: Evidentiary documentation has been prepared, demonstrating the current and
planned actions of the province and RHAs in satisfaction of this recommendation.
The second phase of the Provincial Evaluation of My Health Teams was completed April
2018.
Recommendation #49
That the WRHA review the feasibility of the expansion of Nurse Practitioner-operated
Quick Care Clinics to help ease wait times at EDs and Primary Care Physicians' offices.
MHSAL: Evidentiary documentation has been prepared, demonstrating the current and
planned actions of the province and RHAs in satisfaction of this recommendation.
Recommendation #50
That the WRHA and the Ministry of Health continue to create strategies to educate the
public about the existence, function and location of community health care centres.
MHSAL repeated here, its response (in blue text) to recommendation 49. Furthermore, MHSAL
confirmed that its current educational methods and strategies are sufficient to satisfy the
recommendation, and indicated that:

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 No specific action on this recommendation outside of routine practices is required at this
time. MHSAL and RHAs will continue to adjust tactics and messaging as required to
reach a broad spectrum of the population.

Recommendation #51
That the WRHA review the feasibility of creating an integrated "engagement and
diversion" program for the homeless.
MHSAL: HSLC directed alternate solution be implemented, as transitional housing and
homelessness programs are not within the mandate of the health care system. RHAs were
directed to identify processes by which the RHAs engage with social support/
homelessness service entities within each RHA. Evidentiary documents from each RHA
have been submitted accordingly.
RHAs were required to submit letters to MHSAL, indicating how they partner with these
agencies. All RHAs did so in November 2016, reflecting various kinds of partnerships
with various kinds of social services agencies.
Recommendation #52
That the RHAs review the feasibility of the installation of an electronic board to monitor
the status of the patients in the ED, where deemed appropriate.
MHSAL: An ICT study had been undertaken to assess the feasibility of installation of
electronic boards for monitoring patient status, determining that this practice is standard
in EDIS deployment. EDIS deployment, at in scope facilities, is part of the existing leT
plan and has occurred. EDIS deployment at sites with less than 10,000 visits, but at risk
due to population or geography, are not in scope to the current EDIS leT plan and would
require additional investment and authority from government.
Recommendation #53
That the RHAs and MNU continue to review the feasibility of persons presenting at EDs
seeing a nurse first.
MHSAL: Policy objectives establish intent to do both triage and registration
simultaneously. The ability to electronically register patients at first point of contact is
further limited at in scope facilities by leT and infrastructure. The deployment of ED IS
has addressed leT requirements. The infrastructure assessment completed has identified
the highest risk sites for this issue and proposes risk miti'gation on these sites through
safety and security (see MHSAL's response to recommendations 14 and 24).

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 Recommendation #54
That the RHAs review policies and procedures with a view to implementing uniform pretriage systems at all EDs.
MHSAL: Given the variation in infrastructure, leT and staffing at all in scope EDs, this
recommendation has been determined not feasible.
Recommendation #55
That the RHAs review the feasibility of incorporating training in the area of emotional
safety for health care professionals.
MHSAL: Assessment of existing activities has occurred. Assessment of RHA financial
investments required to attain this recommendation has occurred. Shared Health will take
a lead role on establishing standards of education required for health system employees in
the areas of resiliency training, and cultural safety and competency.
Recommendation #56
That the RHAs review the feasibility of recruiting and retaining an Indigenous Elder for
EDs, where deemed appropriate.
MHSAL: Review and analysis undertaken, and recommendation determined to be not
culturally appropriate. Alternate solution proposed focusing on access to spiritual care
and I or Elder, on request.
Recommendation "#57
That the WRHA Indigenous Health Services continue to make efforts to recruit and retain
the services of Indigenous Elders to be present in the HSC ED during peak hours, seven
days a week.
MHSAL: Review and analysis undertaken and, recommendation determined to be not
culturally appropriate in an ED environment. Alternate solution proposed, focusing on
ensuring access to spiritual care, Elder, interpreter or resource workers on request or as
needed.
Recommendation #58
That the RHAs review the feasibility of the hiring and retention of Indigenous Discharge
planners, where deemed appropriate.
MHSAL: Through review, it has been determined that hiring and retention oflndigenous
Discharge planners is not culturally appropriate. RHAs have undertaken collaboration
with Indigenous communities, to improve processes and the coordination of discharge
planning for Indigenous Manitobans.
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 Recommendation #59
That the WRHA Indigenous Health Services review their informational pamphlets at each
hospital site to ensure that the pamphlets are available in Manitoba's Indigenous and Inuit
languages.
MHSAL: Review and analysis of informational pamphlets was completed. It was
determined that this approach is not culturally responsive or appropriate, and that
.alternate methods of improving communication which are more appropriate, will be
pursued, including the following alternate actions, which are in place among RHAs:
• Indigenous Health Programs Interpreters and the Language Access phone line.
• "It's Safe to Ask" posters are posted in Indigenous languages.
• RHA posters available in English, French, Ojibway and Dakota languages.
Recommendation #60
That the RHAs strategically plan with Manitoba First Nations to review the feasibility of
the establishment of rural Indigenous personal care homes in the Province of Manitoba,
where deemed appropriate.
MHSAL: Evidentiary documentation was provided of work being undertaken by RHAs in
consultation with Indigenous Manitobans, which include determining alternate priorities
relative to First Nation PCH care.
Evidence of the following actions was provided:
• Strategic planning of rural Indigenous personal care homes (PCHs) was raised at the
Intergovernmental Committee on Manitoba First Nations Health (ICMFNH) planning
day in March 2016. Licensing and standards were identified as the focus for work on
this committee rather than any expansion of PCHs for Indigenous persons.
• The Intergovernmental Committee on Manitoba First Nations Health and Social
Development work plan for 2016-17 highlighted the provision of technical support/
coordination for the Manitoba First Nations Personal Care Home Network, to support
accreditation and licensing of all eight First Nations PCHs.
• Two facilities are licensed, with work underway to seek direction around licensing for
the six facilities that remain outstanding.
Recommendation #61
That the WRHA reviews the feasibility of expanding the Indigenous Resource Worker
position to include weekends.
MHSAL: An analysis was undertaken, identifying that this recommendation is not
financially feasible and that focus on service coordination and appropriate resourcing
based on client needs were more appropriate.
The focus was revised towards service coordination and appropriate resource provision
for the following:
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 •
•
•

