Thread by @DennisKendel

Yesterday's explanation of why the Saskatchewan Ministry of Health failed to publicly report any COVID deaths from Jan 6 to Jan 21 raises a multitude of unaddressed concerns & questions. As the responsible Minister, Paul Merriman must address these 🧵(1/12)

To date the only proffered explanation for this serious error is that someone in the Ministry of Health failed to turn on a filter after an annual reset of the Ministry's Panorama data management system. This was a critical incident that warrants deeper analysis (2/12)

The ultimate purpose of critical incident analysis is too reduce risk of future errors by identifying & rectifying policy & procedure flaws & deficiencies. Where human error is identified as the cause of a critical incident, steps must be taken to bolster safety (3/12)

The development & rigorous frequent application of check-lists shield us from harm in many facets of our daily lives. Airline pilots go through a detailed system check before every take off. They also do a visual exterior inspection of the aircraft. (4/12)

We rely on myriad electronic warning systems like smoke defectors & CO detectors to protect us from harm. Optimally effective data management systems have many inherent warning systems. Is the Panorama system used by @SKGov state-of-the art or aged? (5/14)

Data management systems may capture data through highly sophisticated scanning systems or may rely upon manual data input. My understanding of the Health Ministry operations is that it relies on manual input of COVID death data from Medical Certificates of Death (6/12)

If one or more human beings were manually entering COVID death data in Panorama between Jan 6 & Jan 21, why were they not concerned that no deaths were being publicly reported during this long interval? Were no "alarms" going off anywhere in the Ministry? (7/12)

I would liken this situation to electronic heart monitoring in a hospital. If the monitor shows a "flat line" nurses rush to the bedside. If they discover that an electrode became detached, they correct the problem. If there is a cardiac arrest, they trigger a code (8/12)

It boggles my mind that a 15 day gap in reported COVID deaths did not trigger any alarms in the minds of anyone in the Ministry of Health, up to and including the Minister of Health. Such blind acceptance of data that aligns with one's preferred narrative is worrying (9/12)

It is unclear to me if this human error occurred in the Ministry of Health or in @eHealthSask . The boundaries between those 2 agencies are now very blurred since the Minister abolished the eHealth Board. This needs to be clarified. (10/12)

The Health Minister also needs to determine if there is some logistical management competence/capacity gap in the Ministry of Health, disclose his findings to us & take pragmatic steps to fill that gap (11/12)

Finally, Minister Merriman needs to schedule a press conference on Monday, January 24, to personally address all of these concerns & questions. It was not appropriate that he defaulted to the Chief Medical Health Officer to do this. Step up and lead. (12/12)

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