Information sharing without accountability does not create change. It creates documentation. It creates the appearance of action while allowing the same systems, the same assumptions, and the same failures to continue. That is how we arrive here again, reviewing another death, another set of findings, another list of recommendations that mirror what has already been said for decades.
There is no comfort in this document. Because unless something fundamentally changes in how these recommendations are implemented, measured, enforced, and sustained, this will not be the last time we read something like this.
There are recommendations within this report that, if taken seriously and implemented with rigour, could materially change how care is delivered to Indigenous patients in Ontario. But their impact depends entirely on whether they are treated as obligations or as optics.
The directive to mandate and fund Indigenous healing practices within hospital settings, aligned with Truth and Reconciliation Commission Call to Action 22, is one of the most significant recommendations in this report.
This recommendation speaks to more than access. It speaks to legitimacy. It requires hospitals to move beyond acknowledgment and into integration, co-developing protocols with Indigenous communities, Elders, Knowledge Keepers, and traditional healers. It requires that Indigenous medicine and spiritual practices be available when requested, not as a favour, but as a recognized and supported form of care.
If implemented as intended, this would represent a structural shift in how care is delivered. It would recognize that healing is not exclusively clinical, that trust cannot be built in environments where Indigenous ways of knowing are excluded, and that cultural safety is not achieved through training alone but through the presence of systems that reflect the people they serve.
But the risk is familiar. Without enforcement, without resourcing that is sustained and protected, and without integration into clinical pathways, this becomes symbolic. Something that exists in policy but not in practice. Indigenous patients will be told that supports are available, but not when they need them, not in the way they need them, and not consistently enough to build trust.
That is the difference between implementation and performance.
The requirement for continuous and evolving training on Indigenous cultural safety, substance use, and mental health stigma for EMS staff, paired with annual public reporting, introduces a mechanism that is often missing in these discussions: visibility.
Training, on its own, does not change systems. This has been proven repeatedly. What changes systems is when training is tied to expectation, when expectation is tied to measurement, and when measurement is made visible.
The inclusion of annual reporting has the potential to shift this from a passive exercise to an active obligation. It forces the system to acknowledge not only whether training is occurring, but whether it is being taken seriously, where it is failing, and what barriers exist to its uptake.
But even here, the same risk applies. If reporting is generalized, if participation is not enforced, if there are no consequences for failure to engage or improve, then the outcome will be the same as it has always been. Staff will attend sessions. Boxes will be checked. And the conditions that allow bias and assumption to influence care will remain intact.
The difference between awareness and change is accountability. Without it, this recommendation does not move the system forward. It simply documents that the system tried.
The requirement to ensure sufficient staffing for triage and reassessment, and to clearly define expectations for how and when patients are reassessed, speaks directly to what was at the centre of this inquest: time, attention, and response.
This recommendation addresses the mechanics of care. It acknowledges that reassessment is not optional, that triage is not a one-time event, and that patients in waiting rooms are not static. Their conditions change. Their needs escalate. And systems must be built to recognize and respond to that reality.
If implemented properly, this recommendation would create structure where there is currently inconsistency. It would require that reassessments occur at defined intervals, that responsibility for those reassessments is clear, and that staffing levels are sufficient to make those expectations real rather than aspirational.
But this is also where systems often fail. Staffing commitments are made without enforcement. Expectations are communicated without monitoring. Policies are written without being operationalized.
Without transparent reporting on staffing levels, without audits of compliance, and without consequences when those standards are not met, this recommendation risks becoming another statement of intent that does not translate into action.
And in emergency care, intent is not enough.
There are recommendations in this report that are, on their face, strong. They acknowledge bias. They recognize systemic issues. They attempt to introduce mechanisms that could shift how care is experienced. But without enforcement, without consequence, and without a willingness from institutions like Niagara Health to accept responsibility for what happened, these recommendations will not deliver the change they promise.
They will exist. They will be referenced. They will be cited in future reports.
And little else will change.
The recommendation that Niagara Health formally acknowledge that the realities of emergency medicine create conditions where unconscious bias can lead to patient harm is one of the most direct statements in this report.
It is also one of the most fragile.
Because acknowledgment is not the same as accountability.
To state that bias exists at a systemic level, and that it does not require individual intent to cause harm, is an important step. It reflects what was heard in this inquest. It aligns with expert testimony. It recognizes that harm can occur even when no one believes they are acting improperly.
But if that acknowledgment is not tied to action, it becomes a shield.
It allows institutions to say they understand the issue without requiring them to change the conditions that allow it to persist. It creates language that can be used in response to criticism without creating pressure to alter behaviour, decision-making, or outcomes.
