Some 911 call info on Indigenous woman in sepsis death didn't get to paramedics, Ontario inquest hears

niagara falls wellness CEO acknowledges racial discrimination in wellness care at ER death inquest | Hanomansing Tonight

Search asks if EMS has supports for paramedics who have experienced traumatic experiences while on calls. 

Pearson said paramedics can be pulled off the road to get peer support and have their mental state assessed. 

More traumatic calls can also be monitored, for check-ins by superintendents of paramedics.

Pearson says each supervisor goes out each year and watches paramedics on a call, doing a comprehensive evaluation and ensuring compliance rules are all being followed.

The inquest is on a short break while the jury ponders questions for Pearson.

Pearson says EMS has introduced mandatory training in areas such as bias, diversity, equity, inclusivity, implicit bias, people experiencing mental health or addiction issues, racism and Indigenous perspectives.

Superintendents and managers have also taken part in Indigenous experiences training, he says.

EMS is also working with Niagara Health's new Indigenous health council, and has full-time staff at the safe drug consumption site in St. Catharines who can respond to overdoses, Pearson adds.

Daina Search, lawyer for Niagara EMS, is now questioning Pearson.

He says that in response to increased call volumes, EMS added additional ambulances, moved bases so ambulances can be resupplied more efficiently, and increased the number of full-time staff.

"It certainly has improved," he says.

Search asks if EMS staff are protected under law when taking part in internal quality reviews, the way hospital staff are. Pearson says no.

Natai Shelsen, lawyer for the Winterstein family, is now asking Pearson questions.

Shelsen notes the report of Winterstein’s grey skin not making its way to the paramedics on Dec. 10, and adds that reports she was having slow speech did appear to make it to the paramedics.

But, she adds, in the ensuing paramedic report, there’s no mention of slow speech and it should have made its way to clinicians.

"The documentation lacked in certain details," Pearson concedes.

Sim asks Pearson if he has any advice to the inquest jury related to possible recommendations. 

He says more street outreach paramedics might be helpful to help marginalized people such as those with housing instability or substance use disorders.

Pearson says Winterstein's case is having an important impact.

"She still regularly enters my mind. I hope we get some answers from this. It's given us an opportunity to take a hard look at ourselves … and how we can do better."

There’s now a short break.

Pearson says paramedics get ongoing training of eight hours in the spring and eight hours in the fall. They also get other mandatory training. 

Sim asks him of "implicit bias" in training. Pearson says that since Winterstein's tragedy, EMS has introduced new training on bias.

He says there was likely implicit bias in Winterstein's case, and agrees EMS would be eager to participate in enhanced implicit bias training.

Sim asks Pearson what he would have done differently in his investigation. A lot of the findings still stand up, he says.

Pearson agrees there may have been some "anchor bias" in which health-care workers appeared to rely on assessments of previous health-care workers, reducing concerns about her worsening condition. 

A sepsis prompt card for paramedics is shown at the inquest. It has criteria used to help identify a possible infection. They include temperature at or above 38 C, and at or below 36 C, a pulse at or above 90 beats per minute, and a respiratory rate at or above 20 breaths per minute. 

It also has criteria such as low blood pressure and mottled skin.

Skin cellulitis, low alertness, vomiting, shortness of breath, diarrhea with a history of fever or rigours, cough, abdominal pain and changes to urine are among possible signs of infection, the card says.

Sim notes IV drug use is now used by Niagara Health as a risk factor for sepsis. Pearson agrees the EMS sepsis card could be updated to include that.

Winterstein's dad was left with the impression that her condition was more acute than it had been believed, Pearson agrees.

Winterstein's condition was upgraded to a CTAS 2 score versus CTAS 3.

"The intention was not meant to mislead Mr. Winterstein," says Pearson.

The inquest is playing part of the call between the EMS emergency communications nurse and Winterstein's dad.

"I think we can agree the grey skin should have been part" of the information provided to the paramedics, Pearson says.

In hindsight, Pearson says EMS can improve its processes from "the lessons learned from this tragedy."

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.

---

---