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Brian Sinclair, top right in wheelchair, is shown in a screengrab from surveillance footage of his time at the Winnipeg Health Sciences Centre in September, 2008.The Canadian Press

An emergency room was "crazy" and "chaotic" the day a man came in seeking care only to die during a 34-hour wait for treatment.

Allison Peterson told an inquest into Brian Sinclair's death that she and her teenage daughter were at Winnipeg's Health Sciences Centre on Sept. 19, 2008. The emergency room was incredibly busy and "didn't seem right."

"It was so chaotic," Ms. Peterson said Tuesday. "It was just so busy. We just wanted to get out of there. It was crazy."

Ms. Peterson said she and her daughter left without seeing a doctor because "we felt we would be sitting there forever."

A clinic doctor referred Mr. Sinclair to the emergency room on Sept. 19 because he hadn't urinated in 24 hours. The inquest has seen surveillance video from the ER that shows the double-amputee speaking to a triage aide when he arrived just before Ms. Peterson and her daughter.

The triage aide writes something on a piece of paper before Mr. Sinclair wheels himself into the waiting room. He was found dead 34 hours later.

Witnesses have testified that while he languished in the waiting room, Mr. Sinclair vomited several times and was given a bowl but was never examined by medical staff. By the time a patient in the waiting room suspected Mr. Sinclair had died, rigor mortis had set in. He died of a treatable bladder infection caused by a blocked catheter.

The inquest has heard the emergency room was short several nurses the day Mr. Sinclair arrived. Patients, security guards and medical staff noticed him numerous times, but no one asked him if he was waiting to see a doctor.

Some assumed he was drunk and "sleeping it off" while others assumed he was just there to seek shelter and watch TV. Still others thought he had been seen, discharged and then returned to the hospital.

When Ms. Peterson noticed Mr. Sinclair, he didn't seem to be in distress, she said.

"He was just sitting there," she recalled. "I feel very badly about what happened to this gentleman."

Cynthia McKillop, who came to the emergency room Sept. 20 in the late afternoon, said she was triaged fairly quickly once she arrived. Ms. McKillop said she sat near Mr. Sinclair as she waited to be seen.

By that point, Mr. Sinclair had been in the emergency room for more than 24 hours.

"There was a strong odour coming from him," said Ms. McKillop, who described it as a urine smell. "We actually moved to get away from the odour a little bit."

Ms. McKillop said she left the emergency room around 9 p.m. Manitoba's medical examiner has testified Mr. Sinclair was probably dead by that time. Ms. McKillop said she doesn't remember Mr. Sinclair moving at all during her stay in the ER.

"He was slouched over a little bit," she said. "The only thing I recall still to this day was his eyes were closed."

The inquest also heard Tuesday from home-care aides who had tended to Mr. Sinclair at an assisted-living apartment building. They remembered him as a quiet and generous man who enjoyed volunteering at a homeless shelter.

Clarissa Immaculata said Mr. Sinclair would come back from the shelter with food that he tried to share with home-care workers.

"He was a good guy," she remembered. "He always smiled."

"He was not a complainer at all," added Esther Oyas.

The inquest is scheduled to sit until Thursday and to resume in the new year.