Security supervisor Gary Francis told an inquest into Brian Sinclair's death that he had greeted the double-amputee the night he arrived at the Winnipeg Health Sciences Centre ER in September 2008.
The following evening, Francis noticed that Sinclair was still in the same spot.
"He was sort of just sleeping," Francis told Judge Tim Preston.
Around midnight, Francis was approached by a woman who said she thought Sinclair was dead. Francis said he explained that Sinclair slept with his head slumped over, but the woman insisted and added that the man's catheter was disconnected and empty.
The two went over to Sinclair. Francis said he tapped him on the shoulder and called his name.
"There was no response. I pinched his neck and there was still no response."
Francis said he put his hand on Sinclair's forehead and his head was stiff and tough to push back.
"His eyes were completely black."
Francis wheeled Sinclair over to two nurses who were talking and said, "I need help. I think this fellow is dead."
"They looked at me and thought I was joking."
When a male nurse took Sinclair's pulse, they "realized I was speaking the truth." Sinclair was taken into a resuscitation room where Francis helped lift him onto a bed.
"His entire body was stiff as a board."
Doctors tried to revive him, but he was pronounced dead several minutes later, Francis said. Francis tried to get Sinclair's chart from the nurse on duty because he needed it for his report. He was told no chart had been created.
"He was never triaged at all."
Another security guard testified that he had raised concerns about how long Sinclair had been waiting. Ed Latour said he was working the 12-hour night shift when Sinclair first arrived.
Latour said he got worried when Sinclair was still in the same spot in the waiting room the following night.
"He was slumped over in his chair," Latour said. "He had his head bowed."
He said he went to the triage desk and spoke to the nurse on duty.
"I expressed that concern to the triage nurse and asked if he was going to be seen," Latour told the inquiry. "(The nurse) said he had been there the previous night, had been treated, gone home and returned."
Latour said he was assured "all was well with the patient" and that his "concerns were unwarranted."
He continued his patrol and found out a few hours later that Sinclair was dead.
"One receptionist came out in tears and expressed Brian Sinclair had passed away."
Sinclair had been admitted to the hospital's ER dozens of times over the years. The 45-year-old lost both his legs to frostbite in 2007 when he was found frozen to the steps of a church in the dead of winter.
Sinclair often came in and sometimes appeared intoxicated, Francis said.
"He would be yelling at the nurse because he wanted a blanket or a sandwich or some juice," said Francis, who added that Sinclair once took a swing at a nurse who tried to move his backpack.
Later in cross-examination, Sinclair family lawyer Vilko Zbogar suggested Francis may have mistaken Sinclair for others who came to the emergency department because he described Sinclair as a man who had walked with the help of two canes. Sinclair never walked with a cane after losing both legs and had been in a wheelchair ever since.
Francis also agreed Sinclair did not appear intoxicated when he arrived at the emergency department Sept. 19, 2008.
Sinclair was referred to the emergency room by a local clinic on the afternoon of Sept. 19 because he hadn't urinated in 24 hours. He is seen on security footage being wheeled into the emergency department by a taxi driver and speaking to a triage aide.
The aide is seen writing on a piece of paper and Sinclair wheels himself into the waiting room and remains there. The inquest has heard that he threw up several times the next day, but was basically ignored.
He was discovered dead after midnight on Sept. 20.
Sinclair died from a treatable bladder infection caused by a blocked catheter. Manitoba's chief medical examiner has testified that rigor mortis had already set in and Sinclair had probably been dead "for hours."
Garth Smorang, lawyer for the Manitoba Nurses Union, said the hospital had renovated its emergency department in April 2007. He suggested that nurses were concerned that the light in the waiting room area was "significantly dimmer" since the renovation.
"I don't share that concern," Latour responded.
The seating in the new ER was also different. Most chairs faced away from the triage desk, Smorang said. Sinclair would have been sitting about 25 metres away from the triage desk, he added.
Another security guard working that weekend, Howard Nepinak, testified that he also saw Sinclair during both of his shifts on Friday and again on Saturday.
"When I saw him on Friday, he looked OK, but when I saw him on Saturday, he was leaned over and appeared to be very weak and sort of in pain," Nepinak said.
He said he wondered what Sinclair was still doing there, but he assumed the man had been seen, gone home and returned again. Nepinak said he mentioned Sinclair's presence to his supervisor but did not bring him to the attention of medical staff.
The inquest is to sit Thursday and then is to adjourn until October.