ManitobaManitoba saw a significant drop in the number of deaths and major injuries reported while patients accessed health-care services last year, but critical incident reports from Manitoba Health show the vast majority the serious harm was caused by gaps and delays in care.Nurses union warns momentum could stall if facilities remain understaffedLauren Scott · CBC News · Posted: Sep 22, 2025 6:00 AM EDT | Last Updated: 5 hours agoManitoba Health reports show patient deaths declined by nearly 24 per cent in 2024 compared with the previous year, while major injuries dropped by 17 per cent over the same period. (Jeff McIntosh/The Canadian Press)Manitoba saw a significant drop in the number of deaths and major injuries reported while patients accessed health-care services last year, but critical incident reports from Manitoba Health show the vast majority the serious harm was caused by gaps and delays in care. Reported patient deaths declined by nearly 24 per cent in 2024 compared with the previous year, while major injuries dropped by 17 per cent, a CBC analysis of quarterly critical incident reports between 2023 and 2024 has found. Critical incident reports are made when people using the health-care system suffer serious, unintended harm. The province says these reports, often summarized in one- or two-sentence summaries based on initial understandings of the incident, are used to make recommendations for improvement. It is possible that some deaths and serious injuries have gone unreported and are not included in these reports. In 2023, there were 42 deaths and 124 major injuries, including two deaths caused by faulty medical devices and 10 deaths where lacking or delayed care were contributing factors. Last year, public health officials reported 32 deaths and 102 major injuries. One patient died after getting trapped on bed rails. Another patient was seriously injured when a surgical item was left inside their body during an operation. Critical incident reports are typically published for the previous year’s reported serious injuries and deaths. None of the 2025 reports are publicly available yet. The most recent report, which covers the period between Oct. 1 and Dec. 31, 2024, offers limited details on eight deaths and 28 major injuries. Delays and gaps in care were cited in each of the deaths over this period, with officials using phrases such as “missed” or “not realized” opportunities to treat patients’ acute medical conditions, and “delayed interventions” to transfer patients to higher levels of care. One infant was born with an infection that caused a serious injury after “opportunities for earlier treatment were not recognized,” the report said. Two patients were seriously injured after they “experienced elevated drug levels” resulting in harm. Another experienced serious burns. One patient developed an infection after a foreign item was not removed after a surgical procedure. A quarter of all of the serious injuries were related to “skin tissue breakdown” and “pressure injury,” generally referring to bedsores, which can develop when patients who cannot move on their own remain in one position for too long without help. One of these patients developed a Stage 3 pressure injury — a serious open wound that reaches down to deeper tissue and fat. Understaffing a major problem: nursesMore than three quarters of the serious injuries reported included references to delays, missed opportunities or gaps in care and risk assessment. Manitoba Nurses Union president Darlene Jackson, whose organization represents more than 13,000 nurses across the province, says these types of serious injuries could have been prevented with proper oversight from nurses and health-care aides. Darlene Jackson, president of the Manitoba Nurses Union, says the government must establish minimum nurse-patient ratios to help prevent deaths and serious patient injuries at understaffed facilities across the province. (Prabhjot Singh Lotey/CBC)”One of the most important things about nursing is the ability to be able to pick up trends as you’re dealing with your patient throughout your 12-hour shift or your eight-hour shift, noticing very small changes and putting that puzzle together,” Jackson said. Nurses need to have a lot of ongoing contact with their patients to monitor condition deterioration, she said, but that’s not possible when health-care facilities are understaffed. “If your patient load is sometimes double what we would consider to be a safe patient load, then it’s almost impossible to keep your eyes on that patient often enough to be able to pick up on those small nuances and deal with them quickly,” she said. Earlier this year, the union warned that nurses are not seeing improvements on the front-lines of the health-care system, despite the province’s plan to fix it. In February, the government announced it had hired 1,255 net new health-care workers since April 2024, including 481 new nurses. In March, Manitoba began targeting U.S. nurses in recruitment ads. Jackson said one of the most effective ways to further reduce reported deaths and serious injuries is to set minimum nurse-patient ratios. The province recently set up a nurse-to-patient ratio committee The group, which includes representatives from employers, the Manitoba Nurses Union, the Manitoba government and regional health authorities, is still in the process of surveying frontline workers to set nurse-patient ratios. The current survey, which is focused on acute-care settings, is open for feedback until Tuesday. Until there are more nurses on shift, Jackson says, it’s going to be a challenge to keep deaths and serious injuries trending downward.”It’s good to see the numbers go down, but any death or major incident — any one is too many,” Jackson said.”The struggle is going to be to continue to push those numbers down.”CBC News reached out to Health Minister Uzoma Asagwara’s office for comment but did not immediately receive a reply. ABOUT THE AUTHORLauren Scott is a Winnipeg-based reporter with CBC Manitoba. They hold a master’s degree in computational and data journalism, and have previously worked for the Hamilton Spectator and The Canadian Press.
In-care deaths, serious injuries declining across Manitoba health-care system: reports
