The following note was sent by Arlene Wilgosh, president and CEO of the Winnipeg Regional Health Authority (WRHA), to staff as an inquest began on Tuesday into the death of Brian Sinclair.

Sinclair, a 45-year-old double amputee, died in his wheelchair after waiting 34 hours in the emergency room of the Health Sciences Centre in September 2008.

This morning, the Inquest into the tragic death of Brian Sinclair in the Emergency Department (ED) of Health Sciences Centre (HSC) started, and it’s expected the Inquest will continue well into the New Year.

Mr. Sinclair’s death was preventable. He came to us seeking care, and we failed him. His death identified a gap in the way HSC’s ED functioned at that time, a gap that missed an individual seeking care, leaving him untriaged and ultimately resulting in his death.

We’ve apologized to his family, and did so again this morning. We are committed to participating fully in the Inquest, and look forward to receiving its recommendations.

This is going to be a very difficult time for Mr. Sinclair’s family who have waited five years for this Inquest.

It’s also going to be a difficult time for many of us: for those of us who were on duty during the time Mr. Sinclair died, for those who knew and provided care for him throughout the years he received health services from us, and for those of us participating in the Inquest.

As many of you know, we’ve implemented several changes to address issues we identified immediately following Mr. Sinclair’s death.

Patients entering HSC’s ED are now better greeted, identified, and tracked. Once in the waiting room, everyone there – patients, their family members and friends - are checked regularly to ensure we know who is there and why. We’ve also clarified with all staff in the department exactly what their roles and responsibilities are.

As well, primary care clinics sending patients directly to an ED are now expected to call ahead and let the doctors and nurses know a patient is on their way.

Addressing the needs of our patients and residents is our number one priority.

But when we make mistakes, it’s important we own up to it, investigate it, and make changes to improve the system.  Continuous improvement in all health care systems is based on learning from what goes wrong so we can build a better, safer system.

Each of us comes to work each day to help people – from delivering babies, to saving car crash victims, to caring for residents needing assistance with everyday life. We need to be proud of our many accomplishments. We also need to continue treating our patients and residents as we would like to be treated.

As the Inquest unfolds, we are committed to sharing as much information with you as possible so we can all learn and improve. If you have any questions or concerns, please talk to your manager or send me an email.


Arlene Wilgosh, President & CEO