A family is calling for an inquest after an intellectually disabled man who was being cared for at a Manitoba group home died in hospital with significant malnutrition.
Sean Feldsted, 54, died in early 2024 at a Winnipeg hospital, a month after his sister found him at his group home in Gimli — frail, emaciated and with a full catheter bag.
It’s a memory Shelley Shultz says will haunt her for the rest of her life.
“We were in absolute shock — absolute, complete shock,” at her brother’s appearance, said Shultz, who lived in B.C. at the time and flew back to Winnipeg in December 2023 after their father told her Sean was sick.
“It was terrifying. Have you ever seen somebody who starved? Like, actually seen them and touched them? He was pure bones.”
Her brother lived in the group home in Gimli, a town in Manitoba’s Interlake region, for decades. The family helped create the home so Sean, who was mostly non-verbal, would have 24/7 care for the rest of his life after he turned 18.
Ownership of the home was later transferred to Community Bridges, a non-profit that provides services for people with intellectual disabilities.
It took over two years for the family to learn the cause of Sean’s death. Shultz was provided a copy of his autopsy in February 2026 — a delay caused by staffing shortages at the Chief Medical Examiner’s Office, she was told.
The autopsy revealed Sean was significantly malnourished when he got to the hospital in Winnipeg. His cause of death was sepsis, with malnutrition listed as a condition contributing to his death.
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After CBC reached out to provincial officials, Shultz was given access to the internal investigation into her brother’s death.
The internal investigation by the Manitoba’s Provincial Investigation Unit — a Department of Families unit that investigates reports of abuse and neglect involving adults with intellectual disabilities — found that Sean wasn’t neglected at the home, but it was critical of decisions made at the hospital in Gimli in the lead-up to his death.
It found Community Bridges staff tried to help him by seeking out medical professionals like an occupational therapist and dietician, along with multiple trips to the hospital.
‘Afraid something bad would happen’
When Shultz visited her brother at the group home on Dec. 10, 2023, workers warned her that he was very ill.
He was on a mattress on the floor, which workers told her was because he kept falling out of bed. His room was bare, with no pictures or personal belongings, she said.
Shultz’s son, Damon, who was 35 at the time, said his uncle looked like someone with anorexia or severe malnourishment.
There was “a defeated look in his eyes,” he said.
“When he was able to see my mother, his sister, he looked relieved … just kind of, like, so happy that she was there and he was able to see her again.”
The report said Sean kept rolling out of bed, which is why he was on the floor. Staff had removed personal belongings, like stuffed animals or race cars, because they were a tripping hazard, it said.
Shultz called her 82-year-old father, who lived in Winnipeg and was Sean’s substitute decision maker — a person legally empowered to make decisions on behalf of an adult with an intellectual disability. They decided Sean needed to be taken to the hospital.
He was taken by ambulance to the hospital in Selkirk, south of Gimli, and then transferred to Health Sciences Centre in Winnipeg on Dec. 14, 2023. Within weeks, he was put into palliative care and died Jan. 19, 2024.
Sean was six feet tall and always a slender man, but weighed just 92 pounds when he died.
When she got the investigation report from the province, Shultz agreed not to share it. However, CBC was able to see the report and take notes.
The investigation found the agency took Sean to the hospital in Gimli in November 2023 to try to figure out why he wasn’t eating and was throwing up bile.
Community Bridges was frustrated by the lack of support from the Gimli hospital and his family doctor, the investigation found, and feared his worsening condition was terminal.
The report said it is “not the role” of the investigative unit “to criticize the medical system,” but “it is noted that there did not seem to be followup for the underlying causes of the medical issues that [Sean] was experiencing.”
Workers kept taking him to the hospital, but doctors couldn’t figure out what was wrong and sent him home, the report said.
Despite the workers’ attempts, Sean was discharged “multiple times” from Gimli hospital from Nov. 14 to Dec. 5, while “continuing to decline from an unknown source of origin,” it said.
Doctors may have been unsure of how to proceed because Shultz’s father didn’t want any invasive procedures done on his son, according to the report.
At one point, an unnamed person with Sean at the hospital questioned why he was being sent back to the home, noting they were “really afraid something bad would happen if they took him back,” the report said.
The family of a man who lived with intellectual disabilities and was being cared for at a Manitoba group home is calling for an inquest after he died in hospital from sepsis, made worse by malnourishment.
