Free Press reporter Kevin Rollason will be covering the inquest into Brian Sinclair's death live today.
The top nurse on duty when Brian Sinclair arrived at Health Sciences Centre's emergency room in September 2008 offered an emotional apology Monday for his death, saying he didn't die in vain.
Sinclair died on Sept. 21, 2008, after waiting for 34 hours in the ER for care that never came.
Susan Alcock, who was in the ER during two of the three days Sinclair waited -- and who had cared for him in the past -- said Monday at the inquest into the 45-year-old man's death he has become a symbol of the need for improvement in Manitoba's health-care system.
Reading a statement at the end of a long day of testimony, Alcock said Sinclair should not have died in a place where he should have received care.
"We failed Brian and for that I am sorry... sometimes it takes a tragedy to be listened to," said Alcock, the charge nurse who assigned nurses to various positions in the ER on Sept. 19 and 20, 2008.
"I believe Brian was a martyr for us. Because of him, we have changes in emergency rooms.
"I thank you Brian," she ended, her voice cracking.
The inquest resumed Monday after a month's break, following four weeks of hearings in the summer. Sinclair died in the emergency waiting room while waiting for care for a blocked urinary catheter and bladder infection.
The inquest has heard Sinclair may have been dead up to seven hours before he was noticed. The inquest has also heard that among other changes after Sinclair's death, the Winnipeg Regional Health Authority has implemented a system of issuing wristbands to patients who go to the city's emergency departments.
It's believed Alcock's testimony is the first public apology from a health-care professional who was working in the ER at the time Sinclair was left to languish untreated for 34 hours.
The WRHA issued an apology in late 2010 and reiterated it several times since, including just two months ago at the inquest.
William Olsen, the lawyer for the WRHA, said the health authority failed Sinclair.
He apologized to Sinclair's family, saying several erroneous assumptions were made and opportunities missed, leaving Sinclair to fall through the cracks.
Alcock's testimony Monday illustrated many of those problems.
She said because of sickness, the department was down by five nurses on Sept. 19 in the late afternoon and early evening.
She was able to fill two of the nursing positions with other staff but had to reassign the nurse in charge of reassessing patients in the waiting room over to the monitoring of cardiac patients, she testified.
Alcock said at the time, the hospital's emergency room already had a 20 per cent vacancy rate of nurses there.
On top of that, Alcock said Friday was "crazy busy."
"I remember just seeing a sea of people (in the waiting room). I don't remember individuals."
Alcock said while the emergency room normally saw a high of 120 patients, on Sept. 19 there were 134 patients, while the following day it saw 138 patients.
As well, Alcock said, nursing staff had complained several times to upper management about problems with the layout of the emergency room that had opened the year before, including incidents where would-be patients were getting mixed in with others who had been assessed already.
In fact, just three months before Sinclair died, Alcock wrote a letter to the hospital's upper management, signed by other charge nurses, outlining staffing problems in the emergency room.
"I felt we were putting our patients in harm's way because we couldn't adequately care for our patients," she said during questioning by Manitoba Nurses Association lawyer Garth Smorang.
"I might not have the ability to change it, but I wanted them to know we needed to change."
Alcock said in response, her supervisor called her in and accused her of not following the proper chain of command.
As well, Alcock said, nurses told HSC management before Sinclair died that while they could see waiting patients right in front of them in the old emergency waiting room, they had no or limited view of patients after the new department opened in 2007.
Meanwhile, lawyers at the inquest will be arguing whether or not the inquest counsel guiding it is in a conflict of interest.
Vilko Zbogar, who represents Sinclair's family, told provincial court Judge Tim Preston that David Fray told the Assembly of Manitoba Chiefs he would not relay their request to the judge to order transcripts for them because that could cost the province, which he said was his client, money.
"This raises a serious question whether the inquest proceedings may be affected by this same conflict of interest," he said.
Preston said the issue will be argued on Wednesday.