February 12, 2013
The Province’s Chief Medical Examiner, Dr. A. Thambirajah Balachandra, has called an inquest into the death of HEATHER BRENAN, age 68 years, of Winnipeg, Manitoba, who died at Seven Oaks General Hospital (SOGH) on January 28, 2012.
Ms Brenan lived alone and had multiple medical problems. On January 24, 2012, at 14:08 hours, she was brought by a friend to the Emergency Department of SOGH, complaining of weakness, difficulty swallowing, pain when attempting to eat solid food, and continuous weight loss since December 2011. Although Ms Brenan was kept in the hospital from January 24 to 27, 2012, she was never admitted. She underwent numerous tests and was assessed by Occupational Therapy, Social Work, and Home Care regarding a discharge plan for when she was medically stable and ready for discharge. On January 27, 2012, following an assessment by a physician, Ms Brenan was discharged from SOGH at 22:35 hours. Apparently the hospital had made arrangements for Ms Brenan to be met at her residence by a friend who had the house key.
According to the friend, Ms Brenan had arrived in a cab and had collapsed in the doorway of her home almost immediately. An ambulance was called and Ms Brenan was brought back to the Emergency Department of SOGH at 00:13 hours on January 28, 2012. Although a pulse was restored, Ms Brenan was found to be non-responsive and her pupils were fixed and dilated. She was transferred to the Intensive Care Unit where her condition continued to deteriorate. Ms Brenan died on January 28, 2012 at 11:55 hours. The medical examiner was notified and an autopsy was ordered. The cause of death was bilateral pulmonary thromboemboli due to deep vein thrombosis of the lower legs. The manner of death was natural.
The inquest was called in accordance with s. 19(2) of The Fatality Inquiries Act for the following reasons:
INQUEST CALLED
Ms Brenan lived alone and had multiple medical problems. On January 24, 2012, at 14:08 hours, she was brought by a friend to the Emergency Department of SOGH, complaining of weakness, difficulty swallowing, pain when attempting to eat solid food, and continuous weight loss since December 2011. Although Ms Brenan was kept in the hospital from January 24 to 27, 2012, she was never admitted. She underwent numerous tests and was assessed by Occupational Therapy, Social Work, and Home Care regarding a discharge plan for when she was medically stable and ready for discharge. On January 27, 2012, following an assessment by a physician, Ms Brenan was discharged from SOGH at 22:35 hours. Apparently the hospital had made arrangements for Ms Brenan to be met at her residence by a friend who had the house key.
According to the friend, Ms Brenan had arrived in a cab and had collapsed in the doorway of her home almost immediately. An ambulance was called and Ms Brenan was brought back to the Emergency Department of SOGH at 00:13 hours on January 28, 2012. Although a pulse was restored, Ms Brenan was found to be non-responsive and her pupils were fixed and dilated. She was transferred to the Intensive Care Unit where her condition continued to deteriorate. Ms Brenan died on January 28, 2012 at 11:55 hours. The medical examiner was notified and an autopsy was ordered. The cause of death was bilateral pulmonary thromboemboli due to deep vein thrombosis of the lower legs. The manner of death was natural.
The inquest was called in accordance with s. 19(2) of The Fatality Inquiries Act for the following reasons:
- to determine the circumstances relating to Ms Brenan’s death;
- to examine hospital policy regarding the discharge of patients at night, particularly those who are elderly, frail, and who reside alone;
- to examine the hospital acute care bed situation in Winnipeg; and,
- to determine what, if anything, can be done to prevent similar deaths from occurring in the future.
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