But many are hoping the inquest will go further, delving deeper into why many assumed the double-amputee aboriginal man was a homeless person seeking shelter or a drunk "sleeping it off" while he slowly died in the ER waiting room of Winnipeg's Health Sciences Centre in September 2008.
The inquest into Brian Sinclair's death heard from more than 70 witnesses in 2013 and is expected to hear many more when it resumes Monday.
Inquest counsel David Frayer said the court has heard detailed evidence about Sinclair and the 34 hours he spent in the emergency room before he was discovered dead. The court's attention will now turn to the national problem of clogged hospital emergency departments, he said.
"The reasons for delays in treating patients presenting in emergency departments of the Winnipeg Regional Health Authority hospitals and measures necessary to reduce the delays in treating patients — that's really going to be, in part, the focus of Phase 2," Frayer said.
"(It's) essentially the systemic side of this inquest — what can be done to ensure that events of this nature don't occur again."
The inquest, which began in the summer and sat periodically since then, has heard that a clinic doctor referred Sinclair to the emergency room because he hadn't urinated in 24 hours. The 45-year-old can be seen on security footage speaking to a triage aide upon his arrival and then wheeling himself into the waiting room, where he languished for the next 34 hours.
Sinclair vomited several times. He was given a bowl and a housekeeper cleaned up the vomit around him, but no one asked him if he was waiting to see a doctor or whether he was OK.
By the time Sinclair was discovered lifeless, he had been dead for at least a few hours and rigor mortis had set in. He was rushed into the resuscitation room, but was declared dead within a minute.
Sinclair died from a treatable bladder infection caused by a blocked catheter. Manitoba's chief medical examiner has testified Sinclair needed to see a doctor for about half-an-hour for a simple catheter change and a prescription for antibiotics.
The inquest has heard the emergency room was overcrowded and short-staffed — operating without a key triage nurse — when Sinclair came in seeking care.
"One of the concerns is the outflow of patients in the emergency departments because ... patients get stalled in the emergency department and can't get out to get the kind of treatment they need," Frayer said. "There's a backlog and a backlog creates delays and creates the type of circumstances we don't want to see."
Still, Sinclair's family is hoping the inquest will examine what they call the racism that led people to make false assumptions about Sinclair. Family lawyer Vilko Zbogar said Sinclair's relatives believe he was ignored for 34 hours because he was disabled, marginalized and aboriginal.
The inquest into his death can't ignore that, Zbogar said. People made assumptions about Sinclair because of the way he looked, Zbogar added.
An internal review conducted after Sinclair's death found that 17 staff members observed Sinclair, but all made different assumptions about why he was there.
Some assumed he had been triaged already and was waiting for a bed in the back of the treatment area. Others assumed he had been treated and discharged. Others thought he was drunk and was waiting for a ride under the Intoxicated Persons Detention Act or just needed a warm place to rest.
"If people make assumptions that people aren't in need of medical treatment because of judgments they make based on somebody's appearance, in Brian Sinclair's case, that was a death sentence," Zbogar said.
"I don't think anyone is suggesting the assumptions are made maliciously or overtly but the fact is ... we have to find a way to mitigate that risk."
Marcel Balfour, acting executive director with the Assembly of Manitoba Chiefs, said it would be a missed opportunity if the inquest were not to address the role Sinclair's race, social status and disability played in his treatment. Although Sinclair's case is extreme, Balfour said the organization has heard similar complaints from other aboriginal people seeking medical care.
"That intersection of race, poverty and disability, I think, really needs to be examined," he said.
Emily Hill, lawyer for Aboriginal Legal Services of Toronto, which has standing at the inquest, said numerous hospital employees have testified they worked 12-hour shifts in the emergency room but didn't see Sinclair. She said the inquest needs to delve into why the double amputee, who was partially blocking an aisle in the emergency room, was so invisible.
The answer may lie in the negative stereotypes of aboriginal people that are "deeply rooted in Canadian society," she said.
"As a result, there is discrimination," Hill said. "What aboriginal people experience in the health-care system, in the justice system, in the education system — in all kinds of places where Canadian society is reflected — is that extension of systemic racism."
The inquest is scheduled to sit for a week in January and two weeks in February.