
In the coming days, a coroner’s inquest will begin into the death of Heather Winterstein.
We need to be clear about what this is, and what it is not.
An inquest is not a criminal trial. It does not assign legal blame. It examines the circumstances of a death and asks what must change so that it does not happen again.
But for many Indigenous people, this is not just a process. It is something much closer to home.
Because what happened to Heather is not unfamiliar.
Across Ontario and across this country, Indigenous people continue to experience harm within healthcare systems. Not always through dramatic or obvious actions, but through something quieter and more dangerous. Through dismissal. Through assumption. Through a failure to take pain seriously. Through decisions that are shaped, consciously or not, by bias.
We have heard it before. We have lived it before.
People who are struggling with substance use, who are living in poverty, who do not present in ways that systems expect, are often seen as part of their own problem. Their symptoms are questioned. Their credibility is diminished. Their care is delayed.
When this is combined with anti-Indigenous racism, the consequences can be severe.
In some cases, fatal.
This is the context in which this inquest is taking place.
The materials that inform an inquest include medical records, timelines, expert opinions, and testimony from those involved in a person’s care. Together, they begin to tell a story. Not just of what happened, but of how decisions were made, what was prioritized, and what was missed.
And these are not abstract questions.
They are questions about whether someone was listened to. Whether their pain was believed. Whether assumptions replaced assessment. Whether bias, casual or intentional, influenced the care they received.
These are questions about accountability.
In recent years, many institutions have taken visible steps toward reconciliation. Land acknowledgements are read. Cultural safety training is completed. Policies are introduced.
But we need to say this plainly.
That is not enough.
Reading words does not mean understanding them. Completing training does not mean beliefs have changed. Systems can comply with requirements and still fail the people they are meant to serve.
Reconciliation cannot be a checkbox.
It cannot be something that is performed publicly and abandoned in practice.
If healthcare providers, at any level, engage in behaviour that dismisses, stereotypes, or devalues Indigenous patients, whether intentional or not, there must be accountability. Harm does not become acceptable because it was unintentional. And outcomes do not become less serious because bias was subtle.
Lives are still affected.
Lives are still lost.
What this inquest offers is an opportunity to examine these realities openly. To move beyond surface level responses and to ask harder questions about how care is actually delivered.
It is also an opportunity for community voices to be part of that truth.
At Grandmother’s Voice, we know that Heather’s story is not isolated. Many Indigenous individuals and families carry experiences within healthcare systems that have left them feeling dismissed, unheard, or unsafe.
We are inviting community members to share their experiences with us in confidence.
These stories will be held with care. They will not be shared without consent. And they will help ensure that what is brought forward reflects not just one experience, but a pattern that must be acknowledged.
This is not about creating division.
It is about creating honesty.
Because meaningful change does not come from protecting systems. It comes from examining them. From listening differently. From being willing to confront what is uncomfortable.
As this inquest begins, we stand with Heather’s family. We honour her life. And we remain committed to ensuring that what comes forward does not end with recommendations on paper, but leads to real change in how care is delivered.
This is not an isolated incident.
And it cannot be treated as one.


