WINNIPEG–It's an unacceptable tragedy that a man waited 34 hours in a Winnipeg hospital emergency room and was dead for several hours before he was finally brought to the attention of medical staff, Premier Gary Doer said today.

Although the 45-year-old man – who CTV Winnipeg identified as a double amputee named Brian Sinclair – was "a regular" at the emergency room, regional health officials say he was never registered or seen by triage nurses over the weekend until it was too late.

"The bottom line is we are not making an excuse for this," Doer said Tuesday following a grilling over the incident in the legislature. "This is a tragic incident and it shouldn't have happened."

Sinclair was dropped off at Health Sciences Centre by a taxi Friday afternoon after visiting a downtown health clinic which is part of the regional health authority.

Some hospital staff did speak with the man at some point, but it was not until shortly after midnight on Sunday that he was examined and pronounced dead. The cause of death has not been released.

CTV Winnipeg quoted a man who did not want to be named as saying he had been in the emergency room on the Friday night and had seen Sinclair sitting in his wheelchair, looking like he was asleep.

But when the man came back the following night, he noticed Sinclair's position had not changed so he told nurses and security workers, who responded they were too busy to check on Sinclair.

"The nurse said we'll go and check, (but) nobody ever went and checked on him," said the man, who had been there with his wife.

"We waited another hour or so and we told another nurse twice to go and check."

The man said he also told a security officer of Sinclair's condition but the guard told him the case would be "too much paperwork."

Doer said the province followed the recommendation of an earlier task force and hired re-assessment nurses who are required to check up on registered patients waiting in the emergency department, but Sinclair was never even registered with the triage nurses.

"This system broke down and there were tragic circumstances," Doer said. "We're trying to find out what exactly went wrong and we haven't got all the answers yet."

The hospital wasn't short-staffed at the time and a re-assessment nurse was on duty, he added.

Brock Wright, chief medical officer of the Winnipeg Regional Health Authority, said he's baffled about how Sinclair could have fallen through the cracks. When the man was finally discovered by emergency room staff, Wright said he "had been dead for some time."

"It's hard to imagine how somebody could be in the department for 34 hours and somehow it not be apparent that the individual was waiting for care," Wright said Tuesday.

"I understand how that's hard to imagine and yet, it happened."

On cold nights, Wright said it's not unusual for homeless people to take shelter in the emergency room. But he said any potential confusion that may have arisen from that practice doesn't explain why Sinclair died without treatment.

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"Our staff will provide blankets to homeless people who come in and are looking for some place warm. They get to know those individuals and will interact with them," he said. "It's not as if the staff is just focused exclusively on the patients and ignoring everything else around them, which makes it all the more puzzling."

Patients who go into the emergency department are expected to approach the triage desk and register themselves or have someone register them on their behalf, he said. The emergency department treats 50,000 people each year and there are always nurses on staff to process patients, he said.

Both the chief medical examiner and the regional health authority are investigating to ensure this never happens again, Wright said. The hospital hopes to have its investigation complete within a month and will make the findings public, he added.

"We view this as a really tragic event," he said. "We've never encountered this before."

But opposition politicians said the "worst ER failure in Manitoba history" calls for a broad examination of the provincial health care system. Conservative Leader Hugh McFadyen said the government has to take responsibility for the tragedy.

"(This) demonstrates there was some kind of culture of neglect and unresponsiveness that needs to be looked into to be sure this isn't a systemic issue," he said.

Friends of Sinclair told CTV Winnipeg he was a former solvent abuser who had kicked his addictions.

"We haven't seen him in a year," said Joseph Severeight. "He quit using solvents and things like that. And that's how I knew him, he cleaned up his life."

Sinclair's brother, Bradley, told CTV he didn't know his brother had gone to the emergency room and was told by social workers that Brian had died.

"I feel awful, but I'm going to pray for him," he said.

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