WINNIPEG -- A man who died during a 34-hour wait in a hospital emergency room had been dead for at least a few hours before he was discovered, Manitoba's medical examiner said Wednesday.

Thambirajah Balachandra told the inquest into Brian Sinclair's death that rigor mortis had begun to set in when the homeless double-amputee was declared dead on Sept. 21, 2008.

It's likely Sinclair had been dead "for a couple of hours," Balachandra said.

Rigor mortis, the stiffening of the body after death, usually takes some 12 hours to fully set in, but Balachandra said fever or seizure can hasten the onset.

Sinclair died after being referred by a clinic doctor to Winnipeg's Health Sciences Centre because he hadn't urinated in 24 hours.

The 45-year-old died of an infection from a blocked catheter that spread into the bloodstream and caused him to go into shock, Balachandra said.

Sinclair vomited while waiting in the emergency room -- a sign Sinclair was likely going into shock, Balachandra said.

At that point, Balachandra said someone should have checked on Sinclair and asked him if he was OK.

Had he been seen by a doctor, Balachandra said Sinclair would have needed about 30 minutes of medical treatment, which likely would have prevented his death.

He needed to have his pulse and blood pressure checked, his catheter changed and antibiotics prescribed, Balachandra said.

Sinclair was seen on security video footage approaching a triage aide and then sitting in his wheelchair in the waiting room. Someone approached a security guard 34 hours later with concerns about Sinclair's condition and he was pronounced dead.

The medical examiner's office heard from people who were in the waiting room with Sinclair following his death, Balachandra said. One woman suggested medical staff didn't show much interest in the well-being of patients waiting to be seen.

"She was concerned about the attitude of staff and the unwillingness to recognize the need to respond to people in the waiting room," he said.

Balachandra said he called the inquest because Sinclair's death is a sign emergency room procedures and wait times need to be examined.

"There is something wrong somewhere," said Balachandra. "It's nobody's fault, but the system has to be rejigged."

The inquest continues this month and is to resume in October.