The Brian Sinclair inquest findings were released on Friday December 2014 and from the perspective of hospital crowding and emergency access block the report can only be termed a disappointment.
Despite repeated evidence by experts in Emergency Medicine and patient flow, the root cause of emergency crowding (an inability to flow admitted emergency patients to the hospital wards as a result of inadequate hospital bed capacity) received no meaningful attention.
Rather the presiding judge of the inquest focused on the issue of triage and emergency department design and wasted a valuable opportunity by diverting attention away from the root cause to issues such alternate care providers. I have no problem with an enhanced role for paramedics and physician assistants, indeed my personal bias is we need more of them, but as crowding is not a problem of non-urgent patients, it is fatuous to suggest that such providers will help with crowding.
The real issue is bed capacity, both absolute and relative and both in the hospital and community settings.
Canadian urban hospitals now currently function at over 100% bed occupancy rates and thus boarded patients in the ER are inevitable. Boarded patients in turn means prolonged waits for access to treatment areas in both the waiting room and the ambulance offload ramp.
To solve crowding we need to increase bed occupancy rates to something in the order of 85-90%. Something few Canadian politicians want to do given the cost implications and the fear that more beds will be simply occupied faster.
The report made 63 recommendations of which only a couple address the issue of patient flow.
That the WRHA review the feasibility of creating a region wide Overcapacity protocol where deemed appropriate
That the WRHA review the feasibility of creating a process to establish a deadline for admitting a boarded patient to a hospital bed, where deemed appropriate
That the WRHA create a Hospital Length of Stay Reduction Committee to monitor and optimize patient flow
Too little, too soft, too much wiggle room for the WRHA
Below is a WP Free Press Article by Kevin Rollason on the recommendations and the disappointment of the Sinclair Inquest report.
Inquest report disappoints
Review of Sinclair’s ER death fails him, family, doctor say
When the inquest into Brian Lloyd Sinclair’s death began last year, the nation’s emergency room physicians looked forward to recommendations aimed at increasing patient flow through hospitals while his family hoped it would reduce the racism indigenous people believe they face in the health-care system.
Both expressed disappointment on Friday after the release of the 195-page report by provincial court Judge Tim Preston dealing with the death of Sinclair.
Dr. Alan Drummond, a spokesman for the Canadian Association of Emergency Physicians, said he is disappointed by the report.
“I’m looking for evidence that the inquest understood the root cause of the problem — I see very little,” Drummond said.
And Robert Sinclair, Brian’s cousin, said the family is disappointed the inquest didn’t explore racism because they continue to believe he died because hospital staff made racial stereotypes of him as drunk or homeless rather than a person in need of medical care.
“These stereotypes were at the root of why Brian Sinclair was ignored for 34 hours,” he said.
“They made bad assumptions about who he was as an individual. Does this still exist? I guess we’ll never know other than just feeling it when we go into a hospital.”
REMIND ME, WHO WAS BRIAN SINCLAIR?
Brian Sinclair was a 45-year-old double amputee who was sent by a clinic to Health Sciences Centre on Sept. 19, 2008, with a letter saying it was believed he had a blocked urinary catheter. Both of his legs had been amputated the year before when they froze after he was locked out of his residence in winter.
But after Sinclair arrived at emergency, and was seen on a surveillance camera talking briefly to a triage aide who scribbled something down on a piece of paper, he stayed in the waiting room for the next 34 hours, except for a brief period when he rolled past the triage desk while another patient was checking in.
An autopsy found Sinclair died of a treatable bladder infection caused by the blocked catheter. He had been dead up to seven hours, and rigor mortis was setting in, before family of other patients in the waiting room brought his condition to the attention of security and health-care workers.
Only then did health-care staff see the letter from the clinic, still on Sinclair’s person.
Sinclair was not homeless — he had been living in the Quest Inn for about a year before his death and was receiving care by home-care nurses. Shortly before seeking treatment at HSC, he spent the day volunteering at Siloam Mission.
WHAT DID THE JUDGE SAY IN THE INQUEST REPORT?
Provincial court Judge Tim Preston, in his 195-page report released Friday, said while Sinclair “was a man with a number of serious health challenges… the acute peritonitis which caused his death was avoidable.
“Brian Sinclair died because he did not receive the initial treatment he required.”
But Preston said while Sinclair’s death was tragic and avoidable, he didn’t die “in vain.”
“His death prompted a complete overhaul of the front end of HSC ED and a systematic streamlining of the registration and triage process in that facility.
“Hopefully, the recommendations that I make, as a result of hearing from those people who cared for Brian Sinclair during his later years and experts in areas of emergency medicine, will help prevent anything like this from ever recurring.”
WAS IT RACISM?
Sinclair’s family believes it was. Others do, too.
Robert Sinclair said “aboriginal people frequently experience the same kinds of stereotypes when we try to access the health-care system today. Unfortunately, this inquest report does not probe into those issues, and that will not make things any better.”
Sinclair said he wishes his cousin were alive because “it’s really unfortunate Brian had to be the catalyst for changes in the system. Does it always have to be somebody’s death before changes are made?”
