The Black Rod

The origin of the Usher of the Black Rod goes back to early fourteenth century England . Today, with no royal duties to perform, the Usher knocks on the doors of the House of Commons with the Black Rod at the start of Parliament to summon the members. The rod is a symbol for the authority of debate in the upper house. We of The Black Rod have adopted the symbol to knock some sense and the right questions into the heads of Legislators, pundits, and other opinion makers.

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Location: Winnipeg, Manitoba, Canada

We are citizen journalists in Winnipeg. When not breaking exclusive stories, we analyze news coverage by the mainstream media and highlight bias, ignorance, incompetence, flawed logic, missed angles and, where warranted, good work. We serve as the only overall news monitors in the province of Manitoba. We do the same with politicians (who require even more monitoring.) EMAIL: black_rod_usher@yahoo.com

Thursday, February 12, 2009

Smokescreens fail Doer, nurses point to known ingredients for Brian Sinclair tragedy

Four days after Brian Sinclair was discovered dead in the HSC emergency room Gary Doer was manoeuvering to use the death to his political advantage.

Annoyed by questions from the Opposition, Doer went on the attack against Conservative Leader Hugh McFadyen. He talked a lot about accountability.

"You want to talk about backbone in terms of accountability, we need no lectures from the Conservative Party of Manitoba. I have stood up in this House every day. You know, I have stood up in this House and I'll continue to do so and he can be accountable for his comments, Mr. Speaker. We've accepted responsibility. He can be accountable for his comments. I can tell you when nurses here-that he is out there speaking about the culture of neglect with people that work on the front lines and save lives every day.
He's going to be accountable for his comments and we will be accountable for our actions and comments, Mr. Speaker."


And again...

"But, Mr. Speaker, I would say that there is not a human culture of neglect with doctors and nurses on the front line of health care. He owns those words and he'll be accountable for them."

Doer was loading up ammunition to use against the Tories in the next election.


He never expected the sky to fall on his head as it did last week.

When the time came for Doer and Health Minister Theresa Oswald to be held accountable for what they said in the Legislature and in public about Sinclair's death, they were both unusually tongue-tied.

Oswald ducked reporters last week claiming she was just too, too busy. Those ribbons don't cut themselves, mister.

And Doer showed up Tuesday for his regular Town Hall with the Premier slot on CJOB where he fielded questions about traffic at a Winnipeg intersection and a woman's dental bills. Amazingly, not one listener to CJOB was curious about the premier's role in the Sinclair death coverup.

Yet Doer and his strong NDP woman cabinet minister were neckdeep in controversy. Oswald belatedly confessed to the Free Press that she knew in October that Sinclair had, contrary to every statement made by the Winnipeg Regional Health Authority and the NDP, been in the triage line and a hospital employee spoke with him.

But Oswald and Doer failed to tell the Legislature in October, or November, or the public in December, or January, or even in February that they had been misled.


In other words, the Premier and the Health Minister made a conscious decision to deceive the legislators and the people.

They would have continued to lie to the public if their hand hadn't been forced by Chief Medical Examiner Dr. Balachandra last week, with his revelation that there was security video that showed exactly who talked to whom in the ER.

When caught red-handed, Doer and Oswald did what every perp does on Law and Order. They lawyered up.

We really, really, really wanted to tell you the truth, but the lawyers said we couldn't. And still can't. Sob.

Doer and Oswald are hiding behind a legal opinion by their companions-in-coverup, the Winnipeg Regional Health Authority. The WRHA's high-priced hired gun delivered a dandy memo declaring that nobody could say anything about the internal reviews of Sinclair's death. If they did the would contravene the Health Act by revealing the personal health information of Brian Sinclair (note to WHRA, Sinclair is dead, and was dead before the review started. There was no "health" information to reveal...ed)

The WRHA can't reveal any information about its employees, said the lawyer. That's against the law and the law says you even have to hide from the public any views and opinions expressed about those employees, as in who screwed up and how.

Izzata fact?

If that's true, then the WRHA board must immediately censure and punish WRHA vice-president Brock Wright. Wright went to great lengths in November to reveal personal information and internal views and opinions of Dr. Larry Reynolds. Reynolds, you'll remember, was dismissed as Head of the Department of Family Medicine and Professor at the University of Manitoba and Head of the Winnipeg Regional Health Authority's Family Medicine Program.


You'll find the details of Wright's handiwork at
http://blackrod.blogspot.com/2008/12/axe-drops-on-dr-larry-reynolds-real.html


Wright didn't even bother to leak the information. He just blabbed away to reporters and sat back smugly to watch the smear work.

So if the lawyer's legal opinion is anything more than another smokescreen, the WRHA must immediately discipline Brock Wright. Or we'll know how phony their latest ploy is. And we'll know the cover-up continues.

Cover-up? Critics and defenders alike agree on one point---what could the WRHA be hiding? They must have known the security video would show up at the inquest. Their internal reviews have damaging details being kept from the public, but, again, those facts will be put on the record at the inquest. So....?

Well, since the WRHA and the government are playing dumb, it opens the field to speculation.

We'll start.

WRHA CEO Brian Postl said on radio that the security video was seen by only a small number of people who he described as "two HR and legal folks."

