Brian Sinclair wasn't homeless, but he was aboriginal, impoverished, living with disabilities and a past solvent abuser while waiting inside a busy hospital emergency department waiting room for care that never came.
While all that is true, and all areas Sinclair's family wants to have examined in an ongoing inquest, provincial court Judge Tim Preston says he will only look at two of those things before the matter wraps up: how to relieve patient backlogs and increase patient flow in busy emergency rooms and how to provide appropriate health care for indigenous patients.
That's because Preston reminded lawyers involved in the case the examination of Sinclair's death is an inquest not an inquiry, and he is not about to expand its focus.
'I am not turning this inquest into a de facto inquiry'
"I am not turning this inquest into a de facto inquiry," he said during a brief hearing on Friday detailing the parameters of Phase 2 of the inquest that began in August and has already heard from 70 witnesses.
Preston said he will not be dealing with the social determinants, including race, poverty and disability, that cause Sinclair and others to go to emergency.
"It is far beyond the scope of my mandate," he said.
"The reasons for delay that occur once a person presents at an emergency department and measures to reduce that delay are the subject matter of this inquest."
Sinclair, 45, died on Sept. 21, 2008, after spending 34 hours in Health Sciences Centre's emergency department waiting room without being seen. He was a double amputee who had to use a wheelchair.
Sinclair, who succumbed up to seven hours before being found, died of a treatable bladder infection caused by a blocked urinary catheter. He had been sent to the hospital by an outside health clinic in a taxi with a note from a doctor in his pocket.
Vilko Zbogar, one of the two lawyers acting for Sinclair's family, said they won't be pleased with the judge's decision. "The inquest will look very different than what the family wanted and thought was necessary to make sure people like Brian Sinclair don't get ignored the way he did," Zbogar said.
"It is different than what the original inquest judge said would be front and centre and now seems to be off the table."
Emily Hill, of Aboriginal Legal Services of Toronto, which was granted official standing in the inquest, said in a statement ALST is disappointed with the narrowing of the scope of the inquest.
"We are disappointed that the majority of Phase 2 witnesses will be WRHA (Winnipeg Regional Health Authority) staff speaking about patient flow rather than independent experts speaking about systemic issues facing aboriginal patients in the health-care system," Hill said.
"ALST chose to get involved because of the issues we understood the inquest would address... People in Winnipeg, Manitoba and across Canada were concerned about Brian Sinclair's death and a large part of that concern was about how he was treated as someone who was marginalized in a number of ways -- being aboriginal, poor and disabled."
Preston said the inquest will continue for eight days in February and four days in June before wrapping up.