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 waiting for a coroner’s inquest to find out why she wasn’t provided with more medical care.

Heather Winterstein went to the Marotta Family Hospital, formerly called the St. Catharines General Hospital, on Dec. 9, 2021 with a severe backache, her family previously told CBC Hamilton. She was sent home with Tylenol but returned the next day and collapsed in the waiting area.

She died shortly after. Her family later found out the cause was a Strep A blood infection.

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

“Her family believes that her death was preventable.”

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

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

They believe Winterstein didn’t receive proper medical assessment or care at the hospital because of systemic racism and biases — issues a coroner’s inquest would explore, possibly prompting change that could help other Indigenous patients.

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

Coroner’s inquests typically take place years after a person’s death and, according to the Ontario website, there’s no time limit of how long after it can happen.

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

No date or location has been set for Winterstein’s inquest, confirmed spokesperson Stephanie Rea this week.

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

Winterstein wasn’t assessed at hospital: report

Linda Boich, a vice-president at Niagara Health, which runs the St. Catharines hospital, described Winterstein’s death as “a tragedy.”

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

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

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

The panel found that despite Winterstein having abnormal vital signs at her first hospital visit, she was discharged without being assessed, says a report from 2023. It also found her diagnosis had 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 two-and-a-half hours. The panel watched video footage and said it was “difficult to witness.” She attempted to get comfortable in a wheelchair and then on the waiting room floor.

“On several occasions staff from housekeeping and security are seen getting her a blanket and assisting her back into a wheelchair,” the report says.

Another patient pushed her in the wheelchair to the triage desk to speak to a nurse before she collapsed.

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

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

According to Boich, Niagara Health has since:

• Made cultural safety training for staff mandatory.
• Opened a dedicated Indigenous space at the Marotta Family Hospital.
• Created an Indigenous Health Services and Reconciliation team to support Indigenous patients.
• Displayed Indigenous artwork across its sites.
• Begun working to increase Indigenous representation on advisory and decision-making bodies, and to recruit and retrain Indigenous employees, physicians and volunteers.

Family wants ‘lasting’ change

Lunn said she is hopeful when the inquiry does eventually happen, her niece will get justice.

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

“The system needs an overhaul. Anti-Indigenous racism and bias must be disrupted and stopped in all areas of health care and all levels within institutions that offer care to our people.”

Change would mean hiring more Indigenous nurses and doctors and ensuring equal access to substance use treatment, prevention and counselling services, said Lunn.