For this recommendation to matter, acknowledgment must be followed by intervention. It must be tied to measurable changes in how patients are assessed, how decisions are reviewed, and how patterns of harm are identified and addressed.
Grandmother’s Voice will be watching for that shift. Not in statements, but in outcomes. We will be looking at whether this acknowledgment leads to changes in patient experience, whether complaints are handled differently, and whether patterns of bias are actively identified and disrupted. If it is not, we will say so, publicly and without hesitation.
The directive to collect and publicly report on the experiences of Indigenous patients has the potential to introduce a level of transparency that has historically been absent from healthcare systems.
Data, when collected properly, tells the truth systems often avoid. It reveals patterns. It identifies disparities. It makes it more difficult to dismiss individual experiences as isolated incidents.
The requirement that this data be collected through a self-identification model, governed by Indigenous data sovereignty principles, and overseen by an Indigenous Data Advisory Committee is significant. It acknowledges that data about Indigenous people must be controlled and interpreted in partnership with Indigenous communities.
But again, the risk is not in the recommendation. It is in the follow-through.
If the data is collected but not meaningfully analyzed, if it is reported in ways that obscure rather than reveal, if it is delayed, diluted, or disconnected from decision-making, then it becomes another exercise in optics.
Transparency without consequence does not drive change.
Grandmother’s Voice will be tracking whether these reports are produced, whether they are accessible, and whether they reflect the reality Indigenous patients experience. More importantly, we will be looking at whether those findings lead to action. If disparities are identified and nothing changes, then the system has chosen to see the problem without addressing it.
That is not progress. That is documentation of failure.
The expansion of Indigenous patient advocacy through the IHSR team, including the development of pathways that support Indigenous patients throughout their care journey, addresses a gap that should not exist.
Patients should not need advocates to receive appropriate care.
And yet, this recommendation acknowledges that they do.
It recognizes that Indigenous patients may require support to navigate systems that are not designed with them in mind, that consent may not always be fully informed, that diagnoses may need to be challenged, and that discharge decisions may not always reflect the patient’s best interests.
This is a critical acknowledgment.
But it also raises a deeper concern.
If advocacy becomes the solution, then the system has accepted that it cannot be relied upon to function equitably on its own. It has shifted responsibility onto additional supports rather than correcting the underlying conditions that make those supports necessary.
For this recommendation to have meaningful impact, advocacy must not become a substitute for systemic change. It must exist alongside it.
Grandmother’s Voice will be watching how these advocacy supports are implemented. We will be looking at whether they are adequately resourced, whether they are accessible in real time, and whether their involvement leads to different outcomes for patients. We will also be asking a harder question: why those supports are still necessary in the first place.
If the system continues to rely on advocacy to correct its own failures, then it has not changed.
It has adapted.
And adaptation without accountability is not enough.
There is a section of this report that should stop everyone.
Not because it introduces something new, but because it does not.
Several of the recommendations explicitly reference the Truth and Reconciliation Commission of Canada, including Calls to Action 22, 23, and 24.
These Calls to Action were issued in 2015.
They are not emerging ideas. They are not untested frameworks. They are nationally recognized directives that governments, institutions, and professional bodies across this country publicly committed to advancing.
And yet, here they are again.
Rewritten. Repackaged. Reissued in the context of a death that should never have required their repetition.
This is not progress.
This is failure.
The recommendation that hospitals mandate and fund Indigenous healing practices, and co-develop those practices with Indigenous communities, is lifted directly from Call to Action 22.
That Call to Action asked healthcare systems to recognize the value of Indigenous healing and to integrate it into care in collaboration with Elders and traditional healers.
That was eleven years ago.
The fact that this inquest needed to restate that requirement tells us plainly that it has not been implemented in any consistent, enforceable way across the system.
This is not a gap in knowledge.
It is a failure to act.
Hospitals do not need to wait for the federal government to tell them how to build relationships with Indigenous communities. They do not need new legislation to begin co-developing protocols, to ensure access to Indigenous healing practices, or to inform patients of those options.
They can do this work now.
They have always been able to do this work.
And in environments that they themselves acknowledge are shaped by bias, they have an obligation to do it.
The absence of these practices is not a policy issue.
It is a leadership issue.
The recommendations in this report that speak to increasing Indigenous representation in healthcare and mandating cultural competency training reflect Calls to Action 23 and 24.
These calls are clear. They ask for the recruitment and retention of Indigenous healthcare professionals. They ask for mandatory education on Indigenous history, rights, and health practices. They ask for training that goes beyond awareness and into competency.
They have been accepted nationally.
They have been referenced in policy documents, strategic plans, and public statements across the country.
And still, they are being recommended again.
This is not because the system does not understand what is required.
It is because it has not committed to doing it in a way that changes outcomes.
