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HSC ER tapes spark inquest

Sinclair had contact with uniformed staff long before death

By: Jen Skerritt and Alexandra Paul

5/02/2009 1:00 AM | Comments: 3

The Winnipeg Regional Health Authority's explanation of the tragic death of Brian Sinclair has been called into question by hospital security tapes that show the double-amputee approached the emergency room triage desk when he first arrived at the Health Sciences Centre.

Sinclair's high-profile death made national headlines last September after he was found dead by a horrified member of the public in the hospital's ER after waiting 34 hours.

At the time, Winnipeg's top health officials said Sinclair never approached the triage desk to be registered in the queue to see a physician and staff didn't know he was waiting to see a doctor. Two separate reviews undertaken by Winnipeg Regional Health Authority officials have since determined Sinclair's death was a result of "systemic gaps." A flurry of procedural changes has been initiated at the province's largest ER, but no employees have been disciplined.

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Chief medical examiner Dr. Thambirajah Balachandra officially called an inquest into Sinclair's death Wednesday and released a statement saying that a review of HSC's security tapes found an unidentified man who drove a white van wheeled Sinclair into the ER and up to the triage desk around 3 p.m. Sept. 19, 2008. The health authority has previously said Sinclair arrived at the HSC via taxi from a community health clinic.

The tapes show an HSC employee at the triage desk spoke to Sinclair before he was seen wheeling himself away from the desk towards the waiting area.

The 45-year-old died Sept. 21, 2008, and his lifeless body was found slumped over in his wheelchair. An autopsy showed he died of a bladder infection caused by a blocked catheter -- a treatable condition. Security tapes show Sinclair spoke to a uniformed worker in the triage area, but triage staff have no record of his name.

"He knew he was in trouble and a person who goes to the hospital and talks to an employee who is in uniform, I expect him to be looked after," Balachandra said.

The video bombshell incited an immediate political uproar, with critics slamming the Doer government for a culture of secrecy and for keeping the content of the security tapes under wraps.

Health Minister Theresa Oswald did not respond to an interview request.

"We feel that Gary Doer and Theresa Oswald have always been leading us to believe that Brian Sinclair wheeled himself into the Health Sciences Centre emergency room and that he never talked to anybody," Tory health critic Myrna Driedger said. "We've always been led to believe, and the government has led us to believe, that nobody knew that Brian Sinclair was there. "

Salvation Army Maj. Karen Hoeft, who spoke on behalf of Sinclair's brother Bradley, said Sinclair's family was informed of the details of the security tapes in November. She said the media and others may have been led into a false perception that Sinclair and other inner-city residents don't know how the triage process works.

Since Sinclair's death, everyone who enters HSC's ER is greeted at the door by a staff member who writes down their name, medical complaint and date of birth if they want to see a doctor. The registration clerk gives patients waiting to see a triage nurse a green wristband.

"He was not unfamiliar with the process. Brian knew," Hoeft said. "The general public often thinks you don't know how to go into hospital because you're a street person, or (if) the word homeless is attached to you, (that) you don't understand the process."

Driedger questioned why the information Balachandra highlighted Wednesday was deliberately omitted from previous public reports and statements, and said the public has been manipulated by the "rot at the top" of the Doer government, which made it look like Sinclair didn't take responsibility for himself.

"How can you fix health care in Manitoba when you've got this manipulation of the truth right at the top?" Driedger said.

Dr. Brock Wright, WRHA chief medical officer and senior vice-president of clinical services, maintained that Sinclair interacted with an HSC employee near the triage desk, but never formally presented himself to the triage desk or spoke to a triage nurse. Wright said he hasn't watched the security tapes, but was informed of their content by senior HSC staff who did watch them.

He said the WRHA has been forthright in its disclosure of what may have contributed to Sinclair's death.

On Wednesday, Wright said Sinclair had contact with at least three staff members in 34 hours, including one triage aide.

Triage aides typically do minor cleaning in the ER, but should also alert the triage nurse of someone waiting for care.

Wright previously said it appeared Sinclair had contact with aides, a housekeeper and security staff.

The date, time and location of the inquest will be determined by the chief provincial court judge. It's expected the employee Sinclair spoke to will be called to testify at the inquest.

"Why was he not triaged?SDRq the judge will likely ask, the medical examiner said.

"Somehow it fell through the cracks. Perhaps a judge will be able to make recommendations to improve the situation so no other person will die."

jen.skerritt@freepress.mb.ca alexandra.paul@freepress.mb.ca

On the record:

SEPT. 23, 2008

Premier Gary Doer: "We know that the individual in question was not triaged."

Health Minister Theresa Oswald: "...this individual did not see the triage nurse and was not triaged."

Dr. Brock Wright: "He never made it to that triage desk, so he wasn't registered and he wasn't known to the emergency staff as somebody who was waiting for care."

SEPT. 25, 2008

Chief medical examiner Dr. Thambirajah Balachandra: "It's very tragic. People should not die like that."

Doer: "There was a gap and a failure in this case."

SEPT. 29, 2008

Wright: "That's the tragic aspect of this, because there's no doubt in my mind had the patient been triaged when he arrived that he would've been seen within that 34-hour period."

NOV. 19, 2008

Jan Currie, WRHA chief nursing officer: "Lots of people encountered Mr. Sinclair without realizing he was seeking care... The nature of the waiting room, the shape of it, the way you could be sitting at the back for a long period of time contributed to this occurring."

FEB. 4, 2009

Statement from Balachandra: "It appears an employee of the HSC at the triage desk spoke to Mr. Sinclair at that time."

Wright: "I didn't feel the need to review the videotape myself... My information is that he did not formally present himself to the triage desk. If that's later found to be incorrect, then we'll learn that from the inquest. What is not in dispute, I don't believe, was Mr. Sinclair was not triaged."

Excerpts from what the Winnipeg Regional Health Authority has said in the past can be found below:

Republished from the Winnipeg Free Press print edition February 5, 2009 A3

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3 Comments

Posted by: CeeCee

February 5, 2009 at 10:41 AM

How about we hold the WRHA, Gary Doer and Theresa Oswald accountable for this. This is why a lot of provinces don't have RHAs anymore. They don't do anything.

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Posted by: N Eyolfson

February 5, 2009 at 9:15 AM

After having taken my dad to the ER of HSC when he was ill, I have a suggestion for a procedure change. Instead of just registering the patient and then putting their chart in the pile, to be called on a first come first served basis, the Triage Nurse should look at each patient immediately after they are registered, take their temperature, blood pressure, etc and get a decent history. That way the person with abdominal pain caused by appendicitis doesn't die of peritonitis due to rupture, etc. Just because a patient isn't bleeding profusely, or convulsing doesn't mean that they are not gravely ill. If memory serves correctly, Mr. Sinclair wasn't the first patient to die in the ER while waiting to be seen.

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Posted by: Just my opinion

February 5, 2009 at 6:53 AM

On September 21st of 2008 this poor man lost his life due to our overloaded health care system, why is this the first time the security tapes are being talked about. One would think that for an incident as serious as this, the security tapes would have been reviewed immediately. Subsequently to that, if they were and our leaders of governement thought this was something they could hide and out right lie to the public, shame on them. Why is it that something tragic always has to happen before our law makers actually step up, admit that mistakes have been made and changes have to occur. Our Nurses work their butts off each and every day, that is to say the nurses we can manage to get to work in Manitoba. Health care should be at the top of the governments list of priorities, pay our nurses a decent wage already.