Winnipeg Free Press - PRINT EDITION

Lessons from a death in an ER

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What's telling isn't so much what happened to Brian Sinclair, but that everything that happened that day in the Health Sciences Centre emergency room looked so normal.

Much has changed in how patients are now seen at the HSC since Sinclair died of a treatable bladder infection more than five years ago. He died relatively quietly and without anyone noticing, for a while at least, after he spent 34 hours in the ER waiting room without being treated.

The hospital security surveillance video confirms no one paid much attention to him almost from the moment a cab driver wheeled the 45-year-old double amputee in the main door and deposited him in front of the ER's triage desk. The video was publicly released Aug. 26 at the provincial inquest into Sinclair's death.

The video shows that almost from the moment Sinclair arrived, he became part of the furniture, save for a security guard giving him something to throw up in and a cleaner mopping the floor around him.

Sinclair sat there in his wheelchair in an aisle beside a row of chairs facing a TV. People came and went, side-stepping him as they went by on their way to somewhere else.

Aware of, but not acknowledging him.

Much like most of us do walking downtown on lunch break during the week when an outstretched hand asks for some coins.

"Spare change?"

"No, I only use my debit card."

It's the same when we pass by a busker outside a liquor store or refuse to look at a guy offering to wash our windshield when we're stopped at a red light. We'd rather not see, let alone make eye contact.

The provincial inquest into Sinclair's death has already heard a lot of the details leading to Sinclair's death. It will hear a lot more when it resumes for one week today and continues for two weeks Feb. 18.

The inquest has heard Sinclair was a familiar face in the ER -- he'd been there 31 times in the five years before he died. It has heard he was a longtime solvent abuser who showed evidence of brain damage when he was 18. It's heard he lost both legs above the knee to frostbite in 2007 after he was found frozen to the outside wall of a church.

During her testimony, an ER nurse broke down when she told inquest Judge Tim Preston she ignored Sinclair because she believed he was drunk.

During his testimony, a hospital security officer brushed off a woman's concern Sinclair was dead, telling her that was the way he slept when intoxicated.

There is no evidence Sinclair was intoxicated at the time, only that he needed a catheter changed.

A 2008 WRHA review of Sinclair's death found no one was to blame, as no one knew he was waiting to see a doctor. A police investigation found no basis to lay criminal charges.

When the inquest gets into its second phase later this year, much will be said about how the HSC ER and other city ERs have changed in the past five years, so much so there is now almost constant contact with waiting patients. The idea being that what happened to Sinclair won't be repeated -- to anyone.

Although process, procedure and policy have changed, the memory hasn't.

The hospital security surveillance video of a dying Sinclair, and the still images of it in colour, will continue to be replayed and reprinted.

That video and those images tell everything about what the ER was like at the time.

They also serve as a warning to us now. They tell us to pay more attention to the needs of those we'd rather not see.

Republished from the Winnipeg Free Press print edition January 6, 2014 B3

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