On 19 September 2008, Brian Sinclair was sent to the emergency department of Winnipeg Health Sciences Centre by a clinic physician, who provided a letter for the ED physician asking for a foley catheter replacement and antibiotic treatment. For anyone who works in the emergency department, this is common practice. Yet Brian Sinclair, who was a double amputee, waited in vain for care and intervention, and thirty-four hours later, he died in his wheelchair from overwhelming sepsis resulting from a urinary tract infection.
It was pretty obvious, to me at least, when I first read this terrible story, that there were serious systemic issues which contributed to Brian Sinclair’s death. The usual process when a patient presents to an emergency department, is for the patient to report to Triage, where the triage nurse will perform an assessment of the patient’s acuity. For some reason, Brian Sinclair did not make this crucial first step: he was not recognized as being “in the system” by anyone and he died as a result. There was no mechanism — this is true in most emergency departments — of easily recognizing people who may have missed triage or perhaps, like many people, don’t clearly understand the somewhat complex intake process in an emergency department. In my experience, this problem is fairly common. Perhaps, the sending physician told Brian Sinclair he would be “taken right in”, implying there would be no triage/registration process, and so he waited: I’ve seen this as well. Maybe staff were working without breaks: there’s a clear relationship between poor judgement among health care professionals and fatigue. Perhaps there were areas of the waiting room not visible to the triage nurse. Perhaps the emergency department was overwhelmed with patients, or short-staffed. Or perhaps, like most waiting rooms, this waiting room was crowded with people who weren’t patients, and Brian Sinclair was missed in the chaos. Family members. Friends. People seeking shelter.
I write this not to rationalize the death of Brian Sinclair. Clearly, to think a person could wait thirty-four hours in a waiting without intervention of any kind is distressing to me as a nurse, and inexcusable. I know, too, there may be elements of racism/classism in how Brian Sinclair was treated. However I am trying to show that when a death occurs in a health care for reasons easily preventable, it is almost always not because of individual negligence, but because of series of systemic or environmental factors often beyond the control of any one person. So who’s to blame? Everybody. Nobody. It’s a conspiracy of circumstance. The Health Sciences Centre, to its credit, has started new procedures to prevent such a death from ever happening again, something which emergency department across Canada would do well to emulate.
A couple of days ago, Winnipeg Police announced they were launching a criminal investigation against hospital staff.
In March the Winnipeg Police Service said they would do a review into the matter after [lawyer Clayton] Ruby spoke out on the family’s behalf. Police said the decision to launch the investigation came after getting documents and materials related to Sinclair’s death.
“We have determined that an investigation into this incident is warranted,” said Const. Natalie Aitken, a Winnipeg Police Service spokeswoman. “That being said, that should not be any reason to construe that any manner of wrongdoing has been determined as of this time.”
Should deaths like Brian Sinclair’s be criminalized? It seems counter-productive, if undestandable: the first impulse in our culture is to seek blame and retribution. Someone must be to blame. But what if someone is a series of systemic errors? Targeting the triage nurses, which this investigation is bound to do, will do little to address the underlying issues, and deflects attention from real change that would improve patient safety. More broadly, criminalizing health care professionals in such circumstances creates a culture of fear where any death, the result of error or not, might be subject to criminal investigation and retribution, in turn impoverishing morale and hindering recruitment. These, unfortunately, are not trivial issues.
And, it has to be said, the timing of this investigation is a bit odd. I heard Brian Sinclair’s brother speak on CBC Radio One on Friday, when news of the police investigation broke. He welcomed the news — the coroner’s inquest on the death has been delayed for a number of reasons — and he thought it was a step “in the right direction”. He believed the purpose of the investigation wasn’t to scapegoat staff, but to gather information. I’m afraid he’s wrong. The first purpose of any criminal investigation is to assign blame.
The two year gap between Brian Sinclair’s death and police interest in the case — last year, police said there was “no suggestion” of criminal wrong-doing — suggests both political pressure and indeed, a desire somewhere to find a scapegoat, probably among the nurses present. Not uncoincidently, just last month, Brian Sinclair’s family has initiated a potentially politically embarrassing lawsuit against the regional health authority and the Manitoba government. Otherwise, why not let the coroner’s inquest run its course? This is what inquests are supposed to do: investigate root causes and systemic problems. An inquest was planned and will inevitably be delayed until police finish their inquiries, charges are laid, and the creaky mechanism of criminal law runs its course. Charges, I think, of course will be laid; if I were one of the triage nurses on duty during that thirty-four hour period, I would be quaking right now; and then I would call a lawyer. And of course, the coroner’s inquest, which could help effect real reform in emergency departments, will be put off indefinitely.
[Cross-posted at Sister Sage's Musings]