Woman who died in Ontario hospital shouldn’t have been in wait room, needed frequent assessment, inquest told

On the daytime she died of sepsis, ling Winterstein shouldn't feature been placed in the exigency elbow room waiting area at the St. Catharines hospital until she could see a doctor, an emergency medicine expert told a coroner's inquest Wednesday.

But even if she had to be put in the ER wait room due to limited resources and staffing shortages, it would have been critical for her to be reassessed frequently for any signs of her condition deteriorating, Dr. Ron McMillan of McMaster University testified.

The inquest also heard that as paramedics brought Winterstein to what's now known as the Marotta Family Hospital on Dec. 10, 2021, her vital signs appeared to be fluctuating widely.

Winterstein died after spending two days trying to access health care at the hospital. 

On Dec. 9, she arrived by ambulance, complaining of pain after reportedly falling down a flight of stairs the day before. She was given a Tylenol and sent home with instructions to return to the emergency department if her condition worsened. The emergency department physician who assessed her determined "social issues" were behind her hospital visit.

Winterstein's dad called for an ambulance the next morning. After waiting hours in the emergency department’s waiting room, Winterstein collapsed on the floor. Efforts by medical staff to resuscitate her failed and she was pronounced dead.

An autopsy found Winterstein died from sepsis, an extreme response due to  streptococcus pyogenes and staphylococcus aureus bacterial infection.

Since Winterstein’s death, family members and community organizations have expressed concern that addiction discrimination and anti-Indigenous racism may have played a role in how she was treated.

On Wednesday, Dr. David Eden, who’s heading the inquest that began March 30, asked McMillan if it's important to have vital signs repeatedly checked for a patient like Winterstein who had returned to the emergency department for a second time in two days.

McMillan noted Winterstein, of St. Catharines, was triaged at the second highest level of five levels under the Canadian Triage and Acuity Scale (CTAS).

"That means that patient should be seen by an emergency physician within 15 minutes," he said.

If that wasn't possible because of limited resources, then Winterstein should have been reassessed frequently by a nurse for any signs that her condition was worsening, said McMillan.

"They shouldn't be in the waiting room," he said of CTAS 2 patients. "They need close observation, repeated vitals — reassessment should there be any change in their clinical status at all.

"That is extremely important."

McMillan said sepsis is a potentially life-threatening condition that can advance to even more serious septic shock or toxic shock, which have very high death rates when a body's immune response to infection becomes severe.

That can lead to plummeting blood pressure and multi-organ failure, McMillan said.

In inquiry testimony last week, Heather Paterson, executive vice-president of clinical operations with Niagara Health, which runs the hospital, said that due to her CTAS score, Winterstein should have been reassessed every 15 minutes by a triage nurse while she was in the waiting room.

Asked if management was checking to see if those reassessment requirements were being met, Paterson said, "I don't think so."

She was also asked by a lawyer representing the Winterstein family what system was being used by triage nurses to ensure they were re-assessing patients such as Winterstein in the waiting room in a timely manner.

 "I can't answer that question. I''m not sure what system the triage nurses would use."

Paterson also noted the health system was in "unprecedented times" due to the pandemic, and the emergency department was short several nurses on Dec. 10, 2021, with some off sick or unable to come to work because they'd been exposed to people with COVID-19.

"When we're short-staffed nurses, there is [an] impact in the way that we deliver care," said Paterson. "When you're three nurses short or four nurses short, things would not get done potentially in a timely manner. There may be delays in implementing treatment plans. There may be delays in assessment."

Vivian Sim, one of the inquiry lawyers, presented a chart on the day Paterson testified. It showed that on the day Winterstein died, 90 per cent of the patients with a CTAS 2 score waited on average 4.6 hours to see a doctor. That same day, 90 per cent of patients deemed less serious with CTAS 4 scores waited 3.8 hours on average, while 90 per cent of patients deemed least serious with CTAS 5 scores waited 1.8 hours on average before seeing a doctor.

On Wednesday, Brandon St. Angelo, one of two Niagara Emergency Medical Services paramedics who brought Winterstein to the hospital by ambulance on Dec. 10, conceded he didn't take Winterstein's vital signs at first.

He said that's because she was in a small mudroom just off a narrow set of stairs leading up to a second-floor apartment on Elizabeth Street where Winterstein's dad lived.

St. Angelo and the other paramedic had Winterstein walk down the stairs under her own power. He said that was due to the fact the stairs were narrow, with rickety railings that he thought would make a stretcher or a carrying stair chair too dangerous to use.

Once in the ambulance and then en route to the hospital, Winterstein's vital signs were fluctuating noticeably, according to a paramedic document shown at the inquiry.

It showed her heart rate went from 125 beats per minute at 11:36 a.m. To 134 at 11:44 a.m., then 132 at 11:47 a.m. And 109 at 12:17 p.m. Her blood pressure over those same time periods went from 97/66 to 157/139 to 93/65 and then to 121/76.

Her oxygen saturation levels, which should normally be 95 to 100 per cent, went over those same time periods from 96 per cent, to 91 per cent, to 84 per cent and to 96 per cent.

St. Angelo said the machines taking those vitals might have been getting false readings if Winterstein was moving, and noted the ambulance was travelling on a bumpy road at times.

Natai Shelsen, a lawyer for the Winterstein family, asked St. Angelo if, under safety standards, Winterstein should have been brought from the apartment to the ambulance on a stretcher, and if she should have had a cervical neck collar on and have had minimal spinal movement.

"That's fair to say," he said.

Also on Wednesday, the Niagara Ontario Health Team — a network of health-care providers, social service agencies, educational organizations and patient/client/family/caregiver representatives working to improve co-ordination and integration of health services in the region — said it's committed to listening and learning from the inquest proceedings, and from any recommendations that may emerge.

The network "will consider the findings carefully for their relevance to care co-ordination, system navigation, Indigenous health, and efforts to address anti-Indigenous racism in health and social care," the network said in a statement.

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.

The inquest is expected to hear from about 22 witnesses over 13 days and is being conducted virtually.

Reporter/editor

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