Death was preventable for a Winnipeg man found after more than 34 hours in the waiting room of a major hospital's emergency department, the province's chief medical examiner said Wednesday.
Brian Sinclair had a catheter for a bladder problem. The catheter was blocked, so he hadn't been able to urinate for 24 hours and his bladder was full, said Dr. Thambirajah Balachandra.
He died of a resulting infection.
Balachandra called the death over the weekend "entirely preventable," saying the infection could have been addressed with antibiotics. Sinclair had been treated in hospital in March for the same condition, he said.
Balachandra has called an inquest and he expects it to begin almost immediately.
Sinclair, a 45-year-old double leg amputee, took a taxi from a community health centre to the Health Sciences Centre on Friday afternoon. He was found dead after midnight on Sunday, when someone in the waiting room alerted hospital staff.
It appears Sinclair was never assessed by a triage nurse and was not registered as a patient seeking care, so reassessment nurses didn't know he was there for help, officials with the Winnipeg Regional Health Authority said Tuesday.
It's believed he was dead for some time before staff were alerted, officials said. The exact time of his death is not known.
Native patients 'don't fight back'
Doreen Demas, an advocate with the First Nations Disability Association, said she wasn't surprised to hear Sinclair had sat for so long. Aboriginal people have been conditioned not to stand up for themselves, she said.
"They don't have the courage or the assertiveness to demand or to push for better care," she said.
"A lot of our people just feel beaten down, so they sit there and they don't fight back and they end up — this is what happens."
Many aboriginal people with disabilities in Manitoba end up in Winnipeg because there are inadequate services in their home communities, Demas said.
Aboriginal people are often not treated with respect in emergency rooms, she added, as sometimes they're assumed to be drunk when they may be suffering from a stroke or diabetes. When people stand up for themselves, they risk being deemed troublemakers, she said.
In response to Sinclair's death, the Winnipeg Regional Health Authority has issued a directive requiring clinics that send people to the emergency department to follow up by phone.
Manitoba Health has asked emergency department staff to ensure every person in the waiting room is spoken to, to determine whether they have been registered.