10/07/2013 12:26 EDT | Updated 01/23/2014 06:58 EST

Winnipeg inquest told of staff shortage on day Brian Sinclair died in hospital

WINNIPEG - A Winnipeg hospital emergency room was overcrowded and short-staffed — operating without a key triage nurse — when a man came in seeking care and died 34 hours later.

Susan Alcock, a senior clinical resource nurse, told an inquest Monday into the death of Brian Sinclair that the emergency room at Health Sciences Centre was short five nurses on Sept. 19, 2008.

They were only able to fill two of the vacancies, so Alcock said a nurse who would normally triage patients and reassess their condition while they waited was reassigned when Sinclair arrived at the hospital that afternoon.

"When you have that many shortages, it really impacts on the care you can give to patients," said Alcock, who has worked at the Winnipeg hospital for 21 years.

At the time, Alcock said they were also dealing with more patients than normal — 134 patients were admitted on Sept. 19 and 138 triaged the following day. The average patient load was around 120 a day, Alcock said.

"Both of those shifts were horrific," she said Monday. "We were full."

The position of reassessment nurse was created following the death of another woman in the emergency room in 2003 and following recommendations of a task force in 2004, she said.

"People are at risk when they wait," she told the inquest. "Incidents had happened, so that's why they got us a reassessment role."

Sinclair, a double-amputee, was referred to the emergency room by a community doctor because he hadn't urinated in 24 hours. He spoke to a triage aide when he arrived and wheeled himself into the waiting room, where he languished for 34 hours. Although he vomited several times as his condition deteriorated, Sinclair was never officially triaged or examined by a medical professional until rigor mortis had set in.

An inquest is examining why the 45-year old died of a treatable bladder infection without receiving medical care.

Manitoba's chief medical examiner has testified that Sinclair would have required about half an hour of a doctor's time. His catheter required changing and he needed a prescription for antibiotics.

Alcock said she knew Sinclair since he had been a frequent visitor to the emergency room over the years, often for issues relating to substance abuse.

She said she was also Sinclair's bedside nurse when he was admitted to the hospital in 2007 after being found frozen to the steps of a church in the dead of winter.

"I will never forget his legs," she said, her voice trembling with emotion. "They were frostbitten up to his knees. They were like a block of ice."

Sinclair's legs were amputated as a result.

It's not unusual for the emergency room to operate with only 80 per cent of positions filled, Alcock said. Nurses are juggled around to fill the most necessary vacancies, she said.

Often, she said, nurses who are reassigned to the emergency room to fill a vacancy aren't fully qualified to work there.

"You need special training to work competently in the emergency room," Alcock said. "They just don't have the experience we have."

The overcrowding and lack of staff in the emergency room prompted Alcock to write a letter to senior management during the summer of 2008, outlining her concerns.

The response she received was a reprimand for not following the chain of command, Alcock said.

"I felt we needed to do something soon because something was going to happen," she said.

Sandi Mowat, president of the Manitoba Nurses Union, said overcrowding has been an issue for emergency departments across Canada. At the moment, she said emergency rooms in Manitoba are not chronically short-staffed.

But she said such problems can crop up again.

"Those nurses are devastated about what happened to Mr. Sinclair and we're open to finding solutions and that's what this inquest is about," Mowat said outside court.

"We're hoping there will be solutions that will make sure this never happens again."

The inquest is to continue through October and is slated to hear from other nurses and medical staff who were on duty at the time.