Hospital, care home systems failed paralyzed Winnipeg senior in final days, family says

Neglect at a Winnipeg care home and an overrun hospital emergency room marredthe final days of a Winnipeg senior's life, his family says.

Gary Davlut, 76, who was paralyzed from the chest down during heart surgery in 2021, received questionable care at Poseidon Care Home before his death last Nov. 20, they say.

"Not one, but two systems failed him," said a grandchild of Davlut, who spoke on condition of anonymity due to job security risks.

Family members also said"unreasonable" wait times at the Grace Hospital including an estimated 118-hour wait for a medicine bed swayed them to pull him from the ER the day before he died.

Davlut was at the Grace on Saturday, Nov. 18, the same day a patient died thereafter a 33-hour ER wait. The Manitoba Nurses' Union said at the time the ER "was a zoo" that weekend.

That evening, two family members had found the paralyzed senior slumped over some pillows meant to prop him up in a chair next to his bed at Poseidon.

His stepdaughter Denise Youell said Davlut kept saying, "I'm so weak. I'm so weak."

The call button was out of his reach and his family saidthey saw blood in his catheter bag. They asked staff to call an ambulance.

"Definitely that situation was neglect," Youell said.

When they arrived at the Grace that night, Youellsaw "wall-to-wall stretchers" filling the emergency room hallway.

"It was just gridlock," she said.

Davlut spent 20 hours on a stretcher before a doctor called her on the afternoon of Sunday, Nov. 19, she said.

Both family members said the hospital told her it could be 118 hours until a medicine bed opened upor they could send him back to Poseidon.

"I just thought it was unreasonable," Youell said.

"My preference in a perfect situation would have been he would have been admitted to the Grace, had a bed, had proper care give him a bit more time."

But Youell was left with the impression that taking Davlut out of the hospital was the best thing to do.

"The clear message was 'I'm suggesting he go back to the PCH.'"

Davlut was taken back to Poseidon midday on Sunday. By that night, a nurse there called the family to say that a pre-existing abdominal aneurysm and Davlut's overall condition had worsened.

His grandchild said that when Davlut arrived at the Grace again on the morning of Nov. 20, a patient he was placed next to on Saturday, Nov. 18, in the ER hallway a woman lying on a stretcher struggling to breathe was still there.

Within a few hours of arrival at the ER, Davlut's condition deteriorated. He died that afternoon, his family said.

"It's really about the care and dying with dignity," Youell said.

"We knew he was very ill, but it's just that humanity and being treated respectfully."

Questioning critical incident criteria

Davlut's family said a patient relations staff member told them a few weeks ago that his death wasn't deemed a critical incident.

Asituation is deemed a critical incidentwhen health care results in unintended serious consequences to a patient that are "not the result of an underlying health condition" or risk, the Winnipeg Regional Health Authority said.

Acritical incident triggers an internal investigation to see how the hospital can improve its care. Theinvestigations are meant to identify what could have been done differently to help minimize risks in the future.

The patientdeath after a 33-hour ER waiton Nov. 18 was deemed a critical incident.

"I kind of wonder how this isn't a critical incident, especially considering that somebody who also waited over 33 hours in the same hospital in the same place died in the same weekend, and that was named a critical incident," Davlut's grandchild said.

Kerstin Jordan, regional safety lead for the Winnipeg Regional Health Authority, said in a statement on Wednesday that they are "still actively reviewing the circumstances surrounding this event to determine if it meets the criteria for a critical incident."

Jordan said they treat every event as a chance to learn and improve care.

The Winnipeg Regional Health Authority said the median length of stay for patients admitted at the Grace emergency room in November was over 33 hours.

All Winnipeg hospitals have been dealing with "ongoing patient flow concerns," including a bottleneck of patients waiting in emergency rooms for beds to open up, the WRHA said.

In November, the NDP government committed to adding31 acute-care beds to the Grace as a means of addressing some of those concerns.

Care home concerns

Davlut's grandchild said it wasn't until the day he died that they were informed of an injuryfound near the base of his spine and an abscess on his scrotum wounds that "don't happen overnight."

"I'm just really curious as to if these things were caught, could it have prevented his death?" his grandchild said.

They wonder whether Poseidon staff didn't catch those sooner because his briefs weren't changed on schedule.

The family had concerns about the care at Poseidon beforeDavlut's death.

In one interaction, when Youell asked for workers to bathe Davlut, she said a nurse became "very aggressive" with her, calling Davlut a "difficult man" and poking her in the stomach. The nurseinsistedshe needed to help with the bath another day.

In another case, the family asked for a different style of bed for safety reasons after Davlut suffered several falls. They said Poseidon declined.

"Every complaint that we ever had was always brushed off," his grandchild said.

Seniorscare advocate Eddie Calisto-Tavares said Davlut's family wasn't presented with any good options.

"It's either he stays in the hospital for 118 hours leave him abandoned there to what, no one looking after him?" she said.

"He was very ill. He should have gotten immediate medical attention if he was even going to have a chance to either survive or at least die with dignity."

'Keep fighting'

She said the experience underscores why Manitoba needs to appoint an independent seniors advocate.

It'ssomething she's been calling for since her father, who had briefly livedat Poseidon, was among the56 residents at Maples Care Home who died in a COVID-19 outbreak in 2020-21.

"My advice for this family is don't give up," she said. "You can stand up for many others that don't have a voice.Keep fighting."

Winnipeg senior's health-care experience 'horrible,' says advocate

8 months ago

Duration 1:34

Seniors' health and long-term care advocate Eddie Calisto-Tavares said the family of Gary Davlut wasn't given any good options when he wound up in a busy Grace Hospital emergency room Nov. 18. They sent him back to his care home the next day after a 20-hour ER wait, when they were told it could be 118 hours before a medicine bed opened up. He was taken back to the Grace Nov. 20, where he died.

Extendicare, which took over Poseidon from Revera last year, declined to comment specifically on this case.

"We work hard to uphold the trust our communities place in us, and we will continue to collaborate with families as partners in care, as we work to improve the care we provide," a spokesperson said in a statement.

Davlut's family says over two months later, they are still grieving his death and the way he died.

"It's really heartbreaking, because that's not what health care is supposed to look like," his grandchild said.