3 bodies released to wrong families by Manitoba Shared Health

Three bodies were released to the wrong families by Shared Healthafter a series of human and systemic errors, the head of Manitoba's health oversight agency says.

"Our core responsibility is to serve Manitobans well in every stage of their lives, including in death and in this instance, we failed," Shared Health CEO Lanette Siragusa said at a news conference Friday afternoon.

One of the bodies, admitted to Winnipeg's Health Sciences Centre morgue last month, was released to a funeral home on July 22 after an autopsy was completed.

More than two weeks later, a call on the health agency's records alerted of some irregularities, promptingan investigation that has since concludedthe body wasreleased to the incorrect funeral home.

The family of 44-year-old Keith Wilson from Pimicikamak Cree Nation was notified by the health oversight agency earlier this week that they had received the wrong body.

"The family is in shock.We're in shock. We're in disbelief that this would happen to our citizens. We were grieving and mourning the wrong body and now, starting all over again," Pimicikamak Chief David Monias told CBC News earlier this week.

Funeral services for Wilson were held in late July, with the remains buried in Norway House Cree Nation.

"Shared Health accepts full responsibility for this error," Siragusa said.

"For that, I offer my sincere apologies to the family and community members."

An investigation into the error has since revealed two other "near misses" have occurred in recent weeks, with bodies incorrectly signed out of Shared Health facilities and transported to the wrong funeral home.

In those cases, the bodies were returned to the Shared Health morgue, and families were notified.

"They [are] shocked and upset, it adds a layer of grief to them," Siragusa said Friday.

The province's health oversight agency said the incorrect release of the three bodies spanned over the last couple of weeks.

"Like any member of the public, I am appalled, I am outraged, I am heartbroken, not only that this type of error could occur, but that it could be repeated," Siragusa said.

Human, systemic errors at play

Siragusa said the wrong release of a body has not happened in the Health Sciences Centre's recent history.

Shared Health is conducting an internal investigation to examine the different safety checks the agency has in place to sign off on a body's release from its care. Early results from that internal investigation, Siragusa said, have since revealed "some concerning gaps" in the process that exists to prevent a body from being released to the wrong family.

"It is clear that human error played a role in this event," she said. "However, it also signifies systemic failure that allowed it to be repeated."

The province's health oversight agency is reviewing the bodies that have beenreleasedof at least the past month.

Siragusa couldn't specify the errors behind the wrong releases or who was involved in them. But she said Shared Health is now seeking an external partner review of the processes in placefor the custody, identification, and release of a body.

Access to the morgue has also been "significantly" restricted, authorizing limited staff members, part of the transport team, to sign out bodies from the funeral home.

Siragusa said it would continue updating families as more details from the investigation become available. New funeral arrangementswill now be covered by Shared Health.

"I promise we will do better," Siragusa said.