Before the Inquest: What We Already Know

On March 30, a coroner’s inquest will begin into the death of Heather Winterstein, a 24-year-old Indigenous woman from St. Catharines.

An inquest is not a trial. It does not determine guilt or liability. Its purpose is narrower and, in some ways, more difficult. It is meant to establish the facts of what happened and, from those facts, to make recommendations that might prevent a similar death in the future.

That is the formal description.

In practice, an inquest asks something else: whether what happened could have been different.

Heather Winterstein sought care.

In December 2021, she arrived at hospital in severe pain. She had been transported by ambulance. According to the coroner’s summary, she reported full-body pain following a fall. She was assessed at triage. An emergency room physician later discharged her, determining that the reason for her visit was related to “social issues.” She was given non-prescription medication and a bus ticket home.

The next day, her condition worsened. A family member called for help. A paramedic suggested she remain at home and rest. Heather insisted on going to hospital.

She returned.

She waited.

At approximately 2:45 p.m., in the emergency department waiting area, she collapsed. Resuscitation efforts were unsuccessful. An autopsy later determined the cause of death to be sepsis caused by streptococcus pyogenes and staphylococcus aureus.

Sepsis is treatable. It is also time-sensitive.

The inquest will examine what happened in the roughly 48 hours leading up to her death.

It will hear from witnesses, including healthcare providers, and consider the decisions that were made, the information that was available, and the conclusions that were drawn. It will also hear from those who were there, and from those who were not, but who are now tasked with explaining how the system functions.

There are several parties with standing in the inquest, including Heather’s family, Niagara Health, Niagara Emergency Medical Services, the Niagara Region Native Centre, and the Ontario Federation of Indigenous Friendship Centres. Several physicians involved in her care will also be represented.

This is as it should be. An inquest is meant to be thorough.

But the facts, as they are already known, are not unfamiliar.

In 2008, Brian Sinclair, an Anishinaabe man, died in a Winnipeg emergency room after waiting 34 hours without being seen. Staff assumed he was intoxicated or homeless. He had come seeking care for a treatable condition.

In 2020, Joyce Echaquan, an Atikamekw woman, recorded hospital staff speaking about her in degrading and racist terms as she lay in distress. She died shortly after.

In both cases, there were inquiries. In both cases, there were findings. In both cases, there were recommendations.

In 2015, the Truth and Reconciliation Commission issued Calls to Action, including several directed specifically at healthcare. They addressed disparities in outcomes, the need for culturally safe care, the integration of Indigenous knowledge, and the importance of training.

The language was clear. The expectations were not ambiguous.

And yet.

Indigenous patients in Canada continue to report that their symptoms are not taken seriously, that their pain is underestimated, and that their circumstances are interpreted through assumptions about substance use, poverty, or social instability.

This is not always explicit. It does not always appear in records. It is not always something that can be easily measured.

But it appears in outcomes.

It appears in how quickly care is provided, or not provided.
It appears in whether a patient is admitted, or discharged.
It appears in whether a complaint is pursued, or set aside.

In Heather Winterstein’s case, the record shows that her condition was, at one point, understood as social rather than medical.

That determination will be examined.

So will the question of what was known at the time, what should have been known, and what actions followed from those assessments.

There will likely be discussion of protocols, of triage systems, of staffing pressures, and of the complexity of emergency medicine. These are all real considerations.

But the inquest will also, whether directly or indirectly, confront something less easily defined.

It will confront how decisions are made in moments of uncertainty, and what influences those decisions.

It will confront whether assumptions play a role.

And it will confront whether the systems currently in place are sufficient to prevent this from happening again.

Niagara Health has stated that it is committed to strengthening cultural safety and has implemented various measures, including training and policy changes. These efforts will likely form part of the broader context.

The question, as always, is not whether efforts have been made.

It is whether those efforts are enough.

An inquest cannot answer every question. It cannot address every aspect of systemic inequity. It cannot undo what has already happened.

What it can do is make visible the sequence of events.

It can set out, in plain terms, what occurred.

And from that, it can offer recommendations.

Whether those recommendations are implemented, and whether they lead to meaningful change, is a separate matter.

That responsibility does not rest with the jury alone.

It rests with institutions.
It rests with governments.
It rests with those who work within the system.

And, in some measure, it rests with the public, in whether we are willing to pay attention, to remember, and to expect more than acknowledgment.

Heather Winterstein was 24 years old.

Her family has described her as a young woman who loved deeply. Someone connected to her community. Someone who had a future that, at the time, was still unfolding in ordinary ways, work, relationships, creativity, time with people who knew her.

There is no way to say exactly what that future would have looked like.

But there is no question that it existed.

And that it was cut short.

The inquest will focus on the final days of her life.

But the purpose of that focus is not only to understand how she died.

It is to ask whether she was failed by more than a moment.

Whether she was failed by a process.
By a system.
By a set of assumptions that shaped how she was seen, and how quickly she was helped.

And whether those same conditions continue to exist.

Heather’s story now sits alongside others that have come before.

That is difficult to say plainly.

But it is necessary.

Because if this is a pattern, then it is one that can be changed.

And if it can be changed, then it must be.

That is what this inquest must confront.

And that is what comes next.