Brian Sinclair Death & Inquest: Working Group Summary & Interim Recommendations
The Brian Sinclair Working Group and Context
Document Context & Purpose: Released in September 2017 by the Brian Sinclair Working Group (the "Working Group"), this report summarizes the events leading to the death of Brian Sinclair, the inquest that examined his death, and interim recommendations aimed at addressing anti-Indigenous racism within healthcare and improving care for Indigenous patients.
Origin and Mandate of the Working Group:
Formed to examine the role of systemic racism in the death of Brian Sinclair and the legal inquest that followed.
Highlights ongoing structural and systemic anti-Indigenous racism within contemporary Canadian health and legal systems.
Established a cross-discipline collaborative approach to research, analyze, and address systemic discrimination in healthcare.
Key Activities Undertaken by the Working Group:
Published an op-ed in the Winnipeg Free Press on January 7, 2014, explaining their mandate and the systemic problems under examination.
Hosted a public forum in Winnipeg in April 2014 featuring health researchers who discussed how discriminatory assumptions directly impact medical decisions, including diagnostic and treatment choices.
Hosted a presentation in September 2017 by Dr. Sherene Razack examining how Brian Sinclair's death and inquest reflect broader national themes of indifference toward the unnatural deaths of Indigenous people in Canada.
Set a target to release a comprehensive final report in 2018.
Working Group Members:
Dr. Annette J. Browne
Emily Hill
Dr. Barry Lavallee
Dr. Josée Lavoie
Dr. Mary Jane Logan McCallum
Additional Contributors:
Marcel Balfour, Christa Big Canoe, Linda Diffey, Brenda Gunn, Dr. Emma Larocque, Janice Linton, Murray Trachtenberg, Leslie Spillett, and Vilko Zbogar.
Acknowledgements:
Dr. Donna Martin, Amanda Penzick, Charlene Tehkummah, Jill McConkey, and Gordon Hagman (who granted permission to include his original painting of Brian Sinclair in the report).
Events Leading to the Death of Brian Sinclair at the HSC ED
Patient Background:
Brian Sinclair was a Indigenous man and Winnipeg resident who used a wheelchair.
Died in September 2008 from complications of a fully treatable bladder infection after being ignored for in the emergency department of an urban hospital.
Initial Medical Presentation (September 19, 2008):
Afternoon: Mr. Sinclair visited the Health Action Centre, a community health center where he was a frequent patient, seeking assistance for pain and issues with his catheter bag.
Evaluated by a clinic nurse and a family physician, who concluded his catheter required changing.
Clinic staff determined the catheter change could not occur at the Health Action Centre due to:
Concerns over maintaining a sterile environment.
Inability of staff to lift him.
The urgent need to obtain rapid laboratory results.
The family physician referred Mr. Sinclair to the Health Sciences Centre Emergency Department (HSC ED) and offered to arrange transportation.
Although Mr. Sinclair offered to wheel himself to the HSC, staff insisted on arranging transport. Because he was clinically stable, he was sent via taxi.
Prior to departure, Mr. Sinclair was handed a physician's letter detailing his medical condition and instructed to give it directly to the triage nurse upon arrival.
Detailed Chronology inside HSC ED (September 19–21, 2008):
2:53 p.m. (Sept 19): Video footage shows Mr. Sinclair arriving alert at the HSC ED, wheeling himself directly to the triage desk.
A triage aid interacted with him for roughly , leaning over with a triage list. The aid was responsible for logging Mr. Sinclair's name, arrival time, and presenting medical problem.
The aid either failed to record the information or recorded it without initiating a chart; Mr. Sinclair was never called back to the desk, no chart was created, and he was never officially recorded as awaiting assessment by a triage nurse.
Mr. Sinclair wheeled himself into a corner behind the security desk, briefly pulled out the doctor's letter, and returned it to his pocket. He remained stationed in clear sight of staff and visitors.
3:15 p.m.: Moved in front of the security desk, wheeled past the triage area, and parked near the security desk.
3:37 p.m.: Returned from the washroom area of the waiting room.
3:40 p.m.: A security guard requested that he move away from the security desk area; Mr. Sinclair complied.
6:00 p.m.: Wheeled to the security desk and spoke directly with a guard.
8:01 p.m.: Video shows Mr. Sinclair slumped in his wheelchair, remaining in that position overnight.
3:00 a.m. – 5:00 a.m. (Sept 20): A waiting room nurse who knew Mr. Sinclair by name spoke to him. She noted his speech was garbled and described him as lethargic, but failed to ask how he felt or check if he had been seen by medical personnel.
