However, Judge Tim Preston says in his final 200-page report that Sinclair, a 45-year-old aboriginal man and double amputee, "did not have to die."
"But he did not die in vain," Preston added, noting Sinclair's death had prompted an overhaul of the "front end" of the Winnipeg Health Sciences Centre's emergency department, as well as a streamlining of the registration and triage processes.
The report, released Friday, contains 63 recommendations, many of which have already been implemented by the regional health authority.
"Hopefully, the recommendations in this report, a report that was also precipitated by his death, will assist emergency departments to provide timely and appropriate health care to all persons in need of care and in the process, improve the flow of patients through the health care system," Preston's report says.
On mobile? Read the report here
Arlene Wilgosh, president and CEO of the Winnipeg Regional Health Authority, along with provincial Minister of Health Sharon Blady, are holding a news conference to talk about the report, starting at 10:45 a.m. CT.
Blady released the following statement ahead of the news conference:
The death of Mr. Brian Sinclair was a preventable tragedy. The system failed Mr. Sinclair and for that I humbly apologize to his family, friends and loved ones.
Today, Judge Preston released his report into Mr. Sinclair's death. = I want to take this opportunity to commend Judge Preston for this thoughtful and comprehensive report. I would also like to thank all those who appeared at and participated in the independent judicial inquest.
In his report, Judge Preston provided 63 wide-ranging recommendations that will help to improve emergency care across Manitoba. As the minister of health, I accept all of his recommendations.
As such, I am assigning my deputy minister, Ms Karen Herd, to lead an implementation team. In 90 days, this implementation team will be expected to assess the feasibility of the recommendations that have been made by Justice Preston and report back to me with a short-term, medium-term and long-term implementation strategy.
Regional health authority boards shall ensure their chief executive officers have appointed a senior leader to the implementation team and the CEO has enabled their full participation.
We are committed to ensure other families will not face the same tragic and preventable loss that has been faced by Mr. Sinclair's family.
Sinclair died of a treatable bladder infection in September 2008 after sitting in his wheelchair for 34 hours in the Health Sciences Centre's waiting room.
The inquest heard he was never asked if he was waiting for medical care and that nurses at the Health Sciences Centre did not help him even as he vomited on himself.
By the time he was discovered dead, rigor mortis had set in.
The Sinclair family’s lawyer, Vilko Zbogar, had asked Preston to rule Sinclair's death a homicide because of the inaction of hospital staff. He also called on the province to hold a public inquiry into how aboriginal people are treated in the health-care system.
Winnipeg's regional health authority argued it has overhauled the emergency department and cultural training so a tragedy like this never happens again.