Niagara Health CEO tells inquest into patient's death it's 'very clear' racism still exists in health care

goodness forenoon. I'm alice paul Forsyth, and I've been cover this inquest since it began on process 30. 

The coroner’s jury has taken in a lot of emotional testimony on what may have led up to the death of Heather Winterstein on Dec. 10, 2021. The 24-year-old collapsed in the St. Catharines, Ont., hospital’s emergency department waiting room on the second day she tried to seek care for pain from a fall.

We’ve already heard from a number of the about 22 witnesses set to speak during the 13 days of hearings.

They include Winterstein’s mother, father, brother and stepmother, who spoke about the grief the family has endured since she died of sepsis. The life-threatening medical emergency amounts to a severe reaction to a bacterial infection, causing the immune system to harm healthy tissues and organs.

Winterstein was a member of the Cayuga Nation, with ties to Six Nations of the Grand River. Her family and community organizations have raised concerns about whether addiction discrimination and anti-Indigenous racism may have played a role in how she was treated. 

Yesterday, testimony addressed whether there were any medical “biases” in the Winterstein case, in part due to her being Indigenous. 

Among medical professionals who’ve testified was an emergency room triage nurse who said the COVID-19 pandemic put even more strain on staff in the busy emergency room, so she barely had time with Winterstein. 

A range of doctors and medical specialists have weighed in on the type of assessments and care Winterstein received, including on Dec. 9. The physician who saw her, Dr. Emad Nour, looked for signs of infection, but ruled that out in part because she didn’t have a fever. He diagnosed her as having “social issues,” and noted in his doctor's notes that she had a substance use disorder and generalized anxiety disorder. She was sent home with a Tylenol and given instructions to come back to the hospital if her condition worsened. 

The next day, Winterstein died despite frantic attempts by medical staff to save her. A woman who was seeking care and spoke briefly to Winterstein told the inquest she “just looked terrified.… She clearly wanted help" before she collapsed.

Danielle Bisnar, lawyer for Andrea Demery, the triage nurse who was working in the ER waiting room the day Winterstein died, is now questioning Guerriero.

Bisnar says there was acute short-staffing on that day, and asked whether nursing staff shortages are still occurring. The inquest previously heard that in 2021, packed emergency rooms and short-staffing were more common due to the COVID-19 pandemic. 

Guerriero says Niagara Health has dramatically improved its nursing levels since Winterstein's death, with much lower vacancy rates for nursing positions. 

"There will always be vacancies that we're filling," she says.

Bisnar asks Guerriero if she agrees it's "demoralizing" and stressful for nursing staff to not be able to meet required standards such as reassessing patients in the waiting room in a timely manner. 

Guerriero says that situation is something she's committed to looking into.

Bisnar asks about the possibility of adding more staff. Guerriero says she'd be willing to explore that to meet standards, but cautioned Niagara Health is now operating in a financial deficit situation.

Johnson asks Guerriero whether she agrees that asking someone seeking medical care if they are Indigenous is purely optional. 

Guerriero says it will absolutely be voluntary and wouldn’t change patient care.

Johnson asks if "trauma-informed care" and bias prevention are important in preventing deaths like Winterstein’s. Guerriero says yes.

The inquest then moved to a short break.

Guerriero says Niagara Health is committed to all staff in emergency departments having cultural sensitivity and anti-Indigenous bias training, noting that's where patients are most vulnerable. 

She agrees with Shoush, the doctor who testified earlier, that it can be life saving.

Shelsen asks if Niagara Health would be open to releasing a statement that anti-Indigenous racism presents a risk to patients. 

"Of course we would be willing to do that," says Guerriero. "It's very clear" that racism and anti-Indigenous racism exists in health care.

"We need to have the humility to admit that and work on it." 

Aidan Johnson, lawyer for the Niagara Region Native Centre, asks if Guerriero would agree that anti-Indigenous racism played a part in Winterstein's death.

Guerriero says that's difficult to answer directly, because many of the front-line staff said they didn't know she was Indigenous. She wonders if biases related to substance abuse or perceptions of being unhoused played more of a part.

