Krystal Mousseau Report Sheds Light on Lack of Training and “Informal Guidelines” to Transfer ICU Patients

March 15, 2022 

Treaty 1 and Dakota Territory, Homeland of the Red River Métis, Winnipeg, MB--Manitoba NDP Leader Wab Kinew has written to the Chief Medical Examiner (CME), asking government to square their rationale not to hold an inquest into the death of Krystal Mousseau with the information revealed in her critical incident report.  

"Krystal Mousseau’s life mattered. That’s why we cannot allow the questions about her death to go unanswered,” said Kinew. “The province has said no to her family’s call for an inquest, but a critical incident investigation into the circumstances that led to her death have revealed a failure by government to put formal policies, standards, or requirements in place to keep Krystal and other patients safe. Manitobans should have confidence their health care system and government will learn from these mistakes.”  

Krystal Mousseau died on May 25th, 2021 while in transport from Brandon ICU to Ontario during the third wave of the COVID-19 pandemic. A critical incident was called and the results of the investigation were summarized in a letter to the Mousseau family on February 15, 2022.  

In the letter, government assured the Mousseau family that since Ms. Mousseau’s death the private provider used in her transport had undergone additional training for the use of IV infusion pumps. Neither the critical incident investigation nor the CME contemplated why this training had not happened previously or whether it was a requirement for providers who delivered transport services for the government. 

The letter also revealed significant discrepancies in the information provided by the CME as justification to not hold an inquest. The CME listed provincial criteria that were used to select ICU patients eligible for transport, including “age of the patient, their overall level of health at the time, and the existence of comorbities.” However, the critical incident letter asserts the province had “informal guidelines” to select patients, which were exclusively “health issues in one body system,” “oxygen and ventilator settings set within a certain range,” and “the need for minimal amount of life-supporting medication.”  

These final two criteria appear to have been contributing factors in Ms. Mousseau’s death. According to the critical incident letter, health care providers were unable to use an arterial line to monitor Ms. Mousseau’s blood pressure during transport because the equipment was not available. The letter also explains a required safety check for one of Ms. Mousseau’s “high-alert medications” was not done, and as a result she received the inappropriate amount of “at least one of these medications.”  

“There are unanswered questions that need to be addressed. We can help the Mousseau family’s healing journey by making the information about her death and the ICU transport program public,” Kinew said. “I am once again calling on the province to hold an inquest in her case so that these and other systemic failures are righted and her family can get the justice they deserve.”