Aug 072013
 

Brian Sinclair portrait painting

A local artist was so moved by the tragic story of the late Brian Sinclair that he painted a portrait of the man who died in his wheelchair while waiting 34 hours in the waiting room of a Winnipeg hospital emergency department.

The artist, Gord Hagman, graciously donated it to the family.  The family wishes to extend its sincerest thanks to him, as well as to photographer Maurice Bruneau, who took the iconic photograph on which this portrait is based.

Most people only know Brian Sinclair as a news headline. This portrait is a reminder that Brian Sinclair was more than that.  He was a loved one, and he was a human being.   

The family asked the inquest judge to allow the portrait to be displayed in the courtroom during the course of the inquest into Brian Sinclair’s death, to represent the spirit of the man whose death brought the inquest about.

The Sinclair family wants something good to come out of this tragedy.  They hope that the inquest will be a catalyst for real changes in our society including in how emergency health services are delivered.  They see this work of art as a symbol of goodness coming out of sadness and grief.  

Aug 062013
 

Inquest into the death of Brian Sinclair

OPENING STATEMENT OF FAMILY AND ESTATE OF BRIAN SINCLAIR

August 6, 2013

Counsel: Murray Trachtenberg and Vilko Zbogar

Why we need this inquest

Many of the circumstances of Brian Sinclair’s death are already matters of public record.  We already know the medical cause of Mr. Sinclair’s death, and that his condition was treatable.

While those are matters that will be before the inquest, we do not need this inquest just to determine what killed Mr. Sinclair.

We need this inquest to determine why Brian Sinclair died.

We need this inquest to determine why Brian Sinclair was ignored by medical staff for 34 hours, as he sat in his wheelchair in the waiting room of the Emergency Department of a major Canadian urban hospital, helpless, vomiting, his life slowly fading away.

Brian Sinclair’s identity and marginalization

Was it something about Brian Sinclair’s identity that caused the medical staff at the Health Sciences Centre to fatally ignore him?   He was Aboriginal.  He was poor and transient.  He was a double-amputee who was also cognitively disabled.

As stated by former inquest judge Wyant in his standing ruling of August 31, 2009, “his treatment as an aboriginal individual, questions of racism, of poverty, of mental health, of health, of economic status,… all of those are issues … are weaved within the evidence and the circumstances surrounding Mr. Sinclair’s death, and I think it’s very important … that those issues play a significant role as we look at preventing similar deaths in the future.”

Again in February 2010, judge Wyant stated that in this inquest: “Issues surrounding race, poverty, health and others should be front and centre.”

We anticipate that the evidence will show that Brian Sinclair’s identity and his marginalized status had a lot to do with the assumptions that hospital staff made about him and the fatal indifference they showed him.

However, Brian Sinclair’s identity is only part of the picture.

Institutional problems

What was it about the institution itself – the Health Sciences Centre Emergency Department and the people who worked there – that would cause them to ignore a vulnerable patient in visible distress over a 34 hour period and multiple shift changes?

We expect the evidence to show that Mr. Sinclair arrived at the Emergency Department and spoke to the appropriate medical staff person in the triage area.  He did exactly what the patients who arrived before him did.  He did exactly what the patients who arrived after him did. He was told to wait to see the triage nurse. He did as he was told. He waited and waited, growing sicker and weaker by the minute.

We anticipate the evidence will show that Brian Sinclair was never called back to the triage desk.

However, even after that error was made, there were numerous opportunities for medical staff to ensure that he received the help he needed.

Some fellow patients or their family members, who were complete strangers to Brian Sinclair, saw that he was in terrible shape and tried to alert staff to his dire condition.

Mr. Sinclair vomited over himself and onto the floor as sat in his wheelchair in the waiting room – a desperate sign of trouble.

It would have taken only a single staff person to heed these or other red flags, to check on Brian Sinclair and see that he needed help.  Not one did.  Not one seemed to show the kind of empathy that we as members of the public would expect to be at the core of a nurse’s job description.

We do not believe that Brian Sinclair’s death can be fully explained by a single error.  We anticipate that the evidence will show that the problems were systemic.  The problems were institutional.  The problems were widespread.

When you have a catastrophe of this magnitude where everybody who could have averted it failed to do so, we have to ask the question, what is going on within the institution – the Health Sciences Centre, and the Winnipeg Regional Health Authority that administers it – that could allow such a catastrophe to happen?

