The inquest into the death of 45-year-old double amputee Brian Sinclair in a hospital waiting room in Winnipeg has found it was not homicide and doesn't require a public inquiry.
However, Judge Tim Preston says in his final 200-page report that Sinclair "did not have to die."
"But he did not die in vain," Preston added, noting Sinclair's death had prompted an overhaul of the "front end" of the Winnipeg Health Sciences Centre's emergency department, as well as a streamlining of the registration and triage processes.
The report, released Friday, contains 63 recommendations, many of which have already been implemented by the regional health authority.
"Hopefully, the recommendations in this report, a report that was also precipitated by his death, will assist emergency departments to provide timely and appropriate health care to all persons in need of care and in the process, improve the flow of patients through the health care system," Preston's report says.
Robert Sinclair, a spokesman for the family and Sinclair's cousin, said they welcome the report's recommendations, but they're disappointed it does not address what they believe is the main underlying issue: negative stereotyping of aboriginal people.
"It was disappointing because the truth still doesn't exist there. Yeah, it made some good recommendations, but the burning question is why did he wait there 34 hours?" Sinclair told CBC News in an interview.
"We haven't gotten the truth. We're still waiting for that. But I think that's the most important thing. Once we get that, then we can actually say Brian didn't die in vain."
'We failed him,' says health authority CEO
Arlene Wilgosh, president and CEO of the Winnipeg Regional Health Authority, along with provincial Health Minister Sharon Blady, said on Friday that they accept the report's recommendations.
"While many have already been acted upon, "there is still much work we need to do," Blady said, but noted the emergency room process of 2008 "is not the one we have now."
"Mr. Sinclair’s death was preventable. He came to us seeking care, and we failed him," said Wilgosh.
"On behalf of the Winnipeg Regional Health Authority, I would like to again apologize to Mr. Sinclair’s family. We are very sorry we failed him.”
Wilgosh said a “perfect storm of events” at the HSC contributed to death, with missed opportunities, poor communication and a strained system.
Assumptions were being made by many people about Sinclair’s care during his entire stay, Wilgosh said, citing the findings in the inquest report.
She said she holds all staff accountable but no one has been fired.
“This was a professional, career turning point” for many at the hospital, some of whom abandoned their nursing careers as a result, Wilgosh said.
Blady also released the following statement:
The death of Mr. Brian Sinclair was a preventable tragedy. The system failed Mr. Sinclair and for that I humbly apologize to his family, friends and loved ones.
Today, Judge Preston released his report into Mr. Sinclair's death. I want to take this opportunity to commend Judge Preston for this thoughtful and comprehensive report. I would also like to thank all those who appeared at and participated in the independent judicial inquest.
In his report, Judge Preston provided 63 wide-ranging recommendations that will help to improve emergency care across Manitoba. As the minister of health, I accept all of his recommendations.
As such, I am assigning my deputy minister, Ms Karen Herd, to lead an implementation team. In 90 days, this implementation team will be expected to assess the feasibility of the recommendations that have been made by Justice Preston and report back to me with a short-term, medium-term and long-term implementation strategy.
Regional health authority boards shall ensure their chief executive officers have appointed a senior leader to the implementation team and the CEO has enabled their full participation.
We are committed to ensure other families will not face the same tragic and preventable loss that has been faced by Mr. Sinclair's family.
Sinclair died of a treatable bladder infection in September 2008 after sitting in his wheelchair for 34 hours in the Health Sciences Centre's waiting room.
- CBC Manitoba | Brian Sinclair's 34-hour ER wait
- Life and death in Winnipeg's emergency rooms
- Brian Sinclair inquest told aboriginals face racism in ERs
The inquest heard he was never asked if he was waiting for medical care and that nurses at the Health Sciences Centre did not help him even as he vomited on himself.
By the time he was discovered dead, rigor mortis had set in.
The Sinclair family’s lawyer, Vilko Zbogar, had asked Preston to rule Sinclair's death a homicide because of the inaction of hospital staff.
He and family members also called on the province to hold a public inquiry into how aboriginal people are treated in the health-care system.
'Institutional racism' killed Sinclair
On Friday, Zbogar said he was disappointed Preston ruled out homicide. To reject that human factors substantially contributed to Sinclair's death feels like an injustice, he said.
"The evidence presented at the inquest made it crystal clear that this case involved fatal neglect by medical professionals charged with a vulnerable person's care. In law, that is called homicide, even if the result is unintended," he said.
In a news release, Robert Sinclair called for "action to end the pattern of institutional racism and stereotyping that killed Brian Sinclair and that continues to threaten the health and well-being of aboriginal people accessing the health care system."
Hospital staff assumed Brian Sinclair was drunk or homeless rather than a person in need of medical care — assumptions based solely on visual observations of a poor aboriginal double-amputee in a wheelchair, he said.
"Those stereotypes have not gone away. Aboriginal people frequently experience the same kinds of stereotypes when we try to access the health care system today," Robert Sinclair said.
"Unfortunately, this inquest report does not probe into those issues, and that will not make things any better."
Wilgosh, asked at her news conference whether she believes there is systemic racism in the health system, said it would be naive to believe it doesn't.
"But our entire system has learned significantly from this," she said. "People are more aware now, more conscious."