Current Problems

Health (18-24)

Race a factor in negligent care that led to Indigenous woman’s death at Winnipeg hospital, lawsuit alleges

April 19, 2024

Nurse put wrist restraints on 68-year-old hours before she died in April 2022, according to lawsuit

The outside of a hospital is shown from above. A sign saying "EMERGENCY" is shown.
Jean Kemash, 68, sought care at the Grace Hospital’s emergency room about four days before she died at the hospital in April 2022, according to a lawsuit. (Prabhjot Singh Lotey/CBC)

CBC Indigenous: The daughter of a 68-year-old Indigenous woman who died at Winnipeg’s Grace Hospital in 2022 alleges her mother’s race played a role in negligent medical care that caused her death.

Kelly Medwick, the daughter of Jean Kemash, is suing the Winnipeg Regional Health Authority, the Grace Hospital, two doctors and two nurses after her mother died at the hospital on April 19, 2022, according to a statement of claim filed Monday at the Manitoba Court of King’s Bench.

The lawsuit identifies Kemash, 68, as Indigenous, and alleges her Indigeneity “was part of the chain of negligent acts and misconduct” by the doctors, nurses, the health authority and Grace Hospital that caused her death.

None of the accusations have been proven in court. Statements of defence have not yet been filed.

Kemash, who had a history of several respiratory conditions, sought care at the Grace Hospital’s emergency department on the evening of April 15, 2022, after days of experiencing an increasing shortness of breath and chills, the suit says.

She was admitted to the hospital and assessed by a doctor that night.

The doctor examined Kemash again on April 18, the suit says. She was moved to the emergency department’s resuscitation room less than two hours later, as she had become more medically unstable and was experiencing confusion, disorientation, low blood pressure and a lack of oxygen.

An emergency room doctor ordered a chest X-ray and blood work for Kemash that day. The initial doctor responsible for caring for Kemash said he would reassess her but never did so, according to the statement of claim.

Kemash’s oxygen requirements escalated throughout the day, it says.

Kemash’s other daughter told a nurse that her family was concerned about a plan to move Kemash to an in-patient ward, which they thought would be dangerous given her condition, but those concerns were ignored, according to the lawsuit.

Wrist restraints used: suit

Kemash was transferred to the in-patient ward around 10 p.m. on April 18.

She remained under the care of the initial doctor, but a psychiatry resident completing his four-week internal medicine component was responsible for providing direct care to her, the suit says.

The resident failed to reassess Kemash even though nursing staff told him her condition was unstable, according to the lawsuit. He was not competent to care for Kemash and did not consult with the initial doctor or a senior resident, the suit alleges.

The resident also failed to follow proper procedure when using Bluetooth respiratory monitoring devices, after a nurse connected one to Kemash but left it at the end of the hallway where it could not be heard, according to the statement of claim.

The suit also alleges the nurse failed to make hourly checks on Kemash as required by protocol, or to provide scheduled medications.

Sometime after 3 a.m. on April 19, the nurse put wrist restraints on Kemash. The suit doesn’t indicate any reason for doing so, and says it was done “in a manner inconsistent with the [Winnipeg Regional Health Authority] and the hospital policy.”

The nurse did not monitor Kemash between then and about 5:20 a.m., when Kemash became agitated, experiencing extreme breathlessness, according to the suit. A code blue — an alert that calls all nurses to the floor where an incident is happening — was then called.

Kemash was pronounced dead at 5:50 a.m., after about 25 minutes of failed resuscitation efforts, the suit says.

‘Potential unconscious bias’

The Winnipeg health authority’s Indigenous services unit was involved in a critical-incident process following Kemash’s death that “made reference to the potential of unconscious bias by staff against Indigenous patients which resulted in hospital staff receiving training to be aware of and to avoid” such bias, the suit says.

A critical incident is defined by the province as a case where a patient suffers “serious and unintended harm” while receiving health care.

The two doctors and two nurses in the suit breached a duty of care owed to Kemash because they did not provide her with “the level of skill and care” that would be reasonably expected from medical professionals with their training, according to the statement of claim.

The Grace Hospital and the health authority breached their duty to provide her with competent staff who could give her safe and reliable care, the suit alleges.

The WRHA also failed to ensure that the unconscious bias of hospital staff against Kemash due to her Indigeneity did not result in a poorer quality of care, it claims.

Medwick, who is the executrix of her mother’s estate, is seeking damages that include general damages, punitive damages, and funeral and burial costs.

Kemash left behind a husband, two daughters and five grandchildren, the suit says.

Both Medwick’s lawyer and a representative for the WRHA declined to comment on the lawsuit.


Ozten Shebahkeget, Reporter

Özten Shebahkeget is Anishinaabe/Turkish Cypriot and a member of Northwest Angle 33 First Nation who grew up in Winnipeg’s North End. She has been writing for CBC Manitoba since 2022. She holds a master of fine arts degree in writing from the University of Saskatchewan.