Ontario hospital nurse tells inquest she never spoke to Heather Winterstein the day she died, staff overwhelmed

The triage nurse who initially assessed Heather Winterstein on the day she died of sepsis in 2021 says she never spoke to the 24-year-old patient and did not take her vital signs after paramedics told a coroner’s inquest that staff were overwhelmed.

Andrea Demery testified Thursday that her only engagement with Winterstein was to see him briefly in a wheelchair from across the room after talking with one of the paramedics who brought him there by ambulance.

“I probably saw him for three to five seconds,” Demery said.

He also said he did not re-evaluate Winterstein while the patient was waiting for a doctor in the emergency unit, something Demery had to do every 15 minutes to determine whether his condition was worsening.

When Demery was asked why certain protocols were not put in place, he told investigating attorney Julian Roy, “The nurses are exhausted. The nurses are exhausted.”

After waiting two and a half hours, Winterstein collapsed. Attempts by medical staff to revive him failed and he was declared dead on December 10, 2021 – the second consecutive day that he had sought help at the hospital. She developed an overreaction to a bacterial infection, resulting in sepsis, a life-threatening condition that damages the body’s tissues and organs..

Winterstein first arrived at the hospital by ambulance on December 9, reportedly complaining of pain after 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 doctor who assessed her determined “social issues” were behind her hospital visit, the inquest previously heard.

Demri is among the witnesses who have described the events leading up to Winterstein’s death since the inquiry began on March 30. A total of more than 20 people are expected to testify over 13 days during the virtual hearing.

The Ontario Coroner’s Jury takes such evidence into account to determine the facts in a case and may make recommendations to prevent similar deaths, but is not tasked with assigning blame or making findings of guilt or innocence.

During interrogation it was told that the patient was not given a chance to ask questions.

Winterstein was taken by ambulance to the emergency department of what is now known as Marotta Family Hospital just after noon on December 10. Demery said he spoke only to paramedic Brandon St. Angelo, who reported that Wintersteen’s pain had increased to 10 out of 10 on the pain scale.

Triage nurses have advanced experience and perform initial assessment of patients, prioritizing care based on severity rather than time of arrival.

Demery said Winterstein was not given a chance to ask him any questions during the evaluation process, “I didn’t give him a chance.”

St. Angelo also informed Demery that Winterstein said she may be suffering from withdrawal from fentanyl.

Demery, who relied on vital signs taken by paramedics, said Wintersteen’s heart rate was an elevated 130, but said she thought it may have been due to pain or fentanyl withdrawal.

“I attributed it mainly to withdrawal symptoms,” he said.

“The withdrawal symptoms are terrible. It’s a terrible feeling all over the body.”

Demery said she was not aware at the time that standards at Niagara Health, which runs the hospital, require triage nurses to always take vital sign readings themselves.

“This was a standard of our department that was not being enforced. It was never brought to our attention that we were doing it wrong.”

Because Winterstein was placed at the second highest of five levels under the Canadian Triage and Acuity Scale (CTAS), hospital protocol dictated that Demery was responsible for reassessing him every 15 minutes.

“We know his condition could deteriorate very quickly,” Demery said.

But Winterstein was not reevaluated during the two-and-a-half hour wait, he added.

“He should have been re-evaluated at least 10 times.”

‘We can’t do it all,’ nurse testifies.

Roy, one of the investigating attorneys, asked Demery why Winterstein was not reevaluated.

Demery said front-line triage staff were overwhelmed, with 47 patients waiting to be seen in the emergency department and only three triage nurses working instead of the usual four. She said nurses who had been delaying their breaks for hours finally had to take them, and one nurse had to spend time answering phones and handling new patients arriving.

Fighting back tears, Demery said, “Every time you open the door to the waiting room, and you look at all these people and there’s a baby that’s three days old, and someone who’s clutching their chest and someone else puffing on their Ventolin (inhaler), and you have to look at all those people, you have to test them and try to figure out how sick they are, our level of care gets worse and it’s not because we We just want it to get worse.”

Demery said he opted to send Winterstein to the waiting room rather than to another area, where he could be seen by a doctor more quickly.

“She appeared to be relatively comfortable in her wheelchair. She did not appear to be in obvious distress.”

Roy asked Demery if there was any way for nurses to express concern over patient safety in the hospital, despite limited resources. He said that most of the nurses give up trying to raise the alarm bell.

“Expressing it over and over again gets tiring,” he said.

“You get tired trying to fight for the department.”

The staff performed several treatments

After Winterstein collapsed at 2:41 p.m. ET on Dec. 10, Demery said, she went into the waiting room with other medical staff.

The inquest heard that doctors spent hours trying to revive him and save his life.

Dr. Jennifer Tsang, a hospital intensive care unit specialist, testified that Winterstein’s blood had become dangerously acidic — known as metabolic acidosis — And his blood pressure had dropped to dangerously low levels. Tests also revealed that his hemoglobin levels, which carry oxygen to organs and tissues, had fallen sharply. His pulse was fast and breathing was slow.

“She was in a state of severe shock,” Tsang said. “This can lead to multiple organ failure and death.”

For more than two hours, the doctor administered multiple treatments, including various fluids and antibiotics, even though Winterstein showed no signs of infection.

“When someone is that sick, (you) throw the kitchen sink at them to try to keep them alive,” Tsang said.

They reported that Winterstein was taken to intensive care, where his mother agreed to stop resuscitation efforts and he was pronounced dead at 8:42 p.m.

What has changed at the hospital since Winterstein’s death?

Demery said the hospital made several “significant changes” to the emergency department following Winterstein’s death.

She said they’ve added a nurse practitioner and personal support worker to monitor patients in the waiting room, a new lead nurse in what’s known as an acute assessment area to help with patient flow, and a technician for tasks like taking blood work and electrocardiogram readings, so triage nurses can focus on doing patient evaluations.

But, Demery said, CTAS 2 patients are still not getting regular reassessment every 15 minutes.

“I still don’t think there are enough resources to accomplish that task.”

Winterstein was a member of the Cayuga Nation, which had ties to the Six Nations of the Grand River. Since his death, family members and community organizations have expressed concerns that addiction discrimination and anti-Indigenous racism may have played a role in his treatment.

Demery, who said he did not know Wintersteen was Indigenous, addressed the family while testifying virtually and said he hoped his death would help ignite a “revolution” in the health care system.

“I am so sorry that he was taken from you at such a young age and (he) has left such a painful hole in all of your lives.”