This article was published 5/12/2014 (2392 days ago), so information in it may no longer be current.
He had been there for 34 hours, but isn’t listed on the document that tracks when a patient registers and is discharged in the Health Sciences Centre’s emergency department until Sept. 21, 2008, at 12:51 a.m.
Noted simply as male, 45, his chief complaint listed is cardiac/respiratory arrest. He is triaged as a level one patient — the highest priority in the Canadian Emergency Department Triage and Acuity Scale or CTAS — meaning he needed "immediate aggressive interventions" because his condition was life threatening and he had to be seen by a doctor immediately.
The man’s name was Brian Sinclair and he was already dead. As emergency room doctors quickly found out, Sinclair had been dead for so long rigor mortis was setting in, causing doctors to ask: where the heck did this patient come from?
An autopsy determined Sinclair had died of a treatable bladder infection, caused by his blocked urinary catheter, while waiting in the emergency waiting room for 34 hours. The province’s chief coroner said the double amputee may have been sitting dead in his wheelchair as long as seven hours before he was discovered.
An inquest, which began last year and finished hearing evidence earlier this year, heard that as many as 17 hospital staff members observed Sinclair, but didn’t help him get treated.
The deadline for the inquest report is Dec. 12, though provincial court judge Tim Preston could ask for an extension. Preston has been tasked with making the final determination about how Sinclair died, but also to seek ways of reducing the chance it will happen again.
But what we do know is Sinclair wasn’t alone while he was dying in his wheelchair.
Not only was he surrounded by medical staff, but also patients and their families sitting in the same waiting room.
During the hours from when he arrived Friday, Sept. 19 at 3:49 p.m. people were treated for minor ailments and for major conditions. Some were sent home following treatment. Others were admitted into hospital. Still others were sent to different medical services at the complex.
Others waited so long they finally gave up and just left.
It’s that way through hospital emergency rooms in this city, province and across the country.
Here is a 34-hour snapshot of the HSC’s ER waiting room and underscores the problems with a clogged hospital system.
Friday, Sept. 19, 2008, 3:49 p.m.
It was warm outside — 20.8 C with no precipitation — when Sinclair came through the sliding double doors in the HSC’s emergency department, there were 45 patients either in the waiting room or in the treatment area. Two of them had checked in before the 7 a.m. nursing change — one at 12:40 a.m. with an abdominal complaint and another with a head injury at 6:59 a.m.
But another 40 still waiting or being treated when Sinclair arrived were part of the 56 patients who showed up after 7 a.m.
While Sinclair waited, a total of 199 patients with various complaints were treated or waiting for treatment. Nurses who testified at the inquest all said it was busier than usual.
The most serious patient who came in before Sinclair — at 1:19 p.m. — was a 75-year-old man who had syncope, meaning he had passed out or fainted.
He was triaged as a CTAS Level One, the only level one patient to arrive before Sinclair. There were only two others while Sinclair was there.
After Sinclair came in, there were 34 patients triaged as CTAS Level Two. These are patients who have conditions that are "a potential threat to life limb or function" and needing to be seen by a doctor for an assessment within 15 minutes of arrival.
The other three CTAS levels — three, four and five — are patients who need to be seen by a doctor within 30 minutes, one hour, and two hours respectively.
There were 97 patients who were considered level three, 58 who were level four, and eight who were level five.
But many of these are also people that Dr. Alan Drummond, an emergency room physician in Perth, Ont., and a past president of the Canadian Association of Emergency Physicians, says clog ERs when it turns out they didn’t need to be there.
"The fours and fives are irrelevant from a crowding perspective," Drummond said.
"It’s the threes who are the problem children. They usually are elderly and they have complaints that may turn out to be nothing. And someone with abdominal pain, is she constipated or does she have an aneurism? They are vague complaints but they take time."
In the first 20 minutes after Sinclair arrived, only two patients, a 35-year-old man complaining of cuts and bruises and a patient checking in for elective surgery, came to the triage desk to be registered. In the 20 minutes after that, a man came in for elective surgery, a 20-year-old woman came in with a complaint about her back, a 62-year-old man said he had a problem with his nose, and a 27-year-old woman said she was dizzy.
