The Saskatoon Health Region pleaded guilty to two charges under the province's Occupational Health and Safety Act. The region had faced 11 charges related to a gas leak from a boiler at St. Mary's Villa in Humboldt in December 2010.
Health region vice-president Nilesh Kavia said the region admitted that it failed to ensure workers were properly trained on the boiler and ventilation systems and that it failed to arrange regular inspections.
"You know I think it's not just the health region. I think we as an overall health system have learned a lot from this," Kavia said Tuesday.
"We've worked really hard since the incident to ensure that St. Mary's Villa — and all of our facilities — are a safe place for our staff and residents to be in."
Kavia said carbon monoxide detectors have been installed in all facilities.
The health region has also added carbon monoxide to its Code Brown — its response designation for hazardous spills or releases. The previous Code Brown emergency response plan did not recognize carbon monoxide as a chemical substance that could be hazardous to the health or safety of a worker.
"The other thing that we've learned is making sure that people know what to do when there is an incident," Kavia said.
"It's now mandatory for us to have our staff in all Saskatoon Health Region facilities do a practice drill for incidents like carbon monoxide, so that all staff know how to respond if an incident occurs."
Staff initially thought seniors were getting sick because of a stomach virus, exhaustion due to the Christmas season or food poisoning. Even as some workers got splitting headaches and double vision, they never thought gas poisoning was a possibility.
As illness spread through the care home, a nurse called her manager to tell her about it. It was the manager's husband who overheard the conversation and first suggested it might be a gas leak.
A SaskEnergy dispatcher initially suggested staff open some windows instead of evacuating the building. Although some windows were opened, some were not equipped with the right handles to open and some people — unaware of the danger — closed the windows because they were cold.
When a SaskEnergy employee arrived at the centre and suggested an evacuation, it took an hour to start emptying the building.
An 89-year-old priest died an hour after the evacuation began. Two other women, 94 and 98, died in the weeks that followed. Another 22 residents, five workers and two visitors were treated in hospital for exposure to the gas.
There were no carbon monoxide detectors in the seniors home. They were not required under the building code.
"It was a traumatic experience for many people and we understand that some staff members are still affected by the incident," said Kavia, who noted that several staff have been diagnosed with post-traumatic stress.
"With respect to the three residents that passed away, there is a coroner's inquiry on so that will kind of be resolved at a future date. But we do truly apologize for this incident (and) really not want something like this to happen at any facility, not just any of our facilities."
— By Jennifer Graham in Regina