Health officials make changes in ER after patient dies waiting 34 hours

Winnipeg Regional Health Authority is making changes to ensure patients are properly monitored in city emergency rooms following the death of a man whosat 34 hours in a waiting room earlier this fall.

Brian Sinclair, 45, was found dead in an emergency department waiting room Sept. 21 after spending a day and a half waiting to see a doctor at Winnipeg's Health Sciences Centre. It was only when someone in the waiting room alerted hospital staff that Mr. Sinclair was found.

Sinclair was not assessed by a triage nurse and was not registered as a patient seeking care, so reassessment nurses didn't know he was there for help, officials with the health authority said at the time. He had been sent to the hospital by a local clinic after complaining of a kidney problem.

The WRHA said Wednesday no one at the health Sciences Centre was to blame for Sinclair's death, and no disciplinary action is being taken against any staff at the hospital. Still, changes have been made in the way patients who come into the emergency department are registered and monitored while they are waiting to be seen by emergency staff.

"The circumstances surrounding the death of Mr. Sinclair are tragic, and we again extend our sympathies to his family and friends," Adam Topp, CEO of Winnipeg's Health Sciences Centre said Wednesday. "We are committed to making necessary changes to improve patient safety."

Following an autopsy, officials said Sinclair could have been saved by a catheter change and a course of antibiotics. An inquest has been called into the death by Manitoba's chief medical examiner.

In the meantime, some new measures adopted by the health authority include:

• Everyone arriving at an emergency room is now registered electronically before entering a waiting room.
• Emergency room staff must communicate directly with each person in the waiting room at least once every four hours.
• Staff should be rotated between the triage and reassessment areas of the emergency department every four hours to ensure better communication.

"Changes that have already taken place, and changes that will be implemented are all designed to improve quality of care in our emergency departments," said Dr. Brian Postl, CEO of the health authority.

"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."

Meantime, when doctors refer patients to any hospital emergency room, their offices must now follow up with a telephone call to the emergency department telling them a patient is on the way.

The Health Sciences Centre has made some physical changes in the layout of its emergency waiting area and has begun hiring new staff with experience in social work to interact with the hundreds of patients who arrive in the emergency department 24 hours a day, seven days a week.