4 years after Indigenous woman died in Niagara hospital waiting room, family still waits for coroner’s inquest

Four years after a 24-year-old Indigenous woman died in a St. Catharines, Ont., hospital, her family is still awaiting a coroner's inquest to find out why she was not given more medical care.

Heather Winterstein went to Marotta Family Hospital, formerly St. Catharines General Hospital, on Dec. 9, 2021, with severe back pain, her family previously told CBC Hamilton. She was sent home with Tylenol, but returned the next day and passed out in the waiting room.

Soon she died. Her family later learned that the cause was a blood infection caused by streptococcus A.

“Heather's death has devastated us,” Winterstein's aunt, Jill Lunn, said in an email this week.

“Her family believes her death could have been prevented.”

Lunn described Winterstein as a beautiful, “quiet soul” who loved her parents, animals and the color pink.

Winterstein has roots in both Saugeen and Six Nations of the Grand River First Nation, according to the family.

They believe Winterstein did not receive adequate medical assessments or care at the hospital because of systemic racism and bias – issues that will be examined in the coroner's inquest, possibly leading to changes that could help other Indigenous patients.

“There are many questions left and we are still waiting for answers,” she said.

A coroner's inquest usually takes place years after a person's death and, according to Ontario websitethere is no time limit after this can happen.

Last year, the Solicitor General's Office announced that an investigation would be held to “examine the circumstances” of Winterstein's death and allow the jury to make recommendations.

No date or location has been set for Winterstein's investigation, spokeswoman Stephanie Rhee confirmed this week.

She said the length of time it takes to prepare for an investigation varies depending on the complexity of the case, and the province has seen an increase in the number of deaths requiring mandatory investigations since 2016.

Winterstein was not examined at the hospital: report

Linda Beuch, vice president of Niagara Health, which operates St. Catharines Hospital, called Winterstein's death a “tragedy.”

“We recognize broader concerns about racism and bias in health care, including at hospitals like ours,” Beuch, who oversees patient experience and integrated care, said in an email.

“And we remain committed to confronting this and making meaningful and permanent improvements.”

In 2022, an outside panel at the request of Niagara Health reviewed what happened at the hospital that led to Winterstein's death.

The panel found that although Winterstein had abnormal vital signs during her initial hospital visit, she was discharged without evaluation, the 2023 report said. She also determined that her diagnosis indicated social problems rather than physical illness.

Non-medical staff, patients tried to help

When Winterstein returned to the hospital the next day, she waited two and a half hours. The commission reviewed the video footage and said it was “difficult to witness.” She tried to get comfortable in the wheelchair and then on the waiting room floor.

“Housekeeping and security staff were observed several times giving her a blanket and assisting her back into her wheelchair,” the report states.

Another patient pushed her in her wheelchair toward the triage table to talk to a nurse before she passed out.

“Unconscious bias may have played a role in [Winterstein’s] care because she was noted to be experiencing addiction and homelessness,” the panel concluded.

Niagara Health has accepted all of the panel's recommendations, Beuch said.

According to Beuch, Niagara Health has since:

• Cultural safety training for staff has become mandatory.
• Opened a special space for indigenous peoples at the Marotta Family Hospital.
• An Indigenous Health and Reconciliation Services Team has been established to support Indigenous patients.
• Featured indigenous art on his websites.
• Work has begun to increase Indigenous representation on advisory and policy-making bodies, and to recruit and retrain Indigenous staff, doctors and volunteers.

Family wants 'long-term' changes

Lunn expressed hope that when the investigation does take place, her niece will achieve justice.

“Justice for Heather Winterstein will be a lasting, meaningful and impactful change in the Indigenous health care system,” Lunn said.

“The system needs a major overhaul. Racism and bias against Indigenous people must be addressed and stopped in all areas of health care and at all levels of institutions that provide care to our people.”

Changes will mean hiring more Indigenous nurses and doctors and ensuring equal access to substance use treatment, prevention and counseling services, Lunn said.