3:41 a.m.: Wheeled back into the waiting room from the washroom area and slumped in his chair once more.
4:00 a.m.: A triage nurse checked waiting room patients who had been triaged. Seeing no wristband on Mr. Sinclair's wrist and observing him sleeping, the nurse assumed he was either previously discharged and awaiting transport, homeless seeking shelter, or detained due to intoxication. No inquiries were made.
4:39 a.m.: Wheeled out of the washroom area. Sat in his wheelchair throughout Saturday morning, with video logging shifts in body position and movement.
Early Afternoon (Sept 20): Mr. Sinclair vomited. A citizen whose son was an ED patient observed Mr. Sinclair in obvious medical distress.
12:42 p.m.: The citizen alerted a security guard about the vomiting. The guard called housekeeping to clean the spill but failed to notify medical staff, assuming Mr. Sinclair was intoxicated and "sleeping it off."
Later Saturday Afternoon: Mr. Sinclair vomited a second time. The same citizen notified security again. Housekeeping cleaned the area and provided a basin; zero healthcare staff evaluated him despite inquest evidence establishing that vomiting indicates medical distress.
A Nurse Practitioner saw Mr. Sinclair with the vomit basin, assumed another clinician was managing his care, and walked past. Later, seeing his head slumped, she assumed he was sleeping while waiting for an inpatient bed.
Saturday Evening: A couple waiting with their daughter (who had been present the previous evening) noticed Mr. Sinclair in the exact same position. The woman expressed concern to a student nurse, who replied that released patients stay because they have nowhere to go and that homeless individuals use the ED for warmth. The woman also notified a security supervisor, but no check was performed.
11:45 p.m.: Final video capture of Mr. Sinclair alive, located in the same position as at 4:37 p.m.
Just after Midnight (Sept 21): The woman again approached security, expressing fear that Mr. Sinclair was dead. The guard initially dismissed her, but upon her insistence, went to check. When Mr. Sinclair failed to respond to tapping and pinching, the guard realized he was deceased and wheeled him to nursing staff.
Resuscitation (CPR) was attempted, but Mr. Sinclair could not be revived.
12:51 a.m. (Sept 21): Pronounced dead. The physician's letter was found inside his jacket pocket.
Pathology and Autopsy Results:
Rigor mortis had established prior to discovery, preventing an exact estimation of time of death.
Primary Cause of Death: Acute peritonitis resulting from severe acute cystitis (inflammation of the bladder caused by a blocked catheter).
Pathophysiology: Severe infection (sepsis) caused inflammation of the abdominal cavity, a catastrophic drop in blood pressure, inadequate perfusion to vital organs (including the brain), loss of consciousness, and hypotensive shock.
Toxicology: Confirmed zero drugs or alcohol were in his system.
Comparative Institutional Context:
The HSC ED is the primary, most comprehensive healthcare facility in Manitoba and Northwestern Ontario.
During the Mr. Sinclair sat dying in the waiting room, other patients arrived at the HSC ED. All were triaged, and all received treatment or voluntarily left after being assessed.
Legal System Response and Inquest Proceedings
Failure of the Criminal Justice System:
The Winnipeg Police Service (WPS) conducted no initial investigation into the death in September 2008.
March 2010: Prominent criminal lawyer Clayton Ruby reviewed the evidence and concluded reasonable grounds existed to lay criminal charges for criminal negligence causing death and failure to provide the necessaries of life. Ruby declared the absence of a police investigation "inexplicable and shocking," an opinion formally endorsed by two human rights experts, the National Law Centre on Homelessness and Poverty, and 26 senior Canadian criminal law professors.
October 2010: WPS formally opened a criminal investigation.
July 2012: WPS announced no criminal charges would be laid and refused the Sinclair family's request to publicly release the Crown Attorney's legal rationale.
Inquest Mandate and Initial Scope:
The Manitoba government refused calls from the Sinclair family and Indigenous organizations for a broad Public Inquiry into Indigenous healthcare experiences, ordering a narrower statutory Inquest under provincial law instead.
Standing Hearings (Summer 2009): Chief Judge Raymond Wyant granted standing to the Winnipeg Regional Health Authority (WRHA), Manitoba Nurses Union (MNU), HSC physicians, the Sinclair family, Aboriginal Legal Services of Toronto (ALST/ALS), Ka Ni Kanichihk, and the Assembly of Manitoba Chiefs.
Legal Funding Inequities: Family counsel sought public funding parity with Crown and WRHA legal teams. In rulings on June 2009 and February 9, 2010, Judge Wyant noted the funding offered to the family was unfair, but stated he lacked statutory jurisdiction to dictate funding levels. Funding disparities remained uncorrected.
