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It’s daylight 12 of the Ontario medical examiner’s inquest for calluna vulgaris Winterstein, a 24-year-old who died of sepsis in the St. Catharines infirmary.

The Indigenous adult female first sought care on Dec. 9, 2021, for body pain from a fall. She was sent home with Tylenol and told to return if her condition worsened. The next day, she waited more than two hours in the ER for a doctor before collapsing.

Medical staff worked for hours to keep her alive. She died the evening of Dec. 10.

Family, friends and a family physician have all said they believe racism and bias affected the quality of care Winterstein received.

Yesterday, the inquest heard testimony from officials with Niagara Health, which oversees the hospital, which was renamed Marotta Family Hospital in 2024.

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.”

Earlier yesterday, a patient who was in the ER at the same time as Winterstein gave an emotional account about what she witnessed.

"She was crying out loud, moaning, in pain," said Sheryl Hutton. "At first, it was really loud. It got quieter and quieter. Towards the end, it was almost a whimper."

The inquest, which began on March 30, continues Thursday and is expected to conclude this week, with final arguments likely early next week.

The coroner’s jury is tasked with determining the facts and may make recommendations to prevent similar deaths. They don’t assign blame or make findings of guilt or innocence.

The inquest is taking a short break while the jury ponders questions for the doctors, Chan and Setrak.

When asked if he had any reflections on Winterstein's case, Chan says Niagara Health remains "very committed" to evaluating doctors and looking closely for any red flags related to complaints.

Reflecting on Winterstein's death, Setrak says: "By virtue of the fact that Heather died, we failed."

"The question is, could we have succeeded [in saving her], and how could we have succeeded and what do we need to do to succeed?"

Gardner asks Setrak if the phrase "social issues" can create a risk of the public perceiving a bias.

He agrees that could be a risk.

The emergency department doctor who assessed Winterstein on her first hospital visit on Dec. 9, 2021, attributed her complaints of severe pain to "social issues."

Rachael Gardner, a lawyer for the Winterstein family, is now asking the two doctors some questions.

Gardner asks Setrak if he was part of the internal review process in the wake of Winterstein's death. He says he was. There was also an external, independent review.

Gardner asks why some of the medical staff declined to take part in that internal review and if more should be done to make people feel comfortable to take part. She says an expert on anti-Indigenous bias testified that IV drug users face bias in health care.

Setrak says that’s "true to the human nature," adding the proportion of Indigenous people who struggle with homelessness and addiction is higher.

Gardner asks him if these biases are particularly risky to patients in the emergency department.

Roy asks Chan and Setrak if they have any reflections.

Chan says "this is a very challenging case." He says the hospital system needs to look for "red flags" among doctors and address them in a timely fashion.

Setrak says "we are here to listen and learn. To the family, it's not just condolences. We carry Heather with us every day."

"Since Heather died, we have seen thousands of Heathers."

Dr. Rafi Setrak, regional chief of emergency medicine, is questioned by Roy now about an update to the St. Catharines hospital's medical directive for sepsis screening, to include people who are intravenous drug users.

That update, which came about via recommendations made in the wake of Winterstein's death, also says at-risk patients should have vital signs completed on discharge.

Inquest lawyer Julian Roy asks Chan, the regional health authority’s chief of staff and executive vice-president of medical affairs, how suspensions work for doctors who haven't been meeting required standards.

Chan says such a case would go to the president and CEO, or other senior leadership if anyone is being put at risk of harm or injury, or is detrimental to patient care.

The president, chief of staff or chief of the department involved can temporarily suspend doctor privileges.

This is the extreme end of a stepped process for dealing with problems with doctors, Chan says.

The first level is trying to improve behaviour. The second level can involve multiple complaints.

There can be a temporary suspension while other processes take place, says Chan.

When serious problems arise, "it really sets off a number of…safeguards.”

First, Niagara Health’s medical advisory committee would meet "almost instantaneously" regarding recommendations to the board. Then, there could be a board meeting. The doctor can appeal a board decision to suspend a physician.

It is a rigorous process during which the doctor has the opportunity to contest allegations, and there is a rigorous review process, Chan says.

Dr. David Eden, the coroner and presiding officer, gets today’s hearing underway by stressing the role of the coroner’s jury.

It’s to determine the facts and inform the public about the circumstances surrounding a death. It may also come up with recommendations to prevent future deaths.

An inquest is not a trial, so the jury isn’t tasked with determining any legal responsibility.

The coroner’s jury will hear more from two Niagara Health officials when it resumes around 9 a.m. ET.

Dr. Kevin Chan, the regional health authority’s chief of staff and executive vice-president of medical affairs, and regional chief of emergency medicine Dr. Rafi Setrak began testifying yesterday. They’re speaking on how the credentials of physicians in the system's hospitals are reviewed.

Other witnesses include:

It’s Day 12 of the Ontario coroner’s inquest for Heather Winterstein, a 24-year-old who died of sepsis in the St. Catharines hospital.

The Indigenous woman first sought care on Dec. 9, 2021, for body pain from a fall. She was sent home with Tylenol and told to return if her condition worsened. The next day, she waited more than two hours in the ER for a doctor before collapsing.