Why Heather?

Grandmother’s Voice Addresses the Jury

At the close of this inquest, Jody Harbour of Grandmother’s Voice was invited to address the jury. Her role was not to argue law, assign blame, or present new evidence. It was something both more difficult and more necessary. She spoke to the jury as a representative of Indigenous community, lived experience, and cultural knowledge—offering a lens that had, until that moment, been largely absent from the clinical and procedural testimony. In her address, Jody grounded the evidence in a broader truth: that Heather Winterstein’s death cannot be understood without acknowledging the historical and ongoing realities Indigenous people face within healthcare systems. What follows is not a closing argument in the traditional sense. It is a call to see more clearly, to listen more deeply, and to ensure that Heather’s life—and her death—are understood in full.

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Sge’no. Hello.

Thank you to Dr. Eden for guiding this inquest, to the jury for your careful attention, and to counsel for clearly presenting the evidence and key questions.

Most importantly, I want to acknowledge Heather’s family. You have endured difficult testimony with strength and love, and I thank you for being here and allowing her story to be heard.

My name is Jody Harbour. I represent Grandmother’s Voice, a community-rooted organization led by Grandmothers and Elders that works to restore Indigenous ways of knowing in health, healing, and relationship. We support individuals, families, and institutions through teaching, ceremony, and culturally grounded approaches to care, with a focus on compassion, accountability, and community connection. I am here today to offer that perspective, and to speak to what we have heard in this inquest through the lens of care, responsibility, and the life of Heather Winterstein. 

And with that, I want to begin with Heather.

Because it is very easy, in a process like this, for her to slowly disappear.

We have heard about systems. We have heard about protocols, training, policies, documentation, review processes. We have heard about pressure, complexity, and imperfection.

But before any of that, there is a young woman.

Heather was not a case.

She was someone’s daughter. Someone’s loved one. Someone who had people in her life who knew her, who saw her, who understood her in ways no chart or report ever could.

Every person in this room has a special person they love and care about

Someone in their life who is trying. Someone who carries pain, and also carries kindness. Someone who may struggle, but still shows up. Someone who deserves care—not because they are easy to care for, but because they are human.

We know what it feels like to love someone like that.

And even that does not come close to what this family is carrying.

There is a space where Heather should be.

There are conversations she should still be part of. There are moments she should still be living. There is a future that has been taken from her, and from the people who love her.

That is what is missing.

And that absence must remain at the center of this inquest.

I am here to speak from an Indigenous perspective.

I do not speak for all Indigenous people. But I do speak from a place of lived experience, cultural knowledge, and a way of understanding health that has existed for thousands of years—long before the healthcare systems we are discussing today.

Indigenous health is not a program. It is not a service. It is not an add-on.

It is a way of understanding what it means to be well.

At its core, it is about balance.

Many of you will have heard of the medicine wheel. It is not symbolic. It is practical. It teaches that a person’s health exists across four interconnected areas: physical, emotional, mental, and spiritual. When one is out of balance, the whole person is affected.

Western medicine is highly developed in the physical. It is exceptional at diagnosing, intervening, and treating the body.

But Indigenous medicine reminds us that the body does not exist in isolation.

Pain is not only physical. Distress is not only behavioural.

A person’s story—what they have lived through, what they are carrying, how they are seen—affects how illness presents and how it is understood.

Indigenous medicine includes the use of plant-based medicines like sage, tobacco, cedar, and sweetgrass. These are used for grounding, for calming, for prayer, for connection. They help a person feel safe, to feel seen, to feel human in a moment where they may feel anything but.

It includes Elders and Knowledge Keepers—people who support not only the patient, but the understanding of what that patient is experiencing.

It includes ceremony. It includes presence. It includes time.

And it includes listening.

Not listening to respond.

Listening to understand.

That is not separate from medicine.

That is part of medicine.

Indigenous people in this country have been systematically disconnected from their own ways of caring and those ways of caring benefits all people.

This is not distant history. It is recent, and its effects are ongoing.

For more than a century, the residential school system removed Indigenous children from their families, their languages, and their identities. It disrupted parenting, severed cultural continuity, and created intergenerational trauma that continues to shape health outcomes today. The last of these schools closed in 1996.