Chief Medical Examiner Directive (Jan 30, 2009): Mandated an inquest to investigate:
The exact circumstances surrounding the death.
Measures to prevent similar deaths, specifically addressing treatment delays in WRHA emergency departments.
Scope Ruling (Aug 31, 2009): Judge Wyant ruled that systemic factors—including racism, poverty, health, and economic status—were interwoven with the evidence and must play a prominent role in formulating prevention recommendations.
Inquest Execution and Judicial Scope Reduction:
By the start of proceedings in August 2013, Judge Preston had replaced Judge Wyant as presiding judge.
Phase I (Circumstances of Death): Lasted and heard testimony from . Evidence confirmed Mr. Sinclair was visible but ignored due to staff assumptions that he was intoxicated or homeless.
Interim Ruling (Oct 10, 2013): Judge Preston acknowledged the legacy of the Manitoba Aboriginal Justice Inquiry and recognized the historical marginalization and estrangement of Indigenous peoples from the justice system.
Phase II Scope Ruling (Jan 10, 2014):
ALST (in consultation with Ka Ni Kanichihk and Assembly of Manitoba Chiefs) requested , including 7 Indigenous health experts to address systemic discrimination, Indigenous health frameworks, and cultural safety.
Judge Preston restricted Phase II to ( total). Of these, 7 were WRHA staff (6 testifying strictly on ED triage patient flow).
Judge Preston ruled that broad social determinants of health—such as systemic racism, poverty, disability, and substance abuse—fell outside his legal mandate, reversing the framework set by Judge Wyant.
Only 1 outside expert witness was permitted to speak on systemic racial discrimination.
Withdrawal of Indigenous Organizations:
ALS and Ka Ni Kanichihk withdrew from the inquest in protest, asserting that excluding evidence on anti-Indigenous discrimination rendered the process incapable of producing meaningful solutions.
The Sinclair family and Assembly of Manitoba Chiefs refused to present evidence or examine witnesses in Phase II, remaining involved solely to submit final written arguments.
Statement by Leslie Spillett (Executive Director, Ka Ni Kanichihk): Stated that participating organizations had bound themselves before creation through pipe-lifting ceremonies to pursue truth, asserting that reconciliation is impossible without truth and expressing grave concern that excluding systemic factors guaranteed a failure of justice.
Inquest Findings and Report (Dec 12, 2014):
Phase II focused almost exclusively on sightlines, triage algorithms, ER delays, and nurse staffing levels—factors that created no barriers for the other patients treated during the same weekend.
Issues of stereotyping and systemic racism were restricted to 2 witnesses and concluded in under one day.
The final report contained recommendations tangential to Mr. Sinclair's death, such as examining Nurse Practitioner services in personal care homes, on-site ED diagnostic equipment, and 7-day workweeks for Home Care Coordinators.
Lack of Professional and Workplace Accountability:
Zero healthcare personnel or security staff received workplace disciplinary sanctions or regulatory penalties.
Complaints submitted to the College of Registered Nurses of Manitoba (CRNM) were reviewed by the Investigation Committee, which issued letters of guidance or took no action. Zero complaints were referred to the Discipline Committee.
The CRNM Board of Directors dismissed all 6 appeals filed by the Sinclair family.
Interim Recommendations of the Brian Sinclair Working Group
Rationale and Public Advocacy Model:
Highlights that while institutional systems failed, two unrepresented members of the public successfully recognized Mr. Sinclair's humanity and medical distress:
A father who alerted security twice regarding Mr. Sinclair's vomiting, acting as his temporary advocate ("buddy").
A woman who repeatedly challenged student nurses and security guards over two days, eventually identifying that Mr. Sinclair had died.
Systemic change requires robust mechanisms to respect Indigenous patients, validate their care needs, support public advocates, and enforce strict institutional accountability.
Overall Policy Recommendations:
Mandate that all healthcare stakeholders (federal/provincial governments, Regional Health Authorities, professional bodies, unions, post-secondary health faculties) adopt explicit anti-racist policies, allocate resources for anti-racism training, and establish independent complaint investigation processes.
Fund third-party independent entities (guided by Indigenous patient representatives) to produce annual institutional report cards monitoring Indigenous patient experiences.
Distinguish between conventional "cultural sensitivity" training (which risks reinforcing harmful culturalist stereotypes) and mandatory "cultural safety" / explicit anti-racism frameworks that examine power imbalance, structural bias, and systemic oppression.
