The internal review was conducted by the Winnipeg Regional Health Authority a month after Brian Sinclair died while waiting at the city's Health Sciences Centre in September 2008. The document is now an exhibit in the ongoing inquest into the man's death.
"This was truly an exceptional occurrence," the review concluded. "The tragedy of a patient dying in the waiting room of an emergency department without ever having been triaged has not occurred before.
"To hold individuals accountable on a disciplinary basis for such gaps in the system would be inappropriate and unfair."
Sinclair had been referred to the emergency room by a local clinic because he hadn't urinated in 24 hours. The 45-year-old is seen on security footage being wheeled into the emergency department and speaking to a triage aide. The aide writes something on a piece of paper before Sinclair wheels himself into the waiting room. That piece of paper has never been found.
"The triage aide reports having no independent recollection of this interaction," the review said. "The triage list was discarded on the evening of Sept. 19, 2008, as is normal practice."
While Sinclair waited in the emergency department, deteriorating and eventually vomiting on himself several times, some 17 staff members observed the man but no one asked if he was waiting to see a doctor. The review said they all made different assumptions about why he was there.
Some assumed he had been triaged already and was waiting for a bed in the back of the treatment area. Others assumed he had been treated and discharged. Still some thought he was drunk and was waiting for a ride under the Intoxicated Persons Detention Act or just needed a warm place to rest.
"Tragically, there was little or no communication of these observations amongst each other and Mr. Sinclair was neither triaged nor treated during this time," the review said. "Upon learning of Mr. Sinclair's death, staff were devastated. Many reported having reflected on their observations and interactions with Mr. Sinclair and what might have been had they realized that Mr. Sinclair was awaiting care and had not been triaged.
"The assumptions that were made, while clearly mistaken, do not appear to have been made with malice."
Sinclair eventually died of a treatable bladder infection caused by a blocked catheter. By the time a couple in the waiting room raised concerns about Sinclair with a security guard, Manitoba's chief medical examiner testified rigour mortis had set in.
Sinclair's family has alleged assumptions were made about him because he was a dishevelled aboriginal man in a wheelchair. But the review said staff — one who has known Sinclair since he first appeared in the emergency department at the age of 16 — are hurt by such allegations.
Staff are caring and compassionate, serving a disadvantaged population living near the inner-city hospital, the review said. Some even talked about spending their own money to provide food and Christmas presents at local homeless shelters, the review stated.
"The staff of the adult emergency department are hurt, angered and frustrated that they have no been able to tell their story to counteract these allegations," the review said.
Medical staff who were there while Sinclair waited for care are scheduled to have their say when the inquest into Sinclair's death resumes in October.
The inquest, which sat for a month in August, has already heard testimony from Sinclair's family, medical pathologists and security guards who were working that weekend. The inquest has heard that Sinclair was well-known in the emergency room and had come there dozens of times.
He lost both his legs to frostbite in 2007 when he was found frozen to the steps of a church in the dead of winter.