In the coming days, a coroner’s inquest will begin into the death of Heather Winterstein, a young Indigenous woman whose passing in December 2021 has had a profound and lasting impact on her family, community, and many across Ontario.
For many, this process may feel unfamiliar. An inquest is not a criminal trial. It does not determine guilt or assign legal blame. Its purpose is to examine the circumstances surrounding a death and to make recommendations that may help prevent similar tragedies in the future.
But while the process is legal in structure, its impact is deeply human.
At its core, this inquest is about understanding what happened in the hours and days leading up to Heather’s death, and whether those circumstances point to broader issues that must be addressed within our healthcare systems.
Based on publicly available information, Heather sought medical care in St. Catharines in early December 2021 after experiencing severe and widespread pain following a fall.
She arrived at the hospital by ambulance and was assessed in the emergency department. At that time, her condition was determined to be related to “social issues,” and she was discharged with non-prescription medication.
She was provided a bus ticket and transported to a bus stop.
The following day, as her condition worsened, emergency medical services were contacted again. After initial hesitation about returning to hospital, she insisted on being taken back.
While waiting in the emergency department, she collapsed.
Despite medical intervention, she later died.
A subsequent autopsy determined her cause of death to be sepsis, resulting from bacterial infection.
The inquest will examine the events that occurred over approximately 48 hours leading up to Heather’s death. This includes her initial interaction with paramedics, her assessment and discharge from hospital, and her return the following day.
Several parties have been granted standing in the inquest, including Heather’s family, Niagara Health, Niagara Emergency Medical Services, the physicians involved in her care, and the Niagara Region Native Centre. The Ontario Federation of Indigenous Friendship Centres will participate as a Person Permitted to Make Submissions, bringing forward its expertise in Indigenous health and systemic issues.
In advance of the inquest, a motion hearing was held to determine what evidence may be presented and how certain aspects of care will be examined. This includes questions about clinical decision-making, prior concerns related to care, and the role of expert testimony in understanding what occurred.
While the inquest will not assign blame, it will ask important questions.
How were Heather’s symptoms interpreted during her initial visit?
What information was available to those providing care, and how was it understood?
Were there opportunities to recognize the severity of her condition earlier?
How did communication between providers, including paramedics and hospital staff, shape the outcome?
And importantly, how do broader factors, including systemic bias, assumptions about social circumstances, and the lived realities of Indigenous patients, influence care?
These are not abstract questions. They go to the heart of how healthcare systems function, and whether they respond equitably to all patients.
For many Indigenous people, Heather’s experience is not unfamiliar.
Across Ontario, Indigenous patients continue to report being dismissed, misunderstood, or treated with less urgency within healthcare environments. Concerns about pain not being taken seriously, symptoms being attributed to substance use or social conditions, and a lack of culturally safe care have been raised consistently through community advocacy and research.
The inquest creates a space where these realities may be examined publicly.
It also brings forward an important question about accountability.
In recent years, many institutions have taken steps toward reconciliation. Cultural safety training has been introduced. Policies have been updated. Land acknowledgements have become more common.
These efforts matter. But they are not, on their own, sufficient.
There is a growing recognition that reconciliation cannot exist only at the level of policy or training. It must be reflected in practice, in decision-making, and in how care is experienced by patients in real time.
The difference between intention and impact is critical.
The inquest is scheduled to begin on March 30. Over the course of the proceedings, evidence will be presented, witnesses will be heard, and expert perspectives will be shared.
At the conclusion, a jury may make recommendations aimed at improving systems of care and preventing similar deaths.
For Heather’s family, this process is one step in a much longer journey. One that has already required strength, persistence, and a deep commitment to ensuring that her story leads to meaningful change.
For communities, it is an opportunity to listen, to reflect, and to engage in a broader conversation about how care is delivered and how it can be improved.
At Grandmother’s Voice, we will be following this process closely and sharing information in a way that is respectful, accurate, and grounded in community.
We also recognize that Heather’s story does not stand alone.
If you have experienced barriers, challenges, or harm within the healthcare system, we invite you to share your experience with us in confidence. These stories will be held with care and will help inform the collective understanding needed to support change.
This inquest is about more than understanding what happened.
It is about what we choose to do with that understanding.
Heather’s life mattered. The responsibility now is to ensure that what is learned through this process leads to care that is more responsive, more equitable, and more grounded in dignity.
