By now many Manitobans, and indeed many Canadians, are aware of the facts surrounding the deaths of Brian Sinclair, Heather Brennan, David Silver, Phoenix Sinclair, and Tina Fontaine. While the facts surrounding each are unique, sadly the outcomes are not: five victims; five preventable tragedies.

For nearly 34 hours Brian Sinclair languished in his wheelchair in the ER waiting room of the Health Sciences Centre seeking treatment for a blocked catheter. He died in that chair around the 27th hour without having been triaged, let alone seen by a doctor.

Sixty-eight-year-old Heather Brennan collapsed on her doorstep upon returning home from the Seven Oaks ER. Despite being diabetic and requiring blood thinners, medications for both were halted before she was discharged; an autopsy later revealed she died from blood clots in her legs.

At 1:00 a.m. on December 31, 2013, 78-year-old David Silver, suffering from gallstones and kidney stones, was discharged from the Grace Hospital into a taxi cab and sent home in nothing more than a nightgown. Like Heather Brennan, he, too, died on his doorstep. The ambient temperature that night reached a historic -37C.

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Phoenix Sinclair was in and out of CFS care for most of her 5-year-old life; agencies were contacted no less than 13 times concerning her well-being; files were opened and closed without social workers ever actually seeing her. She was finally returned to her biological mother in March of 2005, and was beaten to death in June of that year. Her body, wrapped in plastic and buried in a shallow grave, went undiscovered for nine months.

Tina Fontaine, 15 years old and in Winnipeg for a matter of weeks, came into contact with outreach workers, police officers, health officials and CFS authorities numerous times in the days leading up to her body being discovered by the Alexander docks on August 17. Every time, this 15 year-old girl – by now already known to be missing – was released, discharged or simply let go.

Unquestionably, the system failed these five individuals and others like them. The system: various state apparatuses, charged with the care, protection and well-being of society’s most vulnerable; over-loaded, under-resourced, and ill-equipped.

Yes, the “system” failed Brian Sinclair. It failed Heather Brennan and David Silver. And it failed Phoenix Sinclair and Tina Fontaine.

Is it possible, however, our system has given cover to those individuals working within it, relieving them of any personal responsibility for the people in their care? Is it time we rethink the degree to which we allow inanimate agencies to shoulder the blame for such tragedies? Would holding actual individuals—from front-line workers through to politicians—responsible for the tragedies fix what is so terribly broken?

The provincial government convened inquests into the deaths of Brian Sinclair and Phoenix Sinclair. The WRHA conducted internal investigations into the deaths of Heather Brennan and David Silver. The Winnipeg Police Service is investigating its own. True. However, despite these investigations, inquests and administrative actions, has a single individual resigned their post, been fired from their job, or found guilty of criminal negligence?

No longer can we allow politicians the discretion to convene judicial inquiries. No longer can they be allowed to set their scope. Each death deserves a full judicial inquiry; not just an inquest; not just a verbal apology blaming the system, and certainly not the scapegoating of a taxi driver. No, each victim deserves a full judicial inquiry that is automatically empowered to go where the evidence leads it, and if appropriate, recommend criminal charges be laid against all those individuals working within the system who failed.

There is little doubt autonomous judicial inquiries, free from political interference, would ask very uncomfortable questions while trying to determine responsibility; no doubt, the answers they elicit even more so. However, in asking these questions, what a judicial inquiry would make plain is that individuals have chosen careers that require them to uphold the professional and moral obligation to help others, to do no harm, and to serve and protect.

Yes, these individuals are confronted daily with difficult questions and must make even more difficult decisions about how to handle people like Brian Sinclair, Heather Brennan, David Silver, Phoenix Sinclair, and Tina Fontaine. However, when the answers they arrive at and the decisions they make are inconsistent with the professional and moral code inherent in their positions and this directly affects the outcome of individuals’ very lives, should they not be found culpable? Because it wasn’t just the system’s fault; it was the fault of the people comprising it as well.

Of course, it wouldn’t be fair or just to only blame a single front-line service worker in these cases. Because in each instance there exists a chain of command, a decision-making hierarchy, a Ministerial policy directive and layers of administrators executing it: all actual people working within our system.

Truly autonomous and fully-empowered judicial inquiries would ensure everyone operating within the system—from the front-line service worker all the way up the labyrinthine bureaucratic network to the desk of the related Minister of the Crown—had their various roles in the tragedy examined to determine the extent to which each affected the outcome.

Until the very livelihoods of the professionals working within our system and the politicians who oversee it are at stake, like the very lives they are meant to be safeguarding, our system will continue to languish and people will continue to die. Blame the system? Sure. But hold the people responsible.