British Columbia·CBC Investigates

Ambulance crew took 35 minutes to get into apartment of dying woman

Chelsea Brent blames changes to B.C.'s emergency dispatch policy for it taking the ambulance crew 35 minutes to get into her dying mother's apartment last November. The province's health minister has ordered a review of the case.

Chelsea Brent blames dispatch policy for delay in getting help to her bleeding mother who died alone

Chelsea Brent holds a portrait of her mother, Tracey Gundersen, who died last November in her apartment on Vancouver's Downtown Eastside. (Christian Amundson/CBC)

The last person Tracey Gundersen spoke to was an ambulance call-taker while she frantically begged for help.

It was 8:14 a.m. on Nov. 8, 2018.

"My groin. It's bleeding. Profusely!" Gundersen, 56, stammered in a recording her family obtained through a freedom of information request.

"We're gonna get you lots of help," the call-taker promised.

Paramedics arrived at her low-income housing complex at Powell Street and Gore Avenue on Vancouver's Downtown Eastside in less than five minutes.

But it took them more than 35 minutes to make it to her sixth-floor suite because of extra security features in the building, including a locked elevator. Firefighters had to be dispatched to the scene to help paramedics inside.

Gundersen was found unresponsive with no pulse.

Gundersen bled to death alone in her Downtown Eastside apartment. (Christian Amundson/CBC)

Her daughter, Chelsea Brent, blames a new emergency dispatch policy for the delay. 

The policy prioritizes calls with a colour-coding system that does not send firefighters with paramedics in all cases — but it is firefighters, not paramedics, with master keys to multi-unit buildings like Gundersen's.

Fire crews were not sent to Gundersen's call right away. Brent believes if they had been, her mother may have survived.

"I don't have a word for it," Brent said in an exclusive interview. "It blows my mind. It makes me beyond angry and I don't trust the system."

As a 911 call-taker, Brent is familiar with how the emergency system works.

She wants answers about her mother's death and B.C. Health Minister Adrian Dix has ordered an independent review.

New policy 

Under the new system, purple and red calls are the most critical and the only ones to get ambulance and fire response automatically.

Gundersen's call was tagged code orange: ambulance only, no fire.

B.C. Emergency Health Services explains the new dispatch policy in a promotional video:

Brent said her mother had ongoing issues with rectal and uterine prolapse — conditions where the organs lose their normal attachments inside the body.

"I guess they deemed it to be obviously an emergency, but not life-threatening at the time," Brent said.

Two minutes into the call, the call-taker asked Gundersen to hold a towel on the wound. 

"Is the bleeding controlled or is it bleeding through?"

"No!" she screamed, terrified. "It's not!"

"OK, ma'am, you don't need to get rude with me, here," the call-taker responded firmly.

Gundersen apologized.

The call-taker offered words of understanding.

Gundersen lived on the sixth floor of this building at Powell Street and Gore Avenue in Vancouver. Extra security measures in the common area meant paramedics alone were not able to get up to her suite. (Christian Amundson/CBC)

"I'm all dizzy in the head," Gundersen pleaded, four minutes and 30 seconds into the call.

"Just hang in there with me, we're almost there," he replied.

It took paramedics 11 minutes and multiple buzzings of Gundersen's suite to get through the main door of her building. 

Once inside, the crew encountered another locked door and a locked elevator in the building's common area. 

They tried to call Gundersen again, but got no answer.

At 8:32 a.m., paramedics called for a routine, non-emergency response from fire crews to unlock doors and access the sixth floor.

The nearest firehall to Tracey Gundersen's building is about a block away. (Christian Amundson/CBC)

"There should be no reason fire shouldn't be attending," Chelsea Brent said.

"They made assumptions that she was fine. I don't know if it was assumptions based on her being a Downtown Eastside person or what it was."

'The system really does work' 

B.C. Emergency Health Services senior provincial executive director Neil Lilley said he could not discuss specifics of the case.

Speaking generally, he said the new colour classification system gets help faster to patients who need it most.

He also said it's not true that fire crews would be dispatched with every single call under the old system.

Even under the new system, if paramedics can't arrive in 10 minutes, fire crews are sent out.

"What we don't want is too [many] resources tied up on one incident where they are going to arrive approximately the same time," Lilley said.

"The system really does work."

Vancouver Fire Rescue Services information officer Jonathan Gormick says under the new system, the medical call volume has dropped 30 per cent.

A view inside B.C. Emergency Health Service's dispatch centre. Chelsea Brent believes a new dispatch policy may have contributed to her mother's death. (Christian Amundson/CBC)

Five minutes and 15 seconds into Gundersen's call, the call-taker kept promising help was coming. 

"I'm all blurry," Gundersen told him. "I can't put any pressure on it."

She finally snapped, "I'm dying!"

Provincial government review 

Brent hopes the promised review will provide answers about why her mother had to bleed to death alone. 

BCEHS did an internal review of the matter, which led to a note in its system about Gundersen's building having access issues. 

From now on, BCEHS says, fire crews should be dispatched to all calls at that building.

Brent can't say for sure whether dispatching firefighters right away would have saved her mother, but she doesn't want anyone else's last minutes to be like her mother's.

Six minutes and 29 seconds into Gundersen's last call, she was trailing off.

She begged, "Please hurry."


  • An earlier version of this story provided incorrect information on the timeline of Tracey Gundersen's conversation with a 911 operator. This story has been updated to correct those timeline errors.
    Aug 27, 2019 1:24 PM PT