The findings of an inquest jury into treatment delays that played a role in the death of 24-year-old Heather Winterstein, an Indigenous woman, at a St. Catharines hospital in December 2021 have led to calls for change within the healthcare system.
In their findings released last week, the jury ruled that Winterstein died from septic shock due to sepsis with delayed treatment, caused by a bacterial infection. Winterstein had sought treatment at the Marotta Family Hospital on Dec. 9 and 10. On the first occasion, Winterstein was sent home with Tylenol. She returned to the hospital the following day, but later collapsed in the waiting room, eventually dying.
The jury ruled that Winterstein’s death was an “accident.”
Winterstein was a member of the Cayuga Nation with ties to the Six Nations of the Grand River and lived in St. Catharines.
“Heather’s death is a tragic reminder of the systemic racism First Nations people continue to face in healthcare,” said Ontario Regional Chief Abram Benedict.
The jury released 68 recommendations that might help prevent similar deaths in the future, many of them related to improving the experience of Indigenous patients, both in hospitals and when accessing paramedic services.
Witnesses from the Marotta Family Hospital, including the doctor who assessed her, claimed that they did not realize that Winterstein was Indigenous.
Among the jury’s recommendations include: requiring each Ontario hospital to have policies and practices in place informing Indigenous patients of the availability of Indigenous healing resources; requiring continuous training covering Indigenous cultural safety, substance use and mental health stigma for all paramedic services in Ontario; and exploring maintaining Indigenous cultural safety, substance abuse and mental health stigma training for all front-line workers, administrative staff and executives in hospitals.
Niagara Health, which runs the Marotta Family Hospital, put out a statement following the jury’s findings.
“Niagara Health fully participated in the coroner’s inquest into the death of Heather Winterstein. The jury determined the manner of Heather’s death to be accidental, and we respect the jury’s role in reaching that finding,” reads the statement.
“We accept the jury’s recommendations and see them as an important roadmap for system-level improvement. We are encouraged that many of the recommendations build on the work already underway to improve the care and experience of Indigenous patients and their families within our hospitals,” the statement adds.
“Niagara Health remains committed to our ongoing journey toward reconciliation. As shared during the inquest, we know that systemic racism exists in healthcare, and addressing it is essential to improving safety, trust and outcomes for Indigenous patients and their families. We are grateful for the opportunity to continue learning and to strengthen the care we provide for all why rely on our hospitals.”
Jay Goldberg is the Canadian Affairs Manager at the Consumer Choice Center. He previously served as the Ontario Director at the Canadian Taxpayers Federation and a policy fellow at the Munk School of Public Policy and Global Affairs. Jay holds a Ph.D. in Political Science from the University of Toronto.
