Brian Sinclair died after 36 hours of sitting in the Health Sciences Centre's emergency waiting room without getting care after not being triaged.
Now an official with the Winnipeg Regional Health Authority says Sinclair might still have waited hours in the emergency room even if he'd been triaged when he arrived.
Dr. Alecs Chochinov, the WRHA's director of the emergency program, told an inquest Wednesday emergency room patients are ranked on a scale of one to five with one being the most critically ill and five needing a prescription.
Chochinov told provincial court Judge Tim Preston based on what he knows about Sinclair's condition when he arrived in hospital on Sept. 19, 2008, he likely would have been ranked a three at the highest, meaning he was deemed urgent like a person with appendicitis, but not as critical as a person suffering a heart attack.
That doesn't mean Sinclair would have got through the treatment area to a hospital bed quickly.
Chochinov said the WRHA is "struggling" to meet its targets of eight hours to be treated in emergency and admitted into hospital, and four hours to be treated in emergency and out onto the street for a non-admitted patient.
Chochinov said after a person is treated in emergency, "they can wait days" to be admitted beyond emergency into the hospital.
"They are most at risk in our system," he said.
"They can be in a stretcher for hours or days... (Sinclair) didn't have a serious complaint (when he came in). He is an example of a person put back in the queue in a busy emergency department."
Sinclair had a suspected blocked urinary catheter and 36 hours after arriving at HSC, he was pronounced dead.
An autopsy found Sinclair died of a treatable bladder infection.
Sinclair's death sparked major changes in the waiting room in which he died.
Laverne Sturtevant, the WRHA's director of patient services, showed many of the changes through a video played in the courtroom.
"The video reflects a lot of care and compassion from nurses, physicians (and other staff)," Sturtevant said.
The video showed the changes come immediately after entering the department.
Where Sinclair had been shown in earlier video footage being rolled through a large open area at the entrance by a taxi driver, a security guard is now stationed there to ask if they are there for medical care, while another large desk, with a community service worker, is stationed in front of the three triage desks. There, a green arm band will be put on a person seeking treatment before they have been triaged.
To the side, in front of the triage desks, are several seats for people waiting to be triaged. Once the patient is there, the green arm band is cut off and a white one is put on, along with a blue one if they are to be treated in the minor- treatment area.
After being triaged, patients go to the regular waiting area where people also used to wait. Now the chairs face open nursing desks where they can be watched for any changes in health. And at the extreme west end of the waiting area, where a passageway once allowed people to go in and out of the main hospital through the emergency room, there is now a door allowing only access into the hospital, but not back into emergency.
While hospital staff said at the time Sinclair died, many people would be in the area for reasons other than treatment, Sturtevant said security guards will now ask them if they are there to receive treatment and, if not, direct them elsewhere in the hospital.
She said every hour a computer spits out the names of people still in the waiting room and nurses go out to assess each of them.
Sturtevant said the physical changes in the room are helping people get triaged faster.
While it took 23 minutes on average for a person walking into the hospital to get triaged two months after Sinclair died, Sturtevant said it now takes 6.9 minutes on average.