Brian Sinclair, a 45-year-old double-amputee, died of a treatable bladder infection while waiting for care six years ago at Winnipeg's Health Sciences Centre.
The inquest judge said in his final report released Friday that Sinclair "did not have to die," but Tim Preston rejected the family's pleas to rule the death a homicide on the grounds that failing to provide medical care was akin to failing to provide the necessities of life.
Relatives had also asked that the judge call on the Manitoba government for a public inquiry into how aboriginal people are treated in the health-care system, but Preston said that wasn't necessary. He made 63 recommendations aimed primarily at policy reviews at the Winnipeg Regional Health Authority to ensure what happened to Sinclair doesn't occur again.
Robert Sinclair said he was disappointed the inquest didn't deal with racist assumptions about his cousin and instead focused on how the emergency room should be structured. Brian Sinclair's death will be in vain unless the health-care system deals with the real reasons he was ignored, his cousin said.
"We're stereotyped — we like to drink, we like to be on welfare — all those bad stereotypes which are silly," Sinclair said. "That stuff needs to be addressed. Does that same mentality still exist in that system? You can speak to many aboriginals in this city and they'd tell you that it does."
Sinclair went to the ER in September 2008 because of a blocked catheter. The inquest saw security camera footage of him wheeling himself over to the triage desk where he spoke with an aide before wheeling himself into the waiting room.
There, he languished for hours, vomiting several times and slowly dying. He was never asked if he was waiting for medical care. He was never seen by a triage nurse or registered as a patient.
Some staff testified that they assumed he was drunk, "sleeping it off" or homeless. By the time he was discovered dead, rigor mortis had set in.
The chief medical examiner called Sinclair's death preventable but ruled out homicide, calling his death "natural." Police also investigated and determined no criminal charges were warranted.
The health authority overhauled the emergency department after Sinclair's death so that triage nurses can better monitor the waiting room. Wristbands for those waiting for care now make them more easily identifiable. Cultural training for staff has also been retooled.
An inquest into his death began 18 months ago and heard from 82 witnesses.
"Brian Sinclair did not have to die, but he did not die in vain," Preston wrote, pointing to the changes made by the health authority.
The government and the health authority said Friday they accepted all Preston's recommendations, including one to ensure that vulnerable people are helped through triage when they first arrive at the emergency room.
Others suggest waking people periodically in the waiting room, ensuring that staff intervene when a person is vomiting in the department and looking into an aboriginal elder position for the ER.
Both Health Minister Sharon Blady and the health authority apologized once again to Sinclair's family.
"The death of Mr. Brian Sinclair was a preventable tragedy," Blady said. "It should not have happened at HSC or at any other health facility.
"I want to apologize to Mr. Sinclair's family. None of what we can do can make up for your loss."
Blady didn't completely reject the idea of an inquiry, but noted the judge did not think it was necessary. The government's focus is on implementing the inquest's recommendations, she said. The deputy minister of health has three months to study the feasibility of the recommendations and report back with a plan, Blady said.
Arlene Wilgosh, CEO of the Winnipeg Regional Health Authority, acknowledged that some feel Sinclair was ignored because of his race. Racism does exist and it would be naive to expect the health-care system to be immune, she said.
"However, our expectation within the Winnipeg Regional Health Authority is that every single patient, regardless of race or culture, should receive the same access to safe, high-quality and timely medical care based on medical need," she said. "Our entire system has learned significantly from this.
"People are more aware now, more conscious."
But Emily Hill, a lawyer with Aboriginal Legal Services of Toronto, said the inquest missed an opportunity to explore the barriers faced by aboriginal people across Canada. Although Preston spent 15 of the 200 pages of his report talking about the assumptions made about Sinclair, Hill said he failed to look at the root causes of why people made those faulty assumptions by looking at him.
"That meant the report didn't address the questions that we think continue to plague aboriginal people's experience of health care across the country," said Hill, who participated in the first half of the inquest.
"One of the many barriers to aboriginal people's ongoing health is discrimination within the health-care system. This report fails to fully address that."
Vilko Zbogar, the Sinclair family lawyer, said it's now in the hands of the Manitoba government to call an inquiry to fully explore why workers assumed Sinclair was drunk, homeless and not in need of medical care.
"It's not the end of the road. The issue is still alive," he said. "It's not an easy issue but it's something that has to be dealt with seriously."
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