The inquest into the 2008 death of Brian Sinclair at a Winnipeg emergency room heard today that there is a missing five-minute gap in hospital security video in the hours leading up to his death.
The gap was pointed out by Sinclair family lawyer Vilko Zbogar to Winnipeg police Det. Sgt. John O’Donovan, who lead a year-long criminal investigation into Sinclair’s death. No charges were laid.
O’Donovan, who testifed he spent about 500 hours watching the security video, told the inquest he had not noticed the gap until Zbogar pointed it out this morning.
Those missing five minutes are to be explained this afternoon when the inquest continues at 2 p.m.
Before finishing his testimony O'Donovan said 150 people passed through the Health Sciences Centre ER the weekend Sinclair died in September 2008.
The inquest is looking into the circumstances surrounding why Sinclair ended up spending 34 hours in the ER waiting room without being treated. He was sent to the hospital in a cab by a local medical clinic with a note saying he had a blocked catheter and suspected bladder infection, a condition that was treatable.
O’Donovan said the 45-year-old double leg amputee was the only person not to be seen by a nurse or doctor.
He was found dead in his wheelchair in the waiting room 34 hours after he had first arrived and presented himself at the triage desk.
The only times he appeared to have contact with HSC staff, according to security video released Monday, was with a security guard who told him to move to a different place in the waiting room and a cleaning staff member who gave him a silver basin after he had vomited three times.
"He was the only person who wasn't provided medical treatment," O'Donovan told the inquest. "I don't know if he was being ignored on purpose. They weren't aware of him there. He was ignored during his time there."
Arlene Wilgosh, president and chief executive officer of the Winnipeg Regional Health Authority, said after O’Donovan’s testimony that the HSC’s waiting room layout and triage protocol has changed since Sinclair’s death.
At the time of Sinclair’s visit, it was customary to shred or dispose of paperwork initially filled out by the triage staff when a patient first arrived.
Wilgosh, who attended to the inquest over the past two days for O’Donovan’s testimony on the video, said the triage system has moved from paper to computer.
"Now when you come into the emergency department each individual is questioned as to why they are there," she said outside of the inquest. "Each individual who requires to be triaged is entered into the electronic system.
"They are provided with a wristband that says they have been triaged. In the waiting room there is a reassessment nurse that reassesses the patients that are waiting to be triaged or have been triaged and waiting to go into the treatment area and there’s also a community services worker that provides additional checking of people in the waiting area and other supports."
Wilgosh said she was saddened watching the security video in court.
"We have put in measures to ensure that this does not happen again," she said. "We are accountable."