Leg amputation due to flesh eating disease, cancer missed in 4 tests and burn to eye among critical incidents in latest report

A patient who spent 18 hours in a rural ER before having their leg amputated for flesh eating disease, another who had four pap tests over four years without being told they had cancer and another whose eye was burned by overheated equipment during surgery are among the 28 cases listed in Manitoba Health’s most recent patient safety report.

The report details critical incidents reported in the health care system between April and June of 2018, including three that ended in death.

The incident involving a patient who turned out to have necrotizing fasciitis, also known as flesh eating disease, began when they were taken by ambulant to a rural emergency room after three days of feeling sick that included nausea and vomiting. They arrived with swelling in their leg, bruising and open wounds that were weeping. The patient had very low blood pressure and a CT scan showed blood clots in deep veins, which they were treated for, but the report said there were few records taken overnight and the patient’s blood pressure continued to drop, along with oxygen levels. An ultrasound also revealed signs of infection and inflammation, but the report said there was a delay in bringing a specialist in for consultation. Eventually, they were diagnosed with septic shock, along with necrotizing fasciitis.

The report said the patient spent 18 hours before receiving the treatment they needed. Their leg was amputated.

The incident involving cervical cancer that went undetected began when a patient had a pap test in 2014, but the report said the “pathology indicated no cancer.” The patient had pap tests again in 2015, 2016 and 2018 that were also read as being cancer free. After that, a biopsy found cervical cancer and the original pap tests were looked at again and found to have indicated the presence of cancer. The report said the patient had their cervix removed, with more surgery and radiotherapy needed.

Little information was given about the surgery that left a patient with an eye burn. The report said equipment overheated during surgery, and that the patient had to return to the operating table to treat the burn.

The full report is available on the province’s website.