Did he die in vain?

Opinion

Hey there, time traveller!
This article was published 13/12/2014 (3921 days ago), so information in it may no longer be current.

Brian Sinclair did not have to die.

You can search through the entirety of provincial court Judge Timothy Preston’s remarkable, 190-page inquest report on Sinclair’s 2008 death at Winnipeg’s Health Sciences Centre, but you will find no greater truth than that.

Sinclair came to HSC’s emergency department (ED) and waited 34 hours without receiving medical treatment before being found dead in his wheelchair. He was dead for many hours before anyone took action.

Even before this report came out, the impacts of Sinclair’s death have been profound, including a redesign of the ED from both a physical and procedural standpoint. As well, there have important discussions about improving patient flow to reduce the chaos that is endemic in Canadian EDs.

Even with those positive steps, Judge Preston’s report will still create a lot of anger about what happened to Sinclair.

Little of the evidentiary findings in the report are new; many people followed the inquest closely and heard news reports about the circumstances of Sinclair’s demise. And yet, the complete story of Sinclair’s visit to the ED, and all the people he came into contact with, is difficult, disturbing reading.

In short, Sinclair was sent to emergency with a note in his breast pocket from a physician alerting HSC to the fact the chronically ill, legless man was suffering from an infection brought on by a dysfunctional catheter.

Despite this, he was never recorded as a patient, scheduled to be assessed by a nurse or examined by a physician. With diminished cognitive skills and difficulty speaking, Sinclair did not plead his own case, nor did he reveal the letter in his pocket.

Many others in the ED waiting room did notice Sinclair, and several brought his deteriorating condition to the attention of hospital staff. Either because they didn’t have the time or didn’t want to devote the time, no medical professional approached Sinclair to find out what was wrong with him. He died of a treatable condition while sitting in the middle of one of the busiest and most sophisticated health-care facilities in the city.

That conclusion paints a highly unflattering portrait of the staff of the HSC emergency department. That will be seen as inherently unfair by many of the nurses, aides and security guards working at HSC and throughout the health-care and social-service systems. And they are not wrong. For the most part, these are people who perform heroic, underappreciated work. People who literally save lives every day.

Indeed, the report details the comprehensive and dignified medical and social help that was provided to Sinclair, a man who was in frequent need of treatment but who could do little to care for himself. The report details the complex network of service providers — from home-care workers to social workers, nurses and physicians — who tried to make Sinclair as healthy and comfortable as possible.

And yet, through the inquest’s critical analysis, we can see quite clearly the culture of the HSC emergency department, and the attitudes of the staff on duty over those 34 hours, played a key role in Sinclair’s death.

In testimony at the inquest, it was clear nurses ignored the pleadings of other patients to attend to Sinclair. In their defence, they pointed out chronic understaffing at the ED. And the patient-flow protocols — procedures to move patients from emergency to other areas of the hospital — were insufficient bordering on dysfunctional.

But we also heard about how nurses were predisposed to ignore the pleadings of other patients, even those with medical training. We heard about how nurses believe patients are “not in the best position to assess the urgency” of other patients. And how other nurses deliberately avoided interacting with patients because it took time away from other administrative duties.

Lawyers for Sinclair’s family and others will continue to argue he was a victim of racism. And that may have played a role. However, front-line staff did not just ignore Sinclair; they also ignored the pleadings of non-aboriginals who tried to come to his aid. There are stereotypes at work here, and not just those based on skin colour.

Ultimately, the inquest report confirms this is a story abut the culture of health care, and the canyon separating front-line staff from the people they are supposed to be helping.

Judge Preston’s conclusion was Sinclair’s death, while completely preventable, was not in vain. Although there has been change, it is still much too early to reach that conclusion.

The health-care system, and those who perform God’s work within it, must show much more in the way of commitment to changing both culture and process. The health authorities and the politicians that oversee them must also find the resources to do more than just cover the bases of emergency care.

Only then will we know for sure that Sinclair’s death had meaning.

dan.lett@freepress.mb.ca