Some paramedic protocols not met in taking Indigenous woman to hospital before sepsis death: Ontario inquest

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Testimony in the coroner’s inquest for Heather Winterstein is nearing its end, with proceedings today expected to hear again from an EMS commander who spoke yesterday about how busy the ambulance service was on Dec. 10, 2021.

Ryan Pearson testified the paramedic service was being overloaded with calls around that time. The inquest, which began March 30, previously heard that the COVID-19 pandemic had led to increasing patient loads and understaffing.

Winterstein, 24, was taken by ambulance to hospital twice, on Dec. 9 and 10, and faced lengthy emergency department waits. She died hours after collapsing while waiting to see a doctor.

During testimony by a triage nurse, it was learned that Winterstein had been suffering body pain for six days after a fall. 

A hospital official was questioned yesterday about the ER doctor who saw Winterstein during her first hospital visit and sent her home with Tylenol, telling her to return to the hospital if she got worse.

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

Also yesterday, Dr. Rafi Setrak, the regional chief of emergency medicine at Niagara Health, which runs the hospital (now named Marotta Family Hospital), testified the health system "failed" Winterstein.

Earlier this week, Niagara Health president and CEO Lynn Guerriero said, "There's absolutely systemic racism and Indigenous racism in health care.” But she said she's struggling to accept that anti-Indigenous racism played a part in Winterstein's death, because front-line medical staff who were involved in her care have said they didn't know she was Indigenous.

Scott Cronkwright, a peer support navigator who interacted with Winterstein on both Dec. 9 and 10 at the hospital, described how much pain she was in when he found her lying on the floor of the emergency waiting room on Dec. 10. 

He said it was obvious Winterstein's condition was extremely serious and she should have had a bed instead of being in the waiting room.

The inquest was originally scheduled to hear witnesses for 13 days. It's not clear if testimony will conclude today or if it will stretch to Monday, when the charge to the jury is expected to take place.

Pearson concedes it was "important" that her grey skin was not recorded, as was her shortness of breath and her difficulty speaking.

"That's information that should be recorded."

He says it's "inherent" that bias can impact assessments on a systemic basis.

Sim asks if the credibility of all patients is perceived as equal by paramedics.

Pearson says "some things can be dismissed" by paramedics assessing patients. 

He agrees family members often provide important information about loved ones.

Pearson agrees the COVID-19 pandemic impacted family members often not being allowed to ride in ambulances, and that Winterstein's dad was left with the impression that Winterstein was being taken to the Fort Erie urgent care centre. 

Sim says Winterstein's dad, Mark Winterstein, called 911, and then there was a second call from the EMS emergency communications nurse. 

The inquest counsel notes some information provided by her dad didn't make its way into some documentation.

Sim brings up EMS dispatch data.

She says the information given to the paramedics was missing the fact her dad reported Winterstein looked grey and that she had shortness of breath.

Pearson says the paramedics said her skin was "unremarkable" rather than grey.

Pearson says he considered if those factors affected clinical judgment. 

Sim notes that bias can be unconscious and asks him if he should have considered subconscious or unconscious bias.

Pearson says "potential tunnel vision" by the lead paramedic on Dec. 10 could have been linked to the assessment of Winterstein by a doctor the day before.

The investigative report found the paramedics didn't take vitals of Winterstein until 25 minutes after they arrived, and they had her take the stairs and walk to the ambulance, which did not meet standards.

"The allegations relating to discrimination of the patient by the EMS crew remain unsubstantiated," the report said. 

"No details provided in the records and statements…support a conclusion that bias was shown by or in any way impacted care provided by the attending crew."

Pearson said he considered possible bias related to Winterstein's history of drug use and her status as an Indigenous person.

Pearson’s report said the EMS call on Dec. 10 was "high compliant" and a followup call from an EMS emergency communications nurse was also "high compliant." 

That second call resulted in Winterstein being upgraded to a Canadian Triage and Acuity Scale (CTAS) rating of Level 2, which prevented her from being held in queue at the hospital.

CTAS is based on a five-level scale, with Level 1 representing the sickest patients and Level 6 indicating non-urgency. 

The report said a brief bathroom break taken by the paramedics on the way to get Winterstein didn't affect patient care.

The inquest heard earlier that on the day Winterstein died, one of the paramedics appeared to try to convince Winterstein to remain at home rather than go to the hospital, and the paramedics didn't immediately take her vital signs. 

The paramedics also had her walk down stairs to the ambulance under her own power, and one of the paramedics tried to convince Winterstein to be taken to the Fort Erie urgent care centre, telling her she'd likely have a very long wait to be seen by a doctor at the hospital.

Pearson's report found that EMS noted "some minor documentation issues" related to the Winterstein calls on Dec. 9 and 10, but "no patient care deviations that impacted patient outcome."

Under questioning by inquest counsel Vivian Sim, Ryan Pearson from Niagara Emergency Medical Services has resumed his testimony.

He says he conducted an investigation into the EMS interactions with Winterstein.

The ambulance service had taken Winterstein to the St. Catharines hospital on both Dec. 9 and Dec.10, 2021.

Pearson later wrote a 21-page report with four recommendations, all related to remediation of EMS staff.

In total, 22 witnesses were scheduled to testify at the inquest. We’ve already heard from family members, triage nurses, Niagara Health hospital officials and medical experts.

Today, Ryan Pearson will continue testimony he started yesterday. He’s the commander of regulatory compliance at Niagara Emergency Medical Services, the regional paramedic service.

Other witnesses will also include Dr. Liz Boucher, a forensic pathologist.

Forensic pathologists are medical doctors with additional pathology training, so are experts in disease and injury that result in sudden death, according to the Canadian Society for Forensic Science. Their role is to investigate the death itself so, in a way, they are the voice of the deceased, the society says.

Testimony in the coroner’s inquest for Heather Winterstein is nearing its end, with proceedings today expected to hear again from an EMS commander who spoke yesterday about how busy the ambulance service was on Dec. 10, 2021.

Ryan Pearson testified the paramedic service was being overloaded with calls around that time. The inquest, which began March 30, previously heard that the COVID-19 pandemic had led to increasing patient loads and understaffing.

Winterstein, 24, was taken by ambulance to hospital twice, on Dec. 9 and 10, and faced lengthy emergency department waits. She died hours after collapsing while waiting to see a doctor.

During testimony by a triage nurse, it was learned that Winterstein had been suffering body pain for six days after a fall. 

A hospital official was questioned yesterday about the ER doctor who saw Winterstein during her first hospital visit and sent her home with Tylenol, telling her to return to the hospital if she got worse.

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

Also yesterday, Dr. Rafi Setrak, the regional chief of emergency medicine at Niagara Health, which runs the hospital (now named Marotta Family Hospital), testified the health system "failed" Winterstein.

Earlier this week, Niagara Health president and CEO Lynn Guerriero said, "There's absolutely systemic racism and Indigenous racism in health care.” But she said she's struggling to accept that anti-Indigenous racism played a part in Winterstein's death, because front-line medical staff who were involved in her care have said they didn't know she was Indigenous.

Scott Cronkwright, a peer support navigator who interacted with Winterstein on both Dec. 9 and 10 at the hospital, described how much pain she was in when he found her lying on the floor of the emergency waiting room on Dec. 10. 

He said it was obvious Winterstein's condition was extremely serious and she should have had a bed instead of being in the waiting room.

The inquest was originally scheduled to hear witnesses for 13 days. It's not clear if testimony will conclude today or if it will stretch to Monday, when the charge to the jury is expected to take place.

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