Family Seeks Justice for Heather Winterstein’s Tragic Death

Francine Shimizu-Orgar often wakes from nightmares as her mind revisits the coroner’s inquest surrounding her daughter’s death, particularly when videos showing Heather