Over a year after a carbon monoxide leak at St. Mary's Villa led to the evacuation of some patients, and the death of three, the Saskatoon Health Region (SHR) has been cited with six contraventions of Occupational Health and Safety regulations as a result of that incident.
In the early hours of December 26, 2010, 40 residents of St. Mary's Villa (SMV) were evacuated after carbon monoxide from a failed boiler got into the heating vents.
Thirty-nine residents of Dust wing at SMV and some staff were moved to another wing, before 24 residents were transferred to Humboldt District Hospital (HDH) for treatment.
Three residents died in the days and weeks following, and seven staff members were off for varying amounts of time due to the effects of exposure to carbon monoxide.
Last week, the SHR made public the report issued by the Ministry of Labour in late December, which lists the six contraventions.
According to the report, those six contraventions included:
Failure by the employer to complete maintenance on boilers and pressure vessels as per manufacturer recommendations. Documentation revealed ongoing concerns with the operation of one of the boilers, which has now been taken out of operation, and it was noted that the operator's manual for the system was not present at the work site at the time of inspection.
Failure by the employer to ensure that the mechanical ventilation system was sufficient to protect workers against the inhalation of a contaminant, and failure to ensure that all parts of the mechanical ventilation system were inspected and maintained by a competent person at a frequency sufficient to protect the health and safety of the workers. The employer also failed to ensure ventilation openings were kept free of obstruction, and to ensure that carbon monoxide and other contaminants were exhausted free and clear of the play of employment.
The report noted that a relief vent in the mechanical room had been partially blocked with insulation, and that openings around the heating coil caused flue gases from the boiler to be drawn into the mechanical room, and through a fan, were distributed throughout the affected hallway.
Failure by the employer to ensure that work was competently and sufficiently supervised, as evidenced by the regional and facility supervisor's failure to have sufficient knowledge of their duties and responsibilities. Workers were expected to continue work and nursing care at the workplace after carbon monoxide concentrations were confirmed in the Dust wing. Workers were also not informed of the nature and the extent of the health effects caused by carbon monoxide after its presence had been confirmed in the workplace.
Failure by the employer to ensure that on-site maintenance supervisor and workers are adequately trained to protect their health and safety. Workers had not received a general orientation prior to the commencement of work.
Failure by the employer to develop a written emergency plan to address the accumulation of carbon monoxide and the possibility of harmful exposures. The employer did not ensure competent persons, equipment and supplies were available for the prompt, safe and effective containment of the carbon monoxide leak and accumulation, nor did the employer provide a plan to employees to provide them with appropriate training as to how to respond to a carbon monoxide accumulation.
A "Code Brown" response - used by the SHR for responding to chemical spills - was not initiated, as that emergency response plan did not include a recognition of carbon monoxide as a chemical substance that may be hazardous to the health or safety of a worker.
Carbon monoxide as a source of poisoning was never considered or integrated into emergency plans.
As a result, workers were directed to continue nursing care at the workplace, despite confirmed knowledge of the presence of carbon monoxide in the Dust Wing. Managers also allowed other workers to continue their duties, and some were directed to assist with the evacuation and relocation of residents, without immediate protection from carbon monoxide.
Failure of the employer to ensure the health, safety and welfare of its workers through training, maintenance and inspection of work to ensure it meets the standard and safe operation of the boiler and ventilation system.
On December 26, 2010, at 5:30 a.m., SaskEnergy advised the manager that the facility should be evacuated. Some workers were informed. At 6:11 a.m., emergency medical services were contacted regarding evacuation of residents, but the manager failed to ensure all workers on shift and workers arriving to work of the nature and degree of the effects to their health and safety of the presence of carbon monoxide in the workplace.
The deadlines for dealing with these contraventions range from immediately to the end of February of this year.
In a news release issued January 10, the SHR claims that many of the contraventions and findings of the report have already been addressed in the days and months following the CO exposure.
"We didn't wait for the report to act," stated Nilesh Kavia, vice president of finance and administration for Saskatoon Health Region. "We immediately began taking steps to address the concerns over ventilation and equipment at St. Mary's Villa when the incident took place."
