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Man Who Waited 34 Hours in ER Was Dead for Hours Before Discovered
Canadian Press
September 24, 2008
WINNIPEG — It’s an unacceptable tragedy that a man waited 34 hours in a Winnipeg hospital emergency room and was dead for several hours before he was finally brought to the attention of medical staff, Premier Gary Doer said Tuesday.
Although the 45-year-old man – who was reportedly homeless – was “a regular” at the emergency room, regional health officials say he was never registered or seen by triage nurses over the weekend until it was too late.
“The bottom line is we are not making an excuse for this,” Doer said Tuesday following a grilling over the incident in the legislature. “This is a tragic incident and it shouldn’t have happened.”
The man, who has not been identified, was dropped off at the hospital by a taxi Friday afternoon after visiting a downtown health clinic which is part of the regional health authority.
Some hospital staff did speak with the man at some point, but it was only when someone in the waiting room later brought the man to the attention of staff shortly after midnight on Sunday that he was examined and pronounced dead. The cause of death has not been released.
The province followed the recommendation of an earlier task force and hired re-assessment nurses who are required to check up on registered patients waiting in the emergency department, Doer said. But this man was never even registered with the triage nurses, he said.
“This system broke down and there were tragic circumstances,” Doer said. “We’re trying to find out what exactly went wrong and we haven’t got all the answers yet.”
The hospital wasn’t short-staffed at the time and a re-assessment nurse was on duty, he added.
Brock Wright, chief medical officer of the Winnipeg Regional Health Authority, said he’s baffled about how this man could have fallen through the cracks. When the man was finally discovered by emergency room staff, Wright said he “had been dead for some time.”
“It’s hard to imagine how somebody could be in the department for 34 hours and somehow it not be apparent that the individual was waiting for care,” Wright said Tuesday.
“I understand how that’s hard to imagine and yet, it happened.”
On cold nights, Wright said it’s not unusual for homeless people to take shelter in the emergency room. But he said any potential confusion that may have arisen from that practice doesn’t explain why the man died without treatment.
“Our staff will provide blankets to homeless people who come in and are looking for some place warm. They get to know those individuals and will interact with them,” he said. “It’s not as if the staff is just focused exclusively on the patients and ignoring everything else around them, which makes it all the more puzzling.”
Patients who go into the emergency department are expected to approach the triage desk and register themselves or have someone register them on their behalf, he said. The emergency department treats 50,000 people each year and there are always nurses on staff to process patients, he said.
Both the chief medical examiner and the regional health authority are investigating to ensure this never happens again, Wright said. The hospital hopes to have its investigation complete within a month and will make the findings public, he added.
“We view this as a really tragic event,” he said. “We’ve never encountered this before.”
But opposition politicians said the “worst ER failure in Manitoba history” calls for a broad examination of the provincial health care system. Conservative Leader Hugh McFadyen said the government has to take responsibility for the tragedy.
“(This) demonstrates there was some kind of culture of neglect and unresponsiveness that needs to be looked into to be sure this isn’t a systemic issue,” he said.
(c) YellowBrix 2008
Tan
about 1 month ago
14 comments
The attitude of the ER was very bad. I have seen this many times that hospitals allow patience to sit over hours before attending to them. Sometimes they both have to quarrel. This should be a lesson and warning to all practitioners. The life you save may be yours or that of a friend. Such act should not be repeated anymore.
Nathanielweah
about 1 month ago
14 comments
Emergency toxic test need to be done on the expired patient, or man.
struggling
about 1 month ago
8 comments
To Winnepeg--OH P L E A S E!!!!!!! Shows just how concerned you are for anyone you think is homeless! Someone should have ASKED the man WHAT he was in the waiting room for if he never approached the desk! NOT JUST LOOK DOWN UPON HIM! Wonder what GOD thinks of things like this-Sure HE wasn't pleased. People in that ER-you should be ASHAMED of yourselves!!
christy1966
about 1 month ago
40 comments
Oh,come on,Iv'e seen on many occasions how the gomeless poulation is treated,and it's really not very nice. I think because this man was a "regular" homeless visitor to this e.r. as with other homeless individuals they're shuffled off like cattle and vitualy ignored. I think this hospital attempt to try and tidy up an obvious mistake like they are is shamfull. As if this person because he was homeless didn't really matter to much. it sounds more to me that the only regret thid hospital has,is the fact that they are caught and now it's gotten media attention. People must remember that those who are homeless are human being to,not pices of dirt under someone else's foot. as far as I'm cocerned this incident is just another example of how poorly the homeless are treated,not just by hospitals but society as a whole.
