It took a good seven hours before an ER nurse finally had the chance to call maintenance about a locked-up bathroom door — only to discover the body of a woman who had shown up at the hospital, seeking treatment.
"She was dead on the toilet, in full rigor," the nurse recalls. "She'd been dead for a while."
Welcome to life — and death — in Winnipeg's emergency rooms. Plagued for years with overcrowding, understaffing and a slew of casualties along the way.
"I'll tell you something: We are a Brian Sinclair incident waiting to happen," says the nurse, who asked not to be identified.
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It's also a prediction shared by others, both local front-line workers and national experts in the field.
"Oh, I think it's absolutely true," says Dr. Alan Drummond of the Canadian Association of Emergency Physicians.
"Brian Sinclair? I think it will happen again."
'No support for us'
History also supports this prediction.
Take the woman who died in the bathroom. She was a regular in that emergency room, addicted to drugs and occasionally overdosed.
This time, however, she saw the lineup in triage and made a quick trip to the bathroom first. She didn't come out.
And the triage nurse on duty that night was so busy, it was hours before she had the chance to call maintenance to report what she thought was just a jammed bathroom door.
"It was a really busy shift, so one of the public came up and said, 'You know, we hear water running all the time,'" the ER nurse, who was on duty that night, recalled.
"You know, 'OK, OK, we'll get maintenance, we'll get maintenance'…. So then finally maintenance opened the door and, of course, I was first responder."
The woman's death occurred before Brian Sinclair died, but after the Winnipeg Regional Health Authority (WRHA) had made the first of several commitments to add an extra triage nurse to watch over patients like her.
"Are you kidding? There was no support for us," the nurse said.
In light of Brian Sinclair's death, the WRHA once again vowed that things would get better. They didn't.
In 2009, a man was rushed to the Health Sciences Centre with slurred speech and partial numbness. Deemed a possible stroke victim, he should have been reassessed regularly while waiting to see the doctor.
But the ER was swamped, and nurses short-staffed. Five hours later, he was finally sent for tests.
But they were the wrong tests — they'd been ordered for someone else. By that time, the man had suffered permanent brain damage.
Died after 7-hour ER wait
In February of this year, a woman went to a city emergency room with a possible head injury, but the ER was crowded and they were short-staffed.
So once she was triaged, she was sent to the waiting room — for almost seven hours. Frustrated, her family took her home.
She was dead the next day.
"You know, that tore up the nurses, I'll tell you," one ER nurse said. "They still cry about it today. They did everything in their power. She was a high-risk head injury."
So if she was so high-risk, why was she still waiting to see a doctor after seven hours?
"No beds," the nurse said.
And that, along with the chronic staffing shortage, is at the heart of what ails Winnipeg's ERs, experts say.
For all the WRHA's pronouncements about beefing up triage — and then scaling it back — the real problem is much deeper.
"I mean, fair enough, nobody can really dispute the benefit of continuity of care by better access to primary care," said Drummond.
But as long as there are not enough beds for nurses to direct patients to, and as long as there's not enough support to monitor those patients while they're waiting for those beds, nurses will continue to be set up to fail.
And the results will continue to be fatal.
"We leave every shift defeated," the ER nurse said. "Day in and day out."
If you work in an ER and have a story to share, email Donna Carreiro confidentially at firstname.lastname@example.org.