Staff at Winnipeg's Health Sciences Centre found a doctor's referral note in the pocket of Brian Sinclair's after he died while waiting 34 hours for care, sitting in his wheelchair in the emergency room.
Sinclair, a 45-year-old double-amputee, was awaiting a minor procedure but no one ever came to his assistance, even as he vomited in plain sight, a provincial inquest into his death was told Wednesday.
The inquest, in its second day, is examining what happened between the time Sinclair went to the emergency room in September 2008 and the time someone else in the waiting room told a security guard they believed Sinclair was dead.
Manitoba's chief medical examiner Dr. Thambirajah Balachandra said Wednesday that medical staff should attend to patients who are throwing up. Sinclair, whose death was later attributed to a treatable bladder infection, died of septic shock.
The WRHA says it has changed its ER triage procedures since Sinclair's death.
Balachandra told the inquest on Tuesday afternoon that all Sinclair would have needed was a catheter change and antibiotics.
Balachandra is expected to finish testifying Wednesday morning. The inquest will then hear from a pathologist who examined Sinclair's body following his death.
Security footage at the Health Sciences Centre shows Sinclair went to the triage desk and spoke to an aide before wheeling himself into the waiting room.
That appeared to have been his only interaction with staff.
Almost a day and a half later, another person in the waiting room finally spoke up about Sinclair. Efforts to revive him were unsuccessful.
Family members and friends of Sinclair testified as the inquest got underway Tuesday in Winnipeg.
The inquest is scheduled to run throughout this month, every Monday to Thursday. Additional dates will be scheduled for October and possibly in early 2014.
Police and the Crown attorney's office had investigated Sinclair's death to see if charges of criminal negligence or failing to provide the necessities of life might have applied. However, they decided no charges were warranted.
The Winnipeg Regional Health Authority has paid $110,000 in damages to the Sinclair family for loss of care, guidance and companionship.
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