An inquest into the 2008 death of Brian Sinclair in a Winnipeg hospital's emergency waiting room resumed on Monday with testimony from a senior nurse who said she had raised concerns about the ER being short-staffed and overcrowded.

Susan Alcock, who was the top nurse on duty in the Health Sciences Centre's emergency room when Sinclair arrived just before 3 p.m. on Sept. 19, 2008, told the inquest that hospital management repeatedly ignored her concerns about overcrowding, staff shortages and inexperienced staff.

Sinclair, 45-year-old aboriginal double-amputee, died while waiting 34 hours in the hospital's emergency room without receiving care. His death was later attributed to a treatable bladder infection.

On Monday, Alcock said she wrote a letter to officials in June 2008 to draw their attention to the issues. She also said she had spoken to the head of patient care in March about her concerns. 


Brian Sinclair waits in the Health Sciences Centre emergency room Sept. 19, 2008. He was discovered dead in his wheelchair after 34 hours. (HSC surveillance video)

"I felt we needed to do something soon because something was going to happen," Alcock told the inquest. "I felt it was critical and I wasn't getting listened to and [officials] weren't taking it seriously."

Alcock also testified that she was "slapped on the wrist" for "not following the chain of command."

She also testified that nothing changed after her letter was sent, but changes to the ER have since been implemented as a result of Sinclair's death.

In the afternoon, Alcock testified that the layout of emergency department had an effect on Sinclair's visit, as it was difficult for nurses to see people in the waiting area.

Also, on the day Sinclair arrived, Alcock said the ER was short three nurses and it was a "very, very busy" day.

Read the June 2008 letter from Alcock here:

Inquest's integrity called into question

The resumption of testimony at the inquest was briefly delayed on Monday morning, as the lawyer for Sinclair's family called the integrity of the inquest into question.

Vilko Zbogar brought forward a motion on Monday that requests access to transcripts and audio recordings at the inquest.

The Sinclair family is supporting a similar motion being presented by two local aboriginal organizations, The Assembly of Manitoba Chiefs and Ka Ni Kanichihk, which have legal standing at the inquest but can't afford lawyers.

A Toronto-based lawyer who is representing the two organizations pro bono will argue the motion on their behalf on Wednesday.

Judge Timothy Preston, who is presiding over the inquest, said he would make sure the groups didn't feel marginalized at the inquest because of their lack of funds.

But Zbogar said both groups claim that is what is happening because they are being denied access to the transcripts and audio recordings.

Zbogar also contends that the lawyer for the inquest, David Frayer, has a conflict of interest and is acting in the interests of the provincial government, rather than as a neutral third party.

He said he is basing that argument on a conversation between Frayer and Marcel Balfour from the Assembly of Manitoba Chiefs.

In an affidavit, Balfour said Frayer told him AMC couldn't have access to transcripts because of how much it would cost the provincial government. Zbogar said it shows a conflict of interest on the part of inquest counsel.

Frayer's co-counsel, Melinda Murray, argued against that Monday morning. The judge said the inquest will deal with the matter Wednesday morning.