3 p.m. Brian Sinclair arrives at the Health Sciences Centre.
It will be another four and a half months before details of what transpired in the emergency room are revealed. Even then the reports will be so confusing that we can’t tell with assurance which is accurate.
The earliest reports say Sinclair arrived by taxi. But Chief Medical Examiner Dr. Thambirajah Balachandra says “an unidentified man who drove a white van wheeled Sinclair into the ER and up to the triage desk.” (Winnipeg Free Press, Feb. 4, 2009)
Security video shows that Sinclair wheeled himself into the line at the triage desk where the triage nurse on duty was seeing one person ahead of him. “a triage aide then approached Mr. Sinclair, spoke with him and wrote something down on his clipboard. Mr. Sinclair is then seen wheeling himself into the waiting area. (Brock Wright, vice-president of the WRHA, Winnipeg Free Press Feb. 5, 2009)
Sinclair began to exhibit symptoms of the bladder infection that would kill him.
Brian Sinclair sat vomiting in the Health Sciences Centre emergency room as security guards tried to alert triage staff to the ailing double-amputee’s urgent need for care. Hospital security staff tried “many times” to get the attention of triage and “other staff” because Sinclair needed help. (Dr. Thambirajah Balachandra, Winnipeg Free Press, Feb. 7, 2009)
A man, whose identify is being kept confidential by CTV, saw Sinclair in the waiting room. He appeared asleep. He may have fallen into a coma at this point.
Sept. 21 Just after midnight
The same witness noticed Sinclair was still in the waiting room and in the exact same position as the night before. The man and his wife became concerned and tried to get nurses to examine him. They finally got a security guard to come over. The guard felt for a pulse, then called for help. Sinclair was pronounced dead a minute later
"The nurse said we'll go and check, [but] nobody ever went and checked on him. We waited another hour or so and we told another nurse twice to go and check." The witness said the nurse told him she was too busy and couldn't check right away.
The witness claims he told a security officer of the man's condition, but said the guard told him the case would be "too much paperwork." (CTV Local News)
UNIDENTIFIED MALE: We went to tell the nurse. The nurse said, "We'll go and check." Nobody ever checked on him. My wife grabbed the security, and I was with her. And he went up to the fellow, pinched him on the neck and lifted his head, and he was obviously dead. (CTV National News)
"The security employee recognized Mr. Sinclair and noted that he was sitting in his wheelchair with his head slumped to the side, as if he were sleeping," Balachandra said. The security guard wheeled the unresponsive Sinclair to the treatment area where emergency staff tried to revive him." The man was pronounced dead a minute later.
(Dr. Balachandra, Winnipeg Free Press)
DR. BROCK WRIGHT, WINNIPEG HEALTH SCIENCES CENTRE: There was reason to believe at that time that the patient had passed -- had been dead for some time. We don't know how long. (CTV National News)
Dr. Thambirajah Balachandra said Brian Sinclair, 45, hadn't been able to urinate for 24 hours because of a blocked catheter and his bladder was full. He had been dead for hours and rigor mortis had set in when finally attended to. (Canadian Press, Sept. 24)
At room temperature, rigor mortis starts about 3 hours after death and is complete about 3 hours after that.
The appalled witness calls CTV local news. He says Sinclair had been in the waiting room at least 10 hours.
Morning: CTV reporter Kelly Dehn begins asking questions about the death. The WRHA knows the story has leaked out.
Afternoon: The WRHA finally tells Health Minister Theresa Oswald of the incident.
Evening: CTV breaks the story on its 6 o'clock newscast.
Sept. 23, 2008
Brock Wright blames Sinclair for his own death. It won't be the last time.
"Right now, the system does rely on, and is pretty heavily dependent on the patient, or the patient's family, or the ambulance, bringing the patient to the attention of the triage staff... We don't have a policy that says every person in the waiting room should be approached... That's not part of the process right now." (Brock Wright, CTV Local News, Sept. 23)
Wright gives some details of the investigation that’s underway. Key staff have been interviewed. Security tapes are being reviewed, he says.
"He had some contact with the staff in the department, but he was never assessed by the triage nurse, and was therefore never identified as a patient requiring care...we did interview a few key staff, and further interviews and information gathering is ongoing."
Security tapes of the facility are being reviewed as part of the investigation, Wright said. (Brock Wright, Winnipeg Free Press, Sept. 23)
The WRHA has begun to rely on what will be the cornerstone of their argument for the next 20 weeks: that Sinclair was never assessed by the triage nurse. That’s the truth, but not the whole truth, which they know. They added he “had some contact with the staff in the department” to give themselves plausible deniability in case anyone in the furture accuses them of hiding the facts.
But CTV comes closest to exposing the truth in its story today without knowing it.
