A five-minute, seven-second gap in surveillance video taken during the 34 hours Brian Sinclair waited for treatment at the Health Sciences Centre is due to the normal operation of the hospital's security cameras.
The inquest looking into Sinclair's 2008 death was told of the gap during testimony Tuesday morning, catching a seasoned police detective and HSC officials off guard as it was the first time in five years it had been raised.
It was pointed out by Sinclair family lawyer Vilko Zbogar to Winnipeg police Det.-Sgt. John O'Donovan, who led a year-long criminal investigation into Sinclair's death. No charges were laid.
O'Donovan, who had testified he spent about 500 hours watching the security video of Sinclair at the HSC, told the inquest he had not noticed the gap until Zbogar raised it.
It took until the afternoon for the inquest to be told the gap was not deliberate, but a normal function of the cameras. "If the camera doesn't sense any motion, it stops recording," HSC director of security Norman Schatz testified.
Outside of court, Schatz told reporters gaps are common in surveillance video footage as they only record when they electronically sense motion so they do not needlessly record without pause.
"It takes too much hard-drive space and it's harder to do a review," Schatz said. "You can't alter them. These are proprietary systems. You can't even turn them off. All we can do is control what they are looking at. We can't control the fact that they are recording. That's automatic."
The inquest has only seen footage of Sinclair in the waiting room before he was found dead.
Schatz also told the inquest he led an internal investigation into what's believed to be the initial triage document filled out by an aide when the 45-year-old double amputee first arrived at the HSC. Sinclair 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.
Provincial court Judge Tim Preston is looking into the circumstances of why Sinclair ended up spending 34 hours in the ER waiting room without being treated. The inquest's first phase is to end this week and continue in October with members of the public who had direct contact with Sinclair in the waiting room.
That missing piece of paper, which supposedly contained his name and medical complaint, was one of the main focuses of the police investigation, O'Donovan told the inquest Monday. The video, which was released Monday, shows the aide dropping the piece of paper or pad on the triage desk after speaking to Sinclair while a nurse at the desk speaks to another patient.
Schatz said in the hours after Sinclair was found dead he launched a search for the paper, going through garbage bins until he was told the garbage had already been picked up by truck and taken to the dump. The search was abandoned.
Schatz also said he spoke to the aide, who told him he could not remember writing anything on a note or anything regarding Sinclair.
The only other times Sinclair appeared to have contact with HSC staff, in the security video, 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 vomited three times.
O'Donovan said 150 patients passed through the ER, getting treatment and leaving, while Sinclair waited.
"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 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 the inquest over the past two days for O'Donovan's testimony on the video, said the layout of HSC ER has changed and its triage system has moved from paper to computer.
"We've now made the entranceway so that when you first come in, you are asked a question as to why you are there," she said. "You are referred to registration and to triage. You are entered into the system so that we have track of your name electronically.
"You're provided with a wristband that you 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 room and other supports."
A 2008 WRHA review of Sinclair's death found no one was to blame since no one knew he was waiting to see a doctor.
In February 2012, the WRHA paid Sinclair's family $110,000 on a portion of their lawsuit dealing with his wrongful death.