December 30, 2015

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Wednesday, December 30, 2015

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Volume 55 • Issue 52

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Failure to follow fever protocol or recognize worsening condition contributed to 2011 death of God’s Lake Narrows infant in Thompson BY IAN GRAHAM EDITOR@THOMPSONCITIZEN.NET

SNOW LAKE CHRISTMAS CONCERT A HIT COLUMNISTS - PAGE 2

SCARVES KNITTED FOR COLD WINTER’S DAYCOLUMNISTS - PAGE 6

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The lack of a physician who saw pediatric patients at the God’s Lake Narrows nursing station and inadequate communication between nurses and the attending doctor at Thompson General Hospital are among the factors that led to the death of Drianna Ross before the age of three months in 2011, says an inquest report released Dec. 17. Ross died as a result of an aggressive methicillinresistant staphylococcus aureus (MRSA) infection less than 18 hours after arriving in Thompson via a medevac flight. She had been sick with high fevers for three days in God’s Lake Narrows and made four trips to the nursing station interspersed with numerous calls from her parents before being sent to Thompson. Once there, Ross was admitted to a mixed ward with orders from a pediatrician to have her vital signs monitored every two hours. The doctor decided the next morning that sepsis was a possibility and decided to transfer her to the emergency department for observation

while waiting to be flown to Winnipeg. Ross was disconnected from oxygen for the transfer to the ER and her heart stopped en route. She was revived but a neurological assessment determined her prognosis was poor and her parents consented to withdraw her care and allow their daughter to die. The inquest heard that the doctor employed at the God’s Lake Narrows nursing station works in the community from Monday morning to Friday afternoon and that no other physician is available when she is away. Evidence was also given that the doctor did not see pediatric patients because she was so busy treating patients with chronic diseases like tuberculosis and diabetes and that she had to perform all her own clerical work because there is no physician’s assistant. The nursing station also lacks an electronic health record storage and retrieval system and must rely on paper records. In addition, the nurse who was on duty when Ross was brought to the nursing station had limited experience dealing with infants and she

Nickel Belt News file photo Two-and-a-half-month-old Drianna Ross from God’s Lake Narrows died Nov. 26, 2011 in Thompson General Hospital of aggressive methicillin-resistant staphylococcus aureus (MRSA) infection less than 18 hours after arriving via a medevac flight. An inquest highlighted deficiencies in her care at both the God’s Lake Narrows nursing station and Thompson General Hospital as contributing factors in her death. failed to follow a protocol that requires nurses to consult a physician when an infant had a fever of greater than 38 Celsius, as Ross did. The inquest also heard that when Ross was medevaced to Thompson, she was held in her father’s arms during the flight without other restraints, which was a normal practice for

transporting infants. When Ross arrived at Thompson General Hospital Nov. 25, three days after her first visit to the nursing station, she was diagnosed with pneumonia and given antibiotics, though the doctor did not have information from the God’s Lake Narrows nursing station that the infant was

MRSA-positive. Overnight, at about 3 a.m., her intravenous slipped out of her vein and began pumping fluid into her arm, resulting in swelling and pain. The IV was reinserted and the nurse noted that Ross did not respond to the painful procedure. The doctor was consulted but did not Continued on Page 12

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