AN inquest into the death of Brian Sinclair in the HSC ER saw videotape Monday of the 34 hours he awaited medical attention, to no avail. It included the man’s arrival at the triage desk, where a triage aide came to his side, bent low to speak to the man who had a severe speech impediment, and wrote information on a paper pad.
The quality of the interaction between Mr. Sinclair and the aide has been an important issue — the Winnipeg Regional Health Authority has released the barest of details on what happened from Sept. 19, 2008, when Mr. Sinclair arrived at the ER, until 34 hours later when he was discovered dead by another person in the waiting room. Det.-Sgt. John O’Donovan, who reviewed all ER security videotape in a criminal investigation into the death, noted that the aide’s paper pad was kept at the triage desk so that nurses could track those they had yet to assess and place in line to see a doctor. When Mr. Sinclair arrived, another person was speaking to the nurse. As he waited next to that person, the triage aide intercepted him, spoke briefly and then Brian Sinclair went to wait.
But the aide’s notes were not available to the police for the investigation. In fact, months after the death, a board member of the WRHA noted publicly they had been destroyed. Why the notes would not have been preserved — despite two internal investigations by the WRHA immediately after the death — is a glaring question.
It defies common sense, and responsible record management, that such key documents would be destroyed. The inquest has yet to hear from the aide, the nurses and other staff on duty over the time Mr. Sinclair sat awaiting help. The video reviewed at the inquest showed that for almost all the 34 hours, Mr. Sinclair sat in pretty much the same spot in the waiting room in front of the TV. He had parked his wheelchair in an aisle that led to vending machines and the washrooms and hospital staff and numerous other people walked past him. (Evidence is that Mr. Sinclair vomited and the tape shows a chrome basin in front of the double-leg amputee’s chair.) The missing list of names is evidence the HSC ER had a formal record of Mr. Sinclair’s visit. Many questions remain to be answered, but one obvious outcome of the inquest ought to be a recommendation that all documents of patient contact, from the formal chain of triage on, must be treated as official hospital records and maintained as such.