Brian Sinclair had contact with or was observed 17 times by emergency department staff or security guards during the 34 hours he spent in the waiting room before he died.
That number is in a 13-page administrative review report which was entered as evidence last month in the inquest into the 45-year-old Sinclair’s death on Sept. 21, 2008, but released to the media now.
The review, which was compiled in the days after Sinclair’s death — and before a Critical Incident Review process was undertaken — notes that "assumptions that were made, while clearly mistaken, do not appear to have been made with malice.
"Each of the staff who saw or interacted with Mr. Sinclair during this 34-hour period mistakenly assumed either that he had been triaged already and was awaiting a bed in the back (in the treatment area), that he had been treated and discharged, that he was a patient awaiting pickup under the Intoxicated Persons Detention Act, or that he was just there because he needed a warm place to rest."
The report, compiled by Helga Bryant, vice-president and chief nursing officer at the HSC, Laverne Sturtevant, director patient services in the HSC’s adult emergency department, and Beth Beaupre, the HSC’s director, human resources services, said that after hospital staff learned Sinclair had died "staff were devastated.
"Many reported having reflected on their observations and interactions with Mr. Sinclair and what might have been had they realized that Mr. Sinclair was awaiting care and had not been triaged."
The inquest, which heard testimony through most of August, will begin again in October.