Medical expert defends doctor’s assessment of woman before she died of sepsis in Ontario hospital

scots heather Winterstein didn't exhibit trademark warning signs of potentially life-threatening sepsis when she went through and through triage showing the day before she died at the hospital in St. Catharines, Ont., an emergency medical expert told the coroner’s inquest for the 24-year-old.  

Early detection of the kind of extreme reaction to a bacterial infection that killed Winterstein  on Dec. 10, 2021, is critical, but Dr. Ron McMillan said there’s no magic bullet when it comes to diagnosing the condition.

McMillan, an expert with McMaster University, reviewed hospital records and a post-mortem examination report on Winterstein. On Tuesday, he appeared to support many of the clinical decisions made by emergency physician Dr. Emad Nour, who treated Winterstein on Dec. 9, 2021, the day before the Indigenous woman died.

Winterstein had been complaining of body pain, in particular in her right leg. Although he examined her for possible signs of infection, Nour ultimately determined she didn't have one. 

Nour testified last week, several days after the inquest began on March 30, and is expected to continue his testimony later this week. 

The inquest, which was announced in 2024, is being held virtually. Twenty-two witnesses are expected to testify over 13 days. Those who’ve already testified include members of Winterstein's family, a police officer and a paramedic, a triage nurse and a senior executive with Niagara Health, which runs the hospital that’s now known as Marotta Family Hospital. 

Inquests are held to inform the public about the circumstances of a death, but don’t assign blame or make findings of guilt or innocence. A coroner’s jury reviews evidence to determine the facts surrounding a death and may make recommendations to prevent similar deaths.

Winterstein's mother said earlier that she hopes the jury will make recommendations. Since her daughter's death, family members and community organizations have also expressed concern  that addiction discrimination and anti-Indigenous racism may have played a role in how Winterstein was treated.

On Tuesday, McMillan said the triage screening showed Winterstein had a nearly normal temperature, blood pressure in the low-normal range and normal respiration. While her pulse was slightly elevated at 115 beats per minute, he said that could have been attributed to factors other than sepsis.

Nour opted not to repeat taking Winterstein's vitals and also decided against sending her for bloodwork, the inquiry heard earlier.

Instead, she was given Tylenol, sent home and instructed to return to the emergency department if her symptoms worsened.

In his report, Nour noted "social issues" were behind her trip to the hospital.

The next morning, Winterstein's family called for an ambulance and she returned to the hospital. After spending hours in the emergency department waiting room, Winterstein collapsed on the floor. Efforts by medical staff to resuscitate her failed.

McMillan defended many of Nour’s clinical decisions on Tuesday when he was questioned by lawyer Jaan Lilles, who represents Nour and three other doctors.

McMillan noted that Nour didn't find signs of an infection in Winterstein.

"Sepsis is a life-threatening condition," he said. "[But] you cannot have sepsis without infection."

McMillan noted the post-mortem report also said no source of infection was identified.

"That's important because the post-mortem is factual and objective. If there's no source of infection identified, that supports the clinical examination that was done by Dr. Nour on Dec. 9."

Likewise, a large-scale infection such as sepsis, unlike a localized infection, would likely need a confirmation of fever, McMillan said. The temperature recorded by the triage nurse didn't show that, he added.

When questioned whether he thought Nour should have ordered bloodwork, McMillan said: "No, in my opinion no laboratory investigations were warranted based on the clinical assessment done on Dec. 9."

Questioned by a lawyer representing Winterstein's family, McMillan also defended Nour's decision not to start her on antibiotics.

McMillan said prescribing antibiotics when no infection is present could raise the risk of antibiotic resistance, and doctors shouldn't do that without first determining there’s an infection.

"It is important to treat infection promptly, but it's most important, in fact, it's mandatory and it's essential, that you actually identify the infection first," he said. You can't treat an infection [if] you don't have clinical evidence that it exists.

"Antimicrobial resistance is actually a global health risk."

McMillan also supported Nour's decision not to take Winterstein's vital signs again.

He noted people who have developed sepsis can go on to develop septic shock or, with specific types of bacterial infections, toxic shock, in which blood pressure can plummet to dangerously low levels with multi-organ failure.

"That form of shock can come about extremely quickly, within hours.” 

McMillan noted the hospital has screening tools for sepsis that include the inflammatory response syndrome (SIRS) test. But he said Winterstein's vital signs and her apparent lack of an infection didn't meet that threshold. 

"There isn't one single test that can diagnose sepsis," he said. 

Those screening tools can help in early recognition of sepsis, but aren't absolute, said McMillan.

"They don't replace nor were they meant to replace clinical judgment when assessing a patient."

He also said that in his view, Nour's controversial "social issues" diagnosis of Winterstein in his doctor’s notes — Nour noted her history of substance abuse and housing instability  — wasn't out of line in emergency department diagnoses.

"'Social issues' is … typically used when there is no definitive diagnosis that's apparent on clinical assessment.

"It's certainly not a definitive diagnosis, but it is one that is used in emergency departments by emergency physicians."

McMillan said psychosocial issues, mental health issues and housing issues can lead to physical symptoms in patients who show up at hospital emergency departments.

Reporter/editor

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