Family believes death of woman sent home from hospital in taxi was preventable

WINNIPEG — The death of a Winnipeg woman who collapsed after being discharged from hospital and sent home in a taxi was preventable, her family’s lawyer asserted Wednesday.

Deryk Coward told the provincial inquest into the death of Heather Brenan that doctors at Seven Oaks Hospital were so intent on discharging the woman, they acted without doing a full round of tests.

“No complete functional assessment was done on Ms. Brenan prior to discharge,” he said.

Coward also said that despite continuing health problems, “the momentum for Ms. Brenan’s eventual discharge was well underway” a day earlier.

Brenan was 68, severely obese and suffered from a list of problems when she went to the hospital in January 2012. She suffered from dehydration, hypertension, diabetes, poor kidney function and had a hard time swallowing when she arrived.

There were no beds available in the regular wards, so Brenan was kept in the emergency department for her four-day stay.

As she underwent a battery of tests her kidney function and vital signs improved. The tests showed no physical blockage preventing her from swallowing. She was eventually sent home after the hospital arranged to have a friend meet her there.

The inquest was told Brenan struggled to walk from the taxi to her doorway, taking about 20 minutes with a walker to cover the 15-metre distance. She collapsed and was rushed back to hospital unconscious where she later died.

An autopsy determined that Brenan died from a blood clot in her leg caused by deep vein thrombosis that had not been detected in the hospital. The clot would have travelled to an artery near her heart and lodged there almost immediately before she collapsed, a pathologist testified.

Brenan’s family has said she should not have been discharged because she was still in ill health and was struggling to move around on her own.

But hospital officials told the inquest that Brenan had been walking on her own in hospital. They said no one could have predicted her death, because it was not connected to any of the ailments for which she sought treatment.

“Had she had some presenting symptoms (of deep vein thrombosis), then some criticism might be levied,” Bill Olson, the lawyer for the hospital and the Winnipeg Regional Health Authority, told the inquest.

“There was nothing to suggest to anybody at Seven Oaks … that this was requiring investigation.”

Hospital officials earlier said a full round of tests were done on Brenan for any problems related to her symptoms. One was cut short because she had low blood-oxygen levels, but the doctors had all the information they needed from that probe.

Brenan would likely have died from the blood clot in hospital just as suddenly as she died after going home, Olson added.

The inquest governed by provincial court Judge Margaret Wiebe is to make recommendations to prevent similar deaths. Wiebe is expected to take several months before issuing her findings.

Olson said many changes have occurred since Brenan’s death.

Discharge procedures have been strengthened and a new electronic chart system is being used by nurses.

 

Steve Lambert, The Canadian Press