Anne Findlay struggled to make sense of the scene in front of her.

There was an elderly woman in the bed. Her face was badly swollen and bruised. Her lip was stitched and her knee gashed.  She looked like an assault victim.

“I looked at her and could hardly believe it was my mom,” says Anne. “She was that badly bruised. She looked awful.”

Her mom was conscious, but terrified, says Anne. She couldn’t speak much, because her tongue was swollen.

How could this happen? Anne had been with Beth all day and left her in good care, sleeping soundly in a Calgary hospital.

“I was horrified,” says Anne. “I was horrified because you don’t expect somebody to be injured in a hospital. When you go there you expect things to be safe.”

Beth, 84, was not in good health. She had suffered a stroke two years earlier. She had a history of heart problems and recently developed swelling in her face and abdomen, as well as a shortness of breath.

So Anne took her mom to hospital and spent a long day waiting to get Beth into care. Finally, Beth was admitted and an X-ray of her lungs was ordered.

Beth was asked to stand for the initial X-ray. She barely managed it because she was so weak.  When a second X-ray was ordered later that day, Anne asked that Beth not be made to stand. The technician performed the X-ray with Beth propped up on a gurney.

That evening, Anne stayed with her mother until she was safely off to sleep. What Anne didn’t know was that, after she left for the evening another X-ray was ordered.

During the procedure, for reasons still not clear, Beth rolled off the gurney and dropped to the floor. Paramedics were called and transferred her to the emergency department where she was treated for her injuries.

When an emergency room doctor phoned Anne at home, he wasn’t too optimistic.

“This does not look like a good outcome,” he said.

Over those early hours and in coming days, Anne sought answers to the most obvious question: What happened?

The emergency room doctor said he’d been told the wheels on Beth’s gurney were not properly locked down.  The nurses looking after Beth, though clearly upset, couldn’t provide any answers.  No one seemed to know the exact reason why the gurney had moved, resulting in Beth’s fall.

“I went home and I documented everything that happened from when we first went into the hospital three days before,” says Anne, who then contacted the Patient Concerns Office.

A meeting was arranged with the Patient Concerns’ manager and the manager of Diagnostic Imaging. Anne gave her notes to the managers, who promised to follow-up.

“Our concern at the time was just being there with mom, obviously,” said Anne, who credits the nurses and the doctors with tremendous care and compassion over the following days.

Anne says it’s likely her mom wouldn’t have lived much longer because her heart and kidneys were failing, regardless of the injuries from the fall.

“But to see somebody you love — that badly injured in the hospital and not dying peacefully — and for that to be our final image of her, is really hard to take.”

Anne was asked to meet with Calgary Health Region staff several weeks after her mom’s death.  At the meeting, she was told that the Velcro strips on the gurney pad used that night for Beth’s X-ray weren’t aligned properly with the gurney frame and the mattress slipped.

But what about the gurney’s wheel brakes not being locked? Hospital officials were kind. They apologized. But Anne said it all felt scripted and she was left with many unanswered questions.

Three months later, Anne gathered her family to talk about the possibility of legal action. They felt it might be the only way to get complete answers.

But in the end, they felt Beth wouldn’t want a lawsuit. So they tried to let their feelings go.

However, nine months after Beth’s death Anne saw a news item about the Halifax 5 Patient Safety Conference and a new disclosure policy in the Calgary Health Region. Again she decided to pursue answers.

Anne met with the same hospital official from the previous meeting.  This time he talked more openly about Beth’s accident and was able to answer many of the questions which hadn’t been dealt with before.  Although an investigation wasn’t able to pinpoint an exact cause for why the gurney had moved and why Beth had fallen, Anne felt that now there was an honest effort to provide some answers.

Also, Anne learned of the new policies and procedures developed in the Calgary Health Region to prevent another accident like Beth’s.

“That’s what I needed to know,” said Anne. “When somebody is injured in the hospital, if you don’t feel that the people involved are being honest with you about what happened, you lose trust.  You’re this individual, or this family, and you feel like you’re up against a huge system. Trust is all you’ve got to go on.”

Anne also decided to get involved as a volunteer.  Beth’s legacy carries on in a daughter who is now an advocate for patient safety. Anne sits on Alberta Health Service’s Patient/Family Advisory Group, the Health Quality Council of Alberta’s Patient/Family Safety Advisory Panel, and is a member of Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute).

“I wish you could have met my mom,” she says. “She was a very strong woman. She was gracious. She was intelligent and she was compassionate. I’ve been told I’m a lot like her. I couldn’t receive a higher compliment,” says Anne. “I know my mom would be proud of what I’m doing.”

Anne knew the importance of being actively involved in her mother’s care.