jesusfreak
about 1 month ago
12 comments
Intercity Hospitals are at risk for this. In Flint MI. there are so many prostitutes, homeless etc. that come in. Some just curl up in the corner for shelter and rest. The triage nurse has alot to deal with. You have people coming in for kicks and use the ER for free cough syrup. Some are really attention seeking. Then when someone who really needs the attention are waiting. Some are mentally Ill. There needs to be more steps in place to protect those nurses. This has been an issue for some time.
armstrongcj
about 1 month ago
96 comments
What was those nurses doing that did not notice this man. This makes us nurses look bad. I hope that they get this fixed.
doubled
about 1 month ago
12 comments
Yeah, I heard about the other woman who passed in NJ too! This is ridiculous! I'm not a nurse yet (in school right now), but I've had to wait as much as 3 hours just to be seen by anyone...and where I go is never busy. Sadly enough when I was finally seen, I had a nurse who told me NOT to be a nurse...and he was also a volunteer fireman. And that was REALLY sad.
sap
about 1 month ago
674 comments
This makes us all look good....doesn't it. How terrible. Yes, I've been in the ER and have waited long periods of time. I'm sure we all have. How someone can be dead and not noticed is beyond me. Some changes NEED be put into action for the ER and the patients who go in there. Some cases are serious and really need to be addressed better. Just a few months ago, a woman in a NJ ER died. No one saw her fall to the ground, have a seizure and then pass away. She was in her 40's I believe. She was a psych patient and she was ignored. It's really terrible and it's making all us nurses and medical professionals look like CRAP. I hope things can change in this area of the hospitals.
casassy62688
about 1 month ago
262 comments
That is just dreadful! How can you call yourself a healthcare proffessional but not notice a person SIITTING THERE DEAD!!!! That is just crazy! There needs to be a serious change in the health care system to prevent this from happening! Where I work (and I have only ever been to that hospital ever since I was born) I have never had to wait more then maybe 20 minutes.....no matter how busy the ER was!
LADSIDE
about 1 month ago
6 comments
I was faced with a would-be similar incident a week ago. My daughter was eclamptic and was taken to the ER and then to Labor and Delivery to a hospital 2 hours from my home. By the time I got to the hospital she had had a seizure, BP was out of the roof and her eyelids were so edematous that her eyes could not be seen on the rare occasion that she would even attempt to open them. One of the nurses came in to assess and was visibly having problems with some of the equipment. So I offered an explanation of assistance as I was familar with that particular program, after observing for exactly 2 hours and my daughter's BP wasn't decreasing to acceptable levels, I let it be known that I was a nurse and requested the physician be notified. Overhearing the conversation between the nurse and the physician, part of the report included "her mother's a nurse". Twenty minutes later, my daughter was on an ambulance enroute to a magnet hospital. It is amazing how easily some of our co-professionals continue to judge a book by its cover. (It was 2:30 in the morning when I was awakened and hopped and the car with wrinkly sweats and ungroomed). I'm the only nurse in the family so I have told my loved ones key terms to "throw out there" in the event of an ER visit and explained to them that it just might save their lives one day should they have a "judgemental nurse of physician". Once the crisis was over, my daughter phoned me during every med pass while she was at the hospital (which I explained to her that it was over-kill). But with the nursing shortage and the bean counters being more concerned about a blasted budget rather than patient care and lives, we will probably see more of this, unfortunately. We need to be extremely cautious, careful, and caring if we want to survive life as nurses and patients.
Temaki
about 1 month ago
50 comments
They need to do something about that bc it has happened where i live in Los Angeles, CA
chauntel
about 1 month ago
12 comments
I remember being in ER for 1 hour with horrible pain from a kidney stone, and my fiance was with me and kept going to the front to ask for help and they said they are too busy and she was sitting there relaxing eating a candy bar. I was in so much pain. There is something wrong with that. That was in Albuquerque.
nursinginmyblood
about 1 month ago
6 comments
HOW COULD YOU NOT NOTICE SOMEONE SITTING THERE WHO IS DEAD!!!!!!!
beowulf
about 1 month ago
38 comments
I have to agree with mg1021. So, where does one start?
mg1021
about 1 month ago
420 comments
That is so very heartbreaking! It's no wonder that healthcare reform is a priority for so many of us that care about our fellow citizens. This is a clear indication of why the current state of things just isn't going to work anymore!