She was sent home in a taxi from the emergency room late on a Friday night, Jan. 27, alone and with no house keys.
Heather Brenan, 68, was literally left at death's doorstep. There, she collapsed, lost consciousness and died the next day in hospital.
Her only child, who's lived in London, England, for more than three years, got the call saying her mom was dead.
"I'm numb," said Dana Brenan, 48. "Intellectually, I'm appalled and horrified." Brenan is finishing her PhD dissertation in art history and was looking forward to moving back to Winnipeg this year and spending time with her mother.
"We were going to go looking for houses and travel," she said, choking back sobs. Brenan's mom was looking forward to her coming home, too, she learned from her mother's friends when she returned to Canada the day her mom died.
"My mother was telling them she was so excited and so proud of me... She had all these plans for me and I had all these plans for her... That's been taking away from me and from her."
Her mom hadn't been feeling well since November, she said. She was having a hard time swallowing and saw specialists and had tests. They were inconclusive. Her mom didn't get better.
At Christmas, she told her daughter by phone she could no longer eat because of the difficulty she was having swallowing. For four weeks, she got weaker and kept losing weight. On Jan. 24, she went 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. But Brenan was too weak for the procedure and the doctor sent her to Seven Oaks General Hospital to be admitted for more tests.
That was a Tuesday. Seven Oaks was short of beds and she spent four days on a gurney in the ER.
On Thursday, a nurse wanted to send her home. Brenan said she lived alone, had arthritis and was so weak she was scared she'd fall. A social worker came and agreed she needed home care, assistance and oxygen and they'd arrange it after the weekend.
On Friday, the doctor who performed her first gastroscopy wanted to try again and would do it that day at Victoria General Hospital. She went, but her oxygen levels were so low the procedure had to be stopped. She was sent back to Seven Oaks around suppertime for further testing but instead was put on a gurney. That evening, a 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 she was being discharged.
If her friend hadn't checked her phone messages and discovered the hospital was sending Brenan home at 11 p.m., the weakened woman would have been locked out of her house in weather that had a wind chill of -18 C.
"She would've collapsed in the backyard and died," said Brenan, adding the frozen body likely wouldn't have been found until the next day.
Her mom's friend got to the house before the cab pulled up and helped Brenan, who was using a walker, get to the door of the house, where she collapsed unconscious. Paramedics couldn't revive her. She was taken by ambulance back to Seven Oaks, where she died at noon Saturday.
The cause of death was a pulmonary embolism from one of several blood clots in her calf, her daughter learned from the medical examiner. During the four days she was lying on a gurney in the ER, her mother didn't receive the blood thinners she'd been prescribed, said Brenan.
"My mother was ill, but she shouldn't have died," said her daughter. She's met with hospital officials and it's being treated as a critical incident.
The Winnipeg Regional Health Authority issued a statement Friday saying two separate reviews are underway. Administrators at both Seven Oaks and the regional emergency program are looking into what happened.
A regional critical-incident team is conducting a patient-safety review to see if there are ways to improve policies and procedures to prevent a similar incident.
"This was a tragic incident and we have apologized to Mrs. Brenan's daughter and will be keeping her informed as our work progresses," the WRHA said.
Brenan wants to know why someone so ill was sent home alone at 11 p.m. on a Friday night.
"Was the doctor clearing the ward for the Friday-night drunks?"
She said she asked that question at the critical-incident meeting and was told the timing was suspicious but "everyone is entitled to equal care," Brenan said.
"My mom got less care than the drunks."