Emergency room Dr. Stanley Whyte examined 68-year-old Heather Brenan on January 24th, 2012 - the day she arrived at the emergency room at Seven Oaks General Hospital.

Tuesday, May 12, 2015 was the first time Dana Brenan heard his account of her mother's visit to the ER.

"I have learned new information which I wish I'd have known three years ago,” said Dana Brenan.

Dr. Whyte told the inquest that her mom was a very sick woman who needed to be admitted to hospital after attending the ER.

But that never happened.

After spending most of four days in the ER, Brenan was put in a taxi without her house keys and sent home, where she collapsed on her doorstep.

She died in hospital the next day because of a blood clot.

Dr. Whyte told the inquest the hospital was extremely busy at that time with no beds available.

"There were not enough family doctors for the patients we were seeing,” said Dr. Whyte.

After hearing his testimony, Dana Brenan questioned why her mom wasn’t taken elsewhere.

"If they realized she needed to be admitted and they didn't have doctors and beds, she should've been sent to another hospital that did have those facilities," said Dana.

Another ER physician, Dr. Sheldon Swirsky, examined Heather Brenan three days after her arrival to the ER.

She had pain in her throat, had difficulty eating and was experiencing kidney failure.

He testified her condition had improved, to the point where she was “potentially dischargeable.”

Further testing and examinations were ordered, including a neurology consult and gastroscopy, as well physiotherapy and occupational therapy assessments, but Dr. Swirsky never saw those results because a different ER doctor took over once his shift ended.

Dr. Swirsky also told the inquest, "We have a collective responsibility to move people through the ER as quickly as possible."

Dana Brenan said her mom wasn’t a high enough priority to get a bed.

"They were so busy that they had to, I don't want to say get rid of, but they had to discharge as many patients as they possibly could because they had too many people coming into the emergency department,” she said.

Dr. Swirsky said changes have already been made since January 2012 when Brenan went to the ER.

He said patients staying in the ER can now be watched over by a family doctor instead of being looked after by multiple ER doctors in the same day. Dr. Swirsky said that has led to more consistent care.

Another doctor, as well as a physiotherapist and occupational therapist, are scheduled to testify when the inquest continues on Wednesday.