Moberg critical incident review the first of its kind, offers 7 recommendations

A critical incident review into the disappearance of a man living with dementia has produced seven recommendations and is the first review of its kind in Manitoba.

Eighty-one-year-old Earl Moberg went for a walk in December 2023 and has been missing since. The Winnipeg Regional Health Authority (WRHA) deemed his disappearance as a critical incident, making it the first review of a case where the person has left a room while under WRHA care and not been found.

"This is a family at this point that does not have closure,” said WRHA Client Relations & Engagement director Wendy Singleton, "and in the recommendations that have been made that you've received, we are committed to providing them with completion of those recommendations.”

Those recommendations focus on the authority's Home Care Program. Moberg's wife Brenda was his primary caregiver, and he only received his first home care visit well into his dementia progression on Dec. 12, 2023 — the day he disappeared.

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One recommendation instructs the program to develop a "mandatory refresher series” for case coordinators on documentation, available resources, and communication with caregivers. Another recommendation calls on the program to develop "clinical pathways” for clients — a tool to match patients with resources based on where they are in their progression of the disease.

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"Having access to services that people need when they need it is really important,” said Britt. "In my dad's case, he was assessed as needing 24-hour care, but we didn't really have access to services to meet that.”

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The WRHA recommendations also call for more programming and supports in more areas of the city. Britt noted incidents with day programming Earl attended should have been "red flags” that her father needed more support.

"If someone's having trouble with their transportation to day programing, that means that they are becoming more impaired,” she said.

This could mean more staffing or resources in some instances, and reallocating resources in others, WRHA Centralized Home Care & Regional Palliative Care director Luba Bereza says.

"We have methods of doing that within our system if we need more resources. But a lot of it is also repackaging some of the information that we have because it's much more accessible for people, not only our case coordinators, but also clients and their families,” she said.

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One recommendation includes connecting patients to the Alzheimer Society of Manitoba's First Link program. CEO Erin Crawford says dementia care is often delivered in a "haphazard” way.

"There's not necessarily a comprehensive system of dementia care in the way that you might expect there's going to be,” she said.

"There's examples even here in Manitoba of where coordinated care is provided. I think you can look to other areas such as cancer, for example. But I think with a growing number of people with dementia, I think it is something that we should be looking at.”

Britt Moberg says she intends to follow up on the recommendations' progress.

"What is that going to look like? You know, will there be a review in the future to see how things have been adjusted or how things have been improved?”

She continues to advocate for a Silver Alert system, with a petition to the federal government open for signatures until Jan. 20.

"I hope that something positive can come out of something that's been so horrible,” she said. "I know my dad would have wanted that.”

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