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.
Months later, two other patients were sent home in taxis from the Grace Hospital and died before they got inside their front doors. The Winnipeg Regional Health Authority said there was no systemic problem and an internal investigation found the hospital did nothing wrong.
Dana Brenan said her 68-year-old mother spent four days in the emergency room and was sent home at night without her house keys.
"They just shoved her in a taxi and sent her home. That's not right," Brenan said. "I'd like to see things like that stopping, but clearly they're still happening."
Manitoba's chief medical examiner called the inquest in 2013 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.
The health authority updated its discharge guidelines, but Brenan's daughter said there are still problems. Hospital staff should be well educated on a standard policy that ensures vulnerable people aren't sent home alone at night, she said.
"The policies are written, put on a shelf, and nobody is ensuring that they're being followed. I'd like more accountability."
Miles Pollack has little faith in the inquest.
His uncle, David Silver, was found frozen on his doorstep about 14 hours after he had been sent home in the middle of a frigid winter night last year.
An autopsy found his death was due to a heart condition, but Pollack said no one at the health authority really examined why a 78-year-old man was sent home alone in a cab in the dead of winter.
He said his confidence is shaken after an internal investigation absolved hospital officials.
"My expectations aren't that high," he said. "I sure hope that they do something because even one death is way, way too much."
After the death of another patient, 62-year-old Wayne Miller, then-health minister Erin Selby instructed all health authorities to ensure that patients sent home in cabs make it into their homes. Miller was spotted on a sidewalk by a passing driver who called 911.
Brad Hartle, spokesman for Health Minister Sharon Blady, said in a statement that the province is looking for "answers on what could have been done differently or better in the case of Ms. Brenan and to further make sure patients are being discharged appropriately and safely."
Felicia Wiltshire, spokeswoman for the Winnipeg health authority, said in a statement that officials are focused on "continuous improvement" and look forward to the inquest's recommendations. She wouldn't discuss changes to the hospital discharge process.
For Dana Brenan, the inquest is as much about healing as it is about forcing change.
"I am hoping for closure," she said. "I don't know whether this inquest will bring that about."