Brian Sinclair's home-care nurse put a hold on his monthly catheter-change schedule little more than a month before he died because he was never home.
At an inquest today looking into Sinclair's death, Lisa Blanchette testified that nurses were supposed to check the man's urinary catheter every two weeks - and change it monthly - but he was never at his room in the Quest Inn.
"It was difficult to find Brian," she said. "He just wasn't home."
Blanchette said she once caught Sinclair on the sidewalk in his wheelchair when she was in her car and tried convincing him to go back to the Quest so she could change the catheter.
"He didn't want to. He just wheeled past me, smiled, and wheeled away."
Blanchette said she became "frustrated" with the difficulty trying to meet with Sinclair so she put his care on hold.
But Blanchette said a nurse at Siloam Mission - where Sinclair would visit two of his brothers - indicated she would change the catheter.
She admitted there were no notes in Sinclair's chart indicating if anyone checked with the nurse to see if this was done and home-care nurses never saw him again.
Blanchette said people who delay having catheter checked are at higher risk of having the catheter getting blocked and getting bladder infections.
Sinclair died of a bladder infection in September 2008 after being left untended in the Health Sciences Centre emergency department's waiting room for 34 hours.