Heather Brenan collapsed on her doorstep in January 2012 and was rushed back to Winnipeg's Seven Oaks Hospital, where she died from a blood clot that had moved to her lungs.
Her daughter, Dana, testified Monday that her 68-year-old mother had been in the emergency department at the hospital but was never admitted. She told the inquest the emergency department seemed overwhelmed and staff saw her mother as "an inconvenience."
"I get the sense patient flow is more important to the administration of the hospital and the Winnipeg Regional Health Authority than actually curing patients," she told the court.
"This shouldn't happen to anyone."
Her mother was sent home in a cab in the middle of the night in January without her house keys. Dana Brenan was in the United Kingdom at the time.
Months later, two other patients were sent home in taxis from a different hospital and died on their doorsteps. The health authority said at the time that there was no systemic problem and an internal investigation found the hospital did nothing wrong.
Dana Brenan said that while preparing for the inquest, she found out there were three more instances where people were sent home in a cab only to be rushed back to hospital.
It doesn't appear the health authority or the hospital has learned anything from her mother's death, she said.
"Because she wasn't writhing in pain, because she was dignified, it was assumed that she wasn't ill. And she was ill," Dana Brenan said outside court Monday. "Hopefully this won't happen to anybody else in the future. I just hope to get justice for my mother. She didn't deserve to die, not the way she died."
Bill Olson, lawyer for the health authority, told Dana Brenan the medical consensus is her mother's death "could not have been predicted and, in all likelihood, would have occurred whether your mother was in hospital or not."
Brenan was repeatedly tested during her time in the emergency department and "the conclusion of all these tests were that your mother was medically stable," Olson said.
Dana Brenan said she would have felt better about her mother's death if she could believe an effort was made to help her.
The way she was treated showed "a callous lack of regard for a very ill person."
"While she might have ultimately died ... collapsing in the back lane and perhaps freezing to death is such an undignified way to go," she said.
"Taking her off all her medication and sending her home under stressful circumstances were all contributing factors."
Nayda Northage, who visited Brenan in the emergency department and was with her when she collapsed on her doorstep, said it was obvious to anyone that her friend was not well.
She said a social worker gave Brenan a choice — either go home or be admitted into a nursing home. After she left the hospital, Northage said she got a message Brenan was heading home in a cab.
Northage, who had Brenan's house keys, met her in the back lane and Brenan tried to walk up her walkway. She collapsed face-first inside the doorway.
"I knew she was dead," Northage said. "She wasn't breathing."
Brenan was rushed back to hospital where she died shortly afterwards.
The health authority said in a statement Monday that it has strengthened its discharge guidelines and drawn up a checklist to ensure patients can manage on their own once they are released.
Drivers who take patients home from emergency departments are also now given a specific set of instructions, the health authority said.
Manitoba's chief medical examiner called the inquest to look into Brenan's death and to "examine hospital policy regarding the discharge of patients at night, particularly those who are elderly, frail, and who reside alone."
The inquest, scheduled to sit for three weeks, is also to determine whether a shortage of acute-care beds might have been a factor in Brenan's death.