Changes are coming to B.C.'s 911 system, after an external investigation ordered by B.C.'s health minister found response delays "possibly influenced" the death of a Vancouver woman.

In November, Tracey Gundersen, 56 — a Downtown Eastside resident with a drug addiction — called 911 after she started to hemorrhage.

It took ambulance attendants 35 minutes to reach her, because doors and an elevator in her secure building were locked and firefighters with master keys were called in too late.

Now, an independent review has found Gundersen's death may have been avoidable. It makes 14 recommendations "to improve care of future patients" and prevent deaths, including having firefighters attend whenever access might be an issue.

'I'm bleeding profusely': Listen to 911 phone call made by a dying Tracey Gundersen

Listen to the 911 call made by dying woman Tracey Gundersen. 1:38

The investigation was ordered by Health Minister Adrian Dix after a direct appeal from Gundersen's daughter— a police emergency call-taker.

"No one should call for help and not receive it," said Chelsea Brent, 26.

"It brings me to tears often because it's not something that you ever wish on someone; to die alone and scared and wondering if help was ever going to arrive."

Dix agrees.

"This is a serious case. It's a tragic case. It's a heartbreaking case," he said. "There are lessons to be learned and that's why I did it."

Gundersen's daughter, Chelsea Brent, wrote to B.C.'s health minister appealing for a independent review of her mother's death. (Christian Amundson/CBC)

Chilling 911 call

According to the investigation, Gundersen frantically phoned 911 at 8:15 a.m. on Nov. 8, 2018 to report she was hemorrhaging.

"My groin, it's abscessed and it's bleeding profusely," she says in a recording obtained by Brent through a freedom of information request.

An ambulance is dispatched within one minute to Gundersen's low-income apartment complex at 250 Powell street— a former high-security provincial remand centre.

"There's lotsa help on the way," assures the male call-taker.

He tells Gundersen to apply pressure with a towel, but the blood seeps through.

"I'm getting all dizzy … all dizzy in the head," she states four minutes later.

At the five minute mark, the ambulance siren can be heard in the background.

"I can't put any pressure on it," says Gundersen, referring to the bleeding abscess. "I can't handle opening the door."

"Okay … we're gonna figure-out a way in, okay?" promises the call-taker.

But the ambulance attendants hit the locked doors of her building and Gundersen starts to fade.

"I've lost that much blood I'm blurry," she says. "Oh please!"

Thirty seconds later, Gundersen utters her last intelligible words on the recording.

"Please hurry."

Gundersen lived on the sixth floor of 250 Powell Street, a secure low-income apartment complex that was formerly a provincial remand centre for nearby Vancouver Provincial court. (Christian Amundson/ CBC)

Ten minutes later, around 8:32 a.m., records show ambulance dispatch calls Fire for assistance.

Although a fire hall is one block away, a more distant fire crew takes another 10 minutes to arrive.

At 8:50 a.m., emergency crews finally gain access to Gundersen's sixth floor apartment — 35 minutes after she first called 911.

It's too late.

She's found with no pulse. All resuscitation methods fail.

Firefighters' role expanded

The 26-page report investigating Gundersen's death was authored by two emergency care experts, one from B.C., the other from Ontario.

They call for better communication and coordination among call-takers, dispatchers, ambulance and fire — and for firefighters to attend all medical calls where access might be an issue.

All 14 recommendations will be implemented, said Dix.

He denies the changes will roll-back a controversial policy introduced in May 2018, which stopped firefighters from responding to all but urgent medical calls — a move that was supposed to improve the efficient use of ambulance and fire crews.

"I don't think it's a rollback at all. It just makes sense," said Dix. "Let's get on with making the service better."

The nearest firehall to Gunderson was one block away, but it wasn't called to help. Instead, firefighters from another station were eventually called in. (Christian Amundson/ CBC)

'I can't say a policy killed her, but...'

Brent blames the policy change made six months before Gundersen's 911 call for the delay that may have contributed to her mother's death.

In addition to cutting the number of medical calls attended by both ambulance and fire, B.C. Emergency Health Services (BCEHS) brought in a colour-coded ranking system.

At the time, BCEHS, which oversees emergency dispatching in the province, promised the moves would "better match resources to patient needs."

The B.C. Emergency Health Service's dispatch centre sends ambulance and fire crews to 911 calls in the province. (Christian Amundson/CBC)

Gundersen's call was labelled a mid-level "code orange," which means "urgent/potentially serious," but "not immediately life-threatening."

As a result, firefighters were not dispatched with the ambulance crew. Without master keys, the paramedics couldn't access Gundersen's locked building.

"I can't say a policy killed her," says Brent, "but I can say where [the emergency dispatch system] was in April or May 2018, it would have been a lot different."

Fire and Ambulance react

In a statement, the head of B.C. Emergency Health Services said she welcomes any new recommendations from the independent investigation.

Barb Fitzsimmons said BCEHS will work with the health ministry "to make changes needed to prevent something like this from happening again."

Vancouver Fire Rescue Services Chief Darrell Reid said in a statement that his department supports the review's findings, and is "deeply saddened" by Gundersen's death.

The fire department will work with its partners to make improvements, and "should be dispatched to any emergency where our trained teams and fast response times can improve patient outcomes," wrote Reid. "This includes building access issues" said the statement.

'Something did go drastically wrong'

Brent said she's "very appreciative" B.C.'s health minister listened to her plea for a review of her mother's death.

"He did approve this policy change and people had said 'this is going to go wrong,'" said Brent. "And something did go drastically wrong. I think maybe he just saw …this isn't the right option, maybe things do need to change."

Brent wanted to fight one last fight for her mother.

"My Mom did not receive the respect and the care that I feel she could have received," she said.

"I know she never loved attention, but I think she would be thankful."

With files from Paisley Woodward and Liam Britten