Heather Winterstein’s death after repeated Ontario hospital ER visits was accidental, inquest jury finds

The inquest jury examining the 2021 death of Heather Winterstein has found the Indigenous woman’s death in a St. Catharines, Ont., hospital was from septic shock and accidental.

The family of the 24-year-old, who collapsed in the emergency department after trying to get help over two days before dying Dec. 10, 2021 after frantic attempts to save her life, had sought a homicide finding.

Niagara Health, which runs the St. Catharines hospital where Winterstein died, and Niagara’s paramedic service both disagreed with the homicide argument and said nothing intentional was done leading to her death.

Jurors also assembled 68 recommendations they feel will help prevent similar deaths.

They ruled Winterstein, who had sought care at what is now known as the Marotta Family Hospital on Dec. 9 and 10 for severe body pain, died of septic shock due to sepsis with delayed treatment, caused by a bacterial infection. Many of the recommendations relate to improving the patient experience of Indigenous patients in hospitals and of paramedic services. 

CBC has reached out to Winterstein’s family for comment on the jury’s determinations.

After reading out the findings, Dr. David Eden, the presiding officer at the virtual inquest that began March 30, called it a thorough report.

He said Winterstein “was a young Indigenous woman, daughter, sister, friend. While waiting for care in the emergency room for the second time in two days, she collapsed and died within hours,” Eden noted.

The evidence presented at the inquest “was at times hard to watch and at times was technically complex,” he said in praising the jury’s work.

Eden also acknowledged Winterstein’s family, saying they actively participated before and during the inquest.

“We were aware of your presence throughout and we are aware of your presence now. I hope you will find this inquest honoured Heather’s memory by allowing the jury to hear who she was, the facts surrounding her death and the jury’s recommendations, which I believe will prevent similar deaths and similar losses to families.”

A coroner’s jury in Ontario is tasked with answering questions including medical causes of death and how someone died — by natural causes, accident, homicide, suicide or undetermined, and possibly come up with recommendations. Jurors are prohibited from making any finding of legal responsibility or laying blame on anyone.  

Whether ‘bias’ played a role a prominent question

At the Winterstein inquest, questions put to several of the nearly two dozen witnesses included whether her background played a role in how she was treated in the health-care system. 

Dr. Suzanne Shoush, an expert in biases in health care, testified that anti-Indigenous racism and bias is baked into the system, and biases related to housing instability, substance abuse and mental health issues also impact patient care. 

“Heather was a patient with several features that put her at risk of bias and stereotypes: she was an Indigenous woman, she had a substance use disorder, she was perceived to be homeless, she has a mental health history,” Rachael Gardner, a lawyer for the family, said earlier in the inquest.

The lawyer for Niagara Emergency Medical Services (NEMS), which brought Winterstein to hospital by ambulance on Dec. 9 and 10, had argued the lead paramedic who responded to a 911 call from Winterstein’s dad on Dec. 10 believed she was white and not Indigenous. The lawyer also rejected the assertion that bias due to her history of substance abuse was evident.

Midway through the inquest, a triage nurse testified that Winterstein wasn’t reassessed in the emergency department waiting room because it was overwhelmingly busy amid the COVID-19 pandemic; she said she didn’t know Winterstein was Indigenous.

The inquest heard that on Winterstein’s first hospital visit, the doctor who assessed her determined her symptoms were due to “social issues.” In his notes, he cited her history of substance use and anxiety disorder. She was sent home with a bus ticket, Tylenol and instructions to return to hospital if her condition worsened. 

Vivian Sim, lawyer for the inquest, said systemic biases in the health-care system let Winterstein — who was Indigenous with a history of substance use, anxiety disorder and perceived housing instability — fall through the cracks.

“That systemic issue was one of discrimination,” Sim contended. 

A summary of the jury’s recommendations

Some of the recommendations include:

• Requiring each Ontario hospital to have policies and practices in place informing Indigenous patients of the availability of Indigenous healing resources.
• Requiring continuous training covering Indigenous cultural safety, substance use and mental health stigma for all paramedic services in Ontario.
• Calling on the province to mandate and fund Indigenous healing practices, including traditional Indigenous medicine and spiritual practices, when patients ask for them.
• Calling on the province to require every Ontario hospital to co-develop Indigenous health protocols in consultation with local Indigenous communities, and protocols for Indigenous health in conjunction with elders, keepers and traditional healers.
• Explore mandating Indigenous cultural safety, substance abuse and mental health stigma training for all front-line workers, administrative staff and executives in hospitals.
• Giving arm’s-length Indigenous organizations the chance to monitor how effectiveness of that training is being measured.
• Ensuring hospital have sufficient staffing in the emergency departments, including triage and reassessments of patients.
• Ensuring enough nurses and doctors are available on call when staffing levels are low and demand is high. 
• Paramedic anti-bias training, particularly for patients who are Indigenous, unhoused or underhoused, and/or experiencing substance use disorders.
• Have Niagara regional police, Niagara Health and NEMS look at tech solutions and policies to enhance the transfer of patient information between them.