Ontario inquest hears how hospital system 'failed' Indigenous woman who died after 2 days of seeking help

Officials with niagara falls wellness and a former compeer booster workings provided prominent testimony on Day 12 of the inquest for Heather Winterstein.

Winterstein, 24, died after a lengthy wait in the St. Catharines, Ont., emergency department on the second day she tried to seek help for pain. As an Indigenous woman with personal struggles, she may have been at higher risk in a health-care system with “systemic biases,” the inquest heard previously. She died on Dec. 10, 2021, despite hours of frantic efforts to save her. 

On Thursday, Dr. Rafi Setrak, Niagara Health’s regional chief of emergency medicine, was questioned about the doctor who released Winterstein on Dec. 9 after giving her a Tylenol and telling her to return to the hospital if her condition got worse.

Setrak testified the health authority is “committed” to evaluating doctors, but added: "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?”

Dr. Kevin Chan, regional chief of staff and executive vice-president of medical affairs, said Niagara Health is constantly trying to improve its policies "and build systems that don't fail people."

Chan noted Dec. 10 was an "extraordinarily busy day" in the emergency department. 

The inquest has heard the hospital faced extraordinary demands due to the COVID-19 pandemic. Ryan Pearson, commander of regulatory compliance at Niagara Emergency Medical Services, testified Thursday that call volumes were soaring at the time Winterstein took an ambulance to the hospital on Dec. 10.

Scott Cronkwright was a peer support worker with Niagara HELPS who aided Winterstein during her two days in hospital. He said he had lived experience with drug use and homelessness, so could understand how Winterstein felt.

On the day she died, he found her lying on the floor of the emergency waiting room in obvious pain.

During testimony by a triage nurse, notes presented at the inquest showed Winterstein had been having body pain for six days before she died.

Cronkwright said he’s haunted by the fact he didn't push medical staff harder to get her urgent care.

"This young lady should have been in a bed. I don't think she should have been in the waiting room."

The inquest, which began March 30, continues Friday at 9 a.m. ET. Pearson, the Niagara EMS commander, is expected to resume testimony.

Sim questions Pearson about the way paramedics assign patients a level under the Canadian Triage and Acuity Scale, which has a score from one to five, with one relating to the most serious conditions.

On Dec. 10, after Winterstein's dad called 911 for an ambulance for her, there was a secondary call from an EMS nurse, the inquiry hears. 

EMS also has a priority scale rating the seriousness of calls, from a one to a five, with one being the most pressing.

In cases deemed less serious, Pearson says EMS may encourage patients to go to walk-in clinics or see their family doctor rather than a hospital emergency department.

Sim says she’ll have more questions for Pearson but suggests the hearing wrap for the day given the amount of evidence presented. Inquest proceedings will resume at 9 a.m. ET tomorrow.

Ryan Pearson is commander of regulatory compliance at Niagara Emergency Medical Services, the regional paramedic service.

On questioning from Sim, Pearson says the service covers the entire Ontario region, has about 19 stations, and employs about 245 full-time paramedics, 158 part-time paramedics, 50 dispatchers and six emergency communications nurses.

The service has 53 ambulances and 32 emergency response vehicles.

Pearson says the COVID-19 pandemic strained the region’s EMS resources, with call volumes substantially up.

EMS transported 39,543 patients in 2020, 42,617 patients in 2021 and 68,867 patients in 2022.

Call responses over that period went from 60,000, to 67,000 to 68,867.

On Dec. 10, 2021, the service was in alert status 1, meaning there were more calls for service than there were ambulances able to respond, Pearson says.

Jurors are back from the break and tell Cronkwright they have no questions for him, but wanted to stress the importance of peer support work and his testimony during the inquest process.

“We really enjoyed your recommendations as well and will take those into consideration,” one juror tells him.

We’re now on a short break.

Sim, the inquest counsel, asks Cronkwright if there’s anything else he’d like to recommend to the coroner’s jury.

“We need empathy. We need love,” he says. “There’s an intrinsic bias … that needs to be worked on. That needs to start in school and not window-dress it with a 20-minute video. Have experienced people go in. Let them hear from the people they serve.”

Cronkwright said a deep understanding and respect of what people with mental health, home insecurity and addiction go through is important for medical staff.

We're on a short break while the jury ponders questions for Cronkwright.

Inquiry lawyer Vivian Sim asks Cronkwright if he was asked to debrief after Winterstein's death along with hospital medical staff. He says he was not.

Asked if he could have done anything differently for Heather, Cronkwright said he could have advocated much harder. 

"I feel so bad for Heather, I feel so bad for the family. We could have done much better.

"I'm really sorry I couldn't have done more.

"I wish I would have stood up much more forcefully."

He said people with lived experience like him should be brought in as part of education for front-line medical staff. 

"The stigma around mental health is terrible and you see it all the time" among emergency staff, says Cronkwright. 

There’s now a short break to deal with technical issues.

A document is shown saying the triage nurse came out on Dec. 10 and told Cronkwright to tell Winterstein at one point that she'd have to wait five or six hours.

"I thought it was very insensitive," he says. 

Cronkwright says he had real concerns about Winterstein's condition.

Asked if he was worried about how she was perceived by medical staff, he says he did on Dec. 9.

On Dec. 10, he said it was clear Winterstein needed medical attention urgently.

"This young lady should have been in a bed. I don't think she should have been in the waiting room. She's too sick."

He said he wished he'd pushed medical staff on that.

"I could have advocated better," he said, his voice breaking. "I could have been more forceful."

Cronkwright says he returned to the hospital later on Dec. 10 to see Winterstein. 

"She was on the floor and she was kicking her feet. The floor is cold and dirty, so I asked one of the security staff to help me get her up off the floor" and return her to her wheelchair. A paramedic might also have helped, he says.

A video shown at the inquiry shows Cronkwright approaching Winterstein on the floor, then walking to get security to help him. He is also shown bringing her a clean blanket, and putting the blanket over her, after she was back in her wheelchair.

He says he remembers being angry that she was placed facing the wall in her wheelchair.

Another video is shown of Cronkwright about to leave his shift.

"I hate this part. I wished her well," he says, his voice breaking. 

“She was a very sick girl.

"Her colour was terrible," Cronkwright says. "She was in so much pain. 

"I remember how sweet this young lady was. She was a sweet young girl. It reminded me of my three daughters. It was tough to leave her."

A video is shown of Cronkwright pushing Winterstein in a wheelchair to get her to the bus stop.

He says he left her in a bus shelter.

"I was concerned about how she was going to get on the bus and how she was going to get off the bus."

Cronkwright saw Winterstein again on Dec. 10, 2021, going through the waiting room. 

"She seemed very grey; she seemed to be struggling with movement," he says.

Cronkwright says she was in pain. "She just seemed like she was struggling."

Cronkwright says Winterstein told him she couldn’t stand up. 

"She was speaking very quietly. She didn't look like she had a lot of strength."

A form that Cronkwright filled out related to the interaction and shown at the inquiry mentioned lower back pain and fentanyl withdrawal. 

From his experience, he says, Winterstein didn't seem to have the symptoms of fentanyl withdrawal such as agitation and sweating. "She was calm."

He planned to refer her to an emergency shelter, detox and Quest's Urgent Service Access Team.

In another consent form document signed by Cronkwright and Winterstein, she signed her name with just initials. He says she was having difficulty holding a pen.

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