The ER is not the problem, it’s just where the problem lands

On Sept. 19, 2008, Brian Sinclair wheeled himself into the emergency room at the Health Sciences Centre. He had a blocked catheter and had not urinated in 24 hours. A clinic had referred him there with a note explaining his condition. He spoke briefly with a triage aide. He waited. Thirty-four hours later he was found dead in his wheelchair. He had died of a treatable bladder infection. Rigor mortis had set in. He was never formally entered into the system. No one had asked him if he was waiting to be seen.

The inquest that followed ran for 40 hearing days, heard from 82 witnesses, and produced 63 recommendations. The judge said plainly: he did not have to die.

In February 2023, a patient died waiting in a hallway at the HSC after being triaged. In November 2023, a patient died at Grace Hospital after waiting 33 hours for a bed. In January 2024, a patient died at St. Boniface after a five-hour wait. In January 2025, a middle-aged man arrived at the HSC by ambulance, was triaged as low acuity, and died eight hours later in the waiting room. In January 2026, three weeks apart, Stacey Ross, 55, waited 11 hours at St. Boniface. The hospital’s own emergency room director told her family the wait killed her. Judy Burns, 68, died at the same hospital days later, her family’s concerns repeatedly dismissed by staff. And Genevieve Price, 82, died after a long wait at Grace Hospital the previous November.

Eight deaths. One city. Seventeen years after an inquest that said this does not have to happen.

Once is a tragedy. Twice is a pattern. Eight times is a governance failure over multiple governments, hospital and university administrations.

The emergency room is not where the problem originates. It is where the problem lands. The wards upstairs say they are full. The specialist has a six-month wait. The family doctor, if you have one, cannot see you until Thursday. The emergency room is always open, and so it becomes the default solution to every problem the rest of the system cannot or will not address. No family doctor? Go to the ER. Post-operative complication? Go to the ER. Mental health crisis with nowhere else to turn? Go to the ER. Chronic illness decompensated by cold, hunger, inadequate shelter, or interrupted medication? Go to the ER.

This is a governance failure: the absence of a structure that defines what the system owes patients across the full continuum of urgent care and holds the responsible institutions accountable for delivering it.

Approximately 15 to 20 per cent of ER patients require hospital-level care, the most expensive venue in the system. The remaining 80 to 85 per cent present with conditions manageable in a well-resourced community urgent care setting. An estimated 15 to 40 per cent of presentations represent primary care failures: patients with no family doctor or who could not access one in time.

If four in five emergency presentations could be managed in a community urgent care setting, the question is unavoidable: why does that setting not exist, who decided not to build it, and who is accountable for the consequences?

These statistics are not published systematically, because producing them would make the governance failure explicit and attributable. Manitoba has the Manitoba Centre for Health Policy, a world-class provincial administrative database capable of linking emergency utilization to primary care attachment, housing status and disposition. The capacity to produce these numbers exists. The governance decision to require it has not been made.

Reactive data serves the institution. Proactive mandatory reporting serves the patient. Canada operates almost entirely on the first model.

In Winnipeg, there is a population that arrives at emergency rooms with a burden of illness no emergency room can adequately address: patients managing chronic conditions complicated by poverty, inadequate housing, poor nutrition and interrupted care. In winter, at 40 below, cold, hunger and the vulnerabilities of life without stable shelter do not present in isolation. They arrive together, acute on chronic, in a system designed for the acute.

The ER stabilizes and discharges. The conditions that produced the presentation remain unchanged. The patient returns. A community health hub model, integrating urgent clinical care with housing supports, harm reduction, mental health and addictions capacity, and culturally safe care, is what this population actually requires. It does not exist at the scale needed. Its absence is a governance choice with a measurable human cost.

Beginning in the 1960s, the large psychiatric institutions were closed across Canada. The reformers were right about what they were closing. They were wrong about the sequence.

The community infrastructure, supported housing, mental health centres, integrated addictions services, was promised and never built at the required scale. The patients moved to the street, the shelter system, the criminal justice system and the emergency room. The harm to individuals, communities and society at large flows from a governance decision made 50 years ago in the wrong sequence. Close first. Build later. Later never came. History is not repeating itself. It became default policy.

Manitoba knows what patient-centred pathway design looks like when it works. The CODE STEMI program, designed for patients experiencing a severe, time-critical heart attack, was developed collaboratively by cardiology, emergency medicine and paramedic services at St. Boniface Hospital. Paramedics are trained to acquire and transmit a 12-lead ECG at the scene. If the on-call physician confirms the diagnosis, the patient bypasses the emergency room entirely and goes directly to the catheterization laboratory with a team assembled and a clock running.

A 2016 systematic review in the Canadian Journal of Cardiology, co-authored by colleagues from the Manitoba Cardiac Sciences Program, found this approach associated with a 32 per cent relative risk reduction in mortality.

The system worked because it was built from the patient outward: define what the patient needs, design the pathway to deliver it, measure the outcome against a standard set in advance. That principle is not confined to cardiac care.

Emergency medicine became a recognized specialty in Canada for good reason. Canada now trains emergency physicians through two streams: the Royal College specialist route, designed for high-acuity tertiary centres, and the enhanced family medicine route, originally conceived to staff rural and community emergency departments with breadth, relationships and a holistic approach to care.

In practice, both streams have converged in urban hospitals. Rural and remote emergency care remains largely the domain of family physicians. And the structural conditions that drive patients to emergency rooms, the absence of community urgent care, the primary care gap, the inadequate response to chronic and complex presentations, remain largely outside the scope of what emergency physicians are asked to govern.

This is a missed opportunity. Emergency physicians understand, better than anyone, the geography and population determinants of what their patients need. The demand on an emergency department in a rural Manitoba town is not the same as the demand on an urban academic centre. The right questions start here: what does urgent care demand look like in a given community, what physician capacity already exists, and what incentive structure would make extended-hours team-based care viable where that capacity is present?

Emergency physicians, particularly those trained in the community and family medicine stream, have the clinical knowledge to define what appropriate urgent care infrastructure looks like in each of those contexts. They should be at the table where those questions are asked.

There is also an opportunity the current governance framework has not created and the institutional model alone cannot produce. Entrepreneurial physicians, nurse practitioners and physician assistants, working within the Canada Health Act and the Government of Manitoba’s existing framework with incentives structured through alternate funding arrangements, could build community urgent care at scale if the conditions for doing so existed.

The model is not theoretical. Stand-alone diagnostic imaging facilities, minor injury clinics, sports medicine centres and cataract surgery facilities already operate in Manitoba, delivering publicly insured services outside hospital walls.

Cataract surgery is the most instructive example: long wait times addressed by purpose-built free-standing facilities, publicly funded billing, rigorous accreditation and measurable outcomes, with wait times that fell dramatically when the governance framework permitted the model to scale. The quality is equivalent. The cost per episode is lower. The Canada Health Act was not compromised. The public system was strengthened.

Community urgent care follows the same logic. A physician-led urgent care centre, with appropriate staffing and diagnostic infrastructure, defined referral pathways to hospital care, and clear accountability for outcomes, is entirely consistent with the Act and with Manitoba’s existing framework.

With the right incentives and governance framework, community-based urgent care centres can offer the services patients need, be financially viable, free up tertiary emergency departments and do so at less cost, to the health care system and to human dignity.

Structures exist on paper. Patients experience care in real time.

Dr. Alan H. Menkis writes from Winnipeg.