Coroner's Inquest Examines Care Provided to Heather Winterstein Before Sepsis Death

ST. CATHARINES, Ontario — A coroner's inquest into the death of Heather Winterstein, a 24-year-old from St. Catharines, continued on Wednesday with testimony from Dr. Ron McMillan, an emergency medicine expert from McMaster University.

Winterstein died on December 10, 2021, at what is now known as the Marotta Family Hospital, operated by Niagara Health. The inquest, led by Dr. David Eden and started on March 30, is examining the circumstances surrounding her treatment.

Winterstein first arrived at the hospital emergency department by ambulance on December 9, 2021, reporting pain after falling down a flight of stairs the previous day. An emergency department physician assessed her and determined social issues were behind the visit. She was given Tylenol and sent home with instructions to return if her condition worsened.

The following morning, December 10, Winterstein's father called for an ambulance due to her deteriorating condition. Paramedics noted her vital signs were fluctuating widely en route to the hospital. Upon arrival, she was triaged at level 2 under the Canadian Triage and Acuity Scale (CTAS), which indicates patients should be seen by an emergency physician within 15 minutes.

McMillan testified that patients triaged at CTAS level 2 should not be placed in the waiting room and require close observation with repeated vital sign checks. He stated reassessment is extremely important for such patients, particularly those returning within a short period like Winterstein.

Sepsis, the condition that caused her death, can progress to septic shock or toxic shock, leading to plummeting blood pressure and multi-organ failure.

“They shouldn't be in the waiting room. They need close observation, repeated vitals — reassessment should there be any change in their clinical status at all. " — Dr. Ron McMillan, testifying at the inquest (Cbc) An autopsy determined Winterstein died from sepsis due to streptococcus pyogenes and staphylococcus aureus bacterial infections.”

After hours in the waiting room on December 10, she collapsed, and resuscitation efforts by staff failed.

prior testimony, Heather Paterson, executive vice-president of clinical operations at Niagara Health, stated that CTAS level 2 patients like Winterstein should be reassessed every 15 minutes by a triage nurse while in the waiting room.

Paterson said management was not checking if these reassessments were occurring and she was unsure of the system used by triage nurses. She noted the health system was operating under unprecedented conditions due to the COVID-19 pandemic. Since Winterstein's death, her family and community organizations have raised concerns that addiction discrimination and anti-Indigenous racism may have influenced her treatment.

The inquest aims to provide recommendations to prevent similar deaths. No further testimony dates have been specified, but the proceedings continue to review hospital protocols and resource limitations.