A prominent medical ethicist says high-ranking bureaucrats in the Winnipeg Regional Health Authority should have to testify at an inquest looking into Brian Sinclair’s death in a Health Sciences Centre waiting room about what they knew about his death and when they knew it.
And Sinclair’s family is upset that a confidential Critical Incident Review Committee report into his death — and leaked to a media outlet — shows how many times nothing was done to save him while he waited 34 hours in the hospital’s emergency room waiting area without being treated.
Prof. Arthur Schafer, director of the University of Manitoba’s Centre for Professional and Applied Ethics, said today that he’s concerned that in the wake of Sinclair’s death and for months to come high ranking officials of the WRHA were telling the public Sinclair had never gone to the triage desk when he arrived at the hospital when security video showed he had.
"The public is entitled to hear from Dr. (Brock) Wright and other top officials of the WRHA in their role of communicating to the public what went wrong," Schafer said.
"The inquest should hear that."
Currently, Wright, the WRHA’s chief medical officer now and at the time, and other officials of the WRHA are not on the witness lists given to the lawyers representing individuals and organizations at the inquest.
The 45-year-old Sinclair died on Sept. 21, 2008, after a blocked catheter led to a urinary tract infection.
Sinclair, left a double amputee after an earlier frostbite incident and who lived in a care facility with funding from the province, had rolled his wheelchair into the emergency room 34 hours earlier.
Schafer said he’s also concerned that the report — which CBC News showed him, but then took back — reported that emergency room personnel referred to the area as "a war zone."
"Did the hospital and the WRHA not know at the time what the conditions were like? If they did, why didn’t they do something about it?
"I also want to know what exactly does 'war zone' mean? There certainly is an attitude of us versus them and them is the public. How has that changed?
"I find this disturbing."
Lawyer Vilko Zbogar, who is acting for Sinclair’s family and was shown portions of the report, said, "The overall comment is the more information that comes out the more upset they are.
"It is increasingly apparent that what happened to Brian Sinclair was foreseeable and should have been prevented."
Zbogar said the report — and the inquest itself — has shown that Sinclair was approached by members of the public four times, but their help was ignored by emergency room staff.
Heidi Graham, a spokeswoman for the WRHA, said while the report is not made public, the five recommendations which the review committee came up with to prevent an incident like Sinclair’s from happening again, were publicly released in 2008. The recommendations include electronically registering everyone entering the emergency department before going to the waiting room and having an emergency department staff member speak directly with everyone in the waiting room at least once every four hours.
"The WRHA has already acted on all these recommendations," Graham said.
"Critical incident investigations — which are protected under provincial legislation — facilitate learning and improvement, they do not replace any other investigations, such as an administrative review, police investigation or an inquest. Any of the individuals interviewed by critical incident investigators can also be interviewed through other investigations and can be called to testify in open court during the inquest."
Graham said it is up to legal counsel at the inquest to determine who will be called or not called to testify.