Officials probe Winnipeg man's death after 34-hour ER wait

The head of the medical clinic that sent a Winnipeg man to the Health Sciences Centre emergency room, where he was found dead 34 hours after he arrived, says her clinic is not to blame.

The man, identified asBrian Sinclair, 45, arrived by taxi at the Health Sciences Centre around 3 p.m. Friday from the Health Action Centre, a community health centre in central Winnipeg.

'I, in all conscience, feel that we are squeaky clean in terms of our care.' Dr. Diana Bennett

He was found dead after midnight Sunday, when someone in the waiting room alerted the hospital staff. There has been no word on the cause of death.

It appears Sinclair was never assessed by a triage nurse and was not registered as a patient seeking care, health officials said Tuesday.

Dr. Diana Bennett, who runs the Health Action Centre, said Sinclair was a regular patient at the clinic.

Staff sent him by taxi to theemergency roomFriday afternoon because he needed more care than they could offer, she said. He was given a letter by his doctor explaining his medical situation, she said, and when he left he was fully competent to travel on his own.

"I, in all conscience, feel that we are squeaky clean in terms of our care. We have taken very careful trouble and have that very appropriately documented about his care," she said.

"I have no concerns about his merit of transport and the decision made there, and I have no knowledge of what happened next."

Bennett said clinic staff regularly refer patients, who often have complex but non-emergency health issues, to the HSC emergency room.

"I hope that his death wasn't a death resulting from poor care. And if it is, I hope it will help us to do better," she said.

Her staff is co-operating with investigators examining the case, she said. Officials with the Winnipeg Regional Health Authority said they expected the investigation would take about a month.

Latest addition to tragic list

Sinclair is the latest addition to a list of deaths at Manitoba emergency wards, despite a task-force report meant to correct problems:

• In 2000, Robert Collicott died of a blood infection before he got to see a doctor; he had been sitting in the HSC waiting area for 4 hours.
• In 2001, Herman Rogalsky, 58,died in a waiting room at the Health Sciences Centre while waiting for an ultrasound.
• In 2003, Dorothy Madden, 74,died of a heart attack in the waiting room of St. Boniface Hospital's emergency ward, after a six-hour wait.
• In 2004,after a 20-year-olda woman shared her story about miscarrying after a four-hour wait at the Health Sciences Centre emergency room,nearly a dozen otherwomen reported similar stories.

That same year, the provincial government created an emergency-care task force to examine the issue.

It responded with 46 recommendations for change, including more training for emergency room staff, new computer equipment and technicians, and nurses specially assigned to reassess patients in waiting areas.

The extra nurses were a key issue when the report was published. The Winnipeg Regional Health Authority says it hired those nurses; at the Health Sciences Centre, they are on duty daily from 10 a.m. to 10 p.m.

Staff and their assignments at the hospital over the weekend, while Sinclair waited for care, are part of the ongoing investigation, health officials said.

New directive to ER staff

Health Minister Theresa Oswald noted that theaddition of reassessment nurses to emergency wardsdid notaddress the problem of people who don't present themselves to the triage desk in an emergency room, as appears to have happened in Sinclair's case.

Manitoba Health has asked emergency rooms to make changes to prevent anyone elsefrom falling through the cracks in a similar way, she said.

"We did that yesterday to ensure that every person is spoken to in the waiting room, just to say, you know, 'Hello, have you seen the triage nurse? Have you spoken to someone and registered?'" she said Wednesday morning.

"This is a tragedy. This is the centre, we believe, of this issue and we're immediately putting steps in place to fix that."