Nurse Testifies to Overcrowding and Missed Assessments in Heather Winterstein Inquest

Testimony at an Ontario coroner’s inquest has revealed that a triage nurse did not directly assess Heather Winterstein, a 24-year-old patient who died of sepsis at a St. Catharines hospital on December 10, 2021, citing severe staff shortages and overwhelming conditions during the COVID-19 pandemic.

Nurse Andrea Demery told the inquest on Thursday that she did not speak to Winterstein or take her vital signs upon her arrival at the Marotta Family Hospital, relying instead on readings from paramedics. Demery admitted her only interaction was a brief glance at Winterstein from across the room after consulting a paramedic, who reported the patient’s pain had reached the maximum level on the pain scale and that she may be experiencing fentanyl withdrawal.

Demery acknowledged she was expected to reassess Winterstein every 15 minutes, as mandated for patients placed at the second-highest level of the Canadian Triage and Acuity Scale (CTAS), but did not do so. She described a chaotic emergency department with 47 patients waiting and only three triage nurses on duty instead of the standard four. "We just can't do it all," Demery said, stating that protocols suffered due to staffing shortages and nurse exhaustion during the ongoing pandemic.

Winterstein had first visited the hospital on December 9, after reporting pain from a fall. She was given medication and sent home, returning the following day as her symptoms worsened. After waiting two and a half hours without a reassessment, Winterstein collapsed in the emergency department. Despite hours of intensive efforts by doctors, she was pronounced dead later that evening. The inquest heard that she developed sepsis, a severe complication from a bacterial infection.

The inquest, which began on March 30, is hearing from over 20 witnesses to examine the circumstances surrounding Winterstein’s death. While the hospital has since added staff roles and made procedural changes in the emergency unit, Demery testified that some critical reassessment gaps remain due to persistent resource constraints.

The Ontario coroner’s jury will consider testimony and evidence to establish facts and may offer recommendations to prevent similar cases. The inquiry is ongoing.