Two Human Resources managers, eh? You can bet one of them is Ms. Gloria O'Rourke Vice President & Chief Human Resource Officer. And the WRHA has a second human resources arm--- Aboriginal Human Resources.

Now why would Aboriginal Human Resources be involved? Brian Sinclair was native, but he wasn't an employee of the Health Sciences Centre.
Was the triage aide who spoke with Brian Sinclair the afternoon he arrived at the ER an aboriginal employee? Is that what the WRHA is hiding so fiercely? It would make sense.

An aboriginal patient in a wheelchair waiting in line to see the triage nurse. An aboriginal employee hired to liase with aboriginal patients approaches him and gets some particulars, name, last visit, complaint.

The WRHA revealed Tuesday that the most vital piece of information in the death of Brian Sinclair is missing---the memory of the triage aide who spoke with him.

Only two days after speaking with him, the aide had no recollection of what was said, what was written down, what Sinclair was told before he wheeled himself to the waiting room, what was told, or not told, to the triage nurse.

DID THE WRHA SHOW THE TRIAGE AIDE THE SECURITY VIDEO TO REFRESH HIS OR HER MEMORY?

Or was the aide lawyered up as well. Did the HSC lawyers rush in and give a legal opinion that the video had to be restricted to certain people--like the managers of the WRHA only?

How could the triage aide develop amnesia over the weekend?

It's bad enough that the dead man was aboriginal, leading to the usual (absolutely unfounded)allegations of racism in treatment, but if the person responsible for his not getting treatment turned out to be native as well, imagine the outcry against the hospital.

Okay, enough about what we don't know. Let us tell you what we do know.

Where the WRHA doesn't want information coming out before their lawyers can look at it, we think the public needs to know as much as possible as quickly as possible.

After the news broke of Sinclair's fatal experience at the HSC emergency room, various health professionals turned to the internet to post details of the scene. From them we learn:

* Four shifts of staff came and went in the time he was there.

* The HSC adult emergency room is staffed with at least one triage nurse, a reassessment nurse, a minimum of two security personnel, and, during the day, volunteers in the waiting room.

* The reassessment nurse's duty is to assess triaged patients every four hours at a minimum. She has the power to upgrade a person's urgency status if need be. But she doesn't go into the waiting room to check everyone; names are called and patients present themselves to her. Would she be the one to call if someone saw a patient puking in the waiting room?

*Gary Doer said there was no shortage of doctors at the HSC, and six shifts of doctors changed in the time Sinclair was at the ER. "I'm informed the basic staffing was there at the Health Sciences Centre on the afternoon shift, on the evening shift, on the midnight shift, on the morning shift, on the afternoon shift, again on the evening shift, while the tragedy took place." he told the Legislature.

* security staff do check up on the 'regulars', even during the graveyard shift.

* Sinclair may have been dead as long as 10 hours before anyone noticed. Kelly Dehn, the CTV reporter who broke the story in September, told a radio audience Wednesday that the tip he received said the man had been at the hospital 10 hours before being pronounced dead. It turned out later that he had been there 34 hours.

The tipster said he saw Sinclair in the waiting room Saturday, then again Sunday sitting in the exact same position. This suggests his own hospital visits were 10 hours apart, and the fact Sinclair's position never changed, suggests he had been dead at least that long.

Here's how one nurse described the dynamic of that emergency room:

"If you have had the need to access the emergency area at Health Sciences, you will find that there is very little room for people to line up seeking assistance from the Triage nurse without cluttering the entrance.

The Triage nurse will take particulars then have to reach out through the glass partition, over the desk to take pulse, temperature, etc. providing the nurse has the flexibility to do so. Others standing around have to wait and witness this "painful" process to determine injuries, and queued for treatment. Close to the entrance is a desk that is occupied by security personnel. Other security officers are standing around waiting for the next violent outburst. The Emergency waiting room is usually full of people seeking treatment, some vomiting in trays provided, others trying to get sleep, and some who are in dire pain. This is not a nice scene."

Another nurse wrote to Lindor Reynolds, providing what may turn out to be a major finding of the inquest:

"I work In a Med Sur ICU that is short staffed everyday, with most of us exhausted and discouraged by all the overtime we are asked to work, I CAN imagine how a man who appears to be sleeping can be overlooked. Some times I arrive at work at 7:30 am and the next time I look at a clock it is 3:30 and eight hours have passed in what seems like a blink of an eye.

Every hospital in this city is shortstaffed, be it Drs Nurses, Technicians, etc etc. I believe we are all doing the best we can, and I can feel great empathy for HSC staff who I am sure are devastated by this tragedy."


And still another nurse wrote about the institutional attitude at HSC emergency:

"... my suggestion was to have a separate room for the many homeless ,the intoxicated,the cold and the lonely..what I suggested was this: one nurse and one unit assistant could watch over and care fore ,as well as clean up the people and give them clean clothing ,BE AN ADVOCATE FOR THEIR NEEDS ,a mattress on the floor ,a blanket ,an assist to the washroom ,nothing fancy ,but someone that is willing to watchover them until an appropriate discharge plan could be arranged .We would check and ensure safety ,tolerate being sworn at and @ times assaulted , I was told that it is inappropriate to segregate them (rather than being an object of curiosity and a very smelly entity in the waiting room) and they should be treated like all others and be responsible for their own care and needs."

Tomorrow, the essential timeline...

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