In November 2016, Health Canada launched a review entitled Clinical Review of the Cases of Infant Misidentification at Norway House Hospital to determine what led to the misidentification of four individuals who were switched following their birth and to identify actions that may need to be taken to prevent such circumstances from ever happening again. The summary report is now available on Health Canada’s website.
Although the circumstances of the two incidents were different, the major factors in these cases were similar. The reviewers found that the newborn identification process used at Norway House Hospital in 1975 was insufficient to ensure accurate identification of infants. The report also included recommendations to Health Canada regarding current practices at the hospital. These recommendations have been fully implemented in both remaining federally run hospitals: Percy E Moore Hospital and the Norway House Hospital.
Dr. David Creery and Ms. Maura Davies led the review. Dr. Creery is a pediatric intensive care physician and the Medical Director of Patient Safety at the Children’s Hospital of Eastern Ontario in Ottawa, Ontario. He is also an investigating coroner for the City of Ottawa. Ms. Davies is the former President and CEO of the Saskatoon Health Region and has extensive experience in delivery of health services and patient safety.
Health Canada regrets the suffering that these incidents have caused. We want to thank the men and their families for participating in the review process.
Health Canada continues to offer support to the individuals and their families. While no further cases are suspected, Health Canada will continue to provide maternal DNA testing to any concerned individuals born at the Norway House Hospital before 1980, which is when identification bands were implemented for newborns.