The boilers and ventilation system at SMV, for instance, have already been replaced. Carbon monoxide detectors have also already been installed at all SHR facilities.
"Our maintenance staff will be properly trained in the use and maintenance of the new equipment by the manufacturer," adds Kavia. "An outside agency has already inspected all boilers and ventilation systems in all rural Saskatoon Health Region owned and operated facilities, including St. Mary's Villa. We are considering a service contract or training our own staff to continue these inspections on an ongoing basis."
"We have increased our education and training opportunities for staff and supervisors to ensure they are familiar with safety processes," said Bonnie Blakely, vice president of people strategies for the SHR.
The SHR has already completed significant revisions to its "code brown" (hazardous material) procedures and continues to consult with the Department of Labour and others to ensure the revisions are acceptable.
There are also revisions being considered for the SHR's "code green" (evacuation) processes. All rural facilities will be completing a CO exercise by March 2012. A consistent format to conduct the exercise has been developed and some rural facilities have already completed the CO exercise.
"We want to acknowledge that this has been an extremely difficult time for our residents, their families and our staff. We cannot forget the tragedy of that day in December 2010, but we also want to take our learnings and ensure nothing like this ever happens in the future," Blakely stated.
In a news conference that took place on January 10, Blakely expressed condolences to the families who went through the experience, to the people who passed away, and to their staff.
"We know it's been an incredibly stressful experience for them and they have provided exceptional care during this transition period," she noted.
"The contraventions that we see today from the Department of Labour reinforce for us the areas that we have already been working on," she added.
The contraventions as they stand require the SHR to follow through on each of them in a defined time frame, she explained. "In the event we don't do that, there can always be fines related to it. .... I would say we are well on our way in responding to most of the contraventions," she noted. "I would say we've started to address all of them already. It's whether we've fully addressed them according to what OHS is expecting," she stated.
The SHR is, right now, in the midst of doing additional training for all of their supervisors, she explained.
"We learn from these events in the sense that when we recognized we need to do more supervisory training on these events, we held that out to the entire organization. But we haven't completed all of that training yet for every supervisor," Blakely added.
Three people dying, noted one reporter, seems like a harsh way to learn a lesson.
"I think you can appreciate in a long-term care facility, we often have people who are very frail and elderly and have multiple complex concerns," Blakely said in response. "The incident that happened is something that we regret and obviously feel incredibly sorry for the families in the event... But what we say is that we always need to take these learnings forward to better provide that care moving forward."
Staff turnover and a lack of refreshers for longtime staff were what Blakely pointed to as the reasons behind insufficient training. As the SHR moves toward more of a safety culture, she said, they have to ensure that both initial and ongoing training is in place, she indicated.
They have accelerated and elevated their training for supervisors, she noted, so that it occurs more often and raises the level of consciousness among supervisors as to what their responsibilities are for the employees in their facilities.
No employees - supervisors or otherwise - were disciplined as a result of the SMV incident, she said.
"Our employees reacted as best they could under the circumstances. What we learned is that we need to better prepare them in circumstances like this so they have the skills... and tools to be able to make that call sooner or make that decision on how to move forward sooner," Blakely said.
The incident at SMV has affected other parts of the SHR, and not only when it comes to staff training.
Kavia explained that all the boilers in all the rural facilities in the SHR have been inspected, along with their ventilation systems.
All three boilers at SMV, he added, have been replaced, and ongoing inspections have been taking place.
"We're going to have a preventative maintenance and training program for all our staff," he added.
When questioned, Kavia added that they are in the process of developing "a more robust preventative maintenance program" for equipment in all SHR facilities.
They did have a preventative maintenance program before, he noted, but mechanical systems can still fail. There can always be more failures, and that is when the carbon monoxide detectors that have been installed near the boilers will come into play.
The entire province has learned from this incident at SMV, noted Shan Landry, vice president of community services with the SHR.
"One of the things that we discovered was that carbon monoxide detectors were not required under the building code. So it wasn't simply the health region's facilities that did not have (these detectors) but possibly all of the facilities in the province, because it wasn't a standard. That has now been corrected and what we learned in our health region has been broadened to the entire province."
