Chinta Puxley, THE CANADIAN PRESS

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WINNIPEG - No single person was to blame for the death of a homeless man during a 34-hour wait in an emergency department because it wasn't clear he was in the hospital seeking care, the Winnipeg Regional Health Authority concluded Wednesday.

Although various hospital employees spoke to Brian Sinclair while he languished in the downtown waiting room in September, health authority officials said no one will be disciplined following an internal review of the tragedy.

"There really isn't any single individual that's to blame," said Jan Currie, vice-president and chief nursing officer with the regional health authority.

"I wouldn't say that anyone made assumptions that weren't reasonable in this case. They did not realize that Mr. Sinclair had come seeking care."

Sinclair was never registered or triaged by an emergency department nurse after being referred to the hospital and wasn't noticed for 34 hours. By then he had died of a preventable bladder infection.

Sinclair, who was in a wheelchair after losing both of his legs to frostbite, had been dead for several hours when he was first examined by a doctor.

The province's medical examiner has called a formal inquest into his death.

In the meantime, the regional health authority interviewed staff on duty at the time as part of its own internal review and is making changes to ensure no one falls through the cracks again.

Anyone arriving in any of Winnipeg's six emergency departments will now be registered electronically before going on to the waiting room, Currie said. Hospital staff must also talk to each patient in the waiting room every four hours.

Those working in the emergency department shouldn't have to deal with people who are there for follow-up specialist appointments or other non-emergencies, she added.

Such patients will be admitted to the hospital somewhere else to lessen the burden on triage nurses.

Hospitals will also continue with sensitivity training "designed to honour all cultures and . . . challenge assumptions."

Homeless people often take shelter from the cold in the downtown emergency department and that won't change, Currie said.

Some hospitals around the country actually have shelters attached - something the authority will now look at, she added.

The fact that Sinclair died because he was never even registered was unusual and unprecedented in Canada, Currie said. It's caused hospitals across the country to look at their policies to see if a similar tragedy could occur.

"It's not something that we had contemplated and it's not something across the country that anyone in an emergency department contemplates," Currie said.

"What this case has done is helped us to learn a lot about how people come seeking care."

Winnipeg's downtown hospital, the Health Sciences Centre, has already announced it is adding the equivalent of 10 positions to ensure that someone talks to all incoming patients.

More staff, with training in social work, will also be added to regularly check on people in the waiting room. The hospital is also requiring any clinics that send people to an emergency department to follow up by phone.

"The majority of the changes that we've made at HSC are intended to ... ensure that every patient that comes into the emergency room is triaged and we actually know that they are there for care," said Adam Topp, chief operating officer of the Health Sciences Centre.

"That is the key gap that occurred in Mr. Sinclair's case."

Sinclair was dropped off at the centre by a taxi on Sept. 19 after visiting a downtown health clinic, which is part of the health authority.

Some hospital staff - including housekeeping and security guards - did speak with him at some point, but it was not until shortly after midnight on Sept. 21 that he was examined and pronounced dead.

The hospital has said its emergency department wasn't short-staffed at the time.