Indigenous Resource Workers;
Regional Discharge Planning Coordinators;
Liaisons present in select facilities with larger Indigenous patient populations
across regIOns.

This plan has been implemented.
Recommendation #62
Th~t the WRHA review the training of all ED security personnel to ensure that they
receive cultural safety training.
MHSAL: An assessment of existing activities has occurred. Assessment of RHA
financial investments required to attain this recommendation have occurred. Shared
Health will take a lead role on establishing standards of education required for health
system employees in the areas of resiliency training, and cultural safety and competency.
Indigenous cultural training for security staff is in place in Prairie Mountain Health
(PMH), NRHA and WRHA. Indigenous cultural training is not in place in InterlakeEastern Regional Health Authority (IERHA), but will be addressed through Shared
Health education and standardization. Southern Health / Sante Sud (SH-SS) has advised
that they do not have security. Therefore, this recommendation is not applicable to SHSS.
Recommendation #63
That the RHAs develop and initiate policies for the implementation of mandatory and
ongoing
cultural safety training for all health care workers and that the RHAs ensure that cultural
safety training includes a component that has been designed and delivered with the
assistance of Indigenous persons.
MHSAL: An assessment of existing activities has occurred. An assessment of RHA
financial investments required to attain this recommendation has occurred. SH will take a
lead role on establishing standards of education required for health system employees in
the areas of resiliency training, and cultural safety and competency.
All regions provide Indigenous cultural awareness and/or cultural safety training to staff
on an optional, encouraged or required basis, depending on the role/ position of the staff.
In its response of May 4,2018, MHSAL stated:
"Manitoba has undertaken several studies to identify opportunities for improvement in the health
care system, including the Provincial Clinical Preventative Services Planning Report (PCPSP),
the Wait Times Reduction Task Force Report (WTRTF), and the Health Sustainability and
Innovation Review (HSIR).

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 Acting on the findings from several of these studies, Shared Health Manitoba (SH) was recently
established to improve patient care and services, and provide coordinated clinical support to
RHAs. SH will allow government to work across the province to realign and refocus the health
care system. The development of provincially standardized processes and activities associated
with some recommendations will occur by SH, once it is fully established and operational".
In its most recent response of January 25, 2019, MHSAL repeated its advice in its letter of May
4,2018.
MHSAL further stated, " ... recommendations with actions impacted by the implementation of
Shared Health have been identified". MHSAL identified recomniendation outcomes that required
revision to align with the department's update for accuracy. Accordingly, we included in our
discussion of the recommendations, MHSAL's most recent updates on the 63 recommendations
as of January 25,2019.
CONCLUSION
Given that the majority of the recommendations discussed above have been completed, a few
have been found unfeasible, and the eight outstanding recommendations are in the process of
being implemented by MHSAL and SH, our office is concluding our monitoring of this matter at
this time.
Please note that an electronic copy of this report will be posted on the Manitoba Ombudsman
website at www.ombudsman.mb.ca.
Yours truly,

Marc Cormier
Acting Manitoba Ombudsman
cc: Ms. Karen Herd, Deputy Minister, Manitoba Health, Seniors and Active Living
Mr. Dave Wright, Deputy Attorney General and Deputy Minister, Manitoba Justice
Mr. Brock Wright, Chief Executive Officer, Shared Health
Dr. John K. Younes, Chief Medical Examiner

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