Death in the Waiting Room

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]

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  1. #1 by Terri on Sunday 17 October 2010 - 1413

    Thank you for posting this and reminding us to continue to look for ‘flaws’ in the system. Our town had a college aged girl die in the last couple of years, in a level 1 trauma center waiting room, because she was triaged incorrectly (chest pain = anxiety in anyone who is young mistake).
    We must constantly look for easy ways to fix the system – perhaps someone in the ER waiting room who verbally checks in every hour…”Has anyone who has not spoken with a nurse or physician in this ER yet, raise your hand?” – or “Those of you who have been waiting more than 2 hours please raise your hand” – then following up on those patients who affirm this.
    Under-staffing is a big issue, and an easy solution to such problems.
    Keep writing on these important issues. We are listening.

  2. #2 by Jenn Jilks on Sunday 17 October 2010 - 1657

    I love your posts. You really hit the nail on the head. Finding blame does no one any good. Preventing it will.

    THere are many times when ignorance results is this type of tragedy. I have learned to be a squeaky wheel when advocating for my dad. It’s too late, of course, but in experts, like yourself, pointing what is normal we can prevent another such tragedy.

    I tell my readers and audiences to write it all down, advocate, ask questions and to be vocal in a respectful way.
    I only wish, if I have the need, to visit you and yours. I have learned much from your posts.

  3. #3 by The Nerdy Nurse on Sunday 17 October 2010 - 1917

    this is very sad to hear. Like you, I can see where system had failed and it wasn’t necessarily negligent healthcare providers that caused this tragedy. It was improper communication.

  4. #4 by Nurse Me on Thursday 28 October 2010 - 2035

    One question that you may not know the answer to, why didn’t Brian’s clinic MD replace the foley himself? You’re right, PMD/clinic MD turfing their patients to the ER is common but that’s one way Brian’s death could have been prevented. Especially since MDs know how long ER wait times are for non-urgent patients. Whoops, am I assigning blame and judgement?

    In my ER we’re constantly under scrutiny about our triage process and waiting room. Every week there are new changes all to benefit patients and to prevent waiting room tragedies. It isn’t easy and sadly people will still fall through the cracks no matter what. So hopefully this investigation will lead to changes and not convictions.

  5. #5 by torontoemerg on Thursday 28 October 2010 - 2129

    It’s a good question, esp, if he was known to the clinic. I think in general, it was a systemic failure from A TO Z, from the clinic which (seemingly) did not communicate with the ED to the fact the poor pt waited unattended in the WR for 35 hours and wasn’t aware he needed to report at triage. Unfortunately, I believe the police investigation will hinder change, not facilitate it.

  1. Rosacea

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