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GJ and Hazel van der Werken sit on a bench made in memory their 16-year-old son, Finlay, who died following a visit to the ER at Trafalgar Memorial Hospital in Oakville, Ont.

Re “An Ontario teen died after waiting in agony for hours at an ER. Now, his family wants an inquest” (Aug. 20): The death of a 16-year-old after waiting hours in an Ontario emergency room is a devastating reminder of what happens when situational awareness breaks down. Despite being triaged as a “Level 2″ patient requiring urgent care, he lay in a hallway unseen.

Emergency departments should operate like disaster zones with clear leadership, real-time oversight and structured handovers. A simple whiteboard listing Level 1 and 2 patients could have saved his life. Instead, there seemed to be no system and

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