THE DEATH OF BRIAN SINCLAIR – The Perils of “Risk” Management

Faces of Denial

“Did Brian Sinclair die because of prejudice and racism inherent in Manitoba’s Health Care System or is it more likely that he fell victim to an overburdened, “do more with less” bureaucracy that lacked the proper protocols to make sure patients like Sinclair didn’t fall through the cracks in a chaotic Emergency Department.”

That was a question posed in The Police Insider in a story published on August 14, 2013.

It seems the Insiders experienced based analysis offers more insight into Mr Sinclair’s death than other sources trumpeting inflammatory accusations of racism.

That corroboration came in the form of testimony from Health Sciences Center Emergency Department Head Nurse Susan Alcock who pointed to issues relating to overcrowding, staff shortages and inexperienced staff as contributing factors.  All issues repeatedly ignored by Hospital management.

Mr Sinclair was found deceased in the Hospital after spending 34 hours in the ER waiting room on September 20, 2008.  A total of 138 patients were triaged at the Hospitals ER department that day.  The previous day, 134 patients were triaged.  The average number of patients triaged at the ER department was reported at 120 patients per day.  According to Alcock, “Both shifts were horrific, incredibly busy.”

Alcock reported staffing shortages only exacerbated an already untenable situation.  On September 19, 2008 the Emergency Department was short a total of five (5) nurses.  Alcock testified she was only able to fill two of the shorted positions.

“I felt we needed to do something soon because something was going to happen,” she testified. “I felt it was critical and I wasn’t getting listened to and [officials] weren’t taking it seriously.”

Alcock’s concerns were documented in a letter she wrote to Hospital Management in June of 2008 to bring attention to these issues.  She also shared her concerns with the Head of patient care.  Alcock testified nothing changed after she tried to shine light on these serious issues, in fact, she indicated she was “slapped on the wrist” for not following the chain of command.

I feel Alcock’s pain.

In 2011, I also usurped the chain of command taking serious concerns regarding the operational ability of the WPS Homicide Unit directly to Chief of Police Keith McCaskill.  During that meeting I shared concerns regarding staffing and policies that were having an extremely detrimental effect on Homicide Unit Operations.  Two (2) business days later I received a curt blind side transfer that effectively ended my Police career.  As an astute crime reporter put it, the Police Chiefs “open door” really turned out to be a “trap door.”

I understand Alcock’s struggle, fighting with management to try to get them to do the right thing.  Alcock learned, as I did, that management doesn’t really care about things like staff shortages, detrimental policies, ineffective procedures or operational effectiveness.  These managers are generally moved by one thing, “risk management.”

Risk management is; “The identification of analysis, assessment, control, and avoidance, minimization, or elimination of unacceptable risks.”

(In a 2010 Operational Review Report of WPS Homicide Operations the word “risk” appears in excess of fifty (50) times.)

In the “real” world, Hospital managers balance the dangers of staffing shortages, overcrowding and inexperience with the realities and limitations of their budgets.

In the “real” world, Police managers balance the dangers of bad policy, staffing shortages and inexperience with the realities and limitations of their budgets.

The bottom line is always the number one concern, it’s always all about the money.

(In reality, these “leaders” have the ability to make many cost neutral positive changes to their operations if they would only listen to the people who are tasked to do the work.)

The problem with the people in leadership roles in these types of large bureaucratic organizations is they tend to see the people in the trenches as their adversaries and interpret their feedback as an affront to their rank or authority.  People in these leadership positions often choose to play the “risk management” game and roll the dice over an innovative approach that engages their employees.

For Hospital managers that meant running the ER with staffing shortages, inexperienced nurses and ignoring overcrowding and quality control issues.

For Police managers that meant running the Homicide Unit with staffing shortages, inexperienced supervisors and investigators and ignoring detrimental policies, procedures, morale and quality control issues.

Unfortunately, for Hospital managers, the death of Mr Sinclair was a byproduct of their failed risk management approach.  They rolled the dice and it didn’t work out so well.

Luckily, for Police Managers, the fallout from their risk management gambles are more difficult to quantify and have not become the subject of a public inquiry, at least not yet.

Some may choose to cling to the belief that Brian Sinclair died as a result of prejudice and racism inherent in the Manitoba Health Care System.

It seems the perils of risk management may have been a contributing factor of some significance.

The Inquest continues…..


THE POLICE INSIDER – “The Death of Brian Sinclair – What you Won’t Hear”

CBC NEWS – “Nurse Tells Sinclair Inquiry She Raised Concerns About ER”

WINNIPEG SUN – Dean Pritchard “There was No One to Help Brian Sinclair”


  1. If you mean that it’s inappropriate to judge people harshly for doing what they have to do to survive in a dysfunctional system that sees human resources as exploitable and renewable, I do understand that.

    People will do whatever they have to do to survive. They have families to feed. We need to restructure, re-evaluate and re-purpose the resources (human and other) allotted to healthcare so that their efforts are not damaging to others (patients and staff alike). Then we can have healthy healthcare workers who are willing and able to provide the care that we all deserve. And they won’t have to demean, diminish, or demolish anyone else to do it.

    It really is a human rights issue.

  2. The big question in risk management is always ‘just who’s risk are you managing?’ More often than not the risks that most concern health care institutions are their own, not the patient’s.

    I think the current testimony has illustrated just how much care and compassion that many of ER staff actually had and their ongoing frustration. It’s amazing that day to day, they were able to do as much as they did with as little as they actually had to work with.

    As far as whistleblowing and the consequences of career suicide, I think it’s inappropriate to judge too harshly the actions of others. There is a lot at stake, and individual circumstances vary greatly. It illustrates the need for strong protections in legislation.

    In the end, the system does not possess the capacity for rigorous self examination and change. And we need to fix that.

  3. James G Jewell

    Interesting….thanks for commenting.

  4. I think you nailed it. The risk management strategies actually don’t accord with what’s on paper either…rankism is too prominent a feature in hierarchical, top-down organizational structures. Everyone knows that challenging a “superior” can end a career. Well, most people do. I didn’t. I would have done it anyway. Bullying is rampant, and whistleblowers get the worst of it. It’s devastating.

    David Hutton of FAIR Whistleblower is working on a comparison of (inadequate) provincial whistleblower legislation that should be available soon. Watch for it.

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