It will likely never be known why double amputee Brian Sinclair died without being treated at the Health Sciences Centre's emergency department during the 34 hours he was there.
That's the conclusion of a trio of hospital administrators who in the days immediately following the 45-year-old's death in Sept. 21, 2008, examined why he died and interviewed staff members who had contact with him while he was there.
The hospital's 13-page administrative review -- released to the media by provincial court Judge Tim Preston, who is heading the inquest into Sinclair's death -- says "based on the evidence available, it is not possible to conclusively determine why Mr. Sinclair was not triaged on Friday, Sept. 19, 2008.
"It is possible that his name was taken down and called and that he did not hear his name being called. It is equally possible that the triage aide misunderstood the name given by Mr. Sinclair, given his speech impediment, and that Mr. Sinclair's name may not have been called.
"However, both of these possibilities are in the realm of speculation."
Sinclair went to the HSC on Sept. 19, 2008, after a medical clinic put him in a taxi to the hospital when a doctor diagnosed his urinary catheter was blocked.
An autopsy determined Sinclair died of a bladder infection due to his blocked catheter.
The review states 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 until he died.
The review says "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."
Lawyer Vilko Zbogar, who represents Sinclair's family at the inquest, said the review contains more information the family is dumbfounded about.
"There were 17 occasions of people observing him and not doing anything. The number is just stunning," Zbogar said.
"I accept probably nobody intentionally was ignoring him, but it is grossly negligent or even reckless."
But Zbogar said he was also surprised that within 72 hours of Sinclair's death some hospital staff couldn't remember ever having contact with the man.
The review said when a triage aide was questioned about his contact with Sinclair -- hospital security video shows him meeting with Sinclair and writing something down before Sinclair rolled his wheelchair to the waiting room's seating area -- he replied he had "no independent recollection of this interaction".
"He had just died so you'd think people would go over their mind with their dealings with him," Zbogar said.
The administrative review states no staff were removed from their jobs or disciplined over Sinclair's death because it was "an exceptional occurrence" for a patient to have died in the emergency department without having been triaged by a nurse and there have been changes in handling patients. "To hold individuals accountable on a disciplinary basis for such gaps in this system would be inappropriate and unfair," the review states.
Winnipeg Regional Health Authority spokeswoman Heidi Graham verified that to this day no staff member was ever removed from their job in connection with Sinclair's death.
"The WRHA has always maintained that the death of Mr. Sinclair was our fault," she said.
"He came to us seeking care for a treatable condition and we failed him. For that we have apologized to his family."
The inquest, which heard testimony in August, will begin again on Oct. 7.