Brian Sinclair inquest recommendations could take years to implement

The province will be moving forward with all 63 recommendations to come out of an inquest report that deemed the death of Brian Sinclair "preventable," but not a homicide.

Sinclair family remains critical of inquest report, but hopeful changes will help prevent future tragedies

Brian Sinclair inquest recommendations could take years to implement

7 years ago
Manitoba will be moving forward with 63 recommended health-care changes to come out of an inquest report that deemed the emergency room death of Brian Sinclair "preventable" — changes that could take years to implement. 1:45
Manitoba will be moving forward with 63 recommended health-care changes to come out of an inquest report that deemed the emergency room death of Brian Sinclair "preventable" — changes that could take years to implement.
Brian Sinclair, 45, went to the Winnipeg's Health Sciences Centre's emergency ward in September 2008 with a bladder infection. But nobody came to his assistance. More than 24 hours later, he was found dead in his wheelchair. (Maurice Bruneau/Submitted by family)

Manitoba Health Minister Sharon Blady said Thursday that while there are many practical challenges that lie ahead in terms of preventing similar tragedies in the future, a change in culture is also necessary,

"A lot of this is about culture change, and it's about system change and those are the kinds of things where you need to work on the ground with the individuals involved," said Blady. "You also need to assess broader policy, so again, it's about moving forward in the best way possible to ensure there's thorough and systemic change."

Robert Sinclair, Brian's cousin, said he hopes the province stands by its word.

"I'm hoping that they address the issues that were brought up that were ignored about discrimination about certain groups in the health-care system," said Sinclair. "I believe that it is still a concern.

"Where is that stuff learned? Where does that come from? Why do people make those assumptions?"

'Preventable' death

Sinclair, a 45-year-old who was a double-amputee, died of a treatable bladder infection while waiting for care in the emergency room at Winnipeg's Health Science Centre. He was found dead in his wheelchair 34 hours after arriving at the hospital.

The case drew the ire of health-care and aboriginal advocates, who said Sinclair was ignored and that his death was the product of systemic racism toward indigenous people.

"Something went wrong in that system and we're not going to get the total truth of what happened," Robert said. "They white-washed that all along. The guy sat there because they thought he was a drunk Indian ... somebody that you would see and come across hard times, and they decided to totally ignore him."

An inquest into the 2008 death was conducted and a 200-page report was released in December. The report highlighted several issues and contained a list of 63 recommendations for improving the "front end" of the Health Science's Centre's emergency intake processes.
Manitoba Health Minister Sharon Blady speaks to media Thursday. The province announced it will be following through with the health-care recommendations suggested following an inquest into Brian Sinclair's death. (Sara Calnek/CBC)

But Vilko Zbogar, co-council for family of Sinclair, said the inquest overlooked the root cause that led to Brian's death.

"They made assumptions based on the way he looked, the fact he was aboriginal, based on the fact he was poor, so assumed he didn't need care," said Zbogar. "What the inquest didn't do and what the province isn't doing is really examining why people made those assumptions, based solely on how Brian Sinclair looked."

Blady said there were several changes made at HSC in the immediate aftermath of Sinclair's death. Specifically, Blady said triage protocols were assessed and bolstered to ensure patients received proper care during the intake process.

"Within days, we had already moved to a system there at HSC where it has to do with identification, diagnostics, triaging and the green bracelet protocol," said Blady. "Those kinds of things were immediate actions and are the foundation for future actions that were taken elsewhere and can be taken further."

24-month plan

The province has set out a 24-month timeframe for the plan. Blady was asked by reporters why it will take more than two years to implement some of the recommendations.

"I want to make sure that we are doing the right thing for each area of the province, for each ER and the services that are provided," he responded. "This is about systemic change and that can't happen overnight. It has to be built on a strong foundation."

A task force of senior staff from Manitoba's regional health authorities, the deputy minister of health and several health organization members throughout the province helped develop the plan and timeline for implementing changes. 

In the short term, the province said it will focus on making changes in emergency rooms that see more than 10,000 visitors per year. From there, smaller departments will undergo changes based on the layout of hospital buildings, staffing and the needs of patients.

"Each facility is unique. I'm looking forward to folks staying on top of those timelines, because we do need to move this forward and [ensure] that each community has the best health care that they can provide," said Blady.

"So again, I would like people to stay very tightly to those timelines."

Many of the of the recommended changes are already underway, he said.

"People have already seen changes from the time of his passing to now," she said. "We're looking forward to making more changes. I want every Manitoban to have the highest quality health care. Rapid response, high quality response. It's what we all want and deserve."

Robert said he hopes the changes make a difference.

"We need to help these people from falling through the cracks of the system. It's abuse," he said.

Sinclair's family is continuing with its lawsuit against the province and calls for a public inquiry.


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