Recommendation #1 (Federal Government):
Implement a national, overarching, explicit anti-racist policy applicable across all healthcare jurisdictions in Canada, including provincial/territorial networks, the First Nations and Inuit Health Branch (FNIHB) of Health Canada, and Veterans Affairs.
Hold federal, provincial, and territorial Health Ministers accountable through mandatory annual progress reporting produced in formal partnership with adequately resourced national Indigenous organizations.
Recommendation #2 (Provincial Health Departments & RHAs):
Mandate that Manitoba Health and all provincial/territorial Health Departments implement explicit anti-racism policies requiring Regional Health Authorities (RHAs) to publish anti-racism implementation strategies and progress metrics in annual reports.
Extend these requirements to all contracted service providers, consultants, and capital development entities.
Amend the Manitoba Regional Health Authorities Act to guarantee First Nations, Métis, and Inuit representation on all RHA Boards proportional to healthcare utilization rates (aligning Manitoba with governance structures in Ontario, Nova Scotia, and British Columbia).
Recommendation #3 (Unions and Professional Organizations):
Healthcare unions (MNU, MGEU, CUPE) and medical/nursing regulatory bodies must issue unequivocal zero-tolerance statements regarding workplace racism.
Establish transparent mechanisms to receive and resolve complaints filed by Indigenous patients.
Nursing and medical colleges in Manitoba must develop formal performance management systems, establishing severe disciplinary penalties for repeat acts of racism.
Recommendation #4 (Health Professional Schools):
Adopt anti-racism curricula centered on cultural safety for First Nations, Métis, and Inuit populations across all health professional faculties.
Implement equity policies to recruit and retain First Nations, Métis, and Inuit students, faculty, and administrators.
Ensure anti-racist educational frameworks extend protections and improvements to all marginalized groups, including Two-Spirit, LGBTQ+, racialized communities, immigrants, refugees, and individuals with differing abilities.
Timeline of Key Events (2008–2016)
Sept 19, 2008:
Mr. Sinclair visits Health Action Centre; physician refers him to HSC ED via taxi with an explanatory letter.
2:53 PM: Arrives at HSC ED; speaks to triage aid; no chart is generated; sits in waiting area visible to staff.
Sept 20, 2008:
Early AM: Nurse speaks to him (garbled response); triage nurse checks wrist at 4:00 AM and assumes he is discharged, homeless, or intoxicated.
Early Afternoon (12:42 PM): Mr. Sinclair vomits; public witness alerts security; security calls housekeeping instead of medical staff.
Late Afternoon/Evening: Vomits again; Nurse Practitioner assumes another clinician is treating him; public witness alerts student nurse and security supervisor without result.
Sept 21, 2008:
Just after Midnight: Public witness insists security check Mr. Sinclair; guard finds him non-responsive; CPR fails.
12:51 AM: Pronounced dead after in the ED. other patients triaged and treated during the same period.
Sept – Nov 2008:
WRHA conducts Critical Incident and Administrative Reviews.
Chief Medical Examiner autopsy reveals death was caused by a blocked catheter causing acute cystitis and peritonitis; confirms death was preventable.
Nov 2008 – Feb 2009:
WPS declines to launch a criminal investigation.
Indigenous organizations demand a Public Inquiry; Manitoba government refuses and orders a Judicial Inquest.
Aug 2009 – Mar 2010:
Aug 2009: Judge Wyant includes racism, poverty, and social status within the inquest scope.
Mar 2010: Legal review by Clayton Ruby finds reasonable grounds for criminal charges against staff/hospital.
Sept 2010:
Sinclair family files a civil lawsuit in the Manitoba Court of Queen's Bench naming , including the Manitoba Government and WRHA.
Oct 2010 – July 2012:
Oct 2010: WPS opens a criminal investigation.
July 2012: WPS concludes investigation without laying charges; Crown Attorney refuses to disclose reasons.
Aug – Oct 2013:
Phase I of inquest commences under Judge Preston (, ).
Oct 10, 2013: Judge Preston issues ruling referencing the Aboriginal Justice Inquiry and marginalization.
Jan 2014:
Jan 10, 2014: Judge Preston restricts Phase II scope to triage flow (), excluding racism and social determinants.
ALS and Ka Ni Kanichihk withdraw from the inquest.
Jun – Dec 2014:
June 13, 2014: Inquest hearings conclude.
Dec 12, 2014: Judge Preston releases the Inquest Report.
Feb 2016:
Re-re amended Statement of Claim filed in civil suit; Statements of Defence filed; proceeding moves to case management.