A 200-page report outlines how and why Brian Sinclair died of a bladder infection while waiting for care at Health Sciences Centre.

The double amputee’s lifeless body was discovered 34 hours after he arrived in September 2008.

An inquest report concludes, if Sinclair’s catheter had been changed in a reasonable amount of time by doctors, he likely would have survived.

The inquest judge wrote:

“If the catheter had been changed and antibiotics administered, he likely could have survived, had he been treated within a reasonable time of presentation. A bladder infection like this is an emergency, but is treatable. The CME estimated that treatment time would have taken approximately half an hour to an hour."

The report contains 63 recommendations.

Both Health Minister Sharon Blady and the health authority apologized once again to Sinclair's family.

"The death of Mr. Brian Sinclair was a preventable tragedy," Blady said. "It should not have happened at HSC or at any other health facility.

"I want to apologize to Mr. Sinclair's family. None of what we can do can make up for your loss."

Following Sinclair’s death, the Winnipeg Regional Health Authority made several changes to the emergency room area at HSC.

The inquest report also sums up the long wait Sinclair endured, because it was all captured on camera.

“This inquest literally had bird’s-eye glimpses of 34 hours in the life and death of Brian Sinclair. Closed-circuit cameras captured and were silent witnesses to the last 34 hours of Brian Sinclair’s life. Real-time video evidence starkly mapped out Mr. Sinclair’s last journey.”

The Sinclair family reacted to the report. They say Sinclair died because of “institutional racism.”

“The inquest did not do what we hoped and expected it would,” said Brian’s relative Robert Sinclair. “But that does not get the government or the WRHA off the hook.  If the government and WRHA take these systemic issues seriously, it is now up to them to take action and do something about it. Denial is not good enough anymore.”

Arlene Wilgosh, CEO of the Winnipeg Regional Health Authority, said it expects anyone seeking treatment to be served regardless of race. But she added racism does exist and it would be naive to expect the health-care system to be immune.

"Our entire system has learned significantly from this," she said. "People are more aware now, more conscious."

- with files from The Canadian Press