Just hours before an emergency room doctor realized a meth-using pregnant patient was gone, she was slurring her words, exhibiting bizarre behaviour and had told hospital staff she wanted to leave.
Windy Sinclair was later found frozen and dead outside an apartment block in Winnipeg.
The 29-year-old pregnant mother of four's body was discovered outside a West Broadway apartment block on Dec. 28, days after she sought help for her meth addiction at Seven Oaks Hospital.
New details about Sinclair's time at the hospital and her state that night are outlined in her medical file, which her mother has obtained and shared with CBC News.
The file sheds new light on what happened the night Sinclair left the ER. It says staff noticed she was missing just over two hours after she was given a sedative and a note was recorded in her chart that she was agitated and wanted to leave.
'I want to know why they failed my daughter'
"I want to know why they failed my daughter at this hospital," said Eleanor Sinclair, who believes hospital staff should have restrained her daughter, who was high on meth.
Eleanor said she's also learned her daughter, who was taken by ambulance to the hospital, was moved from a room near the hospital's nursing station to a room out of sight of the station.
"[Patient] wanting to leave ER then agrees to stay. Taking off telemetry and pulling off BP cuff every 5 minutes," says one note in Sinclair's file, time-stamped at 8:39 p.m.
Another note says she is agitated, confused and unco-operative. "[Patient] wanting to leave ER then agrees to stay." A doctor ordered an IV sedative for Sinclair at 8:45 p.m. along with a pregnancy test, which revealed she had another baby on the way.
Hospital medical records say when the doctor went to tell Sinclair at 11:15 p.m. that she was pregnant, she wasn't there, and ER staff said they didn't witness her leaving the department.
At 11:40 p.m., after the doctor had noticed Sinclair was missing, a nurse made a progress note on Sinclair's file that she wasn't in her room and her clothes and jacket were gone.
Eleanor said the hospital has shown her surveillance video of Sinclair outside, leaving the hospital, and no one appeared to notice.
"Nobody coming out the door to look for her. It's heartbreaking, like her life didn't matter at all," said Eleanor.
'Hospital could have done more': Ethicist
"I definitely believe the hospital could have done more, but I think what we often do is blame the hospital for system failures in terms of what's available in terms of resources to keep an eye on people," said Arthur Caplan, head of medical ethics at the New York University School of Medicine in New York City.
Caplan, who reviewed Sinclair's file, said hospital staff should have made sure a search for the patient happened right away. It's still not clear if a code yellow — an alert sent in hospitals when a patient goes missing — was called.
"It's also clear that a search for her when she was gone wasn't as vigorous and as extensive and fast as it ought to have been."
ER no place for drug users: experts
Both Caplan and an Alberta clinical ethicist said Sinclair's death points to the need for a safe location for drug users to go that's not an emergency room.
"This kind of tragedy should get everyone thinking how can we set up facilities better so that we always know where patients who are in the throes of addiction or withdrawal know where they are at all times," Caplan said.
Brendan Leier, a clinical ethicist and professor of medicine at John Dossetor Health Ethics Centre in Alberta, called the ER a "catch-all" for everything in the system.
"It's not an ideal situation," he said about addicts going to hospitals for help.
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Leier said while ER staff could restrain a patient if warranted, it's not necessarily the best idea when dealing with drug users because it might prevent them from coming back for help.
"Locking them up does not establish a good therapeutic relationship."
WRHA won't comment on specifics
The Winnipeg Regional Health Authority is continuing an internal review around the circumstances surrounding Sinclair's time in the ER and declined to comment on the specifics of the case "out of respect for the family and the review," a spokesperson said in an email Monday.
A spokesperson for Seven Oaks General Hospital said "Sorry, no. We don't have anything to add," when CBC asked for a phone interview.
Eleanor is set to meet with senior officials from the WRHA in the near future.
"I'm not going to give up until I get my answers," she said.