WINNIPEG – An inquest was told Tuesday that a man who died in a hospital emergency room was ignored almost the entire 34 hours he was waiting for care, even when he threw up three times.
Sgt. John O’Donovan said 150 people moved through the ER the weekend Brian Sinclair died, but he was the only one who didn’t receive medical treatment.
O’Donovan, who watched the surveillance footage of Sinclair’s time at the Winnipeg Health Sciences Centre in September 2008, said the video shows no one paid attention to the double amputee while he languished in the emergency department.
“He was the only person who wasn’t provided medical treatment,” O’Donovan testified. “I don’t know if he was being ignored on purpose. They weren’t aware of him there. He was ignored during his time there.”
Sinclair went to the emergency room because he hadn’t urinated in 24 hours. The video footage shows Sinclair arriving at the hospital by taxi and speaking to a triage aide. The aide appears to take notes on a pad of paper.
The sick man wheeled himself into the waiting room where he remained until he was discovered dead 34 hours later.
Manitoba’s chief medical examiner has testified the 45-year-old died from a treatable bladder infection caused by a blocked catheter. He said Sinclair needed about half-an-hour of medical treatment, including a catheter change and a prescription for antibiotics.
After Sinclair had been waiting for almost 24 hours, he vomited on himself three times, O’Donovan said. Medical staff moved in and out of the waiting room during that period, but never approached Sinclair, O’Donovan added.
“They were aware he had thrown up. He was provided with a basin by a member of the cleaning staff.”
Arlene Wilgosh, president of the Winnipeg Regional Health Authority, was in court for the video and said she found it disturbing. She also said she it was “concerning” that Sinclair vomited on himself three times but was never examined by medical staff.
“I found the video difficult to watch,” she said. “Mr. Sinclair came to us seeking care. As we’ve said before, we failed to provide that care, so I did find the video difficult to watch.”
The hospital has significantly changed the way it triages ER patients and no longer relies on pads of paper to keep track of people seeking care, Wilgosh said. Names are now entered electronically and people are given a wristband to help keep track of who needs to be triaged.
Staff also routinely go through the waiting room to reassess those who are waiting, she added.
“We are accountable,” Wilgosh said. “We have put in measures to try and ensure this does not happen again.”
Sinclair family lawyer Vilko Zbogar pointed out that six minutes of surveillance footage, covering the time when Sinclair was found dead and was wheeled away, are missing. O’Donovan said he hadn’t noticed the missing footage before and didn’t know why it is missing since the cameras were apparently working.
Norman Schatz, head of security at Health Sciences Centre, told the inquest the cameras record only when they detect motion. Sinclair was seated underneath the camera and wasn’t visible unless the camera scanned the room.
“One can assume there was no motion during that six minutes.”
Police spent a year investigating Sinclair’s death. No criminal charges were laid.
The inquest has heard Sinclair had a difficult life. He abused solvents which caused brain damage, lived on the street and lost both his legs to frostbite when he was found frozen to the wall of a church in the dead of winter.
The inquest is to sit until Thursday and resume again in October.

  1. WINNIPEG – A security guard testified Wednesday that nurses thought he was joking when he told them that a man had died during a 34-hour wait in a hospital emergency room.
    Security supervisor Gary Francis told an inquest into Brian Sinclair’s death that he had greeted the double-amputee the night he arrived at the Winnipeg Health Sciences Centre ER in September 2008.
    The following evening, Francis noticed that Sinclair was still in the same spot.
    “He was sort of just sleeping,” Francis told Judge Tim Preston.
    Around midnight, Francis was approached by a woman who said she thought Sinclair was dead. Francis said he explained that Sinclair slept with his head slumped over, but the woman insisted and added that the man’s catheter was disconnected and empty.
    The two went over to Sinclair. Francis said he tapped him on the shoulder and called his name.
    “There was no response. I pinched his neck and there was still no response.”
    Francis said he put his hand on Sinclair’s forehead and his head was stiff and tough to push back.
    “His eyes were completely black.”
    Francis wheeled Sinclair over to two nurses who were talking and said, “I need help. I think this fellow is dead.”
    “They looked at me and thought I was joking.”
    When a male nurse took Sinclair’s pulse, they “realized I was speaking the truth.” Sinclair was taken into a resuscitation room where Francis helped lift him onto a bed.
    “His entire body was stiff as a board.”
    Doctors tried to revive him, but he was pronounced dead several minutes later, Francis said. Francis tried to get Sinclair’s chart from the nurse on duty because he needed it for his report. He was told no chart had been created.
    “He was never triaged at all.”
    Another security guard testified that he had raised concerns about how long Sinclair had been waiting. Ed Latour said he was working the 12-hour night shift when Sinclair first arrived.
    Latour said he got worried when Sinclair was still in the same spot in the waiting room the following night.
    “He was slumped over in his chair,” Latour said. “He had his head bowed.”
    He said he went to the triage desk and spoke to the nurse on duty.
    “I expressed that concern to the triage nurse and asked if he was going to be seen,” Latour told the inquiry. “(The nurse) said he had been there the previous night, had been treated, gone home and returned.”
    Latour said he was assured “all was well with the patient” and that his “concerns were unwarranted.”
    He continued his patrol and found out a few hours later that Sinclair was dead.
    “One receptionist came out in tears and expressed Brian Sinclair had passed away.”
    Sinclair had been admitted to the hospital’s ER dozens of times over the years. The 45-year-old lost both his legs to frostbite in 2007 when he was found frozen to the steps of a church in the dead of winter.
    Sinclair often came in and sometimes appeared intoxicated, Francis said.
    “He would be yelling at the nurse because he wanted a blanket or a sandwich or some juice,” said Francis, who added that Sinclair once took a swing at a nurse who tried to move his backpack.
    Sinclair was referred to the emergency room by a local clinic on the afternoon of Sept. 19, 2008, because he hadn’t urinated in 24 hours. He is seen on security footage being wheeled into the emergency department by a taxi driver and speaking to a triage aide.
    The aide is seen writing on a piece of paper and Sinclair wheels himself into the waiting room and remains there. The inquest has heard that he threw up several times the next day, but was basically ignored.
    He was discovered dead after midnight on Sept. 20.
    Sinclair died from a treatable bladder infection caused by a blocked catheter. Manitoba’s chief medical examiner has testified that rigor mortis had already set in and Sinclair had probably been dead “for hours.”
    Garth Smorang, lawyer for the Manitoba Nurses Union, said the hospital had renovated its emergency department in April 2007. He suggested that nurses were concerned that the light in the waiting room area was “significantly dimmer” since the renovation.
    “I don’t share that concern,” Latour responded.
    The seating in the new ER was also different. Most chairs faced away from the triage desk, Smorang said. Sinclair would have been sitting about 25 metres away from the triage desk, he added.
    Another security guard working that weekend, Howard Nepinak, testified that he also saw Sinclair during both of his shifts on Friday and again on Saturday.
    “When I saw him on Friday, he looked OK, but when I saw him on Saturday, he was leaned over and appeared to be very weak and sort of in pain,” Nepinak said.
    He said he wondered what Sinclair was still doing there, but he assumed the man had been seen, gone home and returned again. Nepinak said he mentioned Sinclair’s presence to his supervisor but did not bring him to the attention of medical staff.
    The inquest is to sit Thursday and then is to adjourn until October.

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