Death of Brian Sinclair

Brian Sinclair (1963 – September 21, 2008) was an Indigenous Canadian man whose death in a hospital waiting room led to widespread concern on the state of the healthcare system in Canada. On September 21, 2008, Sinclair waited 34 hours for medical attention at Winnipeg's Health Sciences Centre.[1] Sinclair died while waiting and had developed rigor mortis by the time medical staff attended to him.[2]

Hospital visit

On September 19, 2008, after not urinating for 24 hours due to a blocked catheter, Sinclair visited a community health clinic who referred him to the Winnipeg Health Sciences Centre.[3]

At 3:00pm, Sinclair arrived via taxi to the emergency room at the Health Sciences Centre with a note from the clinic explaining his condition.[4][3][5] Sinclair spoke with a triage aide, who instructed him to wait in the waiting room.[4] The aide wrote something on a piece of paper before Sinclair wheeled himself into the waiting room. The piece of paper has never been found.[6]

During the evening of September 19, 2008, the triage list was discarded.[6]

At 1:00am on September 20, 2008, other patients state they spoke to Sinclair, who had then been waiting for 10 hours.[4] One patient allegedly spoke to medical staff urging them to attend to Sinclair with medical staff responding that they were attending to other patients.[4] While waiting, Sinclair had also vomited several times.[4]

Between the late evening of September 20 and the early morning of September 21, 2008, Sinclair dies in the waiting room.[5]

Before 1:00am on September 21, 2008, a nurse was requested to check on Sinclair.[4] The nurse did not believe the request was urgent and instead completed paperwork.[4] Shortly after, a nurse from another facility approached a security guard and stated she thought Sinclair was dead as his neck was "pasty" and his catheter was empty.[7] The security guard attended to Sinclair, pinched his neck, and received no response from him.[7][4] The security guard then contacted medical staff informing them that he believed that Sinclair had died.[7][4] The staff first thought that it was a joke.[7] They then moved Sinclair into a resuscitation room, where he was immediately declared deceased.[4][7]

An autopsy later found that Sinclair had a treatable bladder infection brought on by a blocked catheter and had been deceased for two to seven hours before he was noticed by medical staff.[5][6]

Aftermath

During his time in the waiting room, Sinclair had been observed on at least 17 occasions. In several instances, security staff or other patients in the waiting room raised concerns about his condition to nursing staff, but were ignored.[6][5] An inquest into Sinclair's death found that medical staff assumed he was intoxicated, had already been discharged and had nowhere to go, had been triaged already and was waiting for a bed in the back of the treatment area, or that he was homeless and was seeking shelter from the cold weather.[3][4][6]

Sinclair was Indigenous, a double-amputee, used a wheelchair, and had a history of substance abuse.[4][3][5] Sinclair's family alleged assumptions were made about him because he was an Indigenous man in a wheelchair.[6] The Winnipeg Regional Health Authority conducted an internal review and concluded it would be unfair to discipline staff.[6] The review remarked that staff, including one who had known Sinclair since he was 16 years-old, were hurt by such allegations, stating “The staff of the adult emergency department are hurt, angered and frustrated that they have not been able to tell their story to counteract these allegations". [6]

In 2013, the president of the Winnipeg Regional Health Authority stated that "Mr. Sinclair’s death was preventable. He came to us seeking care, and we failed him".[8] The health authority apologized to Sinclair's family and began an inquest into his death.[8]

In 2014, a report concluded that Sinclair's death was preventable and put forward 63 recommendations to overhaul the front end of Winnipeg's health-care services, including how patients in emergency rooms are triaged and registered.[3]

In 2017, a group of doctors across Canada claimed that Sinclair died due to racism.[3] The group recommended that federal and provincial governments implement policies to address racism in health care.[3]

See also

References
  1. "Brian Sinclair ignored by Winnipeg ER:report". CBC News. September 5, 2013. Archived from the original on August 10, 2020. Retrieved August 10, 2020.
  2. "Death after 34-hour ER wait was preventable: judge". CTV News. December 12, 2014. Archived from the original on August 10, 2020. Retrieved August 10, 2020.
  3. "Ignored to death: Brian Sinclair's death caused by racism, inquest inadequate, group says". CBC News. September 18, 2017. Archived from the original on August 10, 2020. Retrieved August 10, 2020.
  4. "Brian Sinclair's condition didn't seem urgent, inquest told". CBC News. January 6, 2014. Archived from the original on August 10, 2020. Retrieved August 10, 2020.
  5. Lett, Dan (November 19, 2013). "Emergency department problems raised at Sinclair inquest". Canadian Medical Association Journal. 185: 1483. doi:10.1503/cmaj.109-4633. Archived from the original on August 10, 2020.
  6. "'Unfair' to discipline staff for Winnipeg man's death during ER wait: hospital". Maclean's. September 13, 2013. Archived from the original on August 10, 2020. Retrieved August 10, 2020.
  7. ""ER staff didn't believe Brian Sinclair was dead, even when other patients told them". Winnipeg Sun. August 28, 2013. Archived from the original on August 10, 2020. Retrieved August 10, 2020.
  8. "WRHA president's staff note about Brian Sinclair inquest". CBC News. August 8, 2013. Archived from the original on August 10, 2020. Retrieved August 10, 2020.
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