Death at Winnipeg's Health Sciences Centre ER raises questions about capacity issues, wait room protocols

The death of a middle-aged man who spent about eight hours waiting for care at a Winnipeg emergency department has some patient advocates raising questions about what the hospital is doing to prevent similar incidents.

The Health Sciences Centre (HSC) has launched an investigation into the man's death, which happened at the hospital Tuesday morning. The man had arrived to the emergency department shortly after midnight.

The incident drew comparisons to the case of Brian Sinclair, whose death after spending 34 hours in the same waiting room 16 years ago led to an overhaul of how patients in ERs are triaged and monitored.

Vilko Zbogar, the lawyer who represented Sinclair's family, said while Sinclair's case showed some people may be more susceptible to being ignored because of factors like discrimination, the same problems can affect everyone.

"His legacy should have been that [this] would never, ever happen again," Zbogar said.

"That's what the changes that were put in place by the health authorities were meant to to accomplish. And it's quite disheartening to see … something like this happening again."

The last time a patient died while waiting for care at the emergency room happened in February 2023, in what was deemed a critical incident. A report into that death led to recommendations including further reviews into how to address backlogs and patient outflow challenges at the ER.

Dr. Shawn Young, HSC's chief operating officer, said at a news conference Tuesday the investigation would look at how frequently the man was reassessed after being initially triaged.

As per one of the procedural changes put in place after Sinclair's death, emergency department staff must communicate with everyone in the waiting room at certain time intervals.

Young said the man who died this week was triaged as a low-acuity patient and was on track to wait around 10 hours or more to be seen.

Zbogar said he would like to know whether those protocols were followed, as well as whether the patient's identity had anything to do with him not receiving the treatment he needed.

Laura Tamblyn Watts, CEO of the national seniors' advocacy group CanAge, said the incident raises questions about how the hospital assesses and monitors incoming patients.

"We have to understand, 'How does a person who goes in with a low acuity then end up dying in such a short period of time?'" she said. "Obviously something progressed very quickly that wasn't addressed, or he was misassessed."

'I'm sick of it'

Young said at the news conference the death happened as the hospital's emergency room was "well over capacity," though he added the number of patients wasn't abnormal.

Winnipeg resident Jeff Willison said this speaks to a broader problem.

The 57-year-old attended the emergency room of the city's St. Boniface Hospital Friday evening while suffering chest pains. He left after waiting for three hours, having heard others were facing wait times of up to 12 hours.

"I did say to myself, 'There's no way in hell I'm going to stay in this war zone.' I'd much rather go home and die in peace in my own house than stay in that waiting room rotting," Willison said. "I'm sick of it."

Monthly wait times for the 90th percentile of patients at St. Boniface — the maximum amount of time that nine out of 10 patients wait — were at 12.42 hours as of November, according to the Winnipeg Regional Health Authority's latest monthly report. HSC wait times were at 13.16 hours. One in 10 patients wait longer than those times.

All of the city's three emergency departments had longer wait times for 90th percentile patients than the national average of 5.2 hours, according to 2023-2024 data from the Canadian Institute for Health Information.

Young said the fact the hospital was dealing with a number of people who were seeking shelter amid the cold weather was also a factor.

Marion Willis, with St. Boniface Street Links, said there should be more 24/7 safe spaces to meet demand.

Willis said the ones available are overcrowded and often chaotic, which leads people to consider them unsafe.

"Everybody seeks safety.… For a lot of people during the winter, it's waiting rooms in Winnipeg hospitals," she said during an interview with CBC's Up to Speed Tuesday.

"In some ways … hospitals have been expected to provide a service that normally is provided by shelter services. And no, that's not fair."

The latest death marks at least the fourth among patients waiting in Winnipeg emergency rooms in the last two years, including at the St. Boniface Hospital in January 2024, at the Grace Hospital in November 2023 and at HSC in March 2023.

In August 2021, a man was taken off life support after going into cardiac arrest at St. Boniface Hospital, after waiting four hours for care in the hospital's emergency department.

An investigation into the latest emergency room death is expected to conclude in the coming days. As part of the probe, the hospital will be conducting staff interviews as well as reviewing notes, footage and the patient's underlying health conditions, Young said.