Death after 34-hour ER wait was preventable: judge
Brian Sinclair was cool to the touch with rigor mortis setting in when a doctor finally saw him, 34 hours after he arrived at Winnipeg hospital emergency room in September, 2008.
No one knows exactly when he died, but the 45-year-old Aboriginal man’s agonizingly-long wait was recorded in security camera footage that has shocked Canadians.
On Friday, Judge Timothy J. Preston released his final report that concludes Sinclair’s death -- likely from a bladder infection and blocked catheter -- could have been prevented.
“If the catheter had been changed and antibiotics administered, he likely could have survived,” the inquest judge wrote. “The [Chief Medical Examiner] estimated that treatment time would have taken approximately half an hour to an hour.”
Preston offered 63 recommendations aimed at preventing other people from dying in similar circumstances. He heard from 82 witnesses over 40 days, including doctors and nurses from the Winnipeg Health Sciences Centre where Sinclair died, family members, home care nurses, and social workers. The recommendations include better triage in emergency rooms, more hospital staff, the presence of Aboriginal elders in some hospitals, and cultural sensitivity training for all health care workers.
Sinclair’s relatives are not satisfied with the report. Robert Sinclair, his cousin, says Preston failed to address the institutional racism he believes caused the tragedy.
"We're stereotyped -- we like to drink, we like to be on welfare -- all those bad stereotypes which are silly," Robert Sinclair says. "That stuff needs to be addressed.”
The family’s lawyer had asked that the death be ruled a homicide on the grounds that failing to provide medical care was akin to failing to provide the necessities of life. Preston dismissed that idea.
He did, however, outline a number of “incorrect assumptions,” that were made by hospital staff about Sinclair while he was in the emergency room, including that he had already been seen, that he was simply “sleeping off his intoxication,” and that he was “a homeless person seeking shelter.” Preston found no evidence of intoxication and noted that Sinclair was not homeless at the time.
Preston also outlined a number of gaps in communication between social workers and home care providers that preceded his death.
“Brian Sinclair’s pre-existing medical conditions made him vulnerable,” he wrote. “He had a limited awareness of his vulnerabilities and his communication skills were compromised.”
Sinclair was a double-amputee, having lost his legs after being evicted from his rental accommodation and literally freezing to the wall of a church. He struggled with solvent abuse. Many people had difficulty understanding him when he spoke. He had been made a ward of the Public Trustee, a provincial representative who was supposed to look after his welfare, after a doctor decided he “did not appreciate the degree of his disability and dependence… and would lack the capacity to arrange, organize for his care needs.”
The home care nurse charged with changing his catheter every six weeks told the inquest that she did not know he was a ward of the Public Trustee. She had stopped changing his catheters after having trouble tracking him down.
With files from The Canadian Press