Province has acted on most recommendations from Sinclair inquest, ombudsman says

Manitoba's ombudsman will no longer track the progress of an inquest's recommendations following the tragic death of Brian Sinclair, who waited in a Winnipeg emergency room in 2008 for help that never came. 

Double amputee died in 2008 after waiting 34 hours in HSC emergency room

Brian Sinclair was 45 when he died waiting to be seen in the emergency room at Winnipeg's Health Sciences Centre. He was discovered dead 34 hours after he arrived. (Maurice Bruneau/Submitted by family)

Manitoba's ombudsman will no longer track the progress of an inquest's recommendations following the tragic death of Brian Sinclair, who waited 34 hours in a Winnipeg emergency room in 2008 for help that never came. 

Marc Cormier, acting ombudsman, wrote in a letter to the province's chief justice this month that his office is satisfied a majority of the 63 recommendations, made in 2014, have been acted upon. 

He noted eight outstanding recommendations are still in the process of being implemented, while one recommendation is unfeasible.

"Our office is concluding our monitoring of this matter at this time," Cormier wrote in closing.

Ignored to death

Over a span of 34 hours, the 45-year-old double amputee sat in his wheelchair in the waiting room of the Health Sciences Centre for his catheter to be changed.

He died of sepsis before he was discovered on Sept. 21, 2008, without ever being seen by a doctor.

In an inquest into his death, health-care workers said they'd assumed Sinclair was drunk and "sleeping it off," had nowhere to go, or was homeless.

The 21-page letter from the ombudsman, who was unavailable for an interview Wednesday, relies on the government's health and justice departments appraising their own progress.

The province said it's evaluated the floor plan of every emergency department, as requested, and will make recommendations at the locations where people face away from the triage area.

Specific policies were instituted to prevent a person like Sinclair from dying while they wait, such as waking up individuals at regular intervals, assisting vulnerable people when they arrive, intervening when a person vomits, ensuring staff arriving for a shift are briefed on the status of people in the waiting room, and instituting a protocol for overcapacity.

A number of recommendations asked the government to review current practices, but the province decided against it.

The government said the annual $4.5 million cost for a security presence at the entrance of each emergency room is not practical or necessary.

The province also dismissed a call for a pre-triage area in every emergency department, citing existing infrastructure and staffing demands.

A still image from security video shows Sinclair sitting in his wheelchair in the ER waiting room at Health Sciences Centre. (Brian Sinclair inquest)

For other recommendations, the Manitoba government is waiting on Shared Health, the new provincial organization co-ordinating health-care services, to enact new policies. 

It will be up to the new authority to establish a protocol so individuals with mobility or cognitive challenges are safely transported to other health-care facilities.

Deadline for hospital admission

Shared Health will also review the feasibility of a deadline for when patients must be admitted to a hospital bed, provincial benchmarks for a patient's length-of-stay and training for the emotional safety of health-care workers. 

They will also develop a provincial policy to ensure home care updates service providers about the hospitalization of their clients. 

On the possibility of recruiting an Indigenous elder on duty at emergency departments, the province said the suggestion was not culturally appropriate. Instead, health authorities would make spiritual care or an elder available upon request, because not all Indigenous needs are met by a single elder. A spokesperson said this alternate recommendation was suggested by Indigenous health-care providers.

Barry Lavallee, a member of the Brian Sinclair Working Group, wants the government to address the racism that continues to harm Indigenous people in the health-care system. (Jeff Stapleton/CBC)

The inquest has been criticized by Sinclair's family and others for ignoring the role of racism in the health-care system. 

Barry Lavallee, a member of the Brian Sinclair working group that was established to look at the role racism played in his death, maintained the inquest's priorities were out of whack by ignoring the role of race and social status in Sinclair's death. 

"Racism impacting Indigenous peoples occurs in varying degrees. Brian's one of the extreme forms in which he died," Lavallee said, "but there are other people being hurt and unnoticed." 

The report also acknowledges the province is considering a move toward electronic charting and a single electronic health record accessible to all health-care facilities, as per the inquest recommendations, but the technological move would cost $300 million and is not practical.

Watch the reaction after the inquest was made public:

Brian Sinclair's death 'preventable' but not homicide, says inquest report

8 years ago
Duration 2:14
The inquest into the death of 45-year-old double amputee Brian Sinclair in a hospital waiting room in Winnipeg has found it was not homicide and doesn't require a public inquiry.

The province is also holding off on spending $3.3 million to hire community support workers for various emergency departments. 

The recommendation to implement the findings of the confidential Critical Incident Review Committee report, was considered redundant in the context of the other recommendations.

Work continues: province

Health Minister Cameron Friesen called Sinclair's death a "systematic failure" in a statement. 

He said completing 55 of the inquest's 63 recommendations is a noteworthy accomplishment, but the work continues through Shared Health, which has a specific focus on the needs of Indigenous Manitobans. 

"The work underway through the provincial clinical and preventive services plan, which Shared Health is leading, will support the implementation of these remaining inquest recommendations," he said.

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Ian Froese

Provincial Affairs Reporter

Ian Froese is a reporter for CBC Manitoba. You can reach him at


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