Release the report

Hey there, time traveller!
This article was published 10/02/2009 (6444 days ago), so information in it may no longer be current.

THE more the public hears about Brian Sin­clair’s last hours alive in the emergency ward at Health Sciences Centre, the more perplexing his death becomes. The Winnipeg Regional Health Authority, insisting the death was caused by “system­ic” issues, refuses to release the report it prepared following an administrative review of the incident.
 

The WRHA’s “trust us” attitude cannot be tolerated.
  It must be compelled to release the report.

The public cannot be expected to await answers from the inquest that has yet to be scheduled into Mr. Sinclair’s death last September. Why did officials not know that Brian Sinclair did, indeed, "present himself formally to the triage desk" at about 3 p.m., Friday, Sept. 19, contrary to the WRHA’s story since September? What was said between him and the triage aide, who apparently noted something on a clipboard, before Mr. Sinclair, a double amputee, wheeled his chair to the waiting room? Mr. Sinclair made contact with various support staff during his 34 hours in the ER, but the WRHA says that he spoke to no medical staff. How can that be when Mr. Sinclair, suffering from an infection brought on by a blocked catheter, began vomiting, such that security staff repeatedly attempted to get the attention of medical staff?

The details of the triage contact and the vomiting were revealed last week by Manitoba’s chief medical examiner, Dr. Thambirajah Balachandra, who has called an inquest. The revelations, some of which come from security camera tapes, cast a new light on the tragic event, until now portrayed by the WRHA as the result of a poorly designed ER, where visitors could enter the waiting room without meeting triage staff. Initially, the man’s death was explained as a result of a confluence of factors: Mr. Sinclair, a homeless man with a speech impediment, was one of a number of dispossessed people who sought shelter at HSC’s ER. He was well-known to staff but perhaps escaped notice of medical personnel because it was assumed he was merely looking for a place to rest.

Some facts are now clearer. Mr. Sinclair did approach the triage desk; he vomited during his wait. If he did not have contact with a doctor or a nurse after vomiting, why not? Why did the WRHA’s spokesman, Dr. Brock Wright, refuse until days ago, to admit Mr. Sinclair met triage staff? He clung too long to an account that approaches wilful blindness, refusing to review security tapes.

Too much of Mr. Sinclair’s time at HSC remains shrouded in a fog created by a lack of public accountability. The WRHA says it is holding back the findings of the administrative review "out of respect" for the inquest process, which means details of the lack of care are hidden, perhaps for months.

The fixes put in place — waiting room seats now face the triage desk; a greeter at the ER door tags the wrists of those requesting medical attention — may be adequate, but perhaps not. The explanations of officials upon which the public was forced to rely have been misleading and wrong.

Trust has been broken, yet no one has been held to account. Health Minister Theresa Oswald must order the WRHA to release its administrative review report immediately.