November 19, 2008

WRHA Releases Information from Sinclair Reviews

Full Administrative Review to be Submitted to Inquest

The Winnipeg Regional Health Authority today released information flowing from reviews into the September 21, 2008 death of Mr. Brian Sinclair as part of its commitment to keep the public as informed as possible prior to the commencement of the inquest into Mr. Sinclair's death.

The province's Chief Medical Examiner (CME) conducted an autopsy and announced shortly after Mr. Sinclair's death that he was ordering an inquest into the death, and that he would be turning the matter over to a provincial court judge to set a date. The WRHA will cooperate fully in that court process, which has not yet been scheduled.

The circumstances surrounding the death were reviewed by a Critical Incident Review Committee (CIRC), which was struck immediately following Mr. Sinclair's death. While the work of the CIRC is protected under legislation, the recommendations made by the CIRC are being released today because of the exceptional circumstances surrounding this case.

An administrative review, also undertaken immediately following Mr. Sinclair's death, identified actions taken to date and recommendations for further action. Those portions of the report are being released today. The entire report will be submitted as evidence at the inquest.

"Changes that have already taken place and changes that will be implemented are all designed to improve quality of care in our Emergency departments," Dr. Brian Postl, WRHA President & CEO, said.

"We know our Emergency Department staff frequently work under difficult circumstances. We know that a trip to Emergency is stressful for patients. These changes are designed to improve the experience for both."

The Critical Incident Review Committee made a total of five recommendations aimed at improving processes, and ultimately patient care, in the Region's Emergency departments (EDs). It recommended that:

  • A system be put in place to ensure that anyone arriving at an ED needing care is registered electronically before entering the waiting room;

  • The ED triage team not have to deal with any patient presenting to the ED for any reason other than emergency treatment (e.g. for follow-up specialist appointments). An alternate ‘point of entry' should be developed to reduce current demand on the resources of ED triage nurses;

  • The roles and responsibilities of all staff and volunteers working in the ED be clarified and reinforced on an ongoing basis, and that all parties commit to jointly reviewing and updating them on a regular basis;

  • A member of the ED staff communicate directly with each person in the waiting room at least once every four hours; and

  • Because of the challenging and high-stress nature of the triage and reassessment roles in the ED, the nurses filling those positions be rotated into other positions every four hours while ensuring they clearly communicate any ongoing issues to the nurses rotating into those positions.

The recommendations have been forwarded to the regional Emergency Program team who will work with hospital sites to implement them or develop alternate solutions to issues they raise.

The administrative review team interviewed staff who were on duty or working in the HSC Emergency Department during the 34-hour period Mr. Sinclair was there. The review determined that the facts and circumstances surrounding Mr. Sinclair's death did not derive from any action or inaction by any single individual and so no disciplinary action is warranted. Rather, they recommended that action be taken to address the systemic gaps and that direction be provided to all staff working in the ED to ensure that all persons in the waiting room be specifically asked if they are there seeking medical attention.

"The circumstances surrounding the death of Mr. Sinclair are tragic, and we again extend our sympathies to his family and friends," Adam Topp, Chief Operating Officer, HSC, said. "We are committed to making necessary changes to improve patient safety."

Background Information: Chronology

Administrative Review: Actions Taken to Date

Administrative Review: Summary of Next Steps

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