Brian Sinclair spent 34 hours waiting for care in Health Sciences Centre's emergency waiting room before getting a single minute of treatment.
By the time Sinclair, 45, was brought into the resuscitation room, he had already been dead for hours.
Emergency room nurse Nic Wedel told an inquest looking into Sinclair's death nurses and a doctor tried to resuscitate the man because they had no idea how long he had been dead when a security officer rushed in with him slumped over in a wheelchair on Sept. 21, 2008.
Wedel said he could tell when he helped lift the double amputee onto a bed from his wheelchair that his body was already "cool and stiff."
"His eyes were open and fixed. His skin was pale and (had) a waxy appearance... I had no idea what had happened and when he arrived.
"I figured it was required to do resuscitation efforts to give him a chance."
Sinclair arrived in the resuscitation room on Sept. 21, 2008, at 12:50 a.m., and Wedel said one minute later he was pronounced dead after a doctor tried in vain to put an airway tube into him and realized the man's heart wasn't beating.
Sinclair came to HSC's emergency department on Sept. 19, 2008, suffering from a bladder infection and a blocked urinary catheter.
A security video shows Sinclair met briefly with a triage aide, who wrote something down. Sinclair then spent the next 34 hours sitting in the waiting room in his wheelchair without receiving care until a person in the waiting room told a security guard they believed the man was dead.
The inquest has been told not only had staff been telling hospital management for months there were problems with the layout of the emergency department's waiting room, the department had three nursing vacancies the day Sinclair came and it was treating an above-average number of patients.
When told an HSC security guard had testified earlier in the inquest he believed Wedel and another nurse felt he was joking when he first brought Sinclair to him, the nurse said he was shocked.
"The security guard was pushing a man in a wheelchair and said 'We've got a problem. This man's dead,' " Wedel said.
"It was a very unusual way to present to us. I was definitely surprised. I don't remember what I would have said, but relatively quickly I looked at (Sinclair) and took him to the resuscitation room."
Later, Beth Franklin, a nurse who worked full time in HSC's emergency department from 1976 until she retired in January 2009, and then worked casually there until last year, said there are still major problems in that area of the hospital.
Franklin, who was shown an anonymous letter by lawyer Murray Trachtenberg (who is representing Sinclair's family), which was sent to hospital management from unnamed emergency department staff, agreed many of the concerns about patient safety are still there five years after Sinclair died.
"Patient volumes and length of stay in our department are out of control," Trachtenberg said to Franklin, who agreed.
Franklin also agreed with other statements in the letter including "wait times to see a physician are ridiculous," "staff are stressed," and the "concern for patient safety at the emergency department still continues."
When asked about low morale, Franklin said "morale has been an issue in that department for a number of years."