Saskatoon Health Region has been working closely with the Ministry of Health to conduct an inventory of carbon monoxide (CO) detectors in its care homes and hospitals. The Health Region has also launched a review after CO exposure at St. Mary’s Villa, a care home in Humboldt.

In the early morning hours of December 26, 2010, several residents and staff at St. Mary’s Villa were transferred out of the Dust Wing after exhibiting symptoms of carbon monoxide (CO) exposure. Twenty-four residents, five employees and two visiting family members were assessed and treated at Humboldt District Hospital. An 89-year old male resident of the care home died in hospital December 26 and a 94-year old female resident died January 4, 2011. It is believed exposure to CO was one contributing factor in both peoples’ deaths.

St. Mary's Villa

“We extend our sympathy and condolences to the families,” says Shan Landry, Vice President of Community Services. “I also want to acknowledge how difficult a time this has been for the staff of St. Mary’s. They’ve also suffered a tragedy and several of them also felt the effects of carbon monoxide. However, they responded quickly, helping mostly immobile residents leave the affected wing safely and quickly.”

Saskatoon Health Region has struck a critical incident review team to conduct a review of the incident. The team will focus on facilities and equipment operation, as well as the ongoing safety and health of staff, residents, and families.

“We have a number of internal and external experts getting involved in these areas,” says Landry, “including engineers, building inspectors, medical personnel regarding the ongoing effects of carbon monoxide exposure, counselors and social workers. The bottom line is that we want our staff, residents and visitors to know that our buildings are safe.”

The review process includes gathering information, reviewing the incident reports, conducting interviews with individuals involved, conducting site observations and applying a “new lens perspective” analysis which is a systematic model that sees accidents as emerging from interactions between system components and processes rather than failure within them. The review will result in a report outlining the causes of the incident.

“However,” says Landry, “as we uncover things that we need to improve and change during this process, we will make changes and not wait for the final report. We just want to ensure this kind of thing never happens again.”