That's the conclusion of a team sifting through 63 recommendations from an inquest into the death of Brian Sinclair. The 45-year-old aboriginal double-amputee died of a treatable bladder infection in 2008 during a 34-hour wait for care at Winnipeg's Health Sciences Centre.
In an interim report released Thursday, the team highlighted some recommendations that could be put into practice quickly, but said most will take two years to come up with a "work plan."
Health Minister Sharon Blady said the necessary changes will take time, but the government is committed to following through.
"Each ER is unique. Its community is unique. I want to make sure we are doing the right thing for each area of the province," Blady said. "This is about systemic change and that can't happen overnight.
"I would like to think we can move as quickly and as thoroughly as possible."
The inquest recommended that health authorities ensure staff intervene when a person vomits in the emergency department. Thursday's interim report notes that policy reviews on the issue should be completed within four months and any revisions should be made within nine months.
The report estimated it will take up to two years to decide if it's appropriate to have an aboriginal elder and a security guard posted in emergency departments. It also says it will take two years to review staffing levels in Manitoba emergency rooms, as well as to examine the feasibility of a separate pre-triage area for patients who haven't been seen by a nurse.
Sinclair spoke to a triage aide before wheeling himself into the waiting room, but was never seen by a nurse or registered as a patient. He languished in the ER for hours, vomiting and slowly dying. He was never asked if he was waiting for medical care.
Some staff testified that they assumed he was drunk or homeless. By the time he was discovered dead, rigor mortis had set in.
Recommendations from the inquest were aimed primarily at policy reviews at the Winnipeg Regional Health Authority. Sinclair's family said they don't address the real reason why he was ignored by emergency room staff for hours while he died.
"The core issues that explain why Brian Sinclair was ignored for those 34 hours — the biases and stereotypes — that's still not being addressed by anybody. It's what's missing from the report that bothers the family," said their lawyer Vilko Zbogar.
"They have to find some way to deal with that issue. Ignoring it is not acceptable any more."
The family has called for a public inquiry into what they say is systemic discrimination aboriginal people face in health care. Blady has rebuffed the suggestion and noted that the inquest judge did not think it was necessary.
Manitoba Opposition Leader Brian Pallister said the province should have made some of the changes years ago. Some of the inquest's recommendations — such as attending to a patient who is vomiting — are simply common sense, he said.
"There is a certain element of disappointment in that."