That is how we honour her.
And that is how we move forward.
Presented by Samantha Doxtater
Presented by GRANDMA RENEE
In a world seeking direction, Indigenous teachings offer clear and enduring policies for how to live in harmony with one another and the Earth. This workshop invites participants to explore the profound lessons of the Two Row Wampum Belt and other wampum belts as frameworks for mutual respect, environmental care, and collective well-being. These belts, created long before colonization, embody ancestral agreements that guide humanity on how to coexist with honor, dignity, and reciprocity.
Led by Grandmother Renee, this session emphasizes the importance of relearning and honoring the policies established by our ancestors, rather than creating new paths disconnected from this wisdom. Through the teachings of the belts, participants will uncover the principles of self-care, stewardship of the land, and respect for all beings. This is not about inventing something new—it is about rediscovering the instructions that were always there and committing to uphold them.
Key Takeaways:
Through this workshop, participants will be reminded that the wisdom of the belts is not only a guide for Indigenous communities but a path for all of humanity to walk together in respect and care for one another and the Earth.
Presented by Grandma Gail and Angela DeMontigny
Ceremony is more than tradition—it is a deliberate practice rooted in wisdom, responsibility, and foresight. This workshop explores the “science of ceremony” as a guide to living with intention and accountability for the next seven generations. Our ancestors used ceremony to prepare for the future, ensuring that their actions would benefit not only their own time but also those yet to come. Now, it is our responsibility to carry that practice forward.
Led by Grandmother Gail, this session will examine what has been lost and the actions we must take to restore, respect, and reclaim the ceremonial practices that ensure the well-being of future generations. Participants will be encouraged to reconnect with ceremony as a means of healing, reflection, and renewal, building a foundation of responsibility to guide us in restoring balance and harmony.
Key Takeaways:
Through this workshop, participants will rediscover the transformative power of ceremony as a pathway to healing, accountability, and preparation for a sustainable and harmonious future. Together, we will reaffirm our responsibility to the generations to come.
Presented by Asha Frost
Join Asha Frost, an Indigenous healer, teacher, and bestselling author, for a transformative workshop rooted in traditional teachings and the power of self-discovery. Asha’s work often centers on reconnecting with ancestral wisdom, embracing one’s authentic self, and creating pathways for healing and empowerment. Drawing from her Anishinaabe roots, she weaves stories, teachings, and practical tools to inspire participants to reclaim their power and align with their purpose.
Through her signature blend of traditional healing practices and modern insights, Asha guides participants in understanding how to honor their own journey, navigate challenges with resilience, and embrace the interconnectedness of all beings. This workshop is an invitation to explore the sacred within and around us, fostering personal growth and collective transformation.
Key Takeaways:
Whether you are seeking personal healing, professional inspiration, or a deeper connection to traditional wisdom, this session with Asha Frost promises to be a profound and enriching experience.
Presented by Allen Sutherland
The Seven Fires prophecy, as shared by seven prophets across different time periods, offers profound guidance for humanity’s path forward. According to Anishinaabe oral tradition, these teachings speak to the choices we face when the world has been polluted, and the waters turned bitter by disrespect. The prophecy teaches that humanity must choose between materialism and spirituality—one path leading to survival and the other to destruction.
In this workshop, Mishoomis Allen will guide participants through the teachings of the Seven Fires prophecy, exploring its relevance in today’s world and its call for spiritual renewal. Additionally, he will share his Canadian Indigenous Historical Timeline, providing a broader context for understanding the cultural, social, and spiritual significance of these teachings.
Key Takeaways:
This workshop offers an opportunity to reflect deeply on humanity’s collective responsibility and the transformative power of choosing a spiritual path for the survival of future generations.
Presented by Thohahoken Michael Doxtater
In this session, Thohahoken Michael Doxtater explores the ongoing impact of Canada’s colonial policies on Indigenous communities and the historical journey toward Truth and Reconciliation. He examines the systemic attempts to erase Indigenous identity, from residential schools to the suppression of cultural practices, and highlights Indigenous resilience and legal resistance. The presentation also delves into the concept of the “Canada Rafter,” a historical agreement acknowledging Canada’s adoption into the Indigenous Longhouse, raising the question: Has Canada truly upheld its responsibilities in this relationship?
