Brian Sinclair, a 45-year-old double amputee with a speech problem, was found dead in his wheelchair at Winnipeg's Health Sciences Centre (HSC) emergency waiting room on Sept. 21, 2008. He died of a preventable bladder infection after waiting 34 hours for treatment.
The Winnipeg Police Service launched an investigation in October 2010 to determine whether criminal charges should be laid in the death.
Investigators interviewed 170 people and concluded their investigation in late 2011. The file was then sent to Manitoba Justice for an opinion from a Crown attorney.
Manitoba, in turn, forwarded the file to Saskatchewan Justice for independent legal advice.
"The reason this had to go to a Crown is because it's such a unique investigation," Det. Sgt. John O'Donovan, who led the investigation for the Winnipeg Police Service, told reporters on Tuesday.
"We had never done anything like before, and we had nothing in Canada that we could compare it to."
O'Donovan said at issue was whether there was evidence of criminal negligence or a failure by hospital staff to provide the necessities of life to Sinclair.
"There were only several people [who] had contact with Mr. Sinclair, and these were the people that the Crown had to scrutinize what they did or what their involvement was," he said.
'They want the truth,' family's lawyer says
Members of Sinclair's family could not be reached for comment on Tuesday.
Vilko Zbogar, the lawyer representing the family, said he had not spoken to them yet but knows they had been hoping for a different outcome.
"They want the truth about what happened to Brian Sinclair. They want accountability and they want to make sure that something like this doesn't happen again and none of those things have been achieved today," he said.
He added the public has a right to know why the Saskatchewan Crown who reviewed the case chose not to lay charges.
"At the very least, a case of this profile, of this importance, this implication for the public interest … the reasons [should] be told to the public so the public can make up its mind whether this decision was in their interest or not," he said.
Security tape from the HSC showed Sinclair had gone to the hospital's triage desk where he spoke to an aide before wheeling himself into the waiting room.
It took 34 hours for someone in the waiting room to approach a security guard and say they believed Sinclair was dead.
An autopsy later determined that Sinclair died as a result of a blood infection brought on by complications of a bladder infection caused by a blocked catheter.
Manitoba's chief medical examiner, Dr. Thambirajah Balachandra, said within days of the incident that Sinclair's death could have been prevented if the blood infection had been treated.
Nurses feel 'vindicated'
Meanwhile, the Manitoba Nurses Union says its members are pleased to learn no criminal charges will be laid in the Sinclair case.
Union president Sandi Mowat said the latest development confirms the results of a Winnipeg Regional Health Authority (WRHA) investigation that said no one at HSC was to blame for Sinclair's death.
"Once again, those nurses have been vindicated, and that it's been confirmed yet again that they are 100 per cent committed to the patients that they serve," Mowat said.
The internal investigation called for changes to be made in how patients who enter the emergency department are registered and monitored while they are waiting to be seen.
"We know this is the second investigation. Certainly the first one said that it was a systemic issue," she added.
"So now we need to make sure that the recommendations that came out of the first investigation are being followed and to ensure that this won't happen again."
But Arthur Schafer, who teaches ethics at the University of Manitoba, says the hospital should have gone further and acted much sooner in establishing responsibility.
"There were all sorts of mistakes," he said. "Individuals should have been held accountable and punished at work, disciplined, fined, fired, if that was appropriate."
Schafer said a public inquiry is needed to truly clear the air, but the Manitoba government has refused to go that far, opting instead for an inquest.
Inquest dates to be set
The inquest has already been called into Sinclair's death but it was put on hold until the criminal investigation was complete.
A spokesperson for Manitoba Justice said on Tuesday that dates for the inquest must now be chosen.
The next step will be for the judge to meet with the lawyers involved.
The inquest is expected to touch on a number of issues at the heart of Canadian health care, as well as determine why Sinclair died and what can be done to prevent similar deaths.
The WRHA says it is "pleased" to hear the latest review has been completed, as it will now allow for the inquest to proceed.
The authority acknowledged that Sinclair's death could have been prevented, and officials have already apologized to his family.
"While mistakes were made and opportunities missed, no one intended to harm Mr. Sinclair," the health authority said in a statement.