Man’s death at Pukatawagan nursing station, 3 days after calling for help, sparks federal review

A 48-year-old Cree man who called the nursing station in a northern Manitoba community with an urgent medical situation died after waiting three days to be seen, prompting a formal federal government patient safety review.

“If those nurses could’ve seen him right away, or if somebody could see him and send him out, that guy could’ve been still alive today,” said Marcel Caribou, the brother-in-law of Murdock Colomb, who died in Mathias Colomb Cree Nation in April.

Colomb lived with Marcel’s brother, Lawrence, and Lawrence’s partner, Judy Caribou.

On Friday, April 8, Colomb was coughing, complaining of not feeling well and had swollen legs and feet, Judy said.

Currently, due to staffing shortages and the COVID-19 pandemic, community members on First Nations typically have to call nursing stations to be triaged, unless it’s an emergency.

Judy said she called the nursing station late that Friday afternoon and handed Colomb the phone, telling him to say it was an emergency.

At the time she called, his feet were “all puffed up with water,” she said. She asked him if he said during the call that it was an emergency.

“He said yes … [and] they told him, ‘come Monday morning.'”

On Monday, Judy’s daughter drove Colomb to the nursing station as soon as it opened.

Judy said they called later to say he would be medevaced to Winnipeg, more than 700 kilometres to the south.

But before that could happen, the nursing station called back.

“They said that his heart stopped twice. That’s when we went to the nursing [station]. They were trying to revive him but he couldn’t make it,” Judy said.

The family is still waiting on the coroner’s report for his cause of death, but believe the medical system failed him.

“That guy was dying. At least somebody could’ve went and checked,” said Marcel Caribou.

Colomb, who was employed with Mathias Colomb Cree Nation’s public works department, is now being remembered by family and friends as a friendly, kind, hard-working outdoorsman.

He was active and had no obvious health ailments and took no medications, said Judy.

Nursing shortage

The chief of Mathias Colomb Cree Nation, which has an on-reserve population of around 2,300 people, said she can’t comment on Murdock Colomb’s case, but says the nursing station is under a lot of pressure.

“We have a shortage of nurses right now — that’s why everybody has to phone in,” said Chief Lorna Bighetty.

She’d like to see walk-ins available at nursing stations without calling ahead, as was the case before the COVID-19 pandemic, but said the staffing needs to be in place.

Indigenous Services Canada spokesperson Maddy Warlow said a new policy to improve access to primary care on-reserve was issued in June, and the department is working with community leaders and front-line staff on its implementation.

The department is working to “address the shortage situation and ensure safe care and services,” Warlow said in a written statement.

People with non-emergent and non-urgent issues are encouraged to seek care during regular nursing station hours, which are 9 a.m. to 5 p.m. If several people are seeking care at the same time, they’re triaged and seen based on the severity of their illness or injury, wrote Warlow.

Health-care workers, including nurses, are also on-call overnight, she said.

A formal patient safety review into Murdock Colomb’s case will be co-led by the First Nations and Inuit Health Branch Nursing Directorate, along with an external review team of nurses, community members, physicians, the First Nation Inuit Health Branch leads and educators, the spokesperson said.

The team will review Colomb’s care and medical records, in order to make quality improvement recommendations to government and provide his family with answers, wrote Warlow.

“The health and well-being of Indigenous Peoples and communities is a high priority for our government, and our thoughts are with the family for their loss,” she wrote.

Concerns about access to care

A young mother in Pukatawagan said she too had trouble accessing appropriate care at the nursing station.

Cassandra Cook brought her three-year-old daughter, Cassidy Bighetty, to the nursing station three times between March and April for a growing, soft sore on the top of her head.

“[I] felt helpless, like I couldn’t do anything for her,” said Cook.

Each time, she said her daughter was assessed and sent home — once with Tylenol, another time with antibiotics.

“That’s when I said, ‘Good enough,’ and then waited until child tax [payments] and got my kids ready and jumped the train” to The Pas, more than 200 kilometres to the south, she said, where she was immediately seen at St. Anthony’s General Hospital.

“At first they said it was an abscess and the antibiotics that she was given wouldn’t help at all, and that it was a good thing we brought her out. [It] would’ve just got worse,” she said.

Two days later, Cassidy went for surgery to drain the area of fluid. The area has healed and she’s happy now, her mother said.

Cook said a local leader is working with her and the nursing station to review her daughter’s experience.

“The way I see it is, for years now, they wait until somebody’s really sick or their infection gets worse before they send that person out” of the community for care, she said.

“Especially when it was a child, they should’ve sent her out the first time they seen her.”