Winnipeg's health authority has admitted that it failed Brian Sinclair, who died in his wheelchair after sitting for 34 hours in a hospital's emergency waiting room in 2008.
William Olsen, the lawyer for the Winnipeg Regional Health Authority (WRHA), told the long-awaited inquest on Tuesday into Sinclair's death that no single person was responsible for what happened, but there is no doubt that errors were made.
Olsen apologized to Sinclair's family, saying several erroneous assumptions were made and opportunities missed, leaving Sinclair to fall through the cracks.
"A perfect storm occurred," he told Judge Tim Preston. "The WRHA failed him … at all levels of the organization."
The inquest, led by a provincial court judge, is examining what happened between the time Sinclair came to the Health Sciences Centre's emergency room in September 2008 and when someone else in the waiting room told a security guard they believed Sinclair was dead.
Sinclair, a 45-year-old double-amputee, was soft-spoken and hard to understand, Olsen said. He was also cognitively impaired and fiercely independent, he added.
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"That cannot be an excuse for failing to ensure he was properly reviewed by the system as a person requiring care," Olsen said.
The hospital was responsible for Sinclair the minute he came through the door of the emergency room, he said.
"We failed in that respect," Olsen said.
The Sinclair family lawyer, Vilko Zbogar, said similar comments to that of Olsen during his opening remarks.
Zbogar said problems were widespread and he cannot point to one single mistake being responsible for Sinclair's death.
Murray Trachtenberg, another lawyer for the Sinclair family, said Sinclair was told to wait to see a triage nurse and that's exactly what he did.
"He waited and waited, growing sicker and weaker by the minute. There were numerous opportunities for medical staff to ensure he received the help he needed," Trachtenberg said, noting at one point Sinclair even vomited on himself.
The inquest heard that Sinclair was a frequent visitor to the emergency room and struggled with substance abuse. He had been to the HSC emergency room some 50 times, the inquest was told.
"But it was not his demons that killed him," Trachtenberg said.
"It was the angels — the professionals we all turn to in times of urgent medical need — that egregiously and fatally let him down.
"Everyone who could have helped, didn't. How could the system have allowed such a catastrophe to happen?"
Race bias questioned
Emily Hill, a lawyer with Aboriginal Legal Services of Toronto, which has standing at the inquest, said many questions need to be answered.
"Why did he fall through the cracks? How could this happen in a big urban centre with a well-equipped ER that is there to meet the needs the most vulnerable in our community?" she said.
Hill said she also wants to learn more about what kind of assumptions might have been made about Sinclair when he turned up at the ER.
“I think bias may have played a role in some of the assumptions and may have contributed to what would appear to be some indifference with regard to his health needs," she said.
Security tape at the Health Sciences Centre shows Sinclair went to the triage desk and spoke to an aide before wheeling himself into the waiting room.
That appears to have been his only interaction with staff.
Almost a day-and-a-half later, another person in the waiting room finally spoke up about Sinclair. Efforts to revive him were unsuccessful.
Shock 'hasn't worn off' for family
His death was later attributed to a treatable bladder infection.
Manitoba's chief medical examiner, Dr. Thambirajah Balachandra, said Sinclair would have lived if his blocked catheter had been changed and his infection treated.
All Sinclair would have needed was a catheter change and antibiotics, Balachandra told the inquest on Tuesday afternoon.
"Brian's death did come as a shock and the shock hasn't worn off," said Zbogar. "Brian's name has been in the press as a news story, but to his family he was a loved one."
Like Hill, Zbogar said he hopes the inquest will show whether Sinclair was treated differently because he was a low-income aboriginal person.
"There will be some analysis of the systemic issues — whether his race, his disability, his socio-economic status affected the treatment he received, or the indifference he received," he said.
Zbogar said the other goal of the inquest is to identify ways to prevent similar deaths.
But Sinclair’s sister, Esther Grant, said nothing hospital workers can say will excuse what happened to her brother.
"Never. I'll never forget what happened to my baby brother,” she said.
"It's gonna be in my heart 'till the day I die. I'm never gonna forget it."
Ken McGhie, a pastor who had been a close friend of Sinclair, described him as a respectful and quiet man.
"He would have been the kind of person who just waited and waited…. Hopefully something was going happen for him, and [it] never did," McGhie told reporters.
Hospital has made changes
The Health Sciences Centre has already made changes to the registration and triage process and the physical layout of the ER waiting room.
"This could have happened to anyone with similar medical issues," Olsen said, adding it was not an aboriginal issue.
McGhie said the wristbands now being used to identify people waiting in the emergency room should be dedicated to Sinclair.
"A man lost his life because he fell through the cracks," McGhie said.
"That band that they're making them wear now when anybody comes in, looking for attention at the Health Sciences [Centre], should be called the Brian Band."
Police and the Crown attorneys office investigated the death to see if charges of criminal negligence or failing to provide the necessities of life might have applied. But they decided no charges were warranted.
The WRHA has paid $110,000 in damages to the Sinclair family for loss of care, guidance and companionship.
With files from The Canadian Press