The triage nurse who first evaluated Heather Winterstein on the day she passed away from sepsis in 2021 stated that she never interacted with the 24-year-old patient and did not check her vital signs after paramedics had done so. During a coroner’s inquest, she explained that the staff were extremely busy.
Andrea Demery testified Thursday that her only interaction with Winterstein was a brief glance at her in the wheelchair from across the room after speaking to one of the paramedics who had just delivered her by ambulance.
“I probably looked at her for three to five seconds,” Demery mentioned. She pointed out that it was also a “very, very difficult” time – during the peak of the pandemic when many nurses were instructed to stay home if they showed COVID-19 symptoms.
“We were always short. That became the norm.”
Demery admitted she didn’t reassess Winterstein while waiting for a doctor in the emergency unit, which is something she was required to do every 15 minutes to check if the patient’s condition was getting worse.
“Nurses are burned out. Nurses are exhausted,” Demery told inquiry lawyer Julian Roy when asked why certain procedures weren’t followed.
After waiting for two and a half hours, Winterstein collapsed. Attempts by medical personnel to revive her failed, and she was declared dead on Dec. 10, 2021 – marking her second consecutive day seeking assistance at the hospital. She had suffered an extreme reaction to a bacterial infection that led to sepsis, a critical condition damaging the body’s own tissues and organs.
Winterstein died at St. Catharines hospital in 2021. (Google Maps)
Winterstein arrived at the hospital on Dec. 9 via ambulance, complaining of pain after reportedly falling down stairs a day earlier. She received Tylenol and was discharged with instructions to return if her situation worsened. The emergency physician concluded “social issues” contributed to her hospital visit, as previously noted during the inquest.
Demery is among witnesses recounting events leading up to Winterstein’s death since testimony began on March 30. More than 20 individuals are expected to testify over a span of 13 days during these virtual hearings.
An Ontario coroner’s jury reviews such evidence to establish facts in cases and may suggest recommendations aimed at preventing similar fatalities but does not assign blame or determine guilt or innocence.
<پ<“We know their condition can deteriorate very quickly,” said Demery.
<پ<However, Winterstein went without reassessment throughout her two-and-a-half-hour wait.
<پ<“She should have had at least ten reassessments.”
<پ<Demery explained front-line triage staff felt overwhelmed; there were forty-seven patients waiting for treatment in emergency while only three triage nurses were available instead of four.
<Nurses who postponed breaks for hours finally needed them and one nurse spent time answering phones along with handling new arrivals.
<Fighting back tears, Demery expressed: “Every time you open up doors into waiting rooms filled with people including newborns or someone clutching their chest along with others using inhalers needs your help too – then we must figure out how sick they really are; this leads our standard care deterioration which isn’t what we want – we just can’t do everything.”
Heather Winterstein, right, andher mother Francine. The familyandcommunityorganizationshaveexpressedconcernsabouthowthe24-year-oldwastreatedinhospital.(Submittedby Jill Lunn)<Demery decided it would be better for Winterstiento waitintheroominstead oftakingher somewhere else where doctors could attendmore quickly.
“She appeared relatively comfortable sitting inherchairwithout showingany obvious distress.”
Roy questioned whether nurses could express concerns regarding patient safety amidst limited resources; he said most simply stop tryingto raise alarms about issues concerning safety,
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No Opportunity for Patient Questions, Says Inquest
Winterstein was brought by ambulance just after noon on Dec. 10 to what’s now referred to as Marotta Family Hospital’s emergency department. Demery indicated that her only conversation was with paramedic Brandon St. Angelo, who reported Winterstein’s pain had intensified to a level of ten out of ten on the pain scale. Triage nurses possess advanced experience and conduct initial evaluations of patients while prioritizing care based on severity rather than order of arrival. Demery remarked that Winterstein wasn’t given an opportunity to ask any questions during assessment, adding, “I didn’t give her any opportunity.” St. Angelo also informed Demery that Winterstein suggested she might be experiencing withdrawal from fentanyl. Relying on vital signs taken by paramedics, Demery noted Winterstein had an elevated heart rate of 130 but believed it could have been due either to pain or fentanyl withdrawal. “I attributed it mostly” to withdrawal symptoms, she said. “The withdrawal symptoms are so horrendous. It’s just such a terrible feeling throughout the body.” Demery acknowledged being unaware that Niagara Health standards dictated triage nurses should always take their own vital sign readings. “It was a standard of our department that wasn’t being enforced. It was never brought to our attention that we were doing it wrong.” <Because Winterstein was classified as CTAS Level 2 under Canadian Triage and Acuity Scale (CTAS), protocols mandated Demery reassess every fifteen minutes.<پ<“We know their condition can deteriorate very quickly,” said Demery.
<پ<However, Winterstein went without reassessment throughout her two-and-a-half-hour wait.
<پ<“She should have had at least ten reassessments.”
Nurse Shares Challenges Faced
Roy, one of those assisting with inquiries asked Demery why there wasn’t any reassessment conducted for Winterstein.<پ<Demery explained front-line triage staff felt overwhelmed; there were forty-seven patients waiting for treatment in emergency while only three triage nurses were available instead of four.
<Nurses who postponed breaks for hours finally needed them and one nurse spent time answering phones along with handling new arrivals.
<Fighting back tears, Demery expressed: “Every time you open up doors into waiting rooms filled with people including newborns or someone clutching their chest along with others using inhalers needs your help too – then we must figure out how sick they really are; this leads our standard care deterioration which isn’t what we want – we just can’t do everything.”
Heather Winterstein, right, andher mother Francine. The familyandcommunityorganizationshaveexpressedconcernsabouthowthe24-year-oldwastreatedinhospital.(Submittedby Jill Lunn)<Demery decided it would be better for Winterstiento waitintheroominstead oftakingher somewhere else where doctors could attendmore quickly.“She appeared relatively comfortable sitting inherchairwithout showingany obvious distress.”
Roy questioned whether nurses could express concerns regarding patient safety amidst limited resources; he said most simply stop tryingto raise alarms about issues concerning safety,
“You get tiredoftryingto fightforadepartment.”
The Treatment Process Following Collapse
Following Wintersteinscollapseatabout2:41PMETon Dec10th, Dermey statedthat shereachedthewaitingroomalongsideothermedicalstaffmembersasquicklyaspossible. Ateamofdoctorsspenthoursattemptingtoreviveherduringthat time frame accordingto testimony sharedwithinquiry proceedings. Dr. Jennifer Tsang, a specialistworkingin Intensive Care Unitatthishospital, testifiedthat Wintersteinsbloodhadbecomedangerouslyacidic-termedmetabolicacidosis-andbloodpressureplummetedtoextremelylowlevels. Testsrevealedherhemoglobinlevelswereconsiderablyloweralongwithahighpulseandsuperficialbreathingpatternindicatingcriticalcondition. “Itwasasevereshockstate,”said Tsang.”Thatcouldleadtomultipleorganfailureanddeath.” Overa spanoftwo hours, thephysicianadministeredavarietyoftreatmentsincludingdifferentfluidsandantibioticsdespite Wintersteinnotshowingsigns ofinfections. Makingreference totreatmentapproaches, sheexplained:”Whensomeoneisthissick,[you]throwthekitchensinkatthemtryingtokeepemalive.” Eventually transferedinto Intensive Careunitwherehermotherconsentedtohaltresuscitationefforts, shewouldbelaterdeclareddeceasedat8:42 PM. EThour later following continued attempts.Changes Since Wintersteins Death At The Hospital
Accordingto Dermey, hospitalsmade significantimprovementswithin Emergency Departmentposthumouslyafterwards. Demergingreportedadditionalnursepractitionersandpersonalserviceworkerswereassignedtothemonitorpatientswaitingrooms. Newleadnursehasbeenestablishedinthespecifiedrapidassessmentzoneensuringadequatepatientflowreduction henceforth techniciansperformtasksassisting bloodworkandelectrocardiogramreadingsallowingtriagenursesto focusontheirprimaryresponsibilitieswhichareassessingindividualpatients’healthconditions. However, Dermeymaintains CTASleveltwo patientsdonotconsistentlyreceive routine re-evaluationseveryfifteenminutesindicatingongoingresourcechallengesexists.“Isupportiveoftheefforts madeyet I stilldonotbelieveenoughresourcesremainavailable forthesetasks” added Dermey winterstienwaspartof Cayuganationlinkedwith Six Nationsofthe Grand River. Followinghersuddenpassingfamilymembers alongsidecommunitygroups voicedconcernsregardingaddictiondiscriminationandanti-Indigenousracismpossiblyaffectingtreatmentreceived. Here, givingtestimony virtually addressingfamilymemberspresent. Dermyextendedsympathieshopingthisincidentcould ignite change withinhealthcare systeminitiatives moving forward.“Iamsosorryshewastakenfromyouatsuchayoungageand[its]leftsuchapainfulholeinyourlives.”Source link
