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Hundreds of Canadians are dying “needless, avoidable deaths” after languishing hours waiting for care in emergency rooms, three emergency physicians say in a commentary in the Canadian Journal of Emergency Medicine.

These deaths are recurring “with unsettling regularity, not randomly, not rarely,” in Canada’s hospitals, a function of choked and overwhelmed emergency departments, Dr. Paul Atkinson, Dr. Alecs Chochinov, and Dr. David Petrie (photos L to R above) wrote.

While media reports of individual people dying after languishing hours waiting for care in an emergency room are undeniably tragic, individual stories obscure a darker reality, they said –  a “hidden pandemic” of excess deaths.

“A patient waits for hours in a Canadian emergency department, deteriorates quietly, sometimes visibly, then dies before being assessed,” they said.

An estimated 8,000 to 15,000 Canadians are dying unnecessarily each year due to emergency department crowding, according to one analysis extrapolated from U.K. data.

Atkinson is with the Department of Emergency Medicine at Dalhousie Medicine New Brunswick at Dalhousie University; Chochinov is with the Department of Emergency Medicine at the University of Manitoba; and Petrie is with the Department of Emergency Medicine at Dalhousie University.

Emergency departments (EDs) have become the point where downstream failures finally reveal themselves, where consequences can no longer be obscured by administrative language, they said.

“In the early hours of the morning, EDs now resemble less a gateway to care than a holding area for a stalled system. Stretchers line hallways; ambulance crews wait to offload. Patients sit upright in chairs, reassured but not yet safe. Upstairs, beds are full. Elsewhere in the system, capacity exists on paper but not in time.”

By most definitions, this situation represents a chronic, predictable disaster, with all the attendant consequences, “including a mortality rate that exceeds that of a properly functioning system that citizens of a highly developed country have a right to expect,” they said.

The common explanation for this dysfunction is demand, they added. “Too many patients. Too sick. Too complex. Too soon. Demand is an attractive culprit because it feels external and uncontrollable.”

But this explanation does not withstand scrutiny, they said. “The patients have always come. What has changed is not arrival, but movement. Patients cannot move.”

They cannot move to inpatient beds, to lower-acuity facilities, to long-term care, or go home with appropriate support, the emergency department physicians said.

“When patients stop moving, they accumulate. And the place where they accumulate is the only part of the system that cannot refuse entry. Emergency departments have become warehouses for patients who have already been accepted into hospital care, occupying stretchers that are no longer available for new arrivals. In practice, these become stolen beds, capacity taken from emergency care to compensate for downstream failure.”

In Alberta, doctors have called on the provincial government to declare a state of emergency over emergency department wait times. 

Many other systems have already learned how to better mitigate risk, the three emergency physician authors said.

Aviation learned long ago that congestion must never be allowed at the point of greatest danger. Whatever the inconvenience to passengers on the ground, the runways must remain clear to incoming flights.

The emergency physicians likened hospital emergency departments to the pit-stop in Formula One racing. “One car. One narrow space. Seconds matter. Failure is rare not because the task is simple, but because coordination is central to the process and the mission is understood by all. Roles are narrow and precise. One person lifts the car. One removes a wheel. One tightens a nut. One releases the vehicle. Authority is clear. Timing is absolute.”

Emergency care should operate on the same principles, they said.

There are solutions to the crisis in emergency care departments

Health care facilities should have formally tested plans for surge capacity, but in reality rarely practise or evaluate system coordination, they pointed out.

Individuals are trained extensively, but collective performance is assumed. When failure occurs, attention turns instinctively to heroism: the nurse who skipped breaks, the physician who stayed late, and the team that “made it work” despite impossible conditions. 

Health care has spent decades eliminating essential resilience, which was treated as “slack,” they said.

Hospitals run at full occupancy and empty beds are treated as waste. Staffing is minimal outside office hours. When variability inevitably arrives, there is nowhere for patients to go.

Emergency departments become the buffer by default, absorbing patients who should already be elsewhere, converting emergency stretchers into temporary inpatient beds without the staff, space, or mandate to support that role safely.

In England, time-based emergency standards were introduced, forcing hospitals to accept that emergency flow was a system responsibility, they noted. Challenges remain within the National Health Service, but system-wide, enforceable standards represent a necessary first step toward accountability.

Many Organisation for Economic Cooperation and Development countries have reduced emergency department pressure by building integrated primary care and reliable after-hours services, limiting the ED’s role as the default access point. Even in the United States, integrated systems have shown that when accountability spans primary care, hospitals, and emergency services, flow improves.

But Canada, with 2.5 hospital beds for every thousand people, has one of the lowest hospital bed capacities among OECD countries.

A special task force of the Canadian Association of Emergency Physicians has proposed a major redesign of the system. 

In Canada, the 2024 EM:Power Task Force Report on the Future of Emergency Care described an emergency care system that is safe for patients, effective for clinicians, sustainable for the workforce, responsive to communities, and accountable to the public it serves.

The report identified access block as the central problem undermining this goal. It recognized that systems operating near full capacity cannot tolerate everyday variation, and reframed unused beds not as inefficiency, but as essential safety infrastructure. It acknowledged that complex systems require coordinated planning and shared accountability across the entire health system.

“The evidence supporting these conclusions is longstanding. ED crowding is associated with delayed diagnoses, increased error, staff burnout, and excess mortality across jurisdictions and methodologies,” the emergency physicians said.

The argument that health care in Canada is a provincial responsibility “is convenient and incomplete,” they said. “We have agreed, as a country, that some standards are too important to leave entirely to local discretion.”

Canada already enforces the principles of the Canada Health Act where it chooses to do so, they noted. Provinces cannot opt out of universality or portability and still receive federal transfers. Accessibility is a core principle of the Act, and accountability was recommended as a sixth principle by the Romanow Commission’s report in 2002.

“Timely access to emergency care should therefore be a national priority that flows directly from the principles we already accept.”

When patients with moderate-acuity conditions wait eight, 10, 12, or more hours to be seen, this is not a minor deviation, they said. “It is a breach of national expectations that exist but are rarely enforced.”

The federal government need not run hospitals or dictate staffing ratios to matter. Ottawa can insist that agreed-upon emergency access standards are met, that failure requires explanation and remediation, and that persistent failure carries consequences, including for federal health transfers, they said.

Provinces would retain control over how standards are achieved. But a national floor would exist beneath which care could no longer quietly fall. “Standards, after all, only matter when they are enforced.”

Canada’s emergency care crisis is often described as too complex, too entrenched, or too political for decisive action. “That framing is reassuring. It allows failure to be treated as unavoidable rather than preventable. In reality, the problem is well defined. The evidence is consistent. The consequences are predictable.”

What distinguishes this crisis is not a lack of understanding, but a persistent failure to act on what is already known, the emergency physicians said.

Reviews are undertaken. Recommendations are issued. Yet the same conditions recur, and the same harms follow. Over time, abnormal performance becomes routine, and delay is absorbed into the definition of normal care.

“This is how health systems learn to fail,” they said.

Canada has the evidence, the international examples, and a framework for a better system, they concluded. “What remains unresolved is whether we are willing to apply what we already know, or continue to institutionalize failure by default.”

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