Missed diagnoses, PPE failures: How the Misericordia COVID-19 outbreak unfolded

A little under four months into the COVID-19 pandemic, on June 21, 2020, an outbreak was declared at Misericordia Community Hospital in Edmonton.

Less than three weeks later, a full facility-wide outbreak was announced, which would ultimately be one of the largest acute-care COVID-19 outbreaks in Alberta.

The hospital stopped new admissions and transfers.

But the novel coronavirus continued to spread; 58 people, including staff, visitors and patients, ultimately became infected before the outbreak was declared over on Aug. 14, 2020. Eleven patients died.

While a report was ordered and officials said it would be made public, that has not happened — until now.

CBC News obtained a copy of the 38-page final report into the Misericordia outbreak through a freedom-of-information request.

It is the first public glimpse into what went on behind the scenes at the hospital during the outbreak, revealing how transmission spread and the factors that allowed for that.

The report, dated Aug. 27, 2020, identifies missed diagnoses and missed opportunities for testing, and outlines how shared rooms, wandering patients and transfers of patients contributed to the spread of COVID-19. 

"[Redacted] had a wet cough on June 10. Their respiratory status worsened on June 15, followed by diarrhea on June 16, with persistent cough noted from June 16-19. COVID-19 testing was not done until the [cyclical patient testing] prevalence screen on June 21," the report reads.

The report also reveals failures on the part of staff who dismissed subtle symptoms that later turned out to be linked to COVID-19 and who wore personal protective equipment (PPE) improperly or did not wear it continuously when distancing was not possible.

"[One staff member] also used a common work area in [redacted] for charting, where staff were not masked or socialled distanced," the report reads.

Staff who became infected included nurses, physicians, health-care aides, housekeeping staff, pharmacists, security guards and service attendants.

The ages of those who became sick ranged from 19 to 97.

Colin Furness, an infection control epidemiologist at the University of Toronto, reviewed the report at the request of CBC News, and said there is "no question" there were lapses there.