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Whole truth in ER death still secret

brian sinclair case

By: Dan Lett

9/02/2009 1:00 AM | Comments: 7

Act of omission or commission?

This has been the razor-thin line the Winnipeg Regional Health Authority has tried to walk while trying to explain how and why Brian Sinclair, a double-amputee with a long list of health concerns, was ignored for 34 hours at the Health Sciences Centre emergency room until he died last September of a completely preventable affliction.

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The WRHA attempted to portray Sinclair's death as an error of omission, a systemic failure that began with Sinclair's own inability to properly register with ER triage staff. From Health Minister Theresa Oswald to Dr. Brock Wright, the WRHA's chief medical officer, the death was explained away as a tragedy, but an unavoidable one.

We might have continued to believe this version of events if it were not for Dr. Thambirajah Balachandra, Manitoba's chief medical examiner. This past week, Balachandra revealed that security video showed Sinclair did, in fact, see triage staff before he  wheeled himself into a waiting room to die. He also revealed that triage staff repeatedly ignored warnings by ER security that Sinclair's condition was deteriorating.

WRHA officials have tried to downplay these new revelations. The simple fact is these are details that were known, or should have been known, by senior officials at the WRHA. And they are completely at odds with what the WRHA said last September.

While the initial error of ignoring Sinclair may ultimately qualify as one of omission -- although it is increasingly hard to believe that -- subsequent efforts to exclude the truth appear to be clear errors of commission.

It is a well-known phenomenon in wrongful convictions that a miscarriage of justice is often aggravated by efforts to cover up the original wrong. It is also understood that the term "systemic failure" is code for "no one will take responsibility." In the Sinclair case, the unsupportable conclusions expressed last September, and efforts to explain the death as a "systemic gap", suggest a concerted effort to obscure the truth and protect those involved.

That the health-care system has trouble admitting the truth, there should be no doubt. WRHA officials acknowledge they hear about fewer than a fifth of all critical incidents. The province has introduced laws to encourage health-care professionals to admit their mistakes, but it has produced mixed results, as this case clearly shows.

A law proclaimed two years ago compels anyone with knowledge of a critical incident to make a full report. The trade-off is that all details of those admissions are kept strictly confidential; nothing is made public, and nothing can be used against an individual in a criminal or civil proceeding.

In essence, the province traded public accountability for truth. But as is now quite obvious, even a confidential process does not produce the truth. In this case, the confidential review became a tool to suppress the truth.

The WRHA said two separate reviews of Sinclair's death concluded that the double-amputee failed to properly identify himself to triage staff, a statement we now know was not true. Even worse, the very system established to encourage admission of mistakes made it impossible for anyone outside the system to find out what really happened.

The WRHA must release the unedited text of the two reviews. At this point, one must assume with strong justification that the WRHA's investigators had access to both the security video and security staff. It is essential that the public know whether those facts were explicit in the WRHA reviews, or whether they were excluded.

If those details were included, and then excised from the "official" and public version of events, then the buck must stop with senior WRHA officials. If those key facts were excluded from the reviews, then the authors must be compelled to explain publicly how and why these omissions were made.

Finally, we must not lose sight of the original issue: Who was responsible for ignoring Sinclair for nearly a day and a half? It is an act we must now view as one of commission.

Whether any one person can be held responsible for Sinclair's abominable treatment may never be known. It is well documented by patient-safety advocates that doctors and nurses have a troubling habit of ignoring the pleadings of those outside the system. Perhaps Sinclair's death can be explained as simply as that.

Thanks to Balachandra, we know much more now about Sinclair's death than we did before. A coroner's inquest may reveal more; however, it is important to note that even a court of law does not have the power to force the WRHA to disclose its previous reviews.

The health authority will no doubt continue to portray Sinclair's death as an error of omission. We know enough now to know that is not a fair representation, but we are still a long way from the truth. And in a health-care system that puts confidentiality ahead of accountability, we shouldn't hold our breath waiting for the full truth.

dan.lett@freepress.mb.ca

Republished from the Winnipeg Free Press print edition February 9, 2009 A4

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7 Commentscomment icon

Yes there are 2 reports; yes there is coverup; no we will ever know the whole truth; and the WRHA will keep doing what they have been doing all a long. There will be an inquest with recommendations which will just collect dust just like all other investigations have. Edited.

The answer seems quite simple. The people at Triage began to process this individual, and then failed to follow up. This is the primary and foremost failure. Procedural change can rectify that. Those working at triage that day were negligent. They need to be dealt with. They are responsible and need to be dealt with according to the procedures they have in place. As for all the denials, cover-ups and finger pointing, it is impossible for the public to know who really knew what. Trying to lay blame will at best be a shot in the dark, that may punish the wrong people. The focus here needs to be on changing the procedure that failed Mr. Sinclair.

Excellent column Dan. I have been a big critic lately of the Freep but you guys are hammering the WRHA looking for answers. Great job.

This was well written and brings forwards questions that need to be answered. I work for WRHA. I will tell what will happen. No one is to be blamed. It was no one person or managements fault. Mark my words. It is always the same. No one is to blame. Last year they implemented a new software for ordering and delivering supplies. It cost millions for the software and the resulting attention it required to mend. Who’s to blame: not one person: people were on holidays, a number of contributing factors, blah, blah, blah, quack, quack , quack. It is unbelievable how no one is accountable at WRHA. You would think that the TWO new buildings (yes TWO) filled with hundreds and hundreds of new WRHA managers and directors, one building on Main Street and one on Portage, that at least one person would take responsibility. Yeah check into why WRHA needs TWO buildings. The one on Portage and Victor is like a secret. No signage, no articles in the paper. It is like they are afraid to admit they are building TWO huge buildings to house all the bureaucrats. Why not just build one and put the other money to an extra tech for the OR. Unbelievable.

As Mr. Lett stated in closing, the public is unlikely to ever hear the truth due to the legislated cloak of secrecy. Trying to impeach Doer or Oswald is political posturing. They merely comment on what the bureaucracy beneath want them to know, in this case a carefully crafted web. To suggest that Brian Postl and Dr. Wright bear sole responsibility obscures the role of many beneath them. They must go but terminations progressing much, much further down the WRHA food chain are essential so ALL bureaucrats in this top-heavy, obscenely expensive bureaucracy understand that they too will be similarly held accountable for acts of negligence and malpractice. The grassroots employees involved in this nightmare, especially those in triage the day Sinclair died must be gotten rid of...period. They clearly imperil the public at large who come expecting competent treatment and respect. As both an out and in-patient at HSC, I have seen first hand the magnitude of the profound ignorance and indifference of many of those who work at HSC, from physicians down to healthcare aides. Many, many gems can be found in this cesspool, are sullied by association with it and see their undeniable contribution obscured. Fortunately, I'm a vocal and aggressive self-advocate with extensive medical knowledge who in spite of the system, has managed to survive it and side-step the consequences of widespread incompetence. Brian Sinclair, like many others, lacked the knowledge and persistent aggressiveness needed to combat this system and succumbed to it as a result. Edited.

Dan, you must be going soft! Is there no way to tie this to Steven Harper or some conservative somewhere?!

Someone high must lose their job. They were caught in a lie, and if they claim ignorance....well that is just no excuse. They are paid to run their departments, and I am quite sick of executives and politicians claiming they didn't know. They are paid to know. This stinks of misdirection and lawyer speak. The truth is that they lied and they are now caught....Now it is time to pay for that decision, with their jobs.

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