No nurse was assigned to keep a continual eye on patients in a Winnipeg hospital's emergency room on the day Brian Sinclair arrived for care, even though authorities had committed to ensuring such a process would be in place, CBC News has learned.
That finding is contained in a confidential Critical Incident Investigation Committee (CIRC) report, details of which have been obtained by the CBC News I-Team.
Sinclair, a 45-year-old double-amputee, went to Winnipeg's Health Sciences Centre for treatment of a blocked catheter and a urinary tract infection. He died in the emergency department waiting room on Sept. 21, 2008, after sitting for 34 hours without receiving care.
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The committee's report found that when Sinclair arrived in the emergency room on Sept. 19, 2008, "the reassessment nurse was reassigned from his role in the WR [waiting room] at 14:30 to look after high acuity patients in the department."
The 2003 death of a woman who was waiting for care in an emergency room had led authorities to create a reassessment nurse position to ensure patients waiting to be seen are waiting safely.
Reassessment nurses would be responsible for communicating with patients and providing comfort measures such as pain relief, as well as acting as advocates for the patient and family.
The Winnipeg Regional Health Authority (WRHA) says this policy was in place when Sinclair died in the ER in 2008.
"If these things that were supposed to be in place weren't in place, then how did that contribute to the tragedy of this event?" Progressive Conservative health critic Cameron Friesen said Thursday.
"Also, it calls into question then: are those recommendations in place today?"
The Sinclair investigation report says that on Sept. 19, 2008, the emergency department was short five nurses and was only able to fill two of those positions, which explained why the reassessment nurse was reassigned that day.
The report states that there was no shortage of nursing staff the following day starting at 7:30 a.m., while Sinclair remained in the emergency room without receiving treatment.
Task force created following Madden death
The recommendation to establish reassessment nurses was included in the report of the 2004 Emergency Care Task Force, convened by then health minister Dave Chomiak.
The task force was created after 74-year-old Dorothy Madden, who had suffered a heart attack, died while waiting six hours without being seen by a physician, and without having been reassessed following her initial triage.
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It was Chomiak who fielded questions on Thursday — as acting health minister — about why there was no reassessment nurse assigned to the Health Sciences Centre's ER when Sinclair sought care there in 2008.
"The reasons why there were no reassessment nurses in place on the day in question will be answered by the inquest. That is a substantive question that will be answered by the inquest," Chomiak told reporters.
An inquest into Sinclair's death began last month, with testimony to continue in October.
The 2004 task force report examined staffing levels at emergency departments in Winnipeg and looked at ways to reduce wait times.
It recommended that the reassessment nurse role be created at all emergency departments in Winnipeg, at a cost of $1.45 million annually.
The position was initially introduced at the Health Sciences Centre and at St. Boniface General Hospital, and the task force noted that it improved quality of care and patient flow.
The CIRC report into the Sinclair case has been kept confidential under provincial legislation governing critical incident reporting and will not be entered as evidence at the inquest into Sinclair's death.
Manitoba Liberal Leader Jon Gerrard called on the provincial government to find a way for the report to be included in the inquest.
The report also reveals, among other things, that four members of the public had approached ER staff on four separate occasions with concerns about Sinclair's well-being, but their concerns were "largely ignored."
Confusion over staff roles
The CIRC report says there was confusion in the emergency room in 2008 over the roles performed by different staff members, including the triage nurses, reassessment nurse, triage aide, security guards and hospital volunteers.
"There is the greatest role variability with the nursing staff. There are no role descriptions for triage and reassessment, and each nurse interviewed described some variation in how he/she fills that role," the report states.
"This level of variability correlates with a low reliability process, and creates confusion and uncertainty among the staff."
The report continues, "Of great concern is the fact that when a 'role' is absent for any reason … there is no plan for how that absence will be managed. Within the staffing shortages, it is understandable that the role may not be replaced, but there does not seem to be any plan for mitigating the risk associated with losing that role function."
The WRHA says it cannot comment on the Critical Incident Investigation Committee's report because it is protected under provincial legislation.
However, a spokesperson for the health authority told CBC News the issue of nursing roles in 2008 and the present will be examined at the inquest.
While the report says the Health Sciences Centre's ER had a nursing staff shortage of about 19 per cent in 2008, the WRHA says that shortage is now at about one per cent.
The report included five recommendations in November 2008 for improving emergency department care in Winnipeg. The WRHA says all five recommendations have been implemented.
Those recommendations include:
- Clarifying the roles of all staff and volunteers in the emergency department.
- Communicating with each person in the waiting room at least once every four hours.
- Ensuring everyone arriving for care is registered into an electronic system before going into the waiting room.
- Making sure the triage team does not have to deal with patients not needing emergency care.
- Due to the high-stress nature of triage and reassessment, the nurses filling those positions should be rotated into other positions every four hours.