An Ontario coroner’s jury has ruled that the 2021 death of Heather Winterstein, a 24-year-old Indigenous woman, was accidental. Winterstein died of septic shock caused by a bacterial infection and delayed treatment after seeking emergency care in St. Catharines, Ontario.
A Two-Day Struggle for Care
Winterstein sought help at the facility now known as the Marotta Family Hospital on December 9 and 10, 2021, reporting severe body pain. During her first visit, a doctor attributed her symptoms to “social issues,” citing her history of anxiety disorder and substance employ.
She was sent home with Tylenol, a bus ticket, and instructions to return if her condition worsened. Upon returning to the emergency department the following day, Winterstein collapsed and died within hours despite frantic efforts to save her life.
Systemic Bias and Discrimination
A central focus of the inquest was whether anti-Indigenous racism and systemic bias influenced the care Winterstein received. Winterstein was a member of the Cayuga Nation with ties to Six Nations of the Grand River.
Expert testimony from Dr. Suzanne Shoush indicated that anti-Indigenous racism is “baked into the system,” often intersecting with biases regarding mental health, substance abuse, and housing instability. Lawyer Vivian Sim contended that these systemic issues of discrimination caused Winterstein to “fall through the cracks.”
Although the family sought a finding of homicide, the jury ruled the death accidental. Under Ontario law, coroner’s juries are prohibited from laying legal blame or making findings of legal responsibility.
Path Toward Systemic Change
The jury issued 68 recommendations to prevent similar tragedies, focusing heavily on the experience of Indigenous patients and paramedic services. These include calling on the province to mandate and fund traditional Indigenous healing practices and spiritual medicine upon request.
Other recommendations suggest requiring all Ontario hospitals to co-develop Indigenous health protocols with local communities, elders, and traditional healers. The jury also urged continuous training on cultural safety and the stigma associated with substance use for all front-line hospital staff and paramedics.
the jury recommended ensuring sufficient staffing in emergency departments to guarantee proper triage and patient reassessments, especially during periods of high demand.
Family Calls for Immediate Action
Francine Shimizu-Orgar, Winterstein’s mother, stated that the findings reveal the “biased and unfair treatment” her daughter received due to her Indigenous background and history of substance use disorder.
Mark Winterstein, Heather’s father, expressed encouragement regarding the recommendations. He and his family are calling for Niagara Health and the paramedic service to implement the changes immediately to spare other families similar loss.
Potential Next Steps
While inquest recommendations are not legally mandated, they are commonly used to improve public safety. Niagara Health and Niagara Emergency Medical Services may face increased public pressure to adopt the 68 suggestions.
The province could potentially implement recent funding models for Indigenous healing practices or mandate standardized cultural safety training across all Ontario paramedic services to address the biases identified during the proceedings.
Frequently Asked Questions
What was the official cause of Heather Winterstein’s death?
The jury ruled she died of septic shock due to sepsis with delayed treatment, which was caused by a bacterial infection.
Did the jury identify the hospital legally responsible for the death?
No. In Ontario, coroner’s juries are prohibited from making any finding of legal responsibility or laying blame on any individual or institution.
What are some of the key recommendations made by the jury?
The jury recommended mandating Indigenous cultural safety training for hospital and paramedic staff, co-developing health protocols with Indigenous communities, and ensuring adequate staffing for patient reassessments in emergency departments.
Do you believe mandatory cultural safety training is sufficient to eliminate systemic bias in emergency healthcare?
