William Olsen, lawyer for the Winnipeg Regional Health Authority, told the inquest into the death of Brian Sinclair that no single person was responsible for what happened to the double-amputee.
But he said there is no doubt errors were made.
"A perfect storm occurred," Olsen told Judge Tim Preston Tuesday in his opening statement. "The WRHA failed him ... at all levels of the organization."
Sinclair went to the emergency room of Winnipeg's Health Sciences Centre Sept. 19, 2008, with a bladder infection and spoke with a nurse. He stayed in the emergency room waiting room until a fellow patient notified a security guard that he was dead. Preston will hold hearings through August then again in October to determine how Sinclair was dealt with.
Thambirajah Balachandra, Manitoba's medical examiner, told the inquest Sinclair died from an infection because of a blocked catheter. Sinclair needed the tube removed and replaced, along with a prescription for antibiotics, he said.
"From the inception, we knew there was something wrong with the way the patient was handled," Balachandra said. "The death was preventable. Had treatment been given, he would not have died in that way."
Sinclair was soft-spoken and hard to understand, Olsen said. He was also cognitively impaired and fiercely independent, he added.
"That cannot be an excuse for failing to ensure he was properly reviewed by the system as a person requiring care," Olsen said.
The hospital was responsible for Sinclair the minute he walked through the door of the emergency room, he said.
"We failed in that respect," Olsen said.
While some argue Sinclair's race and disability led to him being ignored for 34 hours, Olsen said that wasn't the case.
"These events could have happened to anyone," he said.
But Murray Trachtenberg, lawyer for the Sinclair family, said there is little doubt Sinclair's identity and marginalization led to stereotyping and false assumptions about his need for care.
Instead of receiving care, Trachtenberg said he sat there "helpless, vomiting, his life slowly fading away."
Sinclair was told to wait to see a triage nurse and that's exactly what he did, he said.
"He waited and waited, growing sicker and weaker by the minute," Trachtenberg said. "There were numerous opportunities for medical staff to ensure he received the help he needed."
Sinclair was a frequent visitor to the emergency room and did struggle with substance abuse, Trachtenberg said.
"It was not his demons that killed him," he said. "It was the angels — the professionals we all turn to in times of urgent medical need — that egregiously and fatally let him down."
The first witnesses to take the stand Tuesday told the inquest that Sinclair was not the kind of guy who would complain or advocate for himself.
Esther Grant, Sinclair's sister, said her younger brother was a quiet guy who was always looking out for others — the type who would help an elderly woman with her shopping bags. Before losing his legs, he once broke into a burning house to rescue people trapped inside, she said.
"That's just the kind of guy he was," she said. "He was a special kind of guy."
One of nine children, he got good grades in school but fell in with a bad crowd when the family moved from Berens River, Man., to Winnipeg, she said. He started sniffing substances and was taken into care when his parents split up. He and his brothers were kicked out of a rooming house where they were living and ended up on the street, she said.
That's where he lost both his legs to frostbite and the two siblings lost touch. Grant said she found out her brother had died the day of his funeral.
"I just dropped to the floor. It was like someone was stabbing me in the heart," she said. "I'm overwhelmed, stressed, angry. He was there suffering for 34 hours with no medical attention."
Ken McGhie, a chaplain at Lighthouse Mission, remembered Sinclair as the "epitome of patience."
"He would never push in line," McGhie said. "He never complained."