Provincial court Judge Robert Philp said Samuel Takyi may still be alive had he not tried to stay home and wait out the pain from a surgical complication rather than face a long wait in the Grey Nuns Hospital ER.
An inquest into Takyi's death heard how the 73-year-old had part of his colon removed in 2009 to treat a non-invasive cancer.
The man started experiencing pain shortly after he was sent home and ended up heading back to the emergency room at Grey Nuns Hospital, where he waited over night to be seen.
After being given a painkiller prescription, Takyi was sent home but his condition worsened over the next three days. He started vomiting and sweating and eventually had trouble breathing.
Takyi couldn't reach his doctor for help with his pain and, rather than face another wait in the emergency room, Takyi elected to stay at home and wait it out, said Philp.
Paramedics were eventually called but it was too late — Takyi died from an infection when he arrived at the hospital.
Philp said dealing with the issue of long waits in the emergency rooms was outside the scope of the fatality inquiry he was presiding over. But he noted that Takyi might have survived had he not had to wait so long for care on his first visit.
"Having experienced such a long wait on the previous occasion, it is reasonable that Mr. Takyi was hesitant to return," Philp wrote in his report.
"It is understandable that he would attempt to endure the pain he was experiencing until he felt he had absolutely no option but to return to the emergency room. It is unfortunately Mr. Takyi’s endurance of this pain that resulted in his death. Had emergency treatment been received earlier, he may well have survived."
Philp did recommend that family members should be present, if possible, when a patient is given discharge instructions in hospital.
The inquiry heard how Takyi's wife was not in the room when doctors told him what symptoms to watch for after he got home.