Sinclair is seen on the hospital's security camera footage when he arrived at the department's main entrance Friday afternoon. He is not in the footage the entire time, but health officials say they believe the man was in the waiting room for the full 34 hours. It's also believed the man interacted with aides and cleaning staff, but not medical staff. (CTV News)
Four and a half months later the public will learn that this is a garbled reference to a “triage aide”who spoke with Sinclair when he arrived at the hospital. The Winnipeg Free Press will report that these aides also do some cleaning.
"The challenge for us right now is to explain how it is somebody could be in the department for 34 hours and not have been brought forward to the triage desk area and be entered into the system," Wright said. (CTV News)
This is a complete falsehood. Sinclair did come forward to the triage desk area. Wright won’t admit this for months.
Sept. 24, 2008
The Premier told the Legislature that Health Minister Theresa Oswald was trying to get information out to the public as quickly as possible.
“Premier Gary Doer: We have asked the Chief Medical Examiner to be independent of government and examine this on an urgent basis. The minister has met with the Winnipeg Regional Health Authority and the Health Sciences Centre management to determine as quickly as possible the reasons for this tragedy, to, while they're reviewing this, expedite the process in terms of public disclosure of what went wrong and to fix anything that they discover as part of their review.” (Hansard, Sept. 24)
Gary Doer on CJOB radio blames the Health Action Centre for contributing to Sinclair’s death. The health clinic sent Sinclair to the emergency ward with a note explaining why, but did not call the ER to alert them he was coming.
Gary Doer: The individual was seen at the Health Action Centre by a nurse, seen at the Health Action Centre by a doctor, conveyed to the emergency ward by a taxi with referral material. Because of that, the obvious gap, because of the failure and the tragedy that resulted, the Minister of Health (Ms. Oswald) and the health authority worked on a new protocol yesterday. (Hansard Sept. 25)
Health Minister Theresa Oswald repeats the falsehood that Sinclair never approached the triage area.
Health Minister Theresa Oswald noted that the addition of reassessment nurses to emergency wards did not address 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. ( CBC News )
Its hard to tell whether new facts are coming out or old facts are being garbled in the transmission.
Sinclair was dropped off at the Health Sciences Centre by a taxi Friday afternoon after visiting a downtown health clinic which is part of the Winnipeg health authority.
Some hospital staff - including housekeeping and security guards - did speak with him at some point, but it was not until shortly after midnight on Sunday that he was examined and pronounced dead. (Winnipeg Free Press, Sept. 25)
We assume the “housekeeping” reference is to the triage aide who does cleaning. And we’ve never heard that security guards spoke with Sinclair, just that they tried to get him help when he was vomiting.
A funeral is held for Brian Sinclair.
Brock Wright blames Sinclair for his own death again.
The hospital is no closer to understanding how Sinclair sat waiting so long without care, he said. Wright suggested Sinclair's difficulty communicating may have contributed to what happened, but that will ultimately be answered in an upcoming inquest. (Canadian Press, Sept. 29)
The government introduces changes to emergency rooms to assure that another person doesn’t die of neglect like Brian Sinclair. The Opposition reveals the government issued a gag order on medical staff at the Health Sciences Centre.
Mr. Hugh McFadyen (Leader of the Official Opposition): Earlier today, Mr. Speaker, some seven days after becoming aware of the tragedy in Health Sciences Centre's emergency room, the government announced a program of greeters and green wristbands as a pilot project for the Health Sciences Centre emergency room.
The reality is that the recommendations with respect to reassessments were made more than four years ago in the report that followed several other tragic incidents in Manitoba emergency rooms.
Mr. Speaker, the top priority of the government following the disclosure last week was a directive to doctors and nurses within the emergency room to not communicate either internally or externally with anybody with respect to what had happened in connection with Brian Sinclair's case. In fact, the directive was so specific that they were told not to use, in particular, e-mail communications either internally or externally with respect to what had happened with Mr. Sinclair.
I want to ask the Premier: Why is it that the top priority of government was the political damage control strategy and a week later they got around to thinking about patient safety with a greeter and wristband announcement this morning? (Hansard)
In late October, draft copies of the WRHA reviews of the Sinclair incident are being circulated to government and health officials. Health Minister Theresa Oswald is among those who read the full details of Sinclair’s final moments. She fails to notify the Legislature or the public, keeping the details secret until they’re revealed by the chief medical examiner.
Health Minister Theresa Oswald first learned Brian Sinclair approached the emergency room triage desk for help last October -- a detail she never publicized in the wake of the double-amputee's tragic 34-hour wait for care. (Minister sat on truth about ER death/ Learned last year initial reports were inaccurate, Jen Skerritt, Winnipeg Free Press, Feb. 10, 2009)
Nov. 19, 2008
The WRHA releases partial information from the Sinclair reviews along with "key recommendations" to reform the ER triage system.
