Brian Sinclair spent 34 hours sitting in his wheelchair metres away from help in a hospital ER waiting room, but he could have been dead as long as seven of those hours.
That's the opinion of Dr. Thambirajah Balachandra, the province's chief medical examiner, who told an inquest on Wednesday that while the 45-year-old Sinclair was officially pronounced dead shortly before 1 a.m. on Sept. 21, 2008, evidence suggests he died some time earlier.
Balachandra said no one knows exactly when Sinclair died, but almost seven hours before he was declared officially dead, a security camera in the Health Sciences Centre emergency department showed him moving part of his body -- his hand -- for the last time.
Balachandra said based on the amount of rigor mortis present when Sinclair was pronounced dead, he was probably dead at least two hours.
Balachandra said if Sinclair had been treated -- he needed to have a blocked catheter replaced so he could discharge his urine, and a course of antibiotics to fight the ensuing infection -- he could have survived.
Sinclair, a double amputee, was transported to Health Sciences Centre in a Handi-Transit taxi on Sept. 19, 2008, after being seen by a doctor at the Health Action Centre. The clinic's doctor determined Sinclair needed his catheter replaced -- he told doctors he hadn't voided into his urine bag for 24 hours -- so the clinic called the cab and sent him to HSC with a letter detailing the treatment needed.
The inquest has heard when Sinclair arrived at HSC, he went briefly to the emergency triage desk, where he spoke to a uniformed employee who wrote something down, before rolling his wheelchair to the waiting area.
Thirty-four hours later another person in the waiting room alerted a security guard that a man appeared to have died there.
After HSC staff determined Sinclair was dead, they found the clinic doctor's note still in his pocket. His cause of death was an infected bladder.
Balachandra said he hopes the inquest, which he called, leads to changes in emergency-room procedures and reduces wait times.
"I'm not saying doctors are bad -- we have world-class doctors," he said. "But there's something wrong somewhere. It's no one's fault, but the system has to be rejigged."
Both Balachandra and Dr. John Younes, the coroner who did the autopsy on Sinclair and is now the deputy chief medical officer, told provincial court Judge Tim Preston that while an artery in the man's heart was nearly blocked and there was evidence of chronic solvent abuse, neither led to his death.
Younes said the autopsy was performed 33 hours after Sinclair was pronounced dead.
Younes said the autopsy was held at St. Boniface Hospital to avoid the possibility of conflict of interest.
Under questioning by Shannon Carson, lawyer for the Manitoba Nurses Union, Younes said if Sinclair's body temperature had been taken when he was pronounced dead, the time of death would be more accurate.
Younes said while performing the autopsy he found Sinclair's catheter was still properly placed in his bladder, but it was blocked by dead skin and pus from an infection.
He said about half a litre of pus was found in Sinclair's abdominal area during the autopsy, caused by the infected urine leaking out of a small rupture in his bladder. The doctor said the bladder was so infected, parts of the inner lining were "sloughing off."
The inquest continues today.