The Sixties Scoop followed, removing thousands of Indigenous children from their communities and placing them into non-Indigenous homes, often without connection to their culture, their language, or their identity. That disconnection did not end with those children. It carried forward into families, into communities, and into how Indigenous people experience systems that are meant to provide care.

At the same time, Western healthcare systems developed largely without Indigenous knowledge. Indigenous healing practices were not integrated. Indigenous voices were not centered. And yet, Indigenous people have been expected to enter these systems, trust them, and receive care within them.

The consequences of that history are documented.

In 1990, the Oka Crisis exposed tensions between Indigenous communities and the state, where resistance was quickly framed as a threat. In 1995, at Ipperwash Provincial Park, Dudley George was shot during a land reclamation; a later inquiry found racism and political pressure played a role. In Thunder Bay, inquests into Indigenous youth deaths revealed patterns of inadequate responses and systemic failures.

These are not healthcare cases, but they reflect a broader pattern in how institutions respond under pressure—and how Indigenous people are sometimes not fully seen.

And we see that pattern within healthcare itself.

As Sean mentioned, Brian Sinclair died in a Winnipeg emergency room in 2008 after waiting more than 30 hours for care. He was assumed to be intoxicated. He was never triaged. He was ignored to death.

Joyce (Edgeqwan) died in a Quebec hospital in 2020 after livestreaming the racist treatment she experienced from staff while calling for help.  She was ignored to death.

These are not isolated incidents.

They are part of a documented pattern of systemic bias—where assumptions shape care, where urgency is not always recognized, and where Indigenous patients can be misunderstood or dismissed.

The Truth and Reconciliation Commission identified this clearly. Calls to Action 18 through 24 call for the recognition of Indigenous health inequities as a direct result of past policies, for equitable access to care, for the integration of Indigenous healing practices, for proper training of healthcare providers, and for measurable outcomes that demonstrate real change.

Many of these calls remain incomplete.

That is not a lack of awareness.

It is a lack of sustained implementation and accountability.

Throughout this inquest, we have heard that training exists. We have heard that policies exist. We have heard that recommendations have been developed, implemented, and, in many cases, marked as complete.

But we have also heard, very clearly, that the existence of those measures does not guarantee that they are effective in practice.

Dr. Suzanne Shoush’s testimony was critical in helping us understand why.

She explained that unconscious bias is not an occasional failure—it is a predictable and well-documented part of human decision-making. It operates quickly, often without awareness, and is reinforced by repeated exposure to patterns, stereotypes, and prior experiences. In healthcare settings, particularly in fast-paced environments like emergency departments, those mental shortcuts are not only present—they are relied upon.

She described how patients who present with certain histories—particularly those involving substance use, prior visits, or complex social circumstances—can be unconsciously categorized in ways that influence how their symptoms are interpreted. That categorization can affect whether pain is taken seriously, whether deterioration is recognized, and how urgently care is provided.

Dr. Shoush was clear that this is not about individual intent. It is about impact.

She also spoke about anchoring bias—the tendency to rely heavily on an initial impression or prior diagnosis—and how it can narrow clinical thinking. Once a patient is understood through a particular lens, that lens can persist, even when new information emerges. In practice, that means a patient who returns with worsening symptoms may still be seen through the framework of their earlier assessment, rather than being reassessed fully and independently.

Importantly, Dr. Shoush emphasized that these forms of bias are not corrected simply by awareness.

She stated that while cultural safety and bias training are often implemented, they are frequently treated as one-time requirements rather than ongoing competencies. They are completed, but not consistently reinforced. They are acknowledged, but not always integrated into daily clinical practice. Without continuous evaluation and accountability, the impact of that training is limited.

She went further to say that cultural safety must be understood as a matter of patient safety—not an optional or supplementary consideration, but a core clinical responsibility. When bias affects how a patient is perceived or prioritized, it directly affects outcomes,  as Dr. Shoush stated in her testimony “Ignored to death”.

This is where policy and practice diverge.

The system can have policies that recognize bias.

It can require training that addresses it.

It can develop recommendations intended to mitigate it.

But if those measures are not actively shaping behaviour at the bedside—if they are not interrupting assumptions in real time—then their presence does not prevent harm.

We have also heard that the system operates under pressure. That emergency departments are busy. That clinicians are required to make rapid decisions in complex environments.

Dr. Shoush’s evidence does not dismiss those realities.

It explains how, in those exact conditions, bias becomes more influential, not less.

Because under pressure, people rely more heavily on pattern recognition. They default more quickly to prior assumptions. They are more likely to use mental shortcuts that, while efficient, can lead to error—particularly when those shortcuts are shaped by stereotypes.

All of that may be true.

But none of it changes what happened to Heather.

Because the purpose of this inquest is not to determine whether the system is aware of bias, or whether it has taken steps to address it in principle.

It is to understand whether, in that moment—when Heather came for care, and when she came back—those risks were effectively managed.

And the evidence suggests that they were not.

Heather came for care.

She was discharged.

She was told to return if her condition worsened.

She did exactly what she was told to do.

She came back.

That matters.

Because many Indigenous patients do not come back.

They delay care. They avoid care.

So when someone returns, that is not repetition.

That is urgency.

There is something else that needs to be said clearly.

We have heard that the emergency department was busy.

We have heard about pressure, about volume, about the reality that clinicians must make decisions quickly in complex environments.

But even in a busy emergency department, not every patient is overlooked.

Care continues. Decisions are made. People are seen. Some are prioritized. Some are escalated.

So the question is not simply whether the emergency department was busy.

The question is:

Why Heather?

If the system was under pressure, if decisions had to be made about who required urgent attention, why was she the one who was not seen clearly?

That question cannot be answered by coincidence.

It cannot be answered by randomness.

Because we know—through evidence, through history, through repeated inquiry—that outcomes are not evenly distributed.

We know that Indigenous people are overrepresented in systems where harm occurs.

We see it in the National Inquiry into Missing and Murdered Indigenous Women, Girls, and Two-Spirit people, which found that systemic racism, colonialism, and institutional failures contribute directly to the violence and loss experienced by Indigenous women. These are not just words – they are lives. They are daughters and sisters, mothers and aunties – women, future leaders, knowledge keepers.

We see it in incarceration rates, where Indigenous people—particularly men—are vastly overrepresented in correctional systems across this country.

Again and again, across different systems, we see the same thing:

Indigenous people are more likely to be misunderstood.

More likely to be dismissed.

More likely to have their distress interpreted through assumption rather than investigation.

These are not isolated issues.

They are connected.

They tell us something about how decisions are made under pressure, and whose lives are recognized as requiring immediate care—and whose are not.

And this is where we must be very clear.

There can be no space, in any system of care, for the idea—spoken or unspoken—that some lives are more expendable than others.

That some patients can wait longer.

That some presentations are less urgent.

That some people are easier to overlook.

Because when those ideas exist, even quietly, even unconsciously, they shape outcomes.

And they shape outcomes in ways that are not equal.

Heathers mother does not need a report to ask this question.

She carries it already.

Every day.

Why Heather?

And I want to say this clearly.

The answer to that question should never bring shame to Heather.

It should never bring shame to her family.

The responsibility does not sit with the person who came for care.

It sits with the system that did not respond.

This inquest will end with recommendations.

But Heather’s legacy cannot be a document.

It must be a shift.

I want to leave you with a teaching.

Across many Indigenous Nations, there are stories about what happens after great loss—after imbalance, after harm, after something that changes a community forever.

In Anishinaabe teachings, there is a story of the flood.

When the waters rose and covered the earth, all that people knew was lost. The animals and the beings of the earth worked together to survive, each one offering what they could. One by one, they tried to dive beneath the water to bring back something—anything—that could help rebuild the world.

The strongest could not do it.

The fastest could not do it.

It was the smallest—the muskrat—who went down, who stayed down the longest, and returned with just a small bit of earth in its paw,

It was enough.

From that small piece, the land was restored.

That story is not about perfection. It is not about power.

It is about responsibility.

It is about doing what we can, even when the task feels impossible, even when the loss feels too great.

It is about rebuilding differently.

Heather’s life cannot be restored.

But what comes from this—what grows from this—can still be shaped.

Her legacy cannot be a picture on a wall, or a plaque on a building.

It must be something living.

It must be a system that changes in real ways, not just in words.

It must be care that listens, that sees, that responds—fully, and without assumption.

Because that is what is required now.

And like the muskrat, who may seem small—one change in practice, one moment of listening, one interruption of bias—can be enough to begin rebuilding something better.

That is the responsibility we all carry forward from here.

Thank you.

Nya:węh.