November 19, 2008
WRHA Releases Information from Sinclair Reviews
Full Administrative Review to be Submitted to Inquest
The Winnipeg Regional Health Authority today released information flowing from reviews into the September 21, 2008 death of Mr. Brian Sinclair as part of its commitment to keep the public as informed as possible prior to the commencement of the inquest into Mr. Sinclair's death.
The province's Chief Medical Examiner (CME) conducted an autopsy and announced shortly after Mr. Sinclair's death that he was ordering an inquest into the death, and that he would be turning the matter over to a provincial court judge to set a date. The WRHA will cooperate fully in that court process, which has not yet been scheduled.
The circumstances surrounding the death were reviewed by a Critical Incident Review Committee (CIRC), which was struck immediately following Mr. Sinclair's death. While the work of the CIRC is protected under legislation, the recommendations made by the CIRC are being released today because of the exceptional circumstances surrounding this case.
An administrative review, also undertaken immediately following Mr. Sinclair's death, identified actions taken to date and recommendations for further action. Those portions of the report are being released today. The entire report will be submitted as evidence at the inquest.
Health Minister Theresa Oswald writes to Manitoba Ombudsman asking if the review can be released.
Hon. Theresa Oswald (Minister of Health): There are concerns that have been raised about the release of that full review as it relates to the inquest. I've written a letter to the Ombudsman asking for a judgment on that. If the Ombudsman suggests that the full review can come forward, then we will release it.
It's revealed only this month that Oswald told the Ombudsman to contact Dr. Brian Postl, CEO of the Winnipeg Regional Health Authority, first. The WRHA told the Ombudsman they would not release the full review.
Dr. Balachandra issues a news release advising he is calling an inquest into Sinclair’s death. This is hardly news, since he announced this days after Sinclair’s death. But he includes details of the death, including the bombshell that Sinclair did approach the triage desk, contradicting everything the WRHA said about the incident from Day One.
The cover-up collapses as each succeeding day brings more and more revelations.
Brock Wright, the WRHA spokesman on the Sinclair matter, admits he’s never seen the security video. The next day he’s watched the video and does a full 180, now acknowledging that his statements since September, 2008, have been false.
Oswald says she doesn’t want to see the security tape. Then she admits she’s known since October that Sinclair went to the triage desk but has kept it secret.
Feb. 10, 2009
In a last ditch effort to keep the facts from the public, the WRHA declared they had a legal opinion which said they couldn’t release the reviews into Brian Sinclair’s death. The press, now refusing to believe anything the WRHA says without proof, demands to see the legal opinion. It turns out it's dated the day before the WRHA news conference. And Winnipeg Sun columnist Tom Brodbeck reveals it is full of qualifiers.
(They also claim at the press conference that the triage aide has no recollection of encountering Sinclair and the writings on the clipboard "were not preserved".)
We read through Manitoba’s Privacy Act and found the following:
The Privacy Act
In an action for violation of privacy of a person, it is a defence for the defendant to show
(f) where the alleged violation was constituted by the publication of any matter
(i) that there were reasonable grounds for the belief that the publication was in the public interest; or
(ii) that the publication was, in accordance with the rules of law in force in the province relating to defamation, privileged; or
(iii) that the matter was fair comment on a matter of public interest.
Conflict with other Acts
8(2) Where there is a conflict between a provision of this Act and a provision of any other Act of the Legislature, whether special or general, the provision of this Act prevails.
Nothing prevented the WRHA from releasing its reviews with names blocked out.
Oh, wait, something did.
Manitoba's former deputy justice minister Bruce MacFarlane told the Winnipeg Free Press (Feb. 13) there is nothing in law preventing the Winnipeg Regional Health Authority from publicly releasing an edited administrative review into the death of Brian Sinclair before a provincial inquest is held.
“While the WRHA can take this position as a policy position, they should take responsibility for their decision and not try to portray it as an impediment that the law has created. That is, quite simply, not the case."
The cover-up continues.
Does this point to what the WRHA and the government are so anxious to keep from the public?
Hansard Oct. 9, 2008
Ms. Oswald: Certainly, I can inform the House that when we immediately began the review to learn what went so terribly wrong in this tragic situation, of course one of the initial questions that we asked concerned staffing. We were initially led to understand that there was an 87 percent full staffing level on the Friday and that any gaps that existed were certainly transferred into a reassessment process. We know that part of that process did not work effectively.
We know that the staffing on Saturday was somewhere between 97 percent and 100 percent.
But that's what this inquest is going to show us, Mr. Speaker, is where the errors have occurred. We do not want to presuppose the answers to that.
The Health Sciences Centre ER was short-staffed when Brian Sinclair came in. They were depending on a reassessment nurse to fill the gap. But her job is to watch over patients after they’ve been officially entered as patients.
Was a nursing aide filling the gap at the triage desk and that’s why Sinclair never made it into the system?
Will anything fill the growing credibility gap between the public and Brock Wright, Brian Postl, Theresa Oswald and Gary Doer?