Lawyer Emily Hill, of Aboriginal Legal Services of Toronto, which participated in the inquest until February when the judge limited its scope to only what happened in the emergency waiting room and not issues of racism, said in a statement her team is still looking for answers to questions raised by Sinclair’s death.
“The report spends 61 paragraphs outlining the incorrect assumptions that were made by nurses and security guards about Brian Sinclair’s presence in the HSC emergency department waiting room, yet does not address the reason these assumptions were made,” Hill said.
WRHA president and CEO Arlene Wilgosh said the public still harbours a strong feeling Sinclair’s treatment was born of stereotyping and discrimination. But, she said the WRHA’s expectation is that every patient gets access to timely, good-quality care, regardless of race.
Health Minister Sharon Blady said racism exists in many parts of society. “It would be naive to assume it does not exist in health care,” she said.
But Manitoba Nurses Union president Sandi Mowat sidestepped the question of racism’s role in Sinclair’s death, saying no nurse ever wants to see a similar tragedy.
“I think that always nurses are committed to the community they serve,” she said. “The most important thing is to move forward with the recommendations.”
WHAT HAS CHANGED?
The emergency waiting room Sinclair went into on Sept. 19, 2008, is different than the emergency waiting room a patient would go into on Dec. 13, 2014. In the wake of his death, changes were made to close and lock a door at the far end, preventing the area from being an access hallway to the rest of the hospital, turning the chairs to face the nursing station, moving the television so people could watch it while facing the nurses, stationing a security guard at emergency’s main entrance to meet patients and putting coloured bands on patients after they are triaged so they don’t become lost in the waiting room.
As well, a full-time social worker with links to Siloam Mission has been hired to know how many beds are available there, and a community support worker checks every person in the waiting room at least once an hour.
Wilgosh said suggesting the Sinclair tragedy was a learning experience for health-care staff would be “putting it mildly.”
“This was a professional, career turning point,” and some involved have since left nursing, she said.
WHAT IS NEW IN THE REPORT?
The Winnipeg Regional Health Authority itself says there are few recommendations contained in the report new to them. Many of them were recommended by health-care professionals questioned at the conclusion of their testimony during the inquest by Preston.
Some of the recommendations include having WRHA Home Care review its policies and procedures to make sure service providers know when a client is in hospital; having RHAs review floor plans of emergency departments to make sure nobody waiting there faces away from triage desks; having RHAs review policies and procedures to ensure staff helps a person vomiting in an emergency room, and that RHAs implement mandatory and ongoing cultural safety training for all health-care workers and that part of the training be designed and delivered by aboriginal people.
WHAT IS NOT IN THE REPORT?
Drummond said emergency physicians across the nation have been waiting for the report since the inquest was announced, but he sees little in it addressing problems with crowding in emergency rooms, as well as patient flow and bed capacity in hospitals.
“I’m frankly disappointed… nothing has changed and nothing will change,” Drummond said.
“Did Brian Sinclair die in vain? From the perspective of shedding light on ER crowding, I think regrettably he did.”
Drummond worries the special team of regional health authority representatives, to be led by the province’s deputy health minister, won’t even look at the issue because there are no recommendations to add more beds in hospitals and long-term care centres.
“Nothing has changed and nothing will change until governments look at the issue of capacity,” he said.
“It’s not what we expected… I’m in support of physician assistance, nurse practitioners and paramedics, but none of that will have any impact on crowding.”
And Drummond said that could lead to more situations akin to Brian Sinclair’s.
“Crowding hurts people, makes them suffer unnecessarily and exposes them to a higher death rate. Maybe people won’t die in such a dramatic way, but if we don’t solve crowding, we still will have deaths, but not as dramatic and not as newsworthy.”
WHY WASN’T ANYONE CHARGED?
Winnipeg police investigated Sinclair’s death, interviewing dozens of health-care workers, patients and their families, but after sending the results of their investigation to the Crown’s office in Saskatchewan for review, it was determined no charges would be laid.
While notes from the police investigation were disclosed to lawyers in the inquest, and were used by them to come up with questions for various witnesses, none of it has been made public.
In his report, the judge chided Sinclair family lawyer Vilko Zbogar and said it was “somewhat surprising” he urged him to rule Sinclair’s death a homicide when “no questions were put to the CME (chief medical examiner) by counsel for the family on the issue of Mr. Sinclair’s manner of death.
“I am not persuaded that Mr. Sinclair’s manner of death was a homicide, nor would I consider altering the CME’s expert conclusion.”
Zbogar said while the family called Sinclair’s death a homicide, the judge decided it was “natural,” yet didn’t elaborate.
“To reject that human factors substantially contributed to Brian Sinclair’s death, without explaining in detail why, feels like an injustice to the Sinclair family,” the lawyer said.
WHAT HAPPENS NEXT?
The health minister has assigned her deputy to lead an implementation team that will report back in 90 days with short-, medium- and long-term implementation strategies. Each regional health authority must also appoint an implementation co-ordinator.
The family is still calling for a full-fledged inquiry to look at the deeper issue of racism in health services. Blady wouldn’t entirely rule out an inquiry, but noted Preston’s report does not recommend one.
Of the 63 recommendations made by the judge, only one — the elimination of triage lists on paper — has been implemented. Forty other recommendations are being worked on by the WRHA and 22 others are to be implemented.