The death of Brian Sinclair in the ER of the Health Sciences Centre in central Winnipeg was 'entirely preventable,' Manitoba's top medical examiner said earlier this week. (CBC)

Family members of a wheelchair-bound man who died in a Winnipeg emergency room say they are shocked and angered he was ignored by hospital staff for more than a day.

Brian Sinclair, a double amputee with a speech problem, was found dead in his wheelchair after spending 34 hours in the waiting room of the Winnipeg Health Sciences Centre's emergency department last weekend.

A catheter that the 45-year-old had as a result of a bladder problem was blocked, and he hadn't been able to urinate for 24 hours, said the province's chief medical examiner, Dr. Thambirajah Balachandra.

He died of complications from a serious bladder infection that spread to his bloodstream, said Balachandra.

Robert Sinclair told CBC News he can't understand how his cousin could sit in the hospital for such a long time without being noticed.

"He's my blood," Sinclair said. "I don't like to see any of my blood relatives die for no reason and I believe that.… It was for no reason. The guy sat there for 34 hours for what reason?"

Brian Sinclair took a taxi from a community health centre to the Health Sciences Centre on Friday afternoon. He was found dead after midnight on Sunday, when someone in the waiting room alerted hospital staff.

Sinclair appears never to have been assessed by a triage nurse and was not registered as a patient seeking care, so reassessment nurses didn't know he was there for help, officials with the Winnipeg Regional Health Authority said Tuesday.

He was apparently dead for some time before staff members were alerted, officials said. The exact time of his death is not known.

Bradley Sinclair, a brother, said he has also waited in the emergency room for long periods while seeking care.

"I waited, waited, waited with people that were there. They waited long times to see a doctor. That's what happens there."

Balachandra said Brian Sinclair could have been saved by a catheter change and a course of antibiotics.

"I didn't like that," Bradley Sinclair said. "I wish he was alive, but I can't bring him back alive."

Speech problem likely a factor, says pastor

Winnipeg pastor Ken McGhie, who knew Brian Sinclair, said the man's speech impediment may have made him reluctant to ask for help.

"These have got to be the most vulnerable people in our city, anywhere, people that can't communicate and he should have been known to have not been able to effectively communicate," McGhie said.

"He was very hard to understand and especially if he got a little bit excited there was no way in the world you could understand his excited mumblings."

Balachandra has called an inquest into the death and he expects it to begin almost immediately.

The Winnipeg Regional Health Authority has also issued a directive requiring clinics that send people to the emergency department to follow up by phone. Manitoba Health has asked emergency department staff to ensure every person in the waiting room is spoken with to determine whether he or she has been registered.

Followup a standard practice, says ex-ER director

But Dr. Moe Lerner, a former hospital emergency room director, said those measures should already be standard practice for health-care professionals.

Lerner, now medical director at the Four Rivers Clinic, said something went terribly wrong for Sinclair to sit untreated for 34 hours and then die.

The inner-city clinic Sinclair initially visited sent him to the hospital with a letter explaining his medical situation. But he appears to have never reported to the triage desk at the emergency room.

"What should have happened, what should always happen is communication. Doesn't matter who it is or what the problem is — if a physician thinks a person needs an ER, it means communication," Lerner said. "That includes if a person drives to an ER. The minute they get through the door, they should go to a triage desk."

Phoning the ER when a patient is sent to hospital is the "usual courtesy," he said.

Emergency rooms can be busy places and it can be hard for staff to keep track of who's waiting for care, Lerner said.

"In fairness to those involved, sometimes the departments are so busy you cannot get through or you're on hold, and then it's necessary to write a note," he said. "But then it's also necessary to make sure that the person will get there somehow in a reasonable fashion."