Well Intentioned: When Care Forgets How to Care

There are days in this inquest where the facts are overwhelming. The timelines, the missed signals, the decisions that now sit under a microscope. And then there are days like today, where something shifts. Where we are asked not just to look at what happened to Heather Winterstein, but to understand the conditions that made it possible.

Dr. Suzanne Shoush did not come to reconstruct Heather’s final hours. She came to explain how a system, even one filled with well-intentioned professionals, can still produce harm. Her testimony was not about blame. It was about pattern. It was about how bias, assumption, and deeply ingrained ways of thinking shape the way care is delivered, especially in the fast-moving, high-pressure environment of an emergency department.

She reminded us of something both simple and deeply uncomfortable. Bias is not rare. It is not exceptional. It is not limited to a few bad actors. It is a fundamental part of how the human brain works. It is automatic, learned, and often invisible to the person carrying it. In healthcare, where decisions are made quickly and under pressure, those unconscious patterns can quietly shape what is seen, what is dismissed, and what is acted on.

In Heather’s case, the record shows a pattern that Dr. Shoush described with clarity. Language matters. Documentation matters. When the first lines used to describe a patient consistently center substance use, when terms like “IV drug user” are repeated before a full clinical picture is understood, it creates a frame. And once that frame is in place, it becomes very difficult to see anything outside of it.

This is what she called attribution bias. Symptoms become explained by circumstance rather than investigated as potential illness. Pain becomes expected. Behaviour becomes interpreted. Urgency begins to slip.

And then something else happens.

The system begins to reinforce itself.

An earlier assessment becomes an anchor. A previous visit becomes reassurance that something serious has already been ruled out. A working theory becomes the lens through which all new information is filtered. This is how confirmation bias takes hold. This is how clinical curiosity narrows. This is how a person, rather than being reassessed in full, is understood through what has already been said about them.

None of this requires intent.

That was perhaps the most important thing said today.

Dr. Shoush was clear that systemic racism in healthcare is not defined by individual malice. It is defined by patterns of outcome. When the same groups of people experience delayed care, under-triage, fewer investigations, and worse outcomes, consistently and predictably, the system itself must be examined. Indigenous people in Canada, she told us, have more of what makes people sick and less of what makes people well. That is not accidental. That is structural.

And within that structure, emergency departments become high-risk environments for error.

Time is limited. Decisions are rapid. Information is incomplete. In those conditions, the brain does what it has been trained to do. It reaches for patterns. It fills in gaps. It relies on what feels familiar. When those familiar patterns include stereotypes about Indigenous people, about substance use, about mental health, about poverty, those patterns do not stay abstract. They enter the clinical space. They shape decisions.

Heather Winterstein did not present with a single vulnerability. She carried several. She was an Indigenous woman. She was perceived to be using substances. She had a mental health history. She was described in ways that suggested instability, unpredictability, or social complexity. Dr. Shoush explained that these layers do not exist in isolation. They compound. Each one increases the likelihood that a patient will be misunderstood, minimized, or dismissed. Together, they create a level of vulnerability that is difficult to overcome, no matter how clearly a patient asks for help.

And Heather did ask.

That matters.

In fact, it should have mattered more than anything else.

Dr. Shoush spoke about what it means for someone like Heather to seek care repeatedly. For many Indigenous patients, accessing healthcare is not a neutral act. It is shaped by experience, by history, by the very real expectation that they may not be treated with dignity or respect. Many avoid care altogether. They wait. They endure. They weigh the risk of being dismissed against the reality of their symptoms.

So when someone does come. When they come again. When they call for help, when they return to the hospital, when they approach a police officer because they cannot manage on their own, that is not nuisance behaviour. That is not overuse. That is a signal.

It is a signal that something is wrong.

It is a signal that must be taken seriously.

And yet, what we heard today is that systems can become desensitized to that signal. Repeated visits can be reframed as inconvenience. Pain can be normalized. Suffering can be expected. There is even a term for it, one that many in healthcare have used without thinking about what it implies: “frequent flyer.” A phrase that turns a person into a pattern, and a pattern into something easier to dismiss.

This is where care begins to lose its way.

Not in a single moment. Not in a single decision. But in the accumulation of small shifts. A narrowed lens. A reduced urgency. A missed opportunity to step back and ask, “What else could this be?”

What Dr. Shoush offered was not only a diagnosis of the problem. She offered a way forward.

And it is not complicated.

It is not about replacing clinical care. It is about completing it.

At Grandmother’s Voice, we speak often about Two-Eyed Seeing. It is a way of holding both the clinical and the human at the same time. It asks healthcare providers to bring their full training, their full knowledge, their full diagnostic skill to a patient, while also recognizing that every person carries a story, a history, a lived experience that must be understood alongside their symptoms.

This is not an abstract idea. It is a practical one.

It means slowing down, even briefly, in a system that rewards speed. It means listening not just for symptoms, but for context. It means recognizing when a label, a history, or a first impression may be shaping your thinking more than it should. It means asking whether the diagnosis you have in mind explains everything in front of you, or only the parts that fit comfortably.

It also means creating space within healthcare systems for Indigenous ways of knowing and healing. Not as an add-on. Not as a symbol. But as a recognized and respected part of care. Some patients will seek it. Some will not. Some may not even know it is available. But the option must exist. The respect must exist.

And for those who do not wish to engage in traditional practices, the principles remain the same. Care must be relational. It must be grounded in dignity. It must resist the pull of assumption.

This is where something as simple as a pause becomes powerful.

In every hospital, there are reminders. Wash your hands. Confirm identity. Check medications. These are small interventions that support safety in moments where error is possible. What we are suggesting is no different. A reminder to pause. To reflect. To return to the patient in front of you as a whole person.

Not defined by trauma. Not reduced to a label. Not explained away by circumstance.

Indigenous people are not their trauma.

They are not their worst day.

They are not the assumptions that follow them into a room.

They are people seeking care.

And care must meet them there.

This is not about asking healthcare providers to do more. It is about asking the system to support them in doing what they already intend to do, but under conditions that make it harder. It is about aligning clinical excellence with human understanding.

Because when those two things come together, something shifts.

Care becomes more accurate.

More responsive.

More complete.

And ultimately, safer.

If there is anything to take from today, it is this: the conditions that contributed to Heather Winterstein’s death are not isolated. They are recognizable. They are preventable. And they can be addressed, not through blame, but through a commitment to doing care differently.

Not less clinically.

More completely.

More carefully.

More human.

And that is something every healthcare team, in every setting, can begin to adopt.