WINNIPEG - Manitoba's chief medical examiner called an inquest Wednesday into why a homeless man who died of a bladder infection sat unnoticed by staff for 34 hours in the emergency waiting room of a Winnipeg hospital.
Dr. Thambirajah Balachandra said Brian Sinclair, 45, hadn't been able to urinate for 24 hours because of a blocked catheter and his bladder was full. He had been dead for hours and rigor mortis had set in when finally attended to.
Sinclair was in a wheelchair because he had lost both his legs to frostbite but he was still mobile, he said.
His death was preventable and requires in-depth investigation to ensure it never happens again, Balachandra said.
"I'm sure you would agree that no person in the world should wait 34 hours for treatment in an emergency department," said Balachandra, who added Sinclair could have had his catheter changed and been given antibiotics to treat the infection.
Treatment would have been relatively straight-forward, Balachandra said, adding Sinclair had been briefly hospitalized in March for the same condition.
Sinclair was referred to emergency Friday after visiting a downtown health clinic but was never seen by triage nurses until it was too late.
The death has prompted the Winnipeg Regional Health Authority to require any health-care clinics that send people to an emergency department to now follow up by phone.
The health authority says it is fully investigating what happened and is so far baffled about why Sinclair was never treated. Although the report is expected within a month, Balachandra said he's not waiting for its recommendations.
The inquest will be convened "as soon as possible," he said.
"They can take their sweet time," he said. "I don't care."
Balachandra's office will contact the province's chief judge, who will select a justice to oversee the inquest.
Heidi Graham, spokeswoman for the health authority, would only say officials will "be co-operating fully with the medical examiner's investigation into this tragic event and look forward to the final report."
Sinclair was dropped off at the Health Sciences Centre by a taxi Friday afternoon after visiting a downtown health clinic which is part of the Winnipeg health authority.
Some hospital staff - including housekeeping and security guards - did speak with him at some point, but it was not until shortly after midnight on Sunday that he was examined and pronounced dead.
Hospital officials say it's not unusual for homeless people to take shelter in the emergency room, but they aren't blaming any confusion arising from that practice for Sinclair's death. The hospital has also said its emergency department wasn't short-staffed at the time.
Premier Gary Doer, who has been grilled in the legislature over the death, said the government is concerned that Sinclair's referral was never followed up.
"Something went tragically wrong here," he said. "We want to know what went wrong . . . Obviously there was a gap and a failure in this case."
Brian Bechtel, executive director of the Main Street Project mission, said the tight-knit community is in mourning for Sinclair. But he said unfortunately deaths like Sinclair's are not uncommon. In the last year alone, he said two people have died inside the downtown shelter.
"These are people who have layers of problems and challenges. We're in a harsh climate," he said. "There is a sadness. There are people who know him, people who know the family. There is a strong sense of community. People support each other."
But he said many hope something positive can come out of this tragedy.
The shelter will soon have a nurse on-site which was a recommendation that came out of an inquest several years ago. Sinclair's death may at least highlight the need to bring health care to the homeless directly rather than assuming they will seek help on their own, Bechtel said.
"Good things may come out of these kinds of incidents, as tragic and as senseless as they seem at the moment," he said.