Findings in a report on the mistakes made at the hospital where Brian Sinclair sat for 34 hours unattended must be probed by the inquest looking into the man's unnecessary death from a bladder infection. The report, a critical-incident review, reportedly found four times others waiting in the ER asked, to no avail, for help for the man.
Further, the review said there had been other occasions in which people went to Health Sciences Centre for help, and either did not make it onto the ER triage list in line for assessment by a nurse, or had their names stroked off without being triaged. The use of the list has become central to the inquest now underway into Mr. Sinclair's death in 2008. The legless man sat in his wheelchair at the triage desk, where he was greeted by a triage aide, who wrote details onto the triage list. But Mr. Sinclair was never called by nurses. The paper was never found by investigators.
The reports of the critical-incident review indicate staff in the ER often regarded people waiting there as a threat. The four attempts by people to draw Mr. Sinclair to the attention of security guards, nurses and triage aides were futile -- nurses said they were busy, and one security guard said the aboriginal man was merely seeking shelter. The inquest has heard a guard believed he was intoxicated and sleeping it off, although there is no evidence of that.
The Winnipeg Regional Health Authority says the HSC process has changed, and the waiting room has been rearranged so nurses can see all patients. Now all seeking help are registered in computers and given a wristband; paper lists are not relied upon. (Patients at Misericordia's urgent care centre still sign a paper triage list before they are registered.)
The critical-incident report, written to examine and fix the causes of medical mistakes in the system, is protected by law from all legal proceedings. The facts revealed, however, are critical elements to the purpose of the inquest, which must compare these findings to those of the hospital's own administrative review, which has yet to be released. This is why senior officials of the WRHA, including chief medical officer Brock Wright, must be called to testify.