Guerriero says the Indigenous Health Services and Reconciliation Team has dealt with 900 patients so far, many of whom were in the emergency department. 

The team reports directly to an executive vice-president responsible for patient experience. 

Shelsen asks if Niagara Health is moving to integrate Indigenous individuals into senior leadership or the board of directors. 

Guerriero says the system has been working hard to try to find Indigenous people for the board, but that it's difficult due to the workload those boards require. 

An Indigenous lawyer was recruited, but he had to leave because he had to move, she says, adding, "It is still a goal.”

Shelsen asks Guerriero what policies aimed at creating a safer culture for employees to speak out about concerns have been instituted at Niagara Health.

"There was more of a culture of blame when I first got there" in February 2020, Guerriero answers. "It's safe to say I made some changes related to that…that were significant.

"There has been substantial change in the culture when I'm just looking at the [emergency department]. We have drastically changed the way the [emergency department] is led." 

That's reflected in retention of emergency nurses that's much higher, says Guerriero.

"I would hope you'd get an answer that people feel safer" to come forward with concerns over patient care.

Shelsen says to Guerriero that she wants to explore what changes have been made that could have prevented Winterstein's death. 

The family’s lawyer notes some of the nurses and doctors who took part in Winterstein's care didn't take part in the reviews deemed as voluntary, as mentioned earlier by Guerriero.

Guerriero disagreed that’s a "major barrier" to making improvements.

"It's still a huge help to understand what happened and what steps could be taken to do things differently."

Shelsen says it would have been critical to speak to the triage nurse who testified she only looked at Winterstein for a few seconds when she arrived at the hospital on Dec. 10. 

Natai Shelsen, lawyer for the Winterstein family, is now questioning Guerriero, who it turns out came to the inquest to testify while she was on vacation.

Shelsen asks her about the triage nurse who told the inquiry about her time with Winterstein and said that patients deemed as seriously ill as Winterstein were still not being reassessed in the waiting room as frequently as they're supposed to be. 

Guerriero pledges to "get to the bottom of that."

If nurses are still struggling to meet that standard, then "we will absolutely fix that.”  

Sim asks Guerriero if there's anything she'd do differently in responding to Winterstein's death.

"These things take 10 times longer than you think they're going to," Guerriero responds.

She adds that in hindsight, she would have expanded her outreach to the Indigenous community earlier.  

"Building the trust takes so much longer than one anticipates." 

Guerriero says hearing nurses aren't always following required standards is worrisome.  

"I am very concerned. Nobody should be unaware of the clinical guidelines under which they practise."

Sim argues clinicians are making decisions based on biases, such as whether to conduct more diagnostic testing. 

She asks if Niagara Health has taken steps to address the fact the number of doctors who are Indigenous is so minute. 

Guerriero says the hospital is "absolutely" committed to increasing its Indigenous staff, but that it's a challenge to find more. 

She says she's an advocate of reducing barriers to get Indigenous youth to pursue education for health-care careers. 

"I'd love to see that in Niagara so those individuals stay in Niagara to work."

Guerriero says Niagara Health recently signed an agreement with the Indigenous Primary Health Care Council, making the St. Catharines hospital the first of its kind in Ontario to formalize that collaboration. The partnership aims to improve Indigenous health outcomes and address health-care inequities.

She says Niagara Health is also seeking Indigenous advisers in its Patient Partner program to bring in former patients to provide advice.

Guerriero resumes testifying, with inquest lawyer Vivian Sim asking her about earlier evidence from the triage nurse who assessed Winterstein on Dec. 10. 

The nurse testified earlier that she wasn’t able to do any reassessments in the waiting room to see if Winterstein’s condition was deteriorating.

Under hospital standards, Winterstein should have been reassessed every 15 minutes.

The triage nurse also said she regularly didn't collect vital signs of patients, contrary to hospital standards.

Guerriero says she wasn't aware both those standards weren't being met.

"[But] I'm not surprised" given the chaotic conditions during the pandemic, she adds.

She says there are now additional staff in the emergency department, including in the waiting room to reassess patients, allowing triage nurses to focus on triage.

---

---