The Judicial Inquest into the MRSA-caused death of two-month-old Drianna Ross is taking place in courtroom 114 of the Law Courts Building in downtown Winnipeg. Presiding Judge Don Slough is nearing the end of his two-year investigation into Drianna’s death in November, 2011, in the northern Manitoba city of Thompson.
The Inquest was struck because Drianna’s mother and father, backed by community leaders, say that northern medical services are substandard and that’s why their child died.
The case began when they took Drianna, crying, coughing, and with difficulty breathing, to a local nursing station four times over two days. She was never referred to a doctor; instead, she was sent home with Tylenol. Finally, on her fourth visit to see the community nurse, Drianna was medevaced to Thompson General Hospital. The following day she died from a MRSA-induced septic shock.
The purpose of the Inquest is to examine the adequacy of healthcare in remote northern communities and, if that care is found wanting, to recommend changes in government healthcare practices so cases like Drianna’s don’t happen again. (Judicial Inquests, unlike trials, do not assign blame and do not have the authority to hold anyone legally responsible.)
On the stand yesterday afternoon was Dr. Stasa Veroukis, Pediatric Intensive Care Specialist at the Health Sciences Centre in Winnipeg. She wasn’t directly involved in the case but had reviewed the relevant medical documents in order to offer her expert opinion about the quality of Drianna’s medical care.
A half dozen lawyers from various health authorities questioned Dr. Verooukis, trying to pinpoint where it all went wrong after Drianna got to the hospital.
In Dr. Veroukis’s view the moment of truth was Drianna’s first night in the hospital. By 3:00 a.m. her heart rate had risen to 203 beats per minute, her temperature was a “very high” 39.3 degrees C and, most tellingly, when nursing staff poked Drianna to insert an IV she did not respond – which meant she was unconscious. Stunningly, that’s where it was left — no doctor was consulted to see what they should do next.
Those downward-spiraling vital signs meant that septic shock was setting in, said Veroukis, and as brain and heart cells begin to die off the process quickly becomes irreversible and death inevitable.
Dr. Veroukis was clear: “All the symptoms should have been put together by the nurse and [she should] have called the doctor.” Veroukis could only guess why that wasn’t done: a busy night perhaps, poor communication between nurse and doctor, inexperienced staff, and/or a lack of awareness about what the vital signs meant.
When asked how a two-month-old infant could possibly contract MRSA in the first place, Veroukis told the court there’s “More MRSA in the northern communities. The best option I can offer is the people around her have it.”
The research agrees with her, but with one important qualification: It’s not that MRSA frequents the north more than, say, the south, it’s that remote northern areas are home to First Nation communities and it is First Nation people who are disproportionately affected by MRSA.
For example, in a 7-year study ending in 2002, First Nation patients in Canada were found to be 6-fold more likely to have a Community Associated-MRSA infection than non-FN patients. (Community Associated means the patient picked up the MRSA before going to the hospital.)
And it might be getting worse: A U.S. study of Indigineous populations found that MRSA-associated hospitalizations increased from 4.6 per 100,000 American Indians/Alaska Natives in 1996 to 1998 to 50.6 per 100,000 in 2003 to 2005 – more than a 10-fold increase.
In other words, professional red flags have been waving about the increased prevalence of MRSA in First Nation communities for at least a decade.
Drianna’s death reminds us what happens when those warnings are ignored.