The Family’s objectives

Since Brian Sinclair’s death, the Sinclair Family’s primary objectives have been:

  1. To get proper answers about the cause(s) of his death and the broader circumstances that may have contributed to his death; and
  2. To try to make real changes happen so that this kind of tragedy will not happen again, and so that his death will not have been in vain.

To this end, we will be seeking answers as to whether Mr. Sinclair’s Aboriginal status, disabilities, health situation, and/or social circumstances contributed to him not receiving the care that he needed and deserved.

We will also be seeking answers as to the institutional risk factors that incubated this catastrophe.  Among other things, we submit that it will be important  for the inquest to consider questions such as:

  1. Is there a morale or stress problem at the HSC Emergency Department that causes medical staff to be indifferent about certain patients?
  2. Are there proper accountability mechanisms in place when people do a bad job, and if not, does the lack of accountability increase the risk of bad health outcomes in the first place?
  3. What accounts for the apparent lack of empathy in this case, and how widespread is it?
  4. Is there any appreciation for the fact that vulnerable people need more affirmative and proactive care in the emergency department, or is there instead an attitude that ertain kinds of people are less worthy of care than others?

Only when we fully examine these and other issues can we properly determine what needs to be done to prevent similar tragedies from occurring in the future.

Brian Sinclair is not to blame for being fatally ignored

You will hear evidence about Brian Sinclair’s past troubles with substance abuse.

However, on the day in question, he did not go to the hospital because of a substance abuse issue. He went because he had a clinical emergency, and because he did not want to die.

Brian Sinclair was, like you and I, a human being, and entitled to prompt, attentive, and compassionate emergency medical care.

It was not his demons that killed him.  It was the angels – the professionals that we all turn to in times of urgent medical need – that grievously, and fatally, let him down.  It was the Emergency health care system and a large, modern, urban hospital that failed him.

This is all the more shocking because it contrasts with the dedication and compassion that many health care professionals showed to Brian Sinclair prior to his fateful attendance at the Health Sciences Centre Emergency Department on September 19, 2008. Those individuals did a good job helping him manage his health in spite of many challenges, and their efforts should be commended.  We will hear from some of them over the next few weeks.

Conclusion

It is the hope of the Sinclair family that this Inquest will be a catalyst for real changes in our society including in how emergency health services are delivered.  The family hopes that all Manitobans who attend hospital emergency departments in the future – especially the most vulnerable amongst us – will be safer and less at risk because of the lessons that will be learned from the circumstances surrounding Brian’s Sinclair’s death and the work of this Inquest.

Aug 012013
 

The Brian Sinclair inquest is currently underway and will continue, on and off, until June 2014.

Part 1 of the inquest looked at the circumstances surrounding Brian Sinclair’s death in September 2008, and wrapped up in January 2014. Part 2 of the inquest, which is intended to look at recommendations that could be made to prevent deaths in similar circumstances, will take place during the last two weeks of February and the third week of June, 2014.

A schedule of the specific inquest hearing dates is posted below.

The inquest will sit from 9:30 a.m. until 4:00 p.m. daily, unless otherwise indicated.

The inquest hearings will be held at the Law Courts Building, 408 York Ave., Winnipeg MB, Courtroom 230, before the Honourable Timothy Preston.

MON TUES WED THU FRI
AUGUST 2013

1

2

3

5
Civic Holiday

6
start of Part 1

7
in session

8
in session

9

12
in session

13
in session

14
Cancelled

15
in session

16

19
in session

20
in session

21
in session

22
in session

23

26
in session

27
in session

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in session

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in session

30

SEPTEMBER 2013: No hearings scheduled
OCTOBER 2013

1

2

3

4

7
in session

8
in session

9
in session

10
in session

11

14
Thanksgiving

15
in session

16
in session

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in session

18

21
in session

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in session

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in session

24
in session

25

28
in session

29
in session

30
in session

31
in session

NOVEMBER 2013: No hearings scheduled
DECEMBER 2013: No hearings scheduled
JANUARY 2014

1
New Years Day

2

3

6
in session

7
end of part 1

8
Cancelled

9
Cancelled

10
in session

13

14

15

16

17

20

21

22

23

24

27

28

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30

31

FEBRUARY 2014

3

4

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6

7

10

11

12

13

14

17
Louis Riel Day

18
start of part 2

19
in session

20
in session

21
in session

24
in session

25
in session

26
in session

27
in session

28