The man arrived by ambulance at the Health Sciences Centre early on the morning of Feb. 27, 2023.
Hospital staff tried to intervene, but the man was declared dead a short time later.
The investigation determined there were no issues with staffing levels at the time and the median wait time in the emergency department was more than two hours, which hospital officials say is typical.
The review by provincial health organization Shared Health recommends addressing concerns with patient flow to help ease emergency department backlog, reviewing processes for ordering tests and updating work expectations for staff.
Few details have been released publicly about the man, including his age, what brought him to the hospital or his cause of death. The full report is kept confidential under Manitoba law.
The review does not lay blame on individuals, but looks at environmental, systemic and staffing factors.
The emergency department at the Health Sciences Centre has 58 bed spaces, and there were more than 50 individuals waiting in the emergency room at the time of the man’s death.
“None of us want people in hallways, but it does happen,” Cumpsty said.
“Every day we meet with our partners, we look at what’s in our emergency departments, what’s in our urgent cares, and we move patients appropriately depending on who has the capacity at that moment,” he said.
“We still have challenges. We still see surges at times. It’s not often our waiting room gets up to 50 patients. That’s a pretty rare phenomenon.”
Young added the hospital has just opened up six more beds in the emergency department, but staffing levels prevent more from opening.