Middle-aged man dies in Health Sciences Centre ER waiting room eight hours after arriving by ambulance Ward over capacity with very sick patients, hospital bottleneck preventing access to urgent treatment areas, facility’s top executive says By: Chris Kitching Posted: 3:55 PM CST Tuesday, Jan. 7, 2025 Last Modified: 7:31 PM CST Tuesday, Jan. 7, 2025 Updates

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Winnipeg’s Health Sciences Centre has launched an investigation into the Tuesday-morning death of a middle-aged man who spent eight hours in the emergency department waiting room after arriving by ambulance.

The man’s death immediately raised comparisons to the tragic end of double-amputee Brian Sinclair’s life in 2008 following more than 30 hours in the same waiting room.

The ER was well over capacity and staff were dealing with several high acuity — seriously unwell — patients and an internal bottleneck in moving them when they noticed the man’s condition had significantly worsened in the waiting room, Dr. Shawn Young, chief operating officer of the central Winnipeg hospital, told reporters at a Tuesday-afternoon news conference.

“We had a number of admitted patients in the (ER), and we were unable to get them into beds and into the facility because patients within HSC that we need to get out, we’ve not been able to successfully get them back out to their communities or their residence in a timely manner,” he said.

“The whole health system was backed up that way.”

Young said a detailed and thorough investigation of the man’s death and all potentially contributing factors is underway to determine if it will be deemed a critical incident.

Young said the man, who arrived by ambulance shortly after midnight, was assessed, triaged and directed to the waiting room with instructions to let staff know if his condition changed or worsened.

Officials did not say why he was taken to the ER.

He was classified as a low-acuity patient, Young said, noting people in that category can face waits of 10 hours or more, while high-acuity patients are seen first.

As many as 100 patients were in the ER (in the waiting area or undergoing treatment) at times in the 24 hours up to Tuesday afternoon.

Of that number, about 50 were in the waiting room when the man was there, and all six resuscitation beds were full.

While the ER was over capacity, the situation was “not completely abnormal” because the department typically has more than 70 or 80 patients, sometimes up to 100, Young said.

“When we see cold weather like this, we do have a number of patients that come in seeking shelter and safety as well, and that was a factor in the waiting room,” he said.

Young said he did not yet know how many times the man was reassessed by staff after being triaged, but low-acuity patients are typically reassessed every couple of hours, he said, noting the frequency of reassessments is affected when the ER has a high number of patients.

Staff noticed the man’s condition had deteriorated shortly before 8 a.m. It appeared he had vital signs when he was moved to a resuscitation room, where a pulse could no longer be detected and he was pronounced dead, Young said.

Staffing levels were down about three nurses from a baseline of 24 or 25, but that would not have been a factor because nursing levels are frequently around that figure, Young said.

“We’re not regularly at full staffing but we’re often close,” he said.

Young, union leaders and politicians offered condolences to the man’s family and staff. Employees were offered supports.

“When we see cold weather like this, we do have a number of patients that come in seeking shelter and safety as well, and that was a factor in the waiting room.”–Dr. Shawn Young

“These types of events are incredibly upsetting to our staff — devastating,” said HSC chief medical officer Dr. Manon Pelletier.

The investigation will include interviews with staff, and reviews of surveillance video, the patient’s chart, notes and triage and assessment protocols.

It will also look at any underlying health issues or other factors that were unrelated to the reason he was there that may have played a role in his deterioration of his condition.

Young said the investigation will identify anything that could have been done differently or lessons, practices or protocols that can be implemented in a bid to prevent similar incidents in the future.

The death occurred at a time when health-care workers continue to raise concerns about how staff shortages and heavy loads impede their ability to properly monitor patients.

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“They’re telling me it has been extremely chaotic (in HSC’s adult ER). One of them described it as absolutely brutal,” said Manitoba Nurses Union president Darlene Jackson. “This (death) is a terrible occurrence.”

Jackson said she is waiting for the NDP government to deliver on 2023 election promises to improve health care.

“This is so unfortunate that we haven’t seen the change in our health-care system that this government promised pre-election,” she said. “It takes an incident like this for people to sit up and take notice.”

Jackson said ERs must be appropriately staffed, and bottlenecks that prevent patients from being moved to a hospital ward or personal care home must be eliminated.

