It was a massive heart attack in the middle of a waiting room that scored a patient the attention he needed — and it was only after waiting more than five hours to be seen.
Is this another example of a dysfunctional emergency room pre-Brian Sinclair?
No. It happened just two months ago — that is, almost five years after Sinclair's death in 2008 and after the Winnipeg Regional Health Authority (WRHA) heralded changes in the ER to prevent yet another case.
"That's one example. Like, I could probably give you daily examples," says an ER nurse who was on duty at the time.
"I'm not joking. The WRHA is setting us up to fail."
The nurse, who asked not to be identified for fear of reprisal, was one of several who spoke to CBC News about conditions in ERs in the years following Sinclair's death.
This week, the CBC's I-Team has revealed that on the day Sinclair arrived at the hospital, the reassessment nurse had been reassigned.
This was despite the fact that four years earlier, the WRHA announced that ERs would have a triage nurse dedicated specifically to reassessing patients waiting to be seen.
Days after Sinclair's death, the WRHA announced once again that it was revising the roles of the triage nurse and that — once again — one would be assigned to reassess waiting patients.
'We've reverted back'
But that protocol did not last long, the nurses allege.
"Since the Brian Sinclair incident, we've reverted back," one nurse said.
"So, as a reassessment nurse, [the rules are] if there's three or more people waiting to be triaged, then I have to help with that."
In other words, as long as there's a lineup for triage, no one in the waiting room gets reassessed; at least, not in some of the community hospitals.
And there's rarely a day that there's no lineup in triage.
"On paper, it looks great. In reality, it never works," said the nurse.
"Never have I been able to come in and start reassessing the people that have been there all night, because the chairs are full of people waiting to be triaged."
A WRHA spokesperson confirmed on Friday that the policy was revised as a means to handle excessive lineups in triage.
Workload is 'killing us,' says nurse
It is a grueling workload that's "killing us as humans" and depriving patients of basic care, the nurse said.
"I once had to tell a patient who was elderly [that], because we were so busy, that she had to pee in the bed. I will never forget that," the nurse recalled. "That's demoralizing."
It's also one reason that experts in the field say the WRHA is prescribing the wrong medication to solve the issue of patients not being seen on time.
Dr. Alan Drummond, co-chair of the Canadian Association of Emergency Physicians' public affairs committee, says the problem doesn't lie with the triage nurses, but with the shortage of beds.
"The minute you start talking about that in the context of crowding, it implies to us that you really don't get it … that this is just a useless diversion of time and energy and, in some cases, of money, with no hope of it impacting on wait times in the emerg," he said.
If you work in an ER and have a story to share, email Donna Carreiro confidentially at firstname.lastname@example.org.