A confidential report into the 2008 death of Brian Sinclair at a Winnipeg hospital shows that four members of the public approached emergency room staff on four separate occasions to report concerns about Sinclair but were "largely ignored."
"For largely legitimate reasons the 'public' is not perceived as a useful source of information for the triage team; rather they are an interruption at best and a threat frequently," states the report, which has never before been made public.
Sinclair, a 45-year-old homeless double-amputee, went to the Health Sciences Centre for a blocked catheter and a urinary tract infection. He died in the hospital's emergency department waiting room on Sept. 21, 2008, after sitting for 34 hours without receiving care.
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The finding is among details obtained by the CBC News I-Team from the Critical Incident Review Committee's final report of Nov. 7, 2008 — a document that will not be entered as evidence in a judicial inquest into Sinclair's death that began last month.
Authorities have never shared the report with the Sinclair family or its lawyer, Vilko Zbogar. When CBC News informed him of the document's contents, Zbogar called them troubling.
"There's an approach of contempt or antagonism towards the public, just a lack of respect of the role they have to play in the system," he said.
"It looks like Mr. Sinclair had no chance, no matter how many people came up to nursing staff to seek help for him."
Report kept confidential by law
Recommendations contained in the report were released publicly by the Winnipeg Regional Health Authority (WRHA) in November 2008, but the report itself has been kept confidential under provincial legislation governing critical incident reporting.
"If it turns out the public is viewed as the enemy, a threat, or a disruption, then there is yet one more deep cultural problem in the WRHA that needs to be addressed," says Arthur Schafer, an ethics professor at the University of Manitoba.
In a statement to CBC News, the health authority says it cannot confirm or deny the contents of the Critical Incident Review Committee's report because the document is protected by law.
But WRHA spokeswoman Heidi Graham says the health authority has acknowledged there were "gaps" in the way the emergency department functioned.
"This is why WRHA has always acknowledged that Mr. Sinclair came to us for help with a treatable medical condition, which we failed to provide," Graham said.
"It's why our counsel, on day one of the inquest, called this a 'failure at all levels' and said the WRHA, including its employees, collectively failed Mr. Sinclair."
But Dr. Brian Goldman, an emergency-room physician in Toronto, said the public has a right to know about problems in the medical system.
"Provincial privacy laws can sometimes be self-serving in that they allow things to be kept secret when, really, what we want is openness and transparency so that everybody knows that it was investigated thoroughly and here's the result," he said.
4 attempts to alert staff
The report attempts to explain why ER staff failed to provide care to Sinclair, despite the four attempts by members of the public to alert staff to his deteriorating condition.
After Sinclair had already spent the night at the hospital, "someone from the waiting room approached a security guard to report that a person [Mr. Sinclair] in the waiting room was getting sick," the report states.
"The security guard called housecleaning to clean up," but no one addressed his medical condition, according to the report.
Another visitor in the waiting room later approached a different security guard, who mentioned to the triage aide that there was a person in the waiting room who "didn't look so good."
Again, no medical help was offered, the report said.
Other visitors tried to help, too. The report says a family that was in the waiting room on the night of Sept. 19, 2008 — the day Sinclair entered the emergency room — returned to the ER the following night, a Saturday, for their daughter's care.
"They reported that they were concerned when they saw the same man in his wheelchair in exactly the same place on Saturday night" and they alerted a security guard, according to the report.
"The security guard explained that Mr. Sinclair was a homeless person who was in the ER to get inside and watch TV," the report states.
It also says the couple then "expressed concern about Mr. Sinclair to one of the nurses, who responded, 'We are very busy but we will get to him.' They enquired again after 20 minutes and were told, 'We have not had a chance to see him yet.'"
9 security guards were on duty
Nine security guards who were on duty during Sinclair's time in the ER have been called to testify at the inquest. Several of them testified that members of the public had alerted them because they were worried about Sinclair's condition.
Members of the public are expected to testify in October.
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"In the culture of medicine, there's a tendency to think that patients and their families have nothing to contribute clinically to the discussion … telling staff that something is wrong," said Goldman.
Goldman said it used to be typical for medical staff to ignore new mothers' concerns about their babies, but now that is seen as a sign something could be wrong.
The report into Sinclair's death also describes the staffing level in the Health Sciences Centre's emergency department.
On Sept. 19, 2008, the day Sinclair arrived at emergency, the report says, "The charge nurses was short five nurses for the department and was only able to fill two of those."
But the report says there was no staff shortage on the following day.
"Although many staff noticed Mr. Sinclair in the waiting room during his stay, no staff member saw him as a patient in need. This cannot be explained by staffing shortages as there were full staffing levels from 7:30 on September 20th," the report states in part.
In analyzing why staff largely ignored efforts by the public to draw attention to Sinclair, the report cites staff having very high levels of competing priorities for their attention. It also notes that staff have been influenced by negative experiences.
Waiting room a 'war zone,' say staff
"The staff describe the HSC waiting room as a 'war zone'; 'I am constantly under attack'; 'I have recurring nightmares that I look up from the desk into the barrel of a gun'; and 'security is there to protect us,'" the report says.
Schafer said the committee's report is an indication of major problems.
"One's reaction is shock. How is it possible that conditions in the emergency room were a war zone and yet nothing was being done about this?," he said.
"Does the Health Sciences Centre and its supervisors at the WRHA — are they ignorant of these conditions? Are they unable or unwilling to correct them?"
When the committee's recommendations were announced in November 2008, then WHRA vice-president Jan Currie said staff "did not realize that Mr. Sinclair had come seeking care."
The health authority's chief medical officer, Dr. Brock Wright, initially told the public that Sinclair had failed to present himself to the triage desk, but the Critical Incident Review Committee's report states otherwise.
"The WRHA were putting out statements that were false, misleading and deceptive, and they allowed these statements to stand for months without making any effort to correct them. That's deeply worrying," said Schafer.
Video shows Sinclair at triage desk
In February 2009, the WRHA acknowledged that security camera video footage showed Sinclair approaching the triage desk upon arrival.
However, that acknowledgement came after that information was made public by the province's chief medical examiner.
The Critical Incident Review Committee's report describes Sinclair arriving in a taxi van at the emergency department just before 3 p.m. on Sept. 19, 2008, with the driver pushing him in his wheelchair up to the triage desk before departing.
"Brian is spoken to by the triage aide who is then observed to presumably write something," the report states.
WRHA officials have said from the beginning that Sinclair had not been triaged.
"They knew that there were flaws in the triage system. There were previous instances of individuals not being triaged," said Zbogar, the family's lawyer.
"They knew that there was a problem, and to allow that problem to persist is what killed Brian Sinclair, and that indicates to us that it's not just negligence, it's recklessness."