Representation remains limited. Training exists, but it is inconsistent, uneven, and often disconnected from practice. The integration of Indigenous knowledge into care is still dependent on individual institutions and individual champions rather than being embedded as a system-wide standard.
The result is a system that can point to effort, but not to impact.
This is the question that sits beneath this section of the report.
Why did it take a death for these recommendations to be restated?
Why are we revisiting commitments that were made more than a decade ago?
Why is a jury being asked to reinforce what the country has already acknowledged?
There is no acceptable answer.
Because nothing in these recommendations required new evidence.
Nothing in these recommendations required this inquest to occur.
They were already known.
They were already agreed upon.
They were already understood to be necessary.
And yet, they were not implemented in a way that prevented this outcome.
That is the failure.
Not of one individual.
Not of one department.
But of a system that has been given direction and has not followed it with the urgency or accountability required.
What this section of the report reveals is not a local issue.
It is a national pattern.
Recommendations are made. Commitments are issued. Progress is reported. And yet, when tested in real conditions, in real moments of care, the system continues to fall short.
That is why there is reason to doubt.
Not because the recommendations lack merit, but because they lack enforcement.
Because they rely on institutions to change themselves without requiring them to do so.
Because they allow for delay, for interpretation, for partial implementation.
And because there are no meaningful consequences when they are not fully realized.
Until that changes, there is no reason to believe that repeating these recommendations will produce a different outcome.
There is a section of these recommendations that shifts the focus away from what went wrong and toward what is needed to move forward. On its surface, that shift appears reasonable. Systems require resources. Healthcare environments are under pressure. Staffing, programming, and community supports all depend on funding.
But the way funding is introduced here raises a different concern.
Because these recommendations ask for more resources without clearly requiring demonstrable change in how care is delivered, how outcomes are measured, or how accountability will be enforced.
The Ministry of Health is directed to ensure sufficient funding is provided to Niagara Health and Niagara Emergency Medical Services to enact the recommendations, alongside dedicated funding for Indigenous Health Services and Reconciliation teams, Indigenous-led organizations, and expanded cultural safety programming.
There is also a specific recommendation to fund the Street Outreach and Community Paramedics Team on a permanent basis.
None of these proposals are inherently problematic. Many of them are necessary.
The issue is not the request for funding.
The issue is the absence of clear, enforceable expectations tied to that funding.
There is no defined requirement that increased funding must result in measurable improvements in patient outcomes. There is no requirement that disparities in care be reduced within a defined timeframe. There is no mechanism outlined to evaluate whether these investments actually change the conditions that contributed to Heather’s death.
Funding is presented as a solution.
But without accountability, it becomes an input without a guaranteed outcome.
The inclusion of funding requests, particularly those directed toward paramedic services and community programming, introduces another concern.
It shifts part of the response away from the point of care where the failure occurred.
This inquest examined what happened within the hospital setting. It examined assessment, reassessment, clinical decision-making, and the influence of bias and assumption within that environment.
Those are not issues that can be resolved through external programming alone.
Expanding paramedic services or community outreach may improve aspects of the broader system. It may support earlier intervention in some cases. But it does not address the core issue identified in this inquest, which is how a patient presenting for care was assessed, understood, and responded to within the hospital itself.
When funding recommendations are introduced without a direct line to correcting that core failure, there is a risk that responsibility becomes diffused.
The problem becomes larger, more complex, more distributed.
And in that diffusion, accountability becomes harder to locate.
Funding recommendations also carry the risk of creating the appearance of progress without requiring structural change.
Allocating resources is visible. It can be announced. It can be measured in dollar amounts. It can be presented as a response.
But without clear expectations tied to that funding—expectations that are enforced, monitored, and publicly reported—there is no guarantee that the underlying issues will be addressed.
More training can be delivered without changing how decisions are made in critical moments. More services can be funded without improving how patients are treated when they arrive at the hospital. More programs can be introduced without altering the conditions that allow bias and assumption to influence care.
In that sense, funding becomes a parallel response rather than a corrective one.
It operates alongside the problem without necessarily resolving it.
This matters because this moment carries weight.
This is not a routine policy discussion. It is a response to a death that has been examined in detail, where specific failures have been identified, and where the system has had the opportunity to reflect on what must change.
In that context, recommendations that focus on funding without attaching clear, enforceable outcomes risk missing that opportunity.
They allow the system to move forward with activity rather than transformation.
They create space for investment without requiring accountability.
And they do so at a moment when accountability is precisely what is needed.
There is a section at the end of these recommendations that is meant to speak to legacy. It is meant to honour Heather. It is meant to acknowledge her life and the impact of her death. And yet, when read in full context, it reveals something else entirely. It reveals the limits of what this system is prepared to do when faced with the consequences of its own failure.
