The Saskatoon Regional Health Authority has been fined $154,000 for offences stemming from an incident at St. Mary's Villa in Humboldt nearly three years ago, in which three residents died from carbon monoxide (CO) poisoning.
On July 15 in Humboldt Provincial Court, the health region pleaded guilty to two counts under the The Occupational Health and Safety Regulations, 1996 related to a failure to ensure that workers were trained in all matters that are necessary to protect the health and safety of all workers, and a failure to arrange for the regular examination of a plant under its control.
The health region had been charged with 11 regulatory offences by the provincial justice department in January.
On Dec. 26, 2010, 40 residents of the Dust Wing at St. Mary's Villa were evacuated after the maintenance supervisor determined that carbon monoxide was leaking into the heating vents.
Health region vice-president Nilesh Kavia said it wasn't necessarily incompetence of the region's workers that led to the incident, but instead "more of a question of the degree to which [the Saskatoon Health Region] sees safety."
"Our people do the best they can do," Kavia said.
A number of special care aides (SCA) at the villa had reported feeling sick and disoriented two days prior to the CO outbreak, on Christmas Eve, with a few leaving their shifts suffering from massive headaches.
But initially, it wasn't suspected that the residents and employees were suffering symptoms of a gas leak.
In a report released by the Saskatoon Health Region in June 2011, there were a number of other factors thought to be the cause of the flu-like symptoms. The villa had endured a recent outbreak of Noro-virus in the months leading up to the CO leak, with symptoms ranging from general malaise to vomiting and fever.
It was also the holiday season, so staff attributed their symptoms to just being overworked and tired.
Moreover, the villa had never had a buildup of carbon monoxide gas in their facility prior to the 2010 incident, so Saskatoon Health Region workers were unaware of how to identify symptoms of a gas leak.
But when the symptoms weren't letting up by Boxing Day, the villa manager was contacted by the nurse-in-charge in the early morning of Dec. 26. It was the manager's husband who suggested there may be a gas leak.
After the maintenance supervisor did an inspection of the villa's boiler in the mechanical room and determined the boiler wasn't operating properly and creating a backdraft, a SaskEnergy technician confirmed the suspicions: carbon monoxide was leaking through the vents of the villa's Dust Wing section.
Numerous residents were evacuated, 24 of whom were taken to Humboldt District Hospital, along with five workers and two family members.
An 89-year-old priest, Father Roman Schneider, was the first fatality of the leak, dying within minutes of his arrival at the hospital.
In the ensuing weeks, two other residents, 94 and 98 years old, would succumb to conditions believed to be aggravated by the CO leak.
Some staff returned to work but eventually all seven affected by the poisoning indicated they could no longer perform their work duties.
It was determined that an aging boiler and partially blocked ventilation system contributed to the spread of carbon monoxide into the villa's Dust Wing. A backdraft in the mechanical room caused the flue gas to circulate through the vents.
The health region spent $1.75 million to repair the boiler and ventilation system at the villa, and carbon monoxide detectors were immediately installed in St. Mary's. The Saskatoon Health Region went a step further, ensuring the installation of CO detectors in all facilities in their jurisdiction where there are overnight stays, and are currently working with the provincial government to have them mandated across the province, according to Kavia.
Kavia said it's now mandatory for the staff of the Saskatoon Health Region's facilities to do practice drills for incidents like carbon monoxide poisoning.
He also mentioned that the region now does annual inspections of their facilities, contracting out the work. "If there's a way we can quickly mitigate a situation, we'll do that," he said.
Kavia said he's unsure what the region's inspection process was prior to the St. Mary's incident but said the province has no doubt learned from the crisis and made the necessary changes (when the villa was constructed in the early 1960s, the national building code didn't require the presence of carbon monoxide detectors).
It is known, however, that the Occupational Health and Safety Division conducts approximately 4,000 worksite inspections annually.
As for the deaths of three residents at St. Mary's Villa, it's assumed carbon monoxide poisoning was a contributing factor and a provincial coroner's inquest will be taking place in the near future to officially determine the cause of death.
