A long-awaited inquest, led by a provincial court judge, is to examine what happened between the time Brian Sinclair came to the Health Sciences Centre ER in September 2008 and when someone else in the waiting room told a security guard they believed Sinclair was dead.
Emily Hill, a lawyer with Aboriginal Legal Services of Toronto, which has standing at the inquest, said there are a lot of questions that need to be answered.
“Why did he fall through the cracks? How could this happen in a big urban centre with a well-equipped ER that is there to meet the needs the most vulnerable in our community?”
She also wants to learn more about what kind of assumptions might have been made about Sinclair when he turned up at the ER.
“I think bias may have played a role in some of the assumptions and may have contributed to what would appear to be some indifference with regard to his health needs," she said.
Security tape at the Health Sciences Centre (HSC) shows Sinclair, a 45-year-old double amputee, went to the triage desk and spoke to an aide before wheeling himself into the waiting room.
That appears to have been his only interaction with staff.
Almost a day-and-a-half later, another person in the waiting room finally spoke up about Sinclair. Efforts to revive him were unsuccessful.
His death was later attributed to a treatable bladder infection. Manitoba's chief medical examiner said Sinclair would have lived if his blocked catheter had been changed and his infection treated.
“Brian's death did come as a shock and the shock hasn't worn off," said Vilko Zbogar, the lawyer for the Sinclair family.
"Brian's name has been in the press as a news story but to his family he was a loved one.”
Like Hill, Zbogar also hopes the inquest shows whether Sinclair was treated differently because he was a low-income aboriginal.
"There will be some analysis of the systemic issues — whether his race, his disability, his socio-economic status affected the treatment he received, or the indifference he received."
Zbogar said the other goal of the inquest is to identify ways to prevent similar deaths.
The HSC has already made changes to the registration and triage process and the physical layout of the ER waiting room.
Police and the Crown attorneys office investigated the death to see if charges of criminal negligence or failing to provide the necessities of life might have applied. But they decided no charges were warranted.
The Winnipeg Regional Health Authority has paid $110,000 in damages to the Sinclair family for loss of care, guidance and companionship.