Heather Brenan’s death was “inevitable” but sparked change: Inquest

WINNIPEG — A 68-year-old Winnipeg woman’s death was “unpredictable” and “inevitable” according to an inquest report released Tuesday.

Heather Brenan, 68, died on her front door step after being released from the Seven Oaks Hospital and sent home in a taxi on Jan 24, 2012.

Brenan died of a blood clot in her leg.

RELATED: WRHA defends hospital’s decision on last day of Heather Brenan’s inquest

The inquest found what should have been preventable is the length of time Brenan spent in the emergency department, without being admitted to a ward, and the number of health care providers she saw.

She went to the ER and three days later she was sent home in the cold of winter and collapsed on her door.

An ER doctor told the inquest earlier this year that Brenan was sick enough to be admitted, but she stayed in emergency while tests were carried out because there were no beds available.

RELATED: Winnipeg ER doctor shocked by Heather Brenan’s return, inquest hears

The doctor told provincial court Judge Margaret Wiebe that it is a problem he’d like to see solved.

“We need to have the ability to bring in new patients to the ER,” he said. “There was no place to send them.”

Tweet This Click to share quote on Twitter: "We need to have the ability to bring in new patients to the ER," he said. "There was no place to send them."

After Brenan died, the hospital and the Winnipeg Regional Health Authority made several changes.  When discharging patients a nurse must ensure the patient safely gets into the taxi and the taxi driver must make sure the patient makes it safely into their home. It also changed the length of time a patient waits in the emergency department without a dedicated Physician, better management of handovers, more complete charting and better guidance for functional assessments in the emergency department.

“Heather Brenan is responsible for many of these changes,” read the inquest report. “Her experience at Seven Oaks General Hospital, and the circumstances of her treatment and discharge, has resulted in a number of positive changes in policies and protocols which will benefit other people going forward.”