Sheila North, a former journalist and grand chief, says she suffered her own surgical mistake at Winnipeg's Grace Hospital. Photo: Submitted
Sheila North can still remember the shock of waking from surgery to learn her Manitoba doctor had operated on the wrong hip.
She revisited that horrible experience last week upon learning a First Nations man in Winnipeg had the wrong leg amputated at the same hospital last month.
“My outcome was not as serious as (Jason Kennedy’s),” said North, a high-profile First Nations woman and advocate. “But I know it is a dreadful feeling.”
North’s surgery occurred at the Grace Hospital in 1995.
She said the surgeon indicated he would be operating on her right – more painful – hip in the first of a series of four surgeries she has had. She was told to wash the area and apply a brownish liquid to remain on the skin.
“I remember this distinctly, they tell you to use this cleanser on the area they’re going to operate on. The night before they wanted me to shower and have this – it looks like iodine – put this on the hip I was having operated on. And I put it on my right hip…
“When I woke up it was my left that was done.”
This happened to me back in 1996 (or 95) at the same hospital. Mine wasn’t an amputation, obviously, but I had surgery on my left hip when I fully expected the right one to be done first because it was worse. The doctor’s answer to me was, “Well, both need to be done anyway!”
— Sheila North – Bunibonibee Cree Nation (@TheSheilaNorth) November 14, 2024
North, a former journalist and grand chief in Manitoba, said she was surprised and confused especially after discussing the procedure with the surgeon in advance.
“I thought we agreed we were doing the right one,” she recalled Monday. “I thought we were doing the worst one first.
“It was a few months later when I was following up with my doctor and I asked, and the only answer was, ‘Well, they both need to be done, they’re both bad.’ That was the end of the conversation.”
Amputation due to bone infection
Kennedy, a former commercial fisherman from Bloodvein First Nation, has been homeless in Winnipeg for a few years.
He said he was supposed to have an amputation due to a bone infection.
“I was under the impression that they were going to take the leg that had the infection and this could have been avoided if we were all on the same page,” he told APTN News.
“We were all doing x-rays, doing x-rays, and sure the infection is in my right foot, it’s in my right toe, under my bone and it’s an infection that’s spreading throughout my body.”
The operation was on Oct. 31. Kennedy, 48, said he was transferred from another hospital to the Grace and given a high dose of medication for pain.
He told APTN he lives with diabetes, a condition prone to leg ulcers that can eventually lead to amputation. But he hasn’t said whether the diabetes contributed to the infection.
The botched amputation is now the subject of a critical incident review, Manitoba’s health minister has announced.
A Winnipeg advocate for the homeless says medical conditions take a back seat when people are living on the street and not seeing a doctor regularly.
“They’re in crisis and just surviving every day,” said Al Wiebe on Wednesday. “My diabetes got worse when I was homeless for 18 months. I didn’t want to go to a doctor or the hospital or see anyone.
“My numbers were so high when I got off the street my doctor told me I could die.”
Wiebe says homeless people in wheelchairs with missing limbs are a common site in Winnipeg. He thinks many homeless people die from conditions related to diabetes.
A high number of First Nations people, who are over-represented when it comes to diabetes, are homeless, he added.
A report released last fall said Manitoba surgeons performed an above-average number of leg amputations related to diabetes between 2020 and 2023.
The report “Equity in diabetes care: A focus on lower limb amputation” by the Canadian Institute for Health Information (CIHI) showed age-standardized rates of diabetes-associated leg amputations were 19 per 100,000 in Manitoba, compared with nine per 100,000 nationally.
Manitoba also registered more ankle-and-below amputations compared to the national average with 19 per 100,000 compared with 14.
The CIHI, an independent, not-for-profit organization that provided information on Canada’s health system, found people living in remote areas tended to have higher rates of leg amputations.
Yet what happened to Kennedy is rare, the CIHI noted Tuesday.
“We found that within the past decade, there were less than five hospital visits where the patient had both an amputation and an inappropriate operation,” said spokeswoman Meagan Foreman in an email.
“We don’t have the details of the five incidents due to the small cell sizes and our privacy policy, so we don’t know which provinces and territories they took place in – five is the national number over the past 10 years.”
Kennedy, who said he has already forgiven the surgeon for the life-altering mistake, says his right leg is now being treated with antibiotics.
Speak up
North, of Bunibonibee Cree Nation, encouraged Indigenous people to be vigilant about their health.
“For anyone who feels they aren’t getting the respect they deserve in the healthcare system – speak up – and find the people to help you address the concern,” she said.
Another CIHI study found medical errors are more prevalent in hospitals and operating rooms than patients realize.
Data from the Hospital Harm Project, jointly produced by the CIHI and Healthcare Excellence Canada and released in October, showed hospitals are generally safe, but sometimes harmful events happen that affect patients. Many of these events are preventable, the CIHI added.
It said in 2023–2024, one in 17 hospital stays in Canada involved at least one harmful event (a total of 150,000 out of 2.5 million hospital stays).
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More check and balances needed, says man who had wrong leg amputated in Winnipeg
The harmful events include health care and medications (like bed sores or medication errors), infections (like surgical site infections), procedure-related (like bleeding after surgery), and patient accidents (like falls).
The study noted that due to secrecy, patients rarely receive an explanation let alone an apology. It explained that hospital staff are promised immunity in exchange for information during an investigation.
That fits with North’s experience, who, nearly 20 years later, still doesn’t know why the surgeon operated on her left hip instead of her right. She eventually did get the correct hip taken care of.
“People deserve better health outcomes,” said the executive director of Indigenous Engagement at the University of Winnipeg, questioning whether she and Kennedy were the victims of anti-Indigenous racism.
“Sure, healthcare (staffing) shortages are one thing; pervasive racist attitudes and dismissing us is not helping. It’s creating mistrust.”
Meanwhile, Grace Hospital forwarded an email from APTN seeking comment for this story to the Winnipeg Regional Health Authority (WRHA), which speaks for some hospitals.
The WRHA said it was limited by privacy restrictions on what it could share but confirmed it was aware of “an incident and the distress it has caused the patient, their family and the care providers.”
It said in a statement that members of the care team have “personally met with the patient to offer their sincere apologies and to discuss next steps. The incident is currently under review by our patient safety team to identify potential system learning opportunities.”
It noted the results of the review will be shared with Kennedy.
