Chelsea Brent remembers her mother as someone who always lived her best life, despite her struggles.

"She was well known downtown, everyone said hi to her," Brent recalled, adding many people in her Downtown Eastside neighbourhood knew Tracey Gundersen as "Mom."

The 56-year-old died last November, after calling 911 to report she was bleeding profusely. Her death and the emergency response surrounding it were the focus of an external investigation ordered by the health ministry, after Brent wrote letters and met with the minister.

On Monday, a report has been released, making 14 recommendations for change.

"I hope that no one else has to go through this. I hope there’s not another Tracey Gundersen that loses her life," Brent said.

Brent shared the audio of her mother’s 911 call from November 8, 2018 with CTV News Vancouver. According to the report, the call was placed at 8:15 am.

Dispatcher: BC Ambulance, for what city please?

Gundersen: Vancouver. I’m bleeding profusely.

Dispatcher: Hang on, what’s the address you need help to, ma’am?

Gundersen proceeded to provide her building address on Powell Street and her buzzer number.

She also unlocked the door to her unit. The dispatcher told her how to try and stop the bleeding and continued to reassure her help was on the way.

Gundersen’s voice sounded distressed, and then her speech became less clear as the call continued.

Gundersen: I’m all dizzy and blurry.

Dispatcher: I understand. Just hang in there -- we’re going to be there soon to help you.

Thirty-five minutes passed before first responders reached Gundersen. By then, the report indicated she had no pulse and efforts to save her failed.

The review, conducted by two emergency room physicians from Vancouver and Toronto respectively, found in conclusion: "The investigators are not certain that this death was avoidable although it may have been if paramedics had been able to access the patient more promptly."

A timeline set out in the report shows though paramedics arrived at Gundersen’s building five minutes after the call was placed, they encountered problems getting inside: first at the exterior locked door, and then because a "specific security fob" was required for an elevator. Firefighters were then called, but by the time they reached Gundersen, just over half an hour had passed and it was too late.

The 14 recommendations include: "Fire department should be dispatched where there is any suspicion of access delay to the particular building or at the first sign that access might be a problem."

"They would have been patient-side, they would have been with her, attempting to save her life, getting her to the hospital, and if she had passed away, she would’ve at least not been alone," Brent said.

Health Minister Adrian Dix said he accepts all of the report’s recommendations, calling the circumstances "very tragic for everybody involved."

"It took too long to get to her mother. And whether or not her death was preventable, being there is an important thing," Dix said.

The Vancouver Fire Department has responded to the report. In a statement, Fire Chief Darrell Reid said they support the findings, and "do not want a tragedy like this to happen again."

Brent plans to visit her mother’s neighbourhood on the anniversary of her death, to talk to people and give out handwritten cards that read "Somebody’s Someone" on the front. It’s part of a project she’s started in her mother’s memory, saying Gundersen told her multiple times "that she didn’t belong into my world".

"I want to bridge that gap of communication, and just not turning a blind eye to who they are, because they are people," Brent said.

"They have someone out there who they belong to in some way."