They were all triaged as either CTAS level three or four, not urgent enough to immediately rush them to a doctor.
Friday, Sept. 19, 3:07 p.m.
Kathy Boddy testified she arrived at the hospital less than an hour before Sinclair and left about two hours after he was there without being seen by a doctor.
Boddy said she was met by a man who wrote her name and why she was there on a clip board before telling her to go to the waiting room. A few minutes later she was called to the triage desk to register and then went back into the waiting room where she was told "it would be quite a long wait.
"It was really busy and the waiting room was quite full."
Boddy said she remembered seeing a man in a wheelchair in the waiting.
"I recall him having his head down and I thought... that he was just resting."
Boddy said she became frustrated about waiting so long and because she seemed to be getting better, she told a triage nurse she was leaving.
Friday, Sept. 19, 3:26 p.m.
Two patients later, Allison Peterson arrives with a family member wanting to be seen at emergency, but leaves without seeing a doctor an hour later.
"It was just so chaotic there that it just didn’t seem right," Peterson said.
"It just seemed like we shouldn’t be there because it was far too busy... there were just so many people in there.
"It was just so chaotic there that it just didn’t seem right."–Allison Peterson, patient
"It was crazy... some people were sleeping in there, some people were walking around, there was, the television was going. It was just so chaotic."
During Sinclair’s first eight hours there, 62 patients checked into the ER.
Dr. Howard Ovens, head of emergency at Mount Sinai Hospital in Toronto and a national expert on reducing gridlock in hospital emergency departments, has been able to reduce emergency room wait times by up to 30 per cent at his hospital.
Ovens said you can look at the numbers of patients who flowed through the emergency department, but it might not offer all the answers for what happened to Sinclair.
"The part you can’t reconstruct is what the waiting room looked like," he said.
"If he was allowed to stay there, was the emergency room used as a drop-in centre for the homeless?
"I think part of the operations of that staff is they tolerated a certain amount of hanging out or loitering there."
Saturday, Sept. 20, 1:04 a.m.
Michael Head and his wife arrive at the emergency room so she could be treated. During the 6.5 hours there before she is released, he testified he spoke with Sinclair and helped him.
"He was just sitting there and looking around," Head said. "I asked him how long he was sitting here, he said ‘Quite a while’."
Head also helped Sinclair into and out of the washroom and assisted him in getting a drink from a water fountain.
Head said when his wife was called into the treatment area he went to both a security guard and the nursing station and told them Sinclair had been there for a long time and was hungry.
"The nurse told me... they’re taking the people that’s more, more sick or something like that."
Through the rest of the night and into the morning, 37 patients came to the ER, with the most serious a 20-year-old woman needing a mental health assessment, an 18-year-old man and 24-year-old man with chest complaints caused by trauma, and a 46-year-old woman with an irregular heartbeat.
Saturday, Sept. 20, 9:46 a.m.
Nadir Kharma had been a doctor at HSC for about three months when he came to the ER as a patient.
"It looked really not busy and I remember that I was, I was happy because then I’ll be seen by the physician quickly.
"There were plenty of empty seats at that time."
Kharma said after getting seen in the treatment area he was told to return to the waiting room where it is was starting to fill up again.
Of Sinclair, Kharma said "he didn’t look in acute distress... he just looked like someone who’s been probably chronically ill, less than acutely ill."
Thirteen more patients walked through the doors in the next couple of hours. The most serious were a 41-year-old man with an altered mental status, a 68-year-old woman with toxic ingestion, a 42-year-old woman with a chest complaint, and a 36-year-old woman with a back complaint.
Saturday, Sept. 20, 11:35 a.m.
David Grant, his wife Evelyn, and their son arrive. They spent almost four hours there, the first hour in the waiting room where Sinclair rolls up beside them.
"He was obviously distressed," Grant said. "He was fidgeting and rolling back and forth in his wheelchair."
His wife was beside Sinclair when he threw up for the first time, causing her to move to another area of the waiting room and for him to alert a security guard. He said a hospital worker brought Sinclair a bowl, but when Sinclair threw up a second time he thought the man was blind because he didn’t use the bowl.
