Winnipeg Free Press - PRINT EDITION

Stop the cascades

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The inquest unravelling how Brian Sinclair died after waiting 34 hours at the HSC emergency ward in 2008 has adjourned until January, but the testimony to date has revealed some telling truths. Common threads among the recollections of the two days he spent quietly dying amid nurses, security guards and others in line for care point to classic signs of a massive medical error in the making.

First, nurses and security guards questioned at the inquest made undeserved assumptions about why Mr. Sinclair, who died for want of a change of his urinary catheter, sat almost in the same place over two days. Staff testified they thought the legless, aboriginal man in a wheelchair was silently sitting in front of the TV because he needed to sober up, sleep it off or just wanted shelter, noting homeless people often came in for those reasons. But Mr. Sinclair was not homeless, and there's no evidence he was drunk.

Also, nurses and security guards dismissed repeated pleadings they attend him from people also waiting for care. Finally, a woman demanded attention for the man who was already dead.

Medical errors usually result from not one, but a cascade of critical mistakes. The inquest is showing what widespread assumptions and the dismissal of warnings can do. All of Manitoba's hospitals should be heeding these early lessons to stress the need for vigilance and a higher duty of care in the ER and all wards.

Editorials are the consensus view of the Winnipeg Free Press’ editorial board, comprising Catherine Mitchell, David O’Brien, Shannon Sampert, and Paul Samyn.

Republished from the Winnipeg Free Press print edition November 4, 2013 A10

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