The recommendation that Niagara Health establish a plaque and picture dedicated to Heather in the Healing Garden is presented as an act of remembrance. It is, in reality, a gesture that requires no change to how care is delivered. It asks nothing of the system that failed her beyond acknowledgment. It does not alter clinical practice. It does not strengthen reassessment protocols. It does not confront bias in real time. It does not prevent another patient from experiencing the same delays, the same assumptions, or the same outcome. It allows memory to be fixed in a physical space while the conditions that led to her death remain largely intact. That is not legacy. That is containment.
The creation of a healthcare-related education fund in Heather’s name, with priority given to Indigenous students, carries more substance, but it raises the same fundamental concern. It looks forward rather than inward. It invests in the idea of a better future without requiring accountability in the present. There is value in supporting Indigenous students. There is value in increasing representation within healthcare. Those are necessary and overdue steps. But they do not address what happened here. They do not change the environment in which Heather sought care. They do not correct the conditions that allowed her to be seen, assessed, and ultimately not treated in time. They offer opportunity elsewhere while leaving the system itself insufficiently examined.
The recommendation that Niagara Health, emergency services, and police participate in a healing ceremony with Heather’s family and community is framed as part of reconciliation. Ceremony, in its proper context, carries meaning, responsibility, and truth. But without accountability, it risks becoming symbolic participation rather than genuine engagement. It becomes something institutions attend rather than something they are transformed by. Healing cannot be separated from action. It cannot exist in a space where harm has been acknowledged but not meaningfully addressed. Participation without change does not repair what was broken.
Taken together, these recommendations do not offend because they exist. They are concerning because of what they represent when placed alongside the rest of this report. After weeks of testimony, after evidence of delayed treatment, after acknowledgment of systemic bias, after a detailed examination of how care is delivered and how it can fail, this is what is offered to honour a life. A plaque. A fund. A ceremony. These are not proportional responses to the issues identified in this inquest. They are symbolic responses layered onto systemic problems. They allow the institution to demonstrate care without demonstrating change.
Legacy should not be defined by what is named after someone. It should be defined by what is changed because of them. If Heather’s legacy is reduced to a place in a garden, to a name attached to a fund, or to a moment of ceremony, then the system has chosen the most comfortable path forward. It has chosen remembrance over responsibility. It has chosen symbolism over accountability. And it has done so despite having been shown, clearly and in detail, what needed to change.
There is a temptation, at the end of processes like this, to speak about closure, about moving forward, about lessons learned. That language does not belong here.
Because nothing about this feels like a new beginning.
It feels familiar.
It feels like a system that has been confronted with its own failures and has responded the way it often does—by documenting them, by acknowledging them in controlled language, and by stopping short of the kind of accountability that would force real change.
The verdict of “accident” will be interpreted in many ways. Legally, it reflects a framework the jury was required to follow. But outside of that framework, it risks reinforcing something far more dangerous. It risks softening what was heard. It risks shifting attention away from delayed treatment, from missed opportunities, and from the role that bias and assumption can play in how care is delivered.
It risks sounding, to many, like this was unavoidable.
It was not.
Heather asked for care. She returned when things worsened. She described her pain. Others saw her condition change. Those facts do not disappear because of the language used to classify her death.
And when a system responds to those facts with anything less than full accountability, it creates space for something else to take hold.
It creates space for blame to settle where it should not.
It creates space for questions about behaviour, about history, about substance use, to quietly replace questions about care, about response, and about responsibility.
That is how victim blaming happens.
Not always directly. Not always intentionally. But through omission, through framing, and through the gradual shifting of focus away from what the system did and did not do.
We are not willing to accept that shift.
What was heard in this inquest included testimony about bias. It included acknowledgment that assumptions follow patients. It included recognition that fast-paced environments increase the risk of harm when those assumptions are not actively challenged.
And still, we are left with a system that must be told again to implement practices it has already agreed to, to train staff in concepts it has already accepted, and to collect data on disparities it already knows exist.
This is not the start of something new.
This is more of the same.
And that is what makes this moment so difficult to accept.
Because if this is how the system responds after everything that was heard, after everything that was established, after everything that has already been said at a national level, then there is no reason to believe that change will occur on its own.
Change will have to be forced.
Grandmother’s Voice will not treat this report as an endpoint. We will not accept recommendations as progress in and of themselves. We will track what is implemented, what is delayed, and what is ignored. We will continue to name where systems fall short, and we will do so publicly.
If there is to be a legacy here, it will not be built on language.
It will be built on pressure.
Because what happened to Heather cannot be reduced to a word, a plaque, or a set of recommendations that echo what has already been known.
And if this system is unwilling to change on its own, then it will be pushed.
Relentlessly.
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?
