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'People will die,' HSC ER nurse predicted

Sinclair inquest hears of prophetic words

Posted: 01/8/2014 1:00 AM | Comments: 0

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Robert Sinclair holds a portrait of his first cousin Brian Sinclair at a news conference after Provincial court Judge Ray Wyant said in a ruling that the legal aid rate which the government has offered to the family to date is inadequate for their participation in an inquest that will be lengthy and complicated. Brian Sinclair, a homeless and disabled aboriginal man, died in Sept. 2008, after waiting 34 hours in the emergency room of the Health Sciences Centre.

WAYNE GLOWACKI / WINNIPEG FREE PRESS Enlarge Image

Robert Sinclair holds a portrait of his first cousin Brian Sinclair at a news conference after Provincial court Judge Ray Wyant said in a ruling that the legal aid rate which the government has offered to the family to date is inadequate for their participation in an inquest that will be lengthy and complicated. Brian Sinclair, a homeless and disabled aboriginal man, died in Sept. 2008, after waiting 34 hours in the emergency room of the Health Sciences Centre. Photo Store

A veteran triage nurse predicted "people will die" in Health Sciences Centre's emergency department waiting room, a year before Brian Sinclair died while waiting for care.

Nurse Jan Kozubal, who worked in the hospital's emergency department from 1974 to this past September, told an administrative review interviewing staff in the wake of Sinclair's death on Sept. 21, 2008, she had told a doctor the year before "people will die in that emergency department waiting room."

Under questioning by Sinclair family lawyer Murray Trachtenberg on Tuesday, Kozubal admitted she couldn't remember saying that, but she agreed she must have when read what she had told Winnipeg Regional Health Authority administrators conducting the review.

"I don't recall those exact words, but I expressed concern," Kozubal said she remembered.

Kozubal -- as well as several other staff the inquest has already heard from -- was upset about the layout of the emergency room on William Avenue, built to replace the one on McDermot Avenue.

The inquest has heard staff was upset how far away the waiting room was from the triage desk and how the chairs were turned away from them towards a television. The hospital has made several changes to the room in the years since Sinclair's death.

But Kozubal, who worked as a triage nurse on Sept. 19, 2008, from 7:30 a.m. to 7:30 p.m., during the time when Sinclair was dropped off around 3 p.m., also recalled the emergency department was busy that day.

"There was only two of us there instead of three (triage nurses)," she said.

"It was difficult to keep up. Reassessments weren't being done like they could be."

Kozubal said she doesn't believe she ever helped treat Sinclair when he had come to emergency in the past, and she doesn't remember seeing Sinclair during her shift or seeing his name on the list of patients.

The 45-year-old Sinclair, a double amputee who used a wheelchair after losing his legs to frostbite after collapsing outside the winter before, was found dead after spending 34 hours sitting in the waiting room.

The inquest, which has heard Sinclair had a blocked urinary catheter that led to him getting a treatable bladder infection, has been told the man spoke briefly to a triage aide who appeared to write down his name when he entered the ER, but he never got any closer to being treated.

Seventy witnesses have testified since the inquest began in August with several family members of patients saying they tried unsuccessfully to alert staff to Sinclair's plight, while some hospital staff said they brought him a bowl to throw up in, cleaned the floor under him and checked to see if he had a hospital wrist bracelet on.

The inquest has been told Sinclair may have been dead up to seven hours before he was rushed from the waiting room into the treatment area where medical staff found he had been dead so long rigor mortis was setting into his body.

Meanwhile, provincial court Judge Tim Preston refused requests by lawyers for the family of Sinclair to call the two triage nurses who worked on Sept. 20, 2008, from 7:30 a.m. to 7:30 p.m.

Trachtenberg said the family, along with lawyers for the Aboriginal Legal Services of Toronto, wanted the two nurses to testify because they were the only triage nurses working while Sinclair was in the waiting room who hadn't been called by the inquest. As well, the lawyer argued they were working during the time the inquest has been told Sinclair was throwing up and being given bowls to vomit in.

"These are the two nurses on duty who are responsible for triage," the lawyer argued.

"How can the public have confidence of the thoroughness of the inquest? It is so obvious these two people belong here."

But Preston, after hearing arguments against calling the pair from lawyers for HSC, the Manitoba Nurses Union, and counsel for the inquest -- who said the nurses had been pre-interviewed and there was nothing more they could add -- rejected the request.

"I have concluded their evidence is not necessary," Preston said, noting there is no hospital security camera video showing them interacting with Sinclair and they can't recall seeing the man while they were working.

Preston also denied another request to file as evidence written notes from an interview of triage aide Jordan Loechner conducted by WRHA officials.

Vilko Zbogar, another lawyer acting for Sinclair's family, had argued he wanted the document officially filed in court because Loechner was the only hospital employee interviewed by hospital officials in the wake of Sinclair's death who told the inquest he didn't agree with the notes taken of what he told them.

The inquest has heard that while Loechner doesn't remember most of what occurred during his two shifts on Sept. 19 and 20, 2008, two days after Sinclair died he told hospital administrators he remembered writing down Sinclair's name when he came to the hospital.

Preston said he heard Loechner's testimony and will use that while writing his decision and recommendations.

The inquest has now wrapped up phase one looking into the circumstances around Sinclair's death. The judge will announce on Friday the witnesses that will be called during the second half of the inquest, scheduled to start in February. That stage is expected to look into how to manage patient flows in emergency rooms across the city.

kevin.rollason@freepress.mb.ca

Republished from the Winnipeg Free Press print edition January 8, 2014 0

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