“It takes an incident like this for people to sit up and take notice.”–Darlene Jackson

“You can’t run short in these departments,” she said.

HSC struggled with congestion while the man waited to be seen. A surge protocol was probably implemented at least twice in the 24 hours up to Tuesday afternoon to help move people out of inpatient units so others could be transferred from the ER to a bed, Young said.

While he did not have data at hand, Young said ER wait times have improved considerably over the last year due to measures that have been implemented.

“They’re not where we want them to be,” he said. “It’s going to be a long time before we get them to where we want them to be.”

HSC’s adult ER had a wait time of 8.25 hours at 1:30 p.m. Tuesday, the Winnipeg Regional Health Authority’s website showed.

The page listed 96 patients as waiting or “treating” (those who’ve had an initial assessment).

Individual wait times could be more or less than the time displayed, the website said.

The WRHA’s latest monthly data showed a median wait of 3.77 hours at HSC’s adult ER in November, up from 3.53 hours in October and down from 3.9 hours in November 2023.

One in 10 patients waited 13.16 hours in November, which is comparable to the same month in 2023.

A separate Manitoba Health dashboard said 1,155 people visited HSC’s ER the week of Dec. 23-29, the latest publicly available data.

The dashboard said the daily average number of patients who were waiting for a hospital bed at 8 a.m. was 10, while the daily average waiting in hallways was zero.

Winnipeg’s three ERs had some of the longest wait times in Canada in 2023-2024, according to Canadian Institute for Health Information data.

One in 10 patients waited 12 hours at St. Boniface Hospital, 10.4 hours at Grace Hospital and 7.7 hours at HSC (adult), data showed. The national comparison was 5.2 hours.

The NDP government has promised measures to help reduce patient-flow backlogs and ease pressure on ERs. They include an April 2024 announcement of 35 medicine, 10 psychiatric and five surgical beds at HSC.

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“An investigation of this incident is ongoing and I am in contact with those involved to understand how we can prevent a similar tragedy in the future,” Health Minister Uzoma Asagwara said in a statement.

Progressive Conservative health critic Kathleen Cook accused the NDP government of failing to present a “substantive, credible plan” to reduce backlogs or ease the ER “crisis.”

At least four triaged patients have died while waiting in hospital ERs in Winnipeg in the last two years. Three previous deaths — at St. Boniface Hospital in January 2024, Grace Hospital in November 2023 and HSC’s adult ER in February 2023 — were deemed critical incidents, leading to recommendations to prevent similar incidents.

The patient at St. Boniface had been waiting about five hours, while the patient at Grace had been in the ER for 33 hours, the WRHA said previously.

“An investigation of this incident is ongoing and I am in contact with those involved to understand how we can prevent a similar tragedy in the future.”–Health Minister Uzoma Asagwara

A review of the February 2023 death at HSC found the ER was overcrowded and dealing with a surge in critically ill or injured patients when a man died while waiting for care in a hallway.

The review led to three recommendations to improve patient flow and ease ER backlogs.

Sinclair, a 45-year-old Indigenous man and double-amputee who used a wheelchair, was found dead in HSC’s ER waiting room in September 2008.

He waited 34 hours without being questioned or treated by staff. Sinclair, who was seeking treatment for a blocked urinary catheter, might have been dead for as long as seven hours by the time the family member of another patient noticed his condition.

A nearly 200-page report prepared by a provincial court judge later found the acute peritonitis that caused Sinclair’s death was avoidable. The tragedy led to several protocol changes to prevent similar deaths.

“Both people died in the emergency room, and that’s very concerning,” Young said in response to a question about whether comparisons between Tuesday’s death and Sinclair’s in 2008 are valid.

“That’s the biggest comparative, and the worst comparative.”

chris.kitching@freepress.mb.ca

Chris Kitching
Reporter

Chris Kitching is a general assignment reporter at the Free Press. He began his newspaper career in 2001, with stops in Winnipeg, Toronto and London, England, along the way. After returning to Winnipeg, he joined the Free Press in 2021, and now covers a little bit of everything for the newspaper. Read more about Chris.

Every piece of reporting Chris produces is reviewed by an editing team before it is posted online or published in print — part of the Free Press‘s tradition, since 1872, of producing reliable independent journalism. Read more about Free Press’s history and mandate, and learn how our newsroom operates.