A spokesperson for Families Minister Nahanni Fontaine, whose department oversees Community Living disAbility Services, said in a statement she was unavailable for an interview, but she offered her condolences to the family.
Fontaine said her department is working on better communication and information sharing so families have better access to these types of investigations.
A spokesperson for the Interlake-Eastern Regional Health Authority, which includes Gimli, said they couldn’t comment on specifics about Sean’s care, but said it was not reported as a critical incident — an incident where a patient suffers serious and unintended harm in the health-care system.
Judicial inquest needed: sister
Getting access to the report was a relief, Shultz said, because it provided the family with a clearer picture of what was happening at the group home before her brother died.
But she still has many questions about the days leading up to when she found him.
“I always had some kind of real gap in my understanding, and knowing that Sean had been to the hospital several times and that he still ended up in the situation that he was in,” she said.
A judicial inquest is the only way to get those answers, she says.
Such inquests are called by the chief medical examiner and held in front of a provincial judge. They don’t determine blame but examine the facts surrounding a death. Witnesses are called and a judge can make recommendations to prevent similar deaths.
Shultz said an inquest could examine the gaps in her brother’s care, to determine how hospitals can better support substitute decision makers, and how to better treat terminally ill patients with intellectual disabilities.
She thinks he should have been transferred to palliative care when it became clear he was dying in late November 2023. Instead, she says he was left with workers who aren’t medically trained to deal with someone who is terminally ill.
“I think there has been a lot of unfairness placed on the workers at Community Bridges,” she said. “They are not equipped in any way whatsoever to deal with the health crisis that Sean was going through.”
Community Bridges executive director Heather McNeill declined to do an interview.
Sean’s death is a “matter that touches many of us here, from the staff to the board to the people that we serve,” she said in an emailed statement.
‘Insane amount of guilt’
Shultz remembers her brother as a goofy guy who loved cuss words, the movie Wayne’s World and the band Def Leppard.
Growing up, Shultz would bring him along to parties and take care of him after school.
Damon remembers his uncle’s love for cheeseburgers with a Coke.
“If you gave him that, it was the best day he could have in the world,” Damon said. “He was just always, always smiling.”
Shultz worked as a manager at her brother’s group home when it opened in the 1990s. Eventually though, there was a discussion with their mom, who told her she needed to go live her own life. The home would give her brother the care he needed, and the family could visit him.
“We put the right things into place knowing that my parents would age, knowing that Ian [her other brother] and I would age,” said Schultz.
But Sean’s anxiety increased as he got older, and it became harder for her to visit without upsetting him, Shultz said.
A combination of the COVID-19 pandemic, moving to British Columbia and other life factors meant she hadn’t seen her brother in a couple years before his last months.
“I have an insane amount of guilt,” she said.
Shultz’s father lived in Winnipeg and wasn’t able to travel to Gimli to see Sean, so relied on phone calls from staff and the hospital.
Shultz feels that after his wife died a few years prior, her father wasn’t mentally prepared to deal with Sean’s condition. She also doesn’t think he understood the extent of his son’s medical condition.
She said her dad was “flabbergasted” when she told him how she found her brother, and he insisted they call an ambulance.
“I don’t think that he understood, and was made really aware of … how pressing everything was,” she said.
Disabled people often lost in system: expert
A director at Canada’s largest mental health hospital said people with intellectual disabilities often struggle to get their voices heard.
There are multiple reasons for that, said Yona Lunsky, a program director at the Centre for Addiction and Mental Health, or CAMH, in Toronto.
They can’t always communicate what is wrong with them or ask for help, and it’s hard for their voice to cut through a busy medical system, she said.
“There are many stories like this that happen, and people are quiet and in pain,” said Lunsky, who is the hospital’s director of health care access research and developmental disabilities program.
“We have to look at what we can learn, and we have to do better.”
England’s National Health Service tracks all deaths of people with learning disabilities and autism in annual reports, in order to identify potentially preventable deaths.
Lunsky said a similar approach in Canada would be helpful in fighting conditions that are often non-fatal in the general population, but disproportionately kill people with intellectual disabilities, such as sepsis, constipation and epilepsy.
Shultz will never know what caused her brother to stop eating, or if his death was preventable. But an inquest could help ensure people like her brother are treated with dignity as they age and get sick, she said.
She is comforted knowing her brother’s final days were peaceful, and he wasn’t in pain.
He took his final breaths in 2024 as Vivaldi played in the background, with his sister by his side.