After Grant went to the security guard for a second time, a housekeeper came and mopped up the floor under Sinclair.
"It was so busy... there was people in there with their families... I didn’t think he was even a patient, you know, ‘cause a lot of times, I’ve been there and, you know, they’re there just (to) get out of the weather."
In the next hour there are only eight new patients, but of these there is a 29-year-old man with cuts and bruises and a 38-year-old woman with a chest complaint.
Saturday, Sept. 20, 12:39 p.m.
James Campbell arrives with a broken thumb. He’ll spend almost eight hours in emergency.
Campbell said when he sat down in the waiting room Sinclair was just behind him.
"I would look over my shoulder and see what looked like him having a problem," he said.
"He resembled a fish out of water gasping for air with his eyes rolling back in his head.'–James Campbell, patient
"He resembled a fish out of water gasping for air with his eyes rolling back in his head until he would, until he would vomit... five minutes after that had happened he’d, he’d seem to straighten out and be somewhat coherent."
Dr. Drummond says emergency waiting rooms get crowded because there’s no place to move from the treatment area patients who need further care.
There are no open beds readily available in the hospital because there are few open long term-care beds in the community and there is not enough home care, he said.
"Emergency room crowding is a result of hospital crowding so even if some leave the emergency you will still have a full up hospital," he said. "Diverting people from emergency does nothing about crowding."
The next three hours sees 16 patients come in, including a 49-year-old man with a chest complaint caused by trauma, a 45-year-old woman needing a mental health assessment, and a 55-year-old man with a diabetic complaint.
Saturday, Sept. 20, 3:15 p.m.
Diane Bell arrives with a family member seeking medical attention. She soon sees a man in a wheelchair with no legs who "seemed so weak and the odd time you’d see his hand or arm move." The family member is treated and she leaves about three hours later.
Nineteen people come in during the next 90 minutes. They include a 74-year-old woman with an altered level of consciousness and a 65-year-old man with a limb complaint caused by trauma.
Saturday, Sept. 20, 4:42 p.m.
Shawn Lanceley came in feeling sick after his apartment was fumigated. He left more than two hours later.
Lanceley said he first noticed Sinclair when he went to get a drink at a machine at the far end of the waiting room.
"When I walked by him I noticed there’s a pee smell and it was like, kind of, awful," he said. "(I) assumed... he was in need of some help."
He’s followed by a 44-year-old man with a limb complaint caused by trauma and a 76-year-old man with an abdominal complaint.
Cynthia McKillop arrives at 4:56 p.m. and will spend almost six hours in the emergency department after having a miscarriage.
McKillop said while she was in the waiting room she smelled a "strong odour" coming from Sinclair so she moved to another chair.
"The only thing I recall, still to this day, is that his eyes were closed," she said.
"I don’t recall, like, body movements or anything... he was, kind of, slunched over a little bit."
Dr. Ovens said it’s not uncommon for homeless people to find shelter in ERs.
"In my emergency (Mount Sinai Hospital in Toronto) we serve lots of homeless people. If you walked in and sat down and didn’t ask anyone for help in the busiest time of the day you could sit there for an hour and not attract attention.
"But there are times when our emergency room is not busy and the nurses will scan the waiting room. I have a high degree of confidence you couldn’t just camp there for 30 hours."
Saturday, Sept. 20, 5:51 p.m.
Just moments before, four more patients arrive. They’re followed by a 67-year-old woman who signed in for a booked elective procedure.
And, just a few metres away from the triage desk where this woman was signing in, Sinclair may have taken his last breath. An autopsy determined he could have died up to seven hours before he was discovered.
But no one noticed Sinclair and life went on in the emergency department.
Fifteen more patients came in, including a 56-year-old man needing a mental health assessment, a 26-year-old man with major trauma, which resulted in beinge admitted into hospital, and a 78-year-old woman with a neurological complaint.
Saturday, Sept. 20, 8:28 p.m.
Michelle Anne Samagalski’s husband arrives by ambulance after being injured in an ATV accident. She ended up spending seven hours in the waiting room.
