Homicide.

What the Jury Must Decide

As this inquest moves into its final phase, the responsibility now rests with the jury.

Under the Coroners Act, the jury is required to answer five specific questions. These are not abstract considerations. They are findings of fact that will define how Heather Winterstein’s death is understood.

Three of those five questions have been agreed upon by all parties.

There is no dispute as to who Heather was.

There is no dispute as to when she died.

There is no dispute as to where she died.

Heather Ashley Winterstein died on December 10, 2021, at Niagara Health in St. Catharines.

Those facts are settled.

What remains are the two most consequential determinations:

What was the cause of her death?
And what was the manner of her death?

The evidence on cause has largely converged. Expert testimony established that Heather died from septic shock resulting from sepsis, which itself developed from a bloodstream infection. That progression is medically understood and, in many cases, treatable when recognized and addressed in time.

The question that remains—and the one that carries the greatest weight—is how that death is classified.

Understanding Manner of Death in an Inquest

The jury must choose one of five categories:

Natural.
Accident.
Suicide.
Homicide.
Undetermined.

It is critical to understand that these categories do not function in the same way they do in criminal law.

In a coroner’s inquest, there is no finding of guilt. No one is on trial. There is no assignment of criminal responsibility.

As was explained clearly in proceedings, the term “homicide” in this context is not about blame. It is a factual description of how a death occurred.

A death is classified as a homicide when three elements are met:

First, there must be an injury. That injury is not limited to physical trauma. It can include an omission—something that should have been done, but was not. In a healthcare context, delayed treatment can meet this definition.

Second, that injury must be non-accidental. That does not mean intentional. It means that the outcome was not random, unforeseeable, or beyond the scope of known risk.

Third, that injury must have caused or significantly contributed to the death.

This framework is essential, because it allows the jury to consider deaths that occur within systems—where no one individual intended harm, but where actions and omissions nonetheless produced it.

What the Jury Heard Today

Today’s proceedings reinforced several critical realities that must be held together.

The system was under pressure.

Emergency departments were dealing with staffing shortages, high patient volumes, and competing demands. The evidence referenced provincial audits showing widespread strain across hospitals, including staffing gaps and service disruptions.

The testimony confirmed what many already understand: emergency care does not occur in ideal conditions. It occurs in environments where clinicians must prioritize, triage, and make rapid decisions.

But the jury also heard something equally important.

Even within those conditions, care is not distributed evenly by chance.

Decisions are made.

Some patients are seen sooner.

Some are escalated.

Some are reassessed.

And some are not.

The evidence made clear that staffing shortages and system pressure do not eliminate responsibility. In fact, they heighten the importance of how decisions are made under constraint.

The jury also heard about training—what exists, and what does not.

A nurse testified that formal, skills-based training in Indigenous health, cultural safety, and anti-racism—of the kind called for in the Truth and Reconciliation Commission—was not part of her professional education.

Training that did exist was often self-directed, general, and not integrated into clinical practice.

This matters because the system acknowledges risk—particularly the risk of bias—but has not consistently equipped its practitioners to manage that risk in real time.

And that gap between knowledge and practice is not theoretical.

It is where outcomes are shaped.

The Case for Homicide

The determination of manner of death must be grounded in what was actually seen, heard, and experienced within the emergency department—not only in medical timelines, but in the lived reality of how care was delivered.

The jury heard from a civilian witness who had been present in the emergency department at the same time as Heather. This witness described being assessed and treated while observing Heather in the waiting area. Her testimony was not clinical, but it was direct and grounded in observation.

She described Heather as visibly unwell. She described her as someone who stood out in the room—not because of behaviour, but because of how sick she appeared. The witness spoke about watching Heather over time, noting that she remained in the waiting area while others, including herself, were brought forward for care.

The contrast in her testimony is difficult to ignore.

She described being seen and assessed.

She described being brought forward into care.

And in the same period of time, she described Heather continuing to wait.

She observed that Heather appeared to be getting worse.

She did not describe a patient being disruptive or refusing care.

She described a patient who was present, visible, and unwell—and who remained in the waiting room.

This is not an abstract gap in policy.

It is a real-time account of two patients in the same environment, under the same system pressures, receiving different responses.

That distinction matters.

Because it demonstrates that care was not absent in that moment.

The system was functioning.

Patients were being assessed.

Decisions were being made.

But those decisions did not result in Heather being prioritized, reassessed, or escalated, despite her visible condition and her return to the hospital with worsening symptoms.

The jury also heard that Heather had returned to the emergency department after being discharged the previous day. In clinical practice, a return visit is not treated as a repetition of the same event. It is a recognized point of escalation. It signals that the initial assessment may have been incomplete or that the patient’s condition has changed. It requires renewed attention.

But the evidence suggests that this escalation did not occur in the way it should have.

The concept of anchoring bias, as explained in testimony, is directly relevant. Once a patient is understood through an initial lens, that lens can persist. A returning patient may continue to be viewed through the framework of their earlier visit, rather than being reassessed independently based on new information.

In Heather’s case, that risk was compounded by other factors that the evidence identified as increasing the likelihood of biased interpretation.

She was an Indigenous woman.

She had a history of substance use.

She was perceived, at times, as homeless.

She had a documented history of anxiety.

Expert testimony established that these characteristics are associated with an increased risk of being underestimated, deprioritized, or misinterpreted in clinical settings. They shape how symptoms are understood and how urgency is assigned, often without conscious awareness.

The jury also heard that formal, structured training in Indigenous health, cultural safety, and anti-racism—training that directly addresses these risks—was not consistently embedded in clinical education. Where training existed, it was often general, optional, or self-directed.

This is not a minor gap.

It means that the system acknowledges the risk of bias but does not consistently equip practitioners to interrupt it in real time.

The result, as reflected in the testimony, is not a system that failed to function.

It is a system that functioned unevenly.

Heather’s condition continued to deteriorate while she waited.

She was not reassessed in a way that recognized that deterioration.

She did not receive the timely intervention that her condition required.

And when care was finally initiated, it was in response to collapse—not in response to the earlier signs that had been visible, observed, and, in the words of the witness, concerning.

In the context of sepsis, that delay is critical.

The medical evidence confirms that early recognition and treatment significantly improve outcomes. Delayed treatment increases the likelihood of progression to septic shock and death.

The delay in Heather’s care was not neutral.

It was consequential.

And it occurred within a system that had both the capacity and the opportunity to act sooner.

Within the framework provided to the jury, that delay constitutes an injury.

It is an omission—something that should have been done, but was not—that significantly contributed to the outcome.

That injury was not accidental in the relevant sense.

The risks were known.

The need for reassessment was known.

The significance of a return visit was known.

The system had policies and protocols designed to address these exact situations.

The failure lies in their application.

When the testimony is considered in full—not only the medical evidence, but the lived experience of those who were present, the expert explanation of how bias operates, and the acknowledged gaps in training and implementation—it becomes clear that Heather’s death cannot be understood as solely natural, nor as an unforeseeable accident.

It occurred within a chain of events in which the actions and omissions of others—within a functioning healthcare system—played a significant role.

Under the definition provided to the jury, that meets the threshold for homicide.

Not as an accusation.

But as an accurate description of how this death occurred.