WINNIPEG — A woman who died hours after being sent home in a cab from a Winnipeg hospital was too ill to undergo diagnostic testing the day she was released.
A nurse who escorted Heather Brenan to another hospital for an endoscopy told an inquest Tuesday that the test was called off before a biopsy was obtained because Brenan had trouble breathing. Arvadell Egesz testified she did not see Brenan stand on her own for the seven hours she was with her in January 2012.
Egesz remembered Brenan, 68, as a "very nice lady, very talkative" on her way to the procedure. But she said Brenan was groggy and sleeping on the trip back to Seven Oaks Hospital emergency department, where she had been for three days.
Claudine Knockaert, the nurse in charge of the emergency department that day, said it was understood Brenan would be discharged once the endoscopy was done. Brenan had not been formally admitted to hospital, she said.
Brenan arrived back at the emergency department during the evening shift change. Knockaert said the report she passed on to the incoming charge nurse was not as "thorough" as she would have liked, especially given how long Brenan had been in the ER.
The decision to discharge Brenan would have been a "medical one" made by a doctor, Knockaert said.
Hours later, Brenan was sent home by taxi — without her house keys and in the middle of the night — only to collapse on her doorstep. She was rushed back to the same hospital, where she died.
Months later, two other patients were sent home in taxis from a different hospital and died outside their homes. The health authority said at the time that there was no systemic problem and an internal investigation found the hospital did nothing wrong.
Brenan had been sent to the emergency department because she had lost 40 pounds and couldn't swallow. She died when an undetected blood clot moved to her lungs.
Dana Brenan said her mother never should have been sent home.
"She was on five litres of oxygen," she said. "She was seriously ill. Nobody ever saw her moving."
Dana Brenan says her mother was unsteady on her feet when she returned to Seven Oaks. "But they still sent her home. Alone."
It wasn't her mother's fault that she arrived back at Seven Oaks Hospital at an "inconvenient time," Brenan said.
"She was just pushed aside because she didn't complain and probably because she was so ill that she really wasn't able to state her case."
The inquest was called to look into Brenan's death and to "examine hospital policy regarding the discharge of patients at night, particularly those who are elderly, frail and who reside alone."
It is also to determine whether a shortage of acute-care beds might have been a factor in Brenan's death.
The inquest is scheduled to sit until mid-June.
