Medical expert tells inquest Heather Winterstein should not have remained in waiting room, needed frequent checks

Heather Winterstein should not have been kept in the emergency room waiting area at St. Catharines Hospital until she could see a doctor on the day she died of sepsis, an emergency medicine expert told a coroner’s inquest on Wednesday.

But even if limited resources and staffing had meant keeping her in an ER waiting room, it would have been important to reevaluate her frequently for any signs of worsening of her condition, Dr. Ron McMillan of McMaster University testified.

The inquest also heard that when paramedics brought Winterstein to what is now known as Marota Family Hospital on December 10, 2021, his vital signs appeared to fluctuate widely.

Winterstein died in the hospital after spending two days trying to access health care.

On 9 December, she arrived by ambulance, complaining of pain after reportedly falling down the stairs the day before. She was given Tylenol and sent home with instructions to return to the emergency department if her condition worsened. The emergency department physician who assessed her determined that “social issues” were the driving force behind her hospital visits.

Winterstein’s father called an ambulance the next morning. After waiting for hours in the emergency department waiting room, Winterstein collapsed on the floor. Attempts by medical staff to revive him failed and he was declared dead.

An autopsy found that Winterstein died from sepsis, an extreme reaction caused by Streptococcus pyogenes and Staphylococcus aureus bacterial infection.

Since Winterstein’s death, family members and community organizations have expressed concerns that addiction discrimination and anti-Indigenous racism may have played a role in her treatment.

Inquiry told reassessment is ‘extremely important’

On Wednesday, Dr. David Eden, who led the investigation that began March 30, asked McMillan whether it was important to frequently check vital signs for a patient like Winterstein, who returned to the emergency department for the second time in two days.

McMillan said Winterstein, of St. Catharines, was triaged to the second highest of five levels under the Canadian Triage and Acuity Scale (CTAS).

“This means the patient should see an emergency physician within 15 minutes,” he said.

If this was not possible due to limited resources, Winterstein’s condition should have been repeatedly reassessed by a nurse for any signs of worsening, McMillan said.

“They should not be in the waiting room,” he said of CTAS 2 patients. “They require close observation, frequent critical information — Reevaluate if there is any change in their clinical status.

“This is extremely important.”

McMillan said sepsis is a potentially life-threatening condition that can progress to the more severe septic shock or toxic shock, which have a much higher mortality rate if the body’s immune response to infection becomes severe.

This can lead to low blood pressure and multiple organ failure, McMillan said.

Health system in ‘unprecedented times’ due to pandemic

In testimony at the inquiry last week, Heather Patterson, executive vice president of clinical operations for Niagara Health, which runs the hospital, said that because of her CTAS score, Winterstein should have been reassessed by a triage nurse every 15 minutes while she was in the waiting room.

Asked if management is checking to see if those reevaluation requirements are being met, Patterson said, “I don’t think so.”

An attorney representing the Winterstein family also asked them what system was being used by triage nurses to ensure they could timely reevaluate patients like Winterstein in the waiting room.

“I can’t answer that question. I’m not sure what system the triage nurses would use.”

Patterson also said the health system was in “unprecedented times” due to the pandemic, and the emergency department was short of several nurses on December 10, 2021, with some sick or unable to come to work because they had been exposed to people with COVID-19.

“When we have understaffed nurses, it impacts the way we deliver care,” Patterson said. “When you’re down three nurses or down four nurses, things potentially won’t get done in a timely manner. There may be delays in implementing treatment plans. There may be delays in evaluations.”

One of the investigating lawyers, Vivian Sim, presented a chart on the day Patterson testified. It showed that on the day Winterstein died, 90 percent of patients with a CTAS score of 2 waited an average of 4.6 hours to see a doctor. On the same day, 90 percent of patients deemed less severe with a CTAS 4 score waited an average of 3.8 hours before seeing a doctor, while 90 percent of patients deemed less severe with a CTAS 5 score waited an average 1.8 hours before seeing a doctor.

Paramedic says Winterstein’s vital signs were fluctuating

On Wednesday, Brandon St. Angelo, one of two Niagara Emergency Medical Services paramedics who brought Winterstein to the hospital by ambulance on December 10, admitted that he had not taken Winterstein’s vital signs earlier.

He said this was because it was in a small mud room off a narrow set of stairs leading up to the second-floor apartment on Elizabeth Street, where Winterstein’s father lived.

Sant’Angelo and the other paramedic helped Winterstein walk down the stairs under his own power. He said this was due to the fact that the stairs were narrow, with dilapidated handrails and he felt it would be too dangerous to use a stretcher or a luggage-carrying stair chair.

Once in the ambulance and again on the way to the hospital, Winterstein’s vital signs were fluctuating noticeably, according to a paramedic document shown at the inquest.

It showed that her heart rate increased from 125 beats per minute at 11:36 am, to 134 at 11:44 am, then to 132 at 11:47 am, and to 109 at 12:17 pm. Over the same period of time his blood pressure went from 97/66 to 157/139 to 93/65 and then to 121/76.

His oxygen saturation level, which should normally be 95 to 100 percent, went from 96 percent to 91 percent, 84 percent and 96 percent in the same time period.

St. Angelo said that the machines taking vital signs might have been getting inaccurate readings if Winterstein was driving, and noted that the ambulance was traveling on a bumpy road at times.

Winterstein family attorney Natai Shelson asked St. Angelo whether, under safety standards, Winterstein should have been brought from the apartment to the ambulance on a stretcher, and whether she should have had a cervical collar placed on her neck and minimal movement of her spine.

“It’s fair to say,” he said.

Health Network issued a statement

Also on Wednesday, the Niagara Ontario Health Team — A network of health care providers, social service agencies, educational organizations, and patient/client/family/caregiver representatives working to improve the coordination and integration of health services in the area. — Said he is committed to listening and learning from the investigation proceedings and any recommendations that emerge.

“The network will carefully consider the findings for their relevance to care coordination, systems navigation, Indigenous health, and efforts to address anti-Indigenous racism in health and social care,” the network said in a statement.

Inquiries are held to inform the public about the circumstances of the death, but do not assign blame or conclude guilt or innocence. A coroner’s jury reviews evidence to determine the facts surrounding a death and may make recommendations to prevent similar deaths.

The inquest is expected to hear from around 22 witnesses over 13 days and is being held virtually.