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

Four years after a 24-year-old Indigenous woman died at St. Catharines Hospital in Ontario, her family is still waiting for a coroner’s inquest to find out why she was not provided 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 collapsed in the waiting area.

He died shortly afterwards. Her family later learned that the cause was a strep A blood infection.

“Heather’s death 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.

According to the family, Winterstein’s roots are in both the Saugeen and Six Nations of the Grand River First Nations.

She believes Wintersteen did not receive proper medical assessment or care at the hospital due to systemic racism and prejudice – issues that will be explored at the coroner’s inquest will potentially inspire change that could help other Indigenous patients.

,“Many questions remain and we are still waiting for answers.”

A coroner’s inquest usually takes place years after a person’s death and, according to Ontario websiteThere is no time limit on how long this can happen.

Last year, the Ministry of the Solicitor General announced that an inquest would be held to “investigate the circumstances” of Winterstein’s death and give a jury the opportunity to make recommendations.

Spokeswoman Stephanie Rea confirmed this week that no date or location has been set for Winterstein’s questioning.

He said the length of time to prepare for an investigation varies depending on the complexity of the case, and since 2016 the province has been dealing with an increase in deaths requiring mandatory investigations.

Winterstein not evaluated in hospital: report

Linda Boich, vice president of Niagara Health, which runs St. Catharines Hospital, called Winterstein’s death “a tragedy.”

“We acknowledge the widespread concerns about racism and bias in health care, including in hospitals like ours,” Boitch, who oversees patient experience and integrated care, said in an email.

“And we are committed to confronting this head-on and making meaningful, sustained improvements.”

In 2022, a third-party panel, at the request of Niagara Health, reviewed what happened at the hospital that led to Winterstein’s death.

A 2023 report said the panel found that despite Winterstein having abnormal vital signs on his first hospital visit, he was discharged without being evaluated. It was also found that her diagnosis pointed to social issues rather than physical illness.

Non-medical staff, patients tried to help

When Winterstein returned to the hospital the next day, she waited for two and a half hours. The panel viewed the video footage and said it was “difficult to watch.” He tried to sit comfortably in the wheelchair and then on the waiting room floor.

“On several occasions, housekeeping and security staff are seen giving him blankets and helping him back into his wheelchair,” the report said.

Another patient pushed him in a wheelchair to the triage desk to talk to a nurse before he collapsed.

The panel concluded, “Unconscious bias may have played a role in (Winterstein’s) care as he was diagnosed as experiencing both drug addiction and homelessness.”

Niagara Health accepted all of the panel’s recommendations, Boitch said.

According to Boitch, Niagara Health has since:

• Cultural safety training made mandatory for employees.
• A dedicated Indigenous space opened at Marotta Family Hospital.
• An Indigenous Health Services and Reconciliation Team was created to support Indigenous patients.
• Displayed indigenous artwork on their sites.
• Work began to increase Indigenous representation in advisory and decision-making bodies and to recruit and retrain Indigenous staff, physicians and volunteers.

Family wants ‘permanent’ change

Lunn said she hopes her niece will get justice when the investigation takes place.

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

“Radical change in the system is needed. Anti-Indigenous racism and bias must be disrupted and stopped at all levels within all areas of health care and the institutions that provide care to our people.”

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