Rain poured down Thursday night outside the Sessions on the River recording studio in Fort Erie, Ont., but it did little to dampen the mood inside as friends, family and community members gathered to pay their respects to Heather Winterstein.
Her death four years ago at St. Catharines Hospital raised questions about how Aboriginal people and those with mental health and substance use issues are treated in the health care system.
Just days before a coroner’s inquest begins in late 2021 into Winterstein’s death at what is now Marotta Family Hospital, Thursday’s event was a celebration of the legacy the 24-year-old left behind.
“My nephew was a man, loved his family,” her aunt, Jill Lunn, told CBC News. “We want to support Heather’s parents and remind people that she was a beautiful and wonderful person who deserved to be better.”
Winterstein’s death came after she spent two days in December last year trying to access health care at the hospital.
She was taken to the hospital by ambulance on December 9, 2021 with severe back pain after a fall. But she was given Tylenol and sent home with a bus ticket, the chief coroner’s office said in a report in February. The office said the doctor determined “social issues” behind her visit to the hospital.
The next morning her family called emergency medical services when they noticed Winterstein’s skin looking pale and she returned to the hospital.
Attempts at resuscitation were unsuccessful
After spending hours in the emergency department waiting room, Winterstein collapsed on the floor. She was taken to the intensive care unit where efforts to revive her were unsuccessful, the coroner’s office said.
The coroner’s office said an autopsy found Winterstein died of sepsis, a severe reaction to infection, caused by the bacteria Streptococcus pyogenes and Staphylococcus aureus.
Winterstein’s mother, Francine Shimizu-Orger, is haunted by what her daughter endured in her final moments.
“One witness said he was scared,” she told the CBC on Thursday. “That’s not what a mother needs to hear.”
Shimizu-Orger said Winterstein revealed to her that she was addicted to heroin and fentanyl, but said her daughter also experienced joy in life.
“Heather was a gentle person who loved animals,” she said, recalling her daughter’s pets, cats, dogs, rabbits, guinea pigs, hamsters and lizards. “I called her my little zoo.”
Inside the music studio Thursday evening, a lone pink dress hung from a stand. Winterstein’s mother said it was one of her daughter’s favorite prom dresses.
The investigation begins on Monday
An inquest into Winterstein’s death begins Monday and is expected to last about two weeks, with about 22 witnesses.
Shimizu Orger said the public can expect to hear heart-wrenching testimony in the inquiry into her daughter’s health care.
You will be as angry as I was.– Francine Shimizu-Orgar
“I want to give you fair warning that when you hear the testimony and the evidence, you will be as outraged as I was,” she told the meeting.
Shimizu-Orgar hopes the recommendations from the inquest will help ensure the way her daughter was treated never happens again.
“My whole goal is to prevent any other parent with a child with addiction from having a local child who has a poor person in the family,” she said.
“I’m glad the inquest will be held. I don’t want Heather’s death to be for nothing and it won’t be for nothing. This will be the start of something new and powerful.”
The inspection was announced in 2024. It is a public hearing that “informs the public about the circumstances of the death” but does not impose charges or make findings of guilt or innocence. “The jury makes findings regarding the facts of the death and may make recommendations to prevent further deaths,” the county said.
Niagara Health, which runs St. Catharines Hospital, is one of the parties “with standing” during the investigation, led by Dr. David Eden. These are people or entities that have a “significant and direct interest in the investigation,” including those who may be directly and specifically affected by the potential recommendations, the coroner’s office said.
In an earlier statement to CBC News, Linda Buech, Niagara Health’s vice president, called Winterstein’s death “a tragedy.”
“We acknowledge widespread concerns about racism and bigotry in health care, including in hospitals like ours,” Butch said in an email.
“And we are committed to confronting it and making meaningful, ongoing improvements.”
‘Tragic reminder’ of racism in health care
A third-party panel at the request of Niagara Health reviewed what happened at the hospital that led to Winterstein’s death and found that despite Winterstein having abnormal vital signs at her first hospital admission, she was discharged without evaluation.
The panel noted that there is concern that unconscious bias may have played a role in Winterstein’s care because he was labeled as experiencing addiction and homelessness. The panel released its report in August 2023, making a series of recommendations.
Boech said Niagara Health accepted all of the panel’s recommendations, such as mandating cultural safety training for staff, creating an Indigenous Health Services and Reconciliation Team to support Indigenous patients, and beginning to hire and train Indigenous staff, doctors and volunteers.
The Ontario Federation of Indigenous Partnership Centers said in a statement in February that the inspection is an important opportunity to examine systemic issues such as anti-Aboriginal racism and mental health and addiction discrimination.
“Friendship Centers see first-hand the effects of lack of cultural safety and institutional and systemic racism perpetuates on Indigenous peoples,” said Federation Executive Director Sean Longboat. “These realities must be understood if meaningful change is to be pursued.”
The Ontario organization’s leaders said the inquiry should ask tough questions about bias in the health care system to prevent similar incidents in the future.
“Heather’s death is a sad reminder of the systemic racism First Nations people face in health care,” said Ontario Indigenous Chief Abram Benedict.
“This [inquest] “This is an important moment to look at how systemic racism, stigma and prejudice continue to perpetuate the experiences of First Nations patients in hospitals and emergency departments in Ontario’s health care system.”
The screening begins at 9:30 a.m. and can be viewed online.
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