"It got busier the longer we stayed... it was a Saturday night so there were, you know, a lot of people coming in during the course of our time there," she said.
Over the next 40 minutes, four patients arrive — a 60-year-old man with a neurological complaint and two women, aged 28 and 24, who came in separately reporting problems with their pregnancy.
Saturday, Sept. 20, 9:09 p.m.
Debbie MacPhail-Abraham came with her husband and a family member needing treatment. They wouldn’t leave until 3:36 p.m. the next day. It was the second time she came to the emergency department that weekend, the first being at 7:10 p.m. Friday during which she stayed 10 hours.
MacPhail-Abraham said she saw Sinclair within the first few minutes of arriving Friday night. When she came back the next night, Sinclair was "in the same spot.
“I was fixated on the fact that I wanted to see this fellow adjust himself in the wheelchair... and I didn’t see anything."–Debbie MacPhail–Abraham, patient
"I just had a funny feeling that something wasn’t right to be, you know I mean, 24 hours had almost passed."
MacPhail-Abraham told a nurse that they should check on Sinclair but "it was passed off."
She said when she and her husband went outside for a smoke, she could see Sinclair through the window.
"I was fixated on the fact that I wanted to see this fellow either adjust himself in the wheelchair, or something, and I watched and I didn’t see anything.
"I saw no motion at all."
MacPhail-Abraham said she told the same nurse she should check on him, but she only laughed. Later, after her family member was admitted into hospital, she came back specifically to have someone check on Sinclair.
After talking to a security guard, the guard tapped on Sinclair’s shoulder and lifted his chin, causing the man to slide a bit in his chair, before rushing Sinclair in his wheelchair to the treatment area of the emergency department.
"His face was lifted and I saw his, the colour of his face... he was very blue."
MacPhail-Abraham said the waiting room wasn’t busy.
"It was busy back where (her family member) was. It wasn’t overcrowded in the waiting room... I just felt that, you know, with all the hustle and bustle it was just, I was adding one more, more issue.
"They seemed like they were busy with other stuff."
While MacPhail-Abraham became increasingly concerned about Sinclair, 13 more patients arrive. They included a 39-year-old man having an abdominal complaint, a 44-year-old man with substance abuse, and a 53-year-old woman with a genital complaint.
Sunday, Sept. 21, 12:01 a.m.
Adrienne Martin arrives with a family member. Almost as soon as she sat down in the waiting room she saw a man in a wheelchair "kind of slumped over and I couldn’t see what his face was, his eyes were open or not.
"The nurses and the doctors went right past him, didn’t bother checking him, and I thought that was kind of weird... the doctors and nurses went past him about every 15 to 20 minutes."
Martin said at the time the waiting room "was kind of full and it was busy."
There are only two more patients over the next 50 minutes — a 49-year-old man with a neurological complaint and a 53-year-old woman with a limb injury caused by trauma — before hospital workers discover Sinclair’s plight.
Sunday, Sept. 21, 12:51 a.m.
A security guard quickly pushes Sinclair in his wheelchair into the treatment area and a code blue is initiated.
He is quickly pronounced dead when medical staff realize rigor mortis is setting in and begin asking questions about where he had come from.
Six years later, a judge will try to answer those questions.
"Brian Sinclair is just an egregious example of what happens every day in this country," Dr. Drummond said, noting emergency room physicians across the country are waiting to see the judge’s report.
"Let’s hope the example of Brian Sinclair is not in vain."
But Drummond believes Canadian doctors have to become as assertive as their British and Australian counterparts in their message to politicians.
"They say crowding kills — there is no more politeness."
Emergency room expert Ovens is also blunt when he talks about Sinclair’s death and what he expects will come out of the judge’s report.
"There will never be anything emerge from this that would justify what happened."
Kevin Rollason is one of the more versatile reporters at the Winnipeg Free Press. Whether it is covering city hall, the law courts, or general reporting, Rollason can be counted on to not only answer the 5 Ws — Who, What, When, Where and Why — but to do it in an interesting and accessible way for readers.