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.
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:
- To get proper answers about the cause(s) of his death and the broader circumstances that may have contributed to his death; and
- 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:
- Is there a morale or stress problem at the HSC Emergency Department that causes medical staff to be indifferent about certain patients?
- 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?
- What accounts for the apparent lack of empathy in this case, and how widespread is it?
- 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.
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.