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Inquest into Seven Oaks death

Availability of acute beds focus of probe

Posted: 02/13/2013 1:00 AM | Comments: 0


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A judicial inquest called Tuesday into the death of a 68-year-old woman will examine if there is a shortage of acute-care beds in Winnipeg hospitals.

Heather Brenan was sent home in a taxi from Seven Oaks General Hospital in January 2012. She collapsed on her doorstep and died the next day.

Chief Medical Examiner Dr. Thambirajah Balachandra said the inquest was called, in part, to examine if a lack of acute-care beds contributed to Brenan being sent home prematurely.

"There are far-reaching implications here," Balachandra said.

"Ordinarily, doctors and nurses want to treat patients, but in this case, we're wondering if there were constraints. There were no beds and we want the judge to determine if there are sufficient beds to accommodate all the patients in Winnipeg."

Specifically, he said the inquest will look at whether acute-care beds were taken up by long-term patients waiting for placement in care homes.

Balachandra also said the inquest into Brenan's death will examine the hospital's policy regarding the discharge of patients at night, particularly those who are elderly, frail, or live alone.

Dana Brenan, the woman's daughter, said Tuesday night she's happy with the scope of the inquest she asked for nearly a year ago.

"...My experiences with both (Seven Oaks) management teams and the WRHA's investigative services has led me to seriously question the capacity of both organizations to accurately assess the catastrophic failings in my mother's care by (Seven Oaks) emergency department," she said.

"As well as the failings of the particular doctor who discharged her late at night without her house keys, on a -19 C winter night, without adequately assessing her condition."

Brenan had multiple medical problems and had complained of weakness, difficulty swallowing, pain when attempting to eat solid food and continuous weight loss since December 2011.

On Jan. 24, 2012, just after 2 p.m., she was taken by a friend to the emergency department of the northwest Winnipeg hospital.

Brenan was kept in the hospital from Jan. 24 to 27 on a gurney in the emergency room. She was never admitted. She underwent numerous tests and was assessed by occupational therapy, social work, and home care regarding a plan for when she was medically stable for discharge.

On Jan. 24, Brenan had gone for a gastroscopy in which a long, flexible tube is passed through the mouth and back of the throat into the upper digestive tract to examine the lining of the esophagus, stomach and the first portion of the small intestine.

She was too weak for the procedure and the doctor sent her to Seven Oaks General Hospital to be admitted for more tests.

Three days later, she returned to the Victoria General Hospital to undergo the gastroscopy but her oxygen levels were so low the procedure had to be stopped.

She was sent back to Seven Oaks for further testing but instead was put on a gurney. That evening, another doctor looked at her chart, saw her oxygen levels had improved and discharged her without examining her.

A nurse sent her home in a cab without any house keys and left a message for a friend of Brenan's, saying the patient was being discharged.

Brenan arrived in a cab and using a walker, she walked as far as the front doorway before she collapsed.

An ambulance was called and Brenan was taken back to the ER just after midnight Jan. 28, 2012. Although her pulse was restored, Brenan was found to be non-responsive. She was transferred to the intensive-care unit and her condition deteriorated.

She died just before noon the same day.

The cause of death was a bilateral pulmonary embolism from one of several blood clots in her calf due to deep vein thrombosis of the lower legs.

Dana Brenan credited the media for drawing attention to what happened to her mother.

"Thank you for your early championing of my mother's case as it instigated the media frenzy that followed, all of which I am convinced helped in the decision to call an inquest."

No date for the inquest has been set yet.


-- with files from Alexandra Paul


bruce.owen@freepress.mb.ca carol.sanders@freepress.mb.ca

Health care under

scrutiny in Manitoba

THIS is not the first time Dr. Thambirajah Balachandra has called an inquest into the quality of medical care in Manitoba.

The most notable is the pending inquest into the 2008 death of Brian Sinclair at Health Sciences Centre's emergency waiting room.

Sinclair, a 45-year-old double amputee, was found dead in his wheelchair on Sept. 21, 2008. He died of a treatable bladder infection caused by a blocked catheter after waiting 34 hours for care.

Balachandra has said Sinclair's death could have been prevented if the infection had been treated. A hospital security video showed Sinclair speaking to an aide at the emergency-room triage desk before wheeling himself into the waiting room.

The inquest is scheduled to begin in August.

Balachandra said he also called an inquest into the 2011 death of two-month-old Drianna Ross of Gods Lake Narrows to examine health care on remote Manitoba First Nations.

Ross was taken to a northern nursing station with a fever on Nov. 22. 2011. Her parents were sent home with Tylenol for her. During the next few days, her condition worsened. On Nov. 25, 2011, she was taken to the nursing station three times and arrangements were made to have her transferred by air ambulance to Thompson General Hospital, where she was diagnosed with pneumonia.

Her condition did not improve and she died the next day.

A date for the inquest has not been set.

Republished from the Winnipeg Free Press print edition February 13, 2013 A3

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