A year-long police investigation into the 2008 death of Brian Sinclair in the Health Sciences Centre emergency room focused on the movement of a piece of paper that apparently was filled out by an ER aide moments after the 45-year-old double amputee arrived at the hospital's triage desk.
What happened to the paper, which supposedly recorded Sinclair's name and health condition, is unknown as police and a Winnipeg Regional Health Authority review of Sinclair's death were unable to retrieve it, an inquest into Sinclair's death was told Monday.
"Somehow it got disregarded," Sinclair family lawyer Vilko Zbogar told reporters after the inquest had adjourned for the day. "We don't know exactly why it was discarded before Mr. Sinclair was called to be triaged.
"That piece of paper seems not to be recoverable at this point."
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.
'We don't know exactly why it was discarded before Mr. Sinclair was called to be triaged. That piece of paper seems not to be recoverable at this point'
The existence of the triage document, generally filled out when patients initially arrive at the HSC's ER, was raised by Winnipeg police Det. Sgt. John O'Donovan on Monday. O'Donovan, one of the officers involved in the police investigation, guided the inquest through hospital security surveillance video recorded from when Sinclair arrived at the hospital by taxi shortly before 3 p.m. Sept. 19, 2008, to a short time before he was found slumped dead in his wheelchair 34 hours later in an aisle of the ER's waiting room. No criminal charges were laid.
The video was released to the media after 55 clips were first shown at the inquest.
"What you saw in the video today I think were people who arrived just before Mr. Sinclair," Zbogar said. "There were people who arrived just after Mr. Sinclair at the emergency room and they all were triaged properly. Mr. Sinclair wasn't, and the family want to know why."
O'Donovan said police, using video recorded mostly by three cameras, tried to track Sinclair during those 34 hours, including who he interacted with and what happened to the piece of paper.
Sinclair is first seen being wheeled into the ER by a cab driver and up to the left of the triage desk. The cab driver leaves and Sinclair is next seen wheeling himself up closer to the desk, where he waits for a patient in front of him to finish.
O'Donovan said it then appears a triage aide records on a pad or a piece of paper what is believed to be Sinclair's name and his health complaint. In the next several frames a different camera shows the aide dropping a piece of paper on the triage desk while a nurse deals with another patient.
Sinclair is then seen wheeling himself to a spot next to the security desk in the waiting room, almost in a corner of the room and out of view of the triage desk.
Under procedures at the time, a nurse would use that pad of paper to call patients back to the triage desk for a more thorough review, including measuring blood pressure and getting a clearer picture of their health complaint.
Sinclair was never called back to the triage desk despite being at the same ER five times in the preceding months for a similar issue.
The same triage aide can be seen speaking to other patients who arrive at the ER and is also seen making notes on a pad of paper. Triage nurses also appear to handle a paper pad, but it is unclear if it's the same one used by the aide or one with Sinclair's name on it.
The security video ends with an image of Sinclair slumped in his wheelchair in an aisle facing a TV. He likely died from two to seven hours before his death was discovered. In earlier clips, he is seen wheeling himself in the ER past the triage desk and to a washroom. At some point, someone had given him a bowl or pan. The inquest has already heard he had vomited on himself.
Sinclair is last seen moving his head at 1 p.m. on Sept. 20 and is believed to have died between 7 p.m. and 9 p.m. that day, O'Donovan said.
Not once during the video, other than his initial contact with the triage aide, is anyone from the hospital seen interacting with Sinclair. At one point, another man in a wheelchair looks at a slumped Sinclair as he wheels himself past.
WRHA president and chief executive officer Arlene Wilgosh, who was in court during O'Donovan's testimony, declined comment afterwards.
"I want to respect the process," she said.
O'Donovan also testified in the five years before his death, Sinclair was brought to the HSC ER 31 times, many times by ambulance for treatment for blunt trauma, seizures, frostbite, blurred vision, abrasions to his head, back pain and chest pain.
The inquest has already heard Sinclair was a longtime solvent abuser who showed evidence of brain damage when he was 18.
Sinclair lost both legs above the knee to frostbite in 2007 after being found frozen to the outside wall of a church.