Brian Lloyd Sinclair died in September 2008 in the emergency department waiting room of Winnipeg’s Health Sciences Centre at the age of 45. He was pronounced dead in the early hours of September 21, 2008 after he had spent some 34 hours in the emergency room awaiting attention for what was initially a relatively minor health concern.
Brian Sinclair was an Aboriginal man who lived his early years on the Fort Alexander First Nation and went on to live in Powerview, Manitoba and ultimately, in Winnipeg. He faced a number of health challenges and as well as some cognitive impairment. In 2007, both of his legs were amputated above the knee and after that time he relied on a wheelchair. Soon afterward, the Public Trustee of Manitoba was appointed as his Committee. Though widely reported to be homeless at the time of his death, Brian Sinclair in fact resided in an assisted-care home in downtown Winnipeg.
An inquest was called in early 2009 under the provisions of The Fatality Inquiries Act:
1. To determine the circumstances under which Mr. Sinclair’s death occurred;
2. To determine what, if anything, can be done to prevent similar deaths from occurring in the future with regard to, but not limited to, the following:
(a) reasons for delays in treating patients presenting in Emergency Departments of the Winnipeg Regional Health Authority (hereinafter referred to as “WRHA”) hospitals; and
(b) measures necessary to reduce the delays in treating patients in Emergency Departments.
The inquest report was issued to the public late last week. As expected, inquest Judge Timothy Preston found that Brian Sinclair was never assessed or triaged by a nurse during his 34 hours at the hospital. He found that Brian Sinclair died of natural causes but that his death was avoidable.
Judge Preston pointed to a number of incorrect assumptions that were made with respect to Brian Sinclair’s continued presence in that emergency room, including:
- He was sleeping off his intoxication
- He was homeless or seeking shelter
- He was waiting for a bed in another area
- He was waiting for medical attention after being assessed/attended to
While Judge Preston noted that some of these assumptions were framed as racial stereotyping by counsel for Mr. Sinclair’s family and the intervenor, Aboriginal Legal Services of Toronto, he also noted this view was countered by the Chief Medical Officer:
Dr. Balachandra, CME, was of the strong opinion that no doctor or nurse would lower their standard of care based on a patient’s ethnicity….The CME has never encountered discrimination by doctors or nurses. He claimed that “Snow White” would have died in these circumstances.
Not surprisingly, the report has been criticized for failing to address the underlying reasons for the assumptions that were made. Christa Big Canoe, Legal Advocacy Director of Aboriginal Legal Services of Toronto commented to The Winnipeg Free Press:
“Brian Sinclair was a victim of those stereotypes because staff assumed he was homeless or intoxicated, instead of treating him as someone who needed medical care. Aboriginal patients continue to face these stereotypes every day when they access health care services and this issue was largely ignored in the report.”
The report concludes that “Brian Sinclair did not have to die, but he did not die in vain” pointing to the changes implemented in the emergency room system since his death and the 63 recommendations for changes to prevent similar deaths from occurring in the future.