Heather Brenan's daughter Dana Brenan is not convinced an inquest into her mother's death will improve the health care at Winnipeg's Seven Oaks General Hospital (SOGH).

An inquest report released on Tuesday found Heather Brenan's death was inevitable but her poor treatment at Seven Oaks was unnecessary.

Brenan says based on personal experience in the hospital, Seven Oaks is a "disaster zone."

"I'd like to say I believe that this will make changes, I think that it might make changes at other hospitals, I'm questioning whether it will make changes at Seven Oaks," said Dana Brenan.

Heather Brenan, 68, was sent home in a cab around 11 p.m. on Jan. 27, 2012, after being discharged from the SOGH emergency room. Moving slowly with the help of a walker and a friend, Brenan collapsed and fell to the ground. She was rushed back to hospital and admitted to the intensive care unit. She died the next day.

"I think it was a chaotic situation they said that every bed was filled in the emergency room, and there were 40 patients waiting and there was triage and it was just..they were overwhelmed," said Dana Brenan, who is now focused on a wrongful death lawsuit against SOGH and the WRHA.

"They got her at her most vulnerable time, she didn't have an advocate and they just used it as an opportunity to get rid of her, to get her out."

An autopsy determined her mother died from blood clots in her lower legs that travelled to her lungs.

Dana Brenan believes if Seven Oaks staff had not sent her mother home there may have been a different outcome. 

"If she had actually been in the hospital when she collapsed who knows what would have happened ... and if she had collapsed in the hospital at least I would have felt that she had received the best possible care," she said.

Brenan's death unpreventable: inquest

The inquest into Brenan's case heard from many doctors that her death could not have been detected and therefore, not prevented — that there were no symptoms of  a blood clot. Brenan would have died whether she was at home or in a hospital bed, the inquest was told.

But it also heard that Brenan spent four days in the emergency department and was sent home without a full assessment.

"There was something else wrong with her, there was some other condition that was not identified," said Dana Brenan.

Her mother' friend who was with Heather Brenan when she collapsed, told the inquest she felt Brenan was not properly fed during her time in the hospital and was discriminated against because she was overweight.

In her inquest report, Judge Margaret Wiebe did not find that to be the case and accepted the death was not a preventable one.

However, what should have been preventable is the length of time Brenan spent in the emergency department without being admitted to a ward, Wiebe said.

"The fact that Heather Brenan's death was not preventable does not mean Heather Brenan's death was not a tragedy," Wiebe stated in her report.

RAW: Dana Brenan reacts to the inquest report3:05

Steps taken for improved care

The WRHA said it will look closely at the inquest's recommendations and will create an "action plan" within the next few weeks.

According to the inquest report, the WRHA has already taken steps toward correcting issues faced by Brenan, including length of time in emergency without a dedicated physician, better management of handovers, more complete charting, and a protocol for safe discharges for elderly and vulnerable people.

The WRHA added it is experimenting with a new technology at Grace Hospital which should improve communication between the emergency room and patient beds.

"Heather Brenan is responsible for many of these changes. Her experience at SOGH, 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," the report concludes.

In all, Wiebe made 25 recommendations, including one calling for more patient beds at SOGH. She also suggested hospitals work more closely with families regarding patient care and what the plan is when a patient is sent home.

''We regret the distress that the situation caused for Heather Brenan and her family," said Lori Lamont, WRHA vice president and Chief Nursing Officer.

"The death was not preventable and would have occurred regardless, but recognizing the way in which it happened at her home certainly added to the distress and for that we're very sorry," she said.

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