‘We can learn’ Health minister orders critical-incident probe after HSC waiting-room death By: Chris Kitching Posted: 3:19 PM CST Wednesday, Jan. 8, 2025 Last Modified: 6:48 PM CST Wednesday, Jan. 8, 2025 Updates

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Manitoba Health Minister Uzoma Asagwara has ordered a critical incident investigation after a middle-aged man died in Health Sciences Centre’s emergency department waiting room Tuesday morning, eight hours after arriving by ambulance.

Any necessary improvements will be made to prevent similar deaths, Asagwara vowed, while patient-safety advocates questioned whether lessons from past ER deaths, including that of Brian Sinclair, were learned.

“I want to reassure Manitobans this is being treated with the highest level of urgency, highest level of seriousness, and we’re working very hard and very quickly to make sure that we can learn and take the appropriate action moving forward,” Asagwara told reporters Wednesday.

The minister asked that a preliminary report and assessment be provided to them within a couple of weeks.

Dr. Shawn Young, chief operating officer of HSC, which is run by Shared Health, has said the man arrived by ambulance shortly after midnight Tuesday.

The man was assessed, triaged as low acuity and directed to the waiting room with instructions to speak to staff if his condition changed or worsened.

Staff noticed his condition had deteriorated shortly after 8 a.m. He was pronounced dead in a resuscitation room a short time later.

Officials have shared little information about the man and no details about why he was taken to the ER. They have not said how often he was reassessed by staff.

Young has said the ER was well over capacity with about 100 patients, while the number of nurses on shift was just below baseline and a backlog prevented admitted patients from being moved from the ER to a bed elsewhere in the hospital.

He said low-acuity patients are typically reassessed every couple of hours, and can face waits of 10 hours or more — a period that Asagwara called unacceptable.

Manitoba Health defines a critical incident as a situation where someone using a health service suffers “serious and unintended harm.”

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Investigations typically take months and lead to recommendations for improvement or review. Officials say patient privacy laws limit the information that can be shared with the public afterward. Reports are not prepared for public use.

“When the review is fully complete we will be transparent and open with the public in terms of the findings, what we learned from this, so we can prevent this from happening in the future,” Asagwara said. “This is a tragedy and a devastating loss that should not have happened.”

Sinclair, a 45-year-old Indigenous man and double-amputee who used a wheelchair, died in 2008 in the same HSC waiting room 34 hours after he arrived, seeking care for a blocked urinary catheter. An inquest produced 63 recommendations — a majority of which were completed — and led to protocol changes.

Some recommendations were intended to ensure adequate staffing, reduce wait times and improve patient triage, reassessment and flow.

Vilko Zbogar, a Toronto-based lawyer who represented Sinclair’s family following his death, said what matters most is that officials find out what’s “broken” and fix it.

“It doesn’t seem to have happened in the 16 years since Brian Sinclair died,” Zbogar said.

If “back-end administrative” issues were not addressed following the inquest, it is a disservice to Sinclair’s memory, he said.

“It doesn’t seem to have happened in the 16 years since Brian Sinclair died.”–Vilko Zbogar

A report by a provincial court judge found Sinclair’s death, caused by acute peritonitis, was preventable.

After a man died in a hallway in HSC’s ER in 2023, a critical incident review led to three recommendations to improve patient flow and ease backlogs. The review found the ER was overcrowded and lacked available beds when the man died.

Doctors Manitoba said ER wait times have been “far too long for far too many years.”

“The main cause of ER overcrowding and long wait times is insufficient capacity to get patients out of the ER, often a lack of inpatient hospital beds,” a spokesperson said.

“This means patients back up in the ER, blocking treatment spaces, leaving patients in the waiting room. The best solution for reducing ER waits is adding more hospital capacity, and we are encouraged to see the government opening more inpatient beds and hiring more staff.”

Asagwara said it will take time to build up capacity.

“This tragedy makes it very clear that there’s much more work to be done,” they said.

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Manitoba Nurses Union president Darlene Jackson said critical failures are “symptoms of a system stretched beyond its limits,” and must serve as a wake-up call to people in charge.

“The leadership at HSC and within the minister of health’s office must work tirelessly to uncover the root causes of this failure and implement immediate and sustainable solutions,” she said in a statement.

Jackson said chronic understaffing and a lack of resources create dangerous conditions that put patients and staff at risk.

Young has said wait times improved in the last year.

An MNU review of publicly available data showed a median wait of 3.48 hours at HSC’s ER in 2023. The median wait in 2024 was 3.44 hours, as of the end of November.

Molly McCracken, the Manitoba Health Coalition’s acting spokesperson, agreed more must be done to ensure ERs function efficiently.

“This (death) will be top of people’s minds when they go to the ER. Do I trust the system to take my loved one in, and yet what choice do I have?”–Katharina Kovacs Burns

“This includes adequate staffing, accelerating available non-acute beds to move patients out of needed ER beds, and stepping up resources for the unsheltered population who currently have little choice but to access ERs for shelter and resources,” she wrote in an email.

Young has said a number of people were seeking shelter and safety in the ER due to cold weather.

Katharina Kovacs Burns, Patients for Patient Safety Canada’s board chair, and Laura Tamblyn Watts, president and CEO of CanAge, a national seniors advocate, echoed calls for ER improvements and transparency from Shared Health and the government.

Kovacs Burns said transparency is essential to rebuild trust and confidence that ERs are safe.

“This (death) will be top of people’s minds when they go to the ER. Do I trust the system to take my loved one in, and yet what choice do I have?” she said.

Tamblyn Watts said the man’s death should be a call to action. Any recommended improvements must come with an appropriate timeline and funding to implement them, she added.

“If you take the extraordinary step of going to an ER at a hospital… you should not expect that you’re going to be dying in the waiting room,” Tamblyn Watts said. “That’s unacceptable.”

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.