WINNIPEG – A Winnipeg family says they are now left with more questions than answers, after a critical incident report was released following the death of their loved one.
Stacey Ross was just 55 years old when she died, after waiting several hours in Winnipeg St. Boniface Hospital in January.
On Jan. 3, Stacey was experiencing severe chest pain and went to the emergency room. Her sister, Sheri Ross said Stacey waited more than 12 hours before being told her sickness was a virus and was sent home.
But over time her condition worsened and she returned by ambulance to the same hospital on Jan. 15, where she waited more than 11 hours before being admitted.
A CT scan revealed pneumonia in Stacey’s lungs, but not long after, she went into cardiac arrest and died.
An investigation into the critical incident was launched, and eight months after Stacey’s death, findings into the incident were released to the family.
The report, obtained by CTV News, shows the investigation found “several factors” that contributed to delays in Stacey’s care.
“The long wait times and a shortage of available treatment spaces, resulted in a delay of approximately 12 hours, before Stacey was assessed by a physician,” the report read.
“The review also found that elevated troponin blood test results were not identified and escalated as they should have been,” it adds.
The findings also confirmed Stacey’s concerns regarding chest pains were also not reported to a physician on the night of her death.
In the report, the hospital says it is trying to reduce emergency room delays by improving how patients move through the ER, by making sure the sickest patients are seen first when it gets very busy and making sure critical blood-test results are communicated quickly.
In its list of recommendations, the hospital also plans to change how nurses monitor patients who are waiting, so nurses with the appropriate training can notice if a patient gets worse and quickly alert the medical team.
Manitoba’s Health Minister Uzoma Asagwara told CTV News that the recommendations from the report are being taken “seriously” and has “given direction for all of them to be actioned.”
“No report can undo what Stacey’s family has been through, but they deserve to know that lessons are being learned and acted on,” Asagwara said in a statement.
“We will continue working with health-system partners to strengthen emergency care, including adding more staff and capacity and improving access to care across the system.”
A spokesperson with the Winnipeg Regional Health Authority (WRHA) says these recommendations are being implemented.
“As part of this work, a cardiologist is now providing rapid cardiology consultations in the St. Boniface Hospital emergency department, with the intent to expand the service as staffing allows,” the statement reads.
“This provides emergency department care teams with additional access to specialist consultation for patients presenting with heart-related concerns.”
However, Sheri says her family is frustrated and disappointed with the results of the report.
“They’re taking blame for it, but that doesn’t fix anything,” she said. “It just makes me really angry that this happened because it never should have happened.”
“She should have received treatment right away, or at least within a reasonable amount of time. She should have received treatment or seen a doctor, or something should have been done, not 12 hours later,” she said.
Sheri has been speaking out about her sister’s death to try and prevent others from going through a similar loss. She says the report is making it harder for her family to get closure and does not believe it provides any real change.
“I’m not seeing that. Neither is anybody in my family. We just don’t see what the purpose of it (critical incident report) was,” she said. “There’s no change.”
“It’s very frustrating because we were promised answers to what happened and how it won’t happen again,” she said.
‘Status quo not acceptable’
According to numbers from the Winnipeg Regional Health Authority (WRHA) website, Winnipeg ED and urgent care median wait times have generally increased over time, rising from around two hours in 2021, to 4.4 hours in July 2026.
As of Friday afternoon, the wait time at St. Boniface Hospital was nine hours, where as the wait time at the city’s Grace Hospital was 8.5 hours.
“I do think that while it’s common in many parts of the country, we cannot accept this as a status quo, so we certainly can do better,” said Dr. Bolu Ogunyemi, who is the president of the Canadian Medical Association (CMA).
He says better access to primary care could alleviate long wait times in emergency departments.
“We need to train more family doctors, train more doctors in general, we also need to retain them,” he said.
“It’s one thing about training our own and recruiting folks from different parts of the world can be important, but we need to retain them.”
“We need urgency because people shouldn’t be waiting longer than they need to. We need all hands on deck when it comes to folks getting access to care,” he said.
