Brian Sinclair, who died after waiting 34 hours in a Winnipeg emergency room, should not have been sent to the hospital alone, an inquest into his death heard on Tuesday.
Sinclair, a 45-year-old homeless double-amputee, died in his wheelchair after sitting for 34 hours at the Health Sciences Centre's (HSC) emergency waiting room, without receiving treatment, in September 2008.
His death was determined to have been caused by a treatable bladder infection caused by a blocked catheter.
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The inquest, currently in its second week, has been examining what happened between the time Sinclair went to the HSC emergency room and the time someone else in the waiting room told a security guard they believed Sinclair was dead.
Health-care staff recently testified that Sinclair had a variety of health issues and had been declared mentally incompetent in 2007.
On Tuesday afternoon, the inquest heard from Sylvia Chidlow, a receptionist at the Health Action Centre, the community clinic that sent Sinclair to the hospital.
The inquest has heard that a doctor from the clinic sent Sinclair in a taxi to the HSC, unaccompanied, so he can be treated for abdominal pain and catheter problems.
Chidlow testified that in the days after Sinclair died, she overheard two clinic nurses saying Sinclair should have been escorted in the taxi or sent in an ambulance.
Social worker testifies
Also testifying on Tuesday was Leonard Koberstein, a social worker who dealt with Sinclair after he was locked out of his rooming house in early 2007.
Sinclair was found almost frozen to death several days after he was locked out, curled up in the fetal position outside a Winnipeg church, a doctor who cared from him at the time said Monday.
Both of Sinclair's legs were later amputated above the knee as a result of frostbite.
Koberstein told the inquest that it was difficult to find Sinclair housing because he was in a wheelchair, had little money, and had solvent abuse issues.
Lawyers for Sinclair's family and Toronto-based Aboriginal Legal Services, which has standing at the inquest, tried on Tuesday to get Koberstein to portray the health-care and social services system as one that neglects people like Sinclair.
Emily Hill, a lawyer for Aboriginal Legal Services, also asked Koberstein about whether the Health Sciences Centre had specific policies and practices regarding the care of aboriginal patients.
Koberstein said he was not aware of any such policies or practices.
Lawyers for the Winnipeg Regional Health Authority (WRHA) argued that Sinclair's care was by the book and everything possible was done to help him.
Koberstein said a staff member from the HSC's aboriginal health services was part of Sinclair's health-care team during his time there.
Surveillance video to be shown
The inquest also heard from Sinclair's speech pathologist, who testified that Sinclair had significant difficulty in expressing himself and understanding questions.
When inquest hearings resume on Thursday afternoon, a police detective who investigated Sinclair's death is expected to testify.
The inquest is also expected to watch excerpts of Health Sciences Centre surveillance video footage from the time Sinclair was there.
Meanwhile, lawyers for Sinclair's family have asked inquest counsel to fully disclose the Winnipeg Police Service's criminal investigation report into his death.