The investigation phase of the inquest into Brian Sinclair's death is done. Testimony from those working or waiting in Health Sciences Centre's ER wrapped up this week. The next phase will look at systemic issues shared by Winnipeg's ERs, such as waiting times.
Those issues, however, cannot explain why Mr. Sinclair died, having sat for 34 hours in his wheelchair in the waiting room. A change of urinary catheter and antibiotics would have treated his infection, which seeped into his abdominal cavity and killed him -- under the eyes of nurses, aides, security guards and cleaning staff.
No matter how busy the ER was when he was dropped off by a taxi driver on Sept. 19, 2008, it cannot explain the fact Mr. Sinclair was ignored to death. The ER was crowded the afternoon he arrived, and was busy at times over the two days he sat waiting. But security video also shows long periods when few people sat in the room. No one from HSC asked Mr. Sinclair, a double amputee with a host of medical issues, if he needed help.
The inquest revealed a serious error was made when Mr. Sinclair wheeled himself close to the triage desk to speak to a nurse. Instead, he was intercepted by a triage aide, who bent to speak to Mr. Sinclair, who had a speech impediment, then wrote something on a piece of paper. Mr. Sinclair then wheeled himself into the busy waiting room. The paper is thought to have been the list of those awaiting triage -- who would be called in order to be triaged. He was not triaged, and the paper was never found in an investigation by HSC.
Human error is inevitable. But inquest testimony shows that assumptions, compounded by prejudices, of HSC ER staff turned the initial error into a tragedy. Repeatedly, nurses and security staff said they assumed the quiet man who rarely moved his wheelchair in 34 hours was not there for medical care, was not sick (or sick enough) for immediate attention. Some have testified, tearfully, they believed he was homeless, intoxicated and there for shelter, to sober up.
Mr. Sinclair was not homeless in 2008. A long medical history meant he was well known to some staff, but his name was not in the book of inner-city people who often sought refuge, and a warm drink, in HSC's ER. The WRHA in 2008 noted those seeking shelter received attention from the nursing staff, had their blood pressure or other details recorded in the book.
So the ER staff accommodated the homeless or intoxicated, who would just come to sit. And staff that weekend saw Brian Sinclair as just such a person. He was aboriginal, he was quiet, he just sat there, he didn't inquire or complain. He fit their view, the view of many Winnipeggers, of the homeless who hang about the warm public places.
When other ER visitors repeatedly tried to get him attention, told staff he appeared sick and in need of help -- including when he vomited on the floor -- their entreaties were dismissed. All he got was a vomit basin.
Prejudice infects Winnipeggers' relationship to fellow citizens seen ambling on the streets. But hospital staff are professionals and it is professionalism that is meant to override assumptions and prejudices, to protect those in need of help. That didn't happen in September 2008.
Many changes have been made to protocol and the ER's layout after followup reports pinned the tragedy on a confluence of unfortunate circumstances; nurses had complained the waiting room was barely visible to the triage desk.
But the blind spot that killed Brian Sinclair was not physical. He was seen by many, and approached or repeatedly passed by staff. Provincial court Judge Tim Preston will soon hear about all of the complexities of patient flow, staff scheduling and job responsibilities. He must bear in mind, however, that the first job of ER staff is to attend to the sick, to fix what ails. Brian Sinclair died because no one thought to ask why he was there. Judge Preston, finally, must underscore that hospital and medical staff must always assume individuals in their workplace need medical attention. Their assumptions are not benign when they are on the job.
As the tears of nurses who testified reveal, prejudice makes victims of some but damages us all.