Staff at the Health Sciences Centre observed Brian Sinclair at least 17 times during his 34-hour wait in the hospital's emergency room, but took no action to address his medical needs, according to an administrative review of his death.

"Tragically, there was little or no communication of these observations amongst each other and Mr. Sinclair was neither triaged nor treated during this time," said the 13-page report, prepared by the Winnipeg Regional Health Authority and entered as an exhibit at the inquest into Sinclair's death.

'Tragically, there was little or no communication of these observations.' —WRHA Administrative Review, Death of Brian Sinclair 

Sinclair, a 45-year-old double amputee, went to the emergency department for a blocked catheter and a urinary tract infection but died after not being triaged and receiving no treatment for 34 hours.

"Each of the staff who saw or interacted with Mr. Sinclair during this 34-hour period mistakenly assumed either that he had been triaged already and was awaiting a bed … [or] that he had been treated and discharged, that he was a patient awaiting pickup under the Intoxicated Persons Detention Act … or that he was just there because he needed a warm place to rest," the report says.

"Upon learning of Mr. Sinclair's death, staff were devastated."

The report continues, "The assumptions that were made, while clearly mistaken, do not appear to have been made with malice."

Reassessment nurse knew Sinclair was vomiting

Last week CBC News reported on a different document, the Critical Incident Review Committee confidential report of November 2008, which said that a reassessment nurse, who was to keep an eye on patients waiting for care, had been reassigned to other duties on the first day of Sinclair's 34-hour wait.

'[Sinclair] appeared to be okay. … [I]t is not unusual for patients to be vomiting in the waiting room.'  —Nurse quoted in WRHA administrative review

However, the Oct. 27, 2008, administrative review report submitted at the inquest indicates a reassessment nurse was on duty Saturday, the second day of Sinclair's ordeal.

Even with a reassessment nurse on duty, treatment was not initiated, the report found.

It said the reassessment nurse saw Sinclair and knew he had been vomiting but took no further action.

"She remarked that he appeared to be okay and that it is not unusual for patients to be vomiting in the waiting room. She has no further recollection of observing Mr. Sinclair for the remainder of her shift."

"Of note, Mr. Sinclair was well known to one of the triage nurses on duty on Friday afternoon when he presented to the emergency department. She had known him since he first started coming to the department when he was 16 years old," the report says.

"This triage nurse recalls that the list had been worked through by 1800 hours on Friday, September 19, 2008, as she recalls commenting to the other Triage Nurse at that time that they had finally caught up."

The report notes that Sinclair went to the triage desk in his wheelchair upon arrival and spoke to the triage aide who was seen on security camera video to write something down.

The report says, "Based on the evidence available, it is not possible to conclusively determine why Mr. Sinclair was not triaged…. It is possible that his name was taken down and called and that he did not hear his name being called. It is equally possible that the triage aide misunderstood the name given by Mr. Sinclair, given his speech impediment, and that Mr. Sinclair's name may not have been called."

However, those possible explanations are described as "speculation."

Another nurse assumed Sinclair in ER for shelter

Additional interactions between Sinclair and staff include one with a nurse in the 'minor treatment area' during the early morning hours of Saturday, September 20, 2008.

That nurse, who knew Sinclair, "approached him and said words to the effect of 'Hey, Brian. How's it going?' He acknowledged her with a mumble, and she returned to her work. She reported that he did not appear to be in distress and that she mistakenly assumed that he was there for shelter, or that he had been seen and discharged," the report says.

Later that day, shortly before 1:30 p.m., Sinclair began to vomit in the waiting room.

The report says a housekeeping aide observed Sinclair while cleaning up the vomit using a kidney basin. A security officer went to get a larger basin, the report says, because the kidney basin was not large enough.

The security officer also spoke to the triage aide about the need for a bigger basin but the triage aide was busy with another patient.

'None of the staff … during that 34-hour period were aware that Mr. Sinclair was awaiting treatment. '  —WRHA administrative review

Later, the security officer told the triage aide he had "taken care of it," meaning disposing of the vomit, the report says.

"The triage aide appears to have taken this to mean that the patient's needs had been taken care of, and accordingly, he did not believe there was any further action to be taken by him in relation to the security patrol officer's earlier comment to him."

The report says the triage aide had no independent recollection of that conversation.

Review found 'gaps in system,' but no fault

The administrative review conducted by three WRHA officials was intended to find out what happened during Sinclair's 34 hours in the waiting room, as well as make recommendations, and determine whether any staff should be disciplined or receive training.

Interviews for the report were conducted with nursing, support, security, and housekeeping staff that were on duty during the four shifts in the time period.

The report concluded "there is no evidence to demonstrate that any individual staff member acted or failed to act in accordance with the expectations of them within the scope of their jobs in a way that would warrant disciplinary action."

Instead, the report says "gaps in the system" were at fault.

The WRHA has said since the fall of 2008 that no individuals were to blame.

"None of the staff on duty during that 34-hour period were aware that Mr. Sinclair was awaiting treatment and had not yet been triaged. The assumptions that they made were mistaken. They are each experiencing regret, sadness and frustration reflecting on what might have been, had they realized that he was awaiting care and had intervened."

And while the report concluded discipline was not warranted, it does say assumptions were made by staff about Sinclair's presence in the waiting room "without directly asking him if he was there to see a doctor."

'[Staff] spoke of spending their own money to provide a dinner at Main Street Project and …Christmas presents for those patients'  —WRHA administrative review 

The report also addresses the issue of racism, which has been raised because Sinclair was aboriginal.

"There have been allegations that in making such assumptions, staff in the Adult Emergency Department demonstrated racism," the report says.

Staff angered by allegations of racism

"Racism is a highly charged word, evoking a considerable emotional response and has a number of connotations. The staff of the Adult Emergency Department are hurt, angered and frustrated that they have not been able to tell their story to counteract these allegations," the report says.

"They describe their caring and compassion for a disadvantaged population living in the area surrounding the Health Sciences Centre, who demographically comprise the majority of patients seen in the Adult ER."

"They passionately describe their efforts to care for those who attend at the Adult ER on a regular basis for shelter, warmth and food. They spoke of spending their own money to provide a dinner at Main Street Project and to provide Christmas presents for those patients," the report says.

The report points out it is imperative staff not make assumptions about why someone is at the ER and instead specifically ask whether the person is there to see a doctor.

Layout of ER prompts concern, anger

The physical layout of the emergency department is also addressed in the report, noting "considerable anger was directed towards management for not addressing staff concerns regarding the configuration of the waiting room."

Prior to Sinclair's death, "staff were concerned that the waiting area was not visible to the triage nurses sitting at the triage desk and that some of the chairs were facing away from the triage nurses and security due to the location of the television at the back of the waiting room," the report says.

However the report says the problem with the Sinclair case was not that staff didn't see him but rather that they didn't understand he was awaiting treatment.

The report says actions had already been taken to address the physical configuration issue and other problems identified in the review.

The inquest into Sinclair's death began in August and is on a break until October. It will hear from doctors and nurses at that time.

Read the administrative report

Read the full text of the Winnipeg Regional Health Authority's administrative review report into the 2008 death of Brian Sinclair: