Inquest to Examine Death of Indigenous Woman at St. Catharines Hospital

A public inquest into the death of Heather Winterstein, a 24-year-old Indigenous woman who died at the Marotta Family Hospital in St. Catharines in December 2021, is set to begin Monday. The case has drawn attention to how Indigenous people seeking care for mental health and substance use issues are treated in Ontario's health-care system.

Winterstein's family, friends, and community members gathered Thursday evening at the Sessions on the River recording studio in Fort Erie for a tribute ahead of the inquest. The event included reflections from Winterstein's mother, Francine Shimizu-Orgar, and aunt, Jill Lunn, who described Heather as a loving family member and advocated for changes to prevent similar tragedies.

According to a February report from the Office of the Chief Coroner, Winterstein sought care at the St. Catharines hospital on December 9, 2021, reporting severe back pain, but was sent home with Tylenol and a bus ticket. The following day, after her condition worsened, she returned to the hospital and collapsed following hours in the emergency department’s waiting room. Despite resuscitation efforts, she died in intensive care. An autopsy determined the cause of death was sepsis resulting from bacterial infection.

A third-party review requested by Niagara Health found Winterstein was discharged following her first visit despite abnormal vital signs, and it expressed concerns that bias related to addiction and homelessness may have influenced her care. In response, Niagara Health accepted recommendations for improvements, including mandatory cultural safety training and increased Indigenous representation among staff.

Indigenous advocacy organizations have described Winterstein's case as emblematic of systemic racism within the health-care system. The upcoming inquest, which will hear from about 22 witnesses over two weeks, is considered by advocates a critical step in examining institutional biases and preventing further deaths.

The proceedings will begin at 9:30 a.m. Monday and are open to the public online. No final conclusions have been reached; the inquest is tasked with making recommendations to prevent similar incidents in the future.