What to know about today’s inquest proceedings
Day 11 of the Ontario coroner’s inquest for Heather Winterstein death focused largely on what role, if any, systemic racism and bias might have played in her sepsis death in a St. Catharines hospital more than four years ago.
Jurors and the inquest’s head, Julian Roy, heard testimony from officials with Niagara Health, which oversees the hospital where Winterstein died in 2021. The 24-year-old first sought care on Dec. 9 for body pain from a fall, but was sent home with Tylenol and told to return if her condition got worse. The next day, she waited more than two hours in the ER for a doctor before collapsing.
Winterstein died after medical staff worked for hours to keep her alive.
Lynn Guerriero, the regional health authority’s president and CEO, told the inquest she was “struggling” to point to anti-Indigenous racism as a factor in Winterstein’s death, as front-line staff repeatedly told her over the years that they didn’t know the patient’s background.
However, Guerriero acknowledged, “There’s absolutely systemic racism and Indigenous racism in health care.” She also said she still wonders whether “unconscious bias” relating to intravenous drug use and housing instability might have played larger roles in the way Winterstein was treated.
After Winterstein’s death, the hospital system launched an internal review required by law, as well as an external review with a panel that included Indigenous members to examine the case and come up with recommendations to improve Indigenous care.
Many of those recommendations have been implemented, Guerriero noted. For example, in the ER department, IV drug use is now seen as a red flag for sepsis screening and there’s additional waiting room staff to reassess patients.
Guerriero’s testimony came after a patient who was in the ER at the same time as Winterstein on Dec. 10, 2021, gave an emotional account about what she witnessed.
Sheryl Hutton told the inquest she saw Winterstein writhing on the floor in agony in the fetal position as she waited to see a doctor.
“She was crying out loud, moaning, in pain,” said Hutton.
“At first, it was really loud. It got quieter and quieter. Towards the end, it was almost a whimper.”
Hutton said she was too “scared” to approach hospital staff to tell them she was concerned about Winterstein.
To conclude the hearing, Roy asked Dr. Rafi Setrak, the regional health authority’s chief of emergency medicine, about how the hospital complaints process works and whether he had heard of any issues with the ER doctor who assessed Winterstein on her first hospital visit.
Setrak said he didn’t know about those complaints, but was aware that the doctor sometimes “struggled with communications.”
The inquest, which began on March 30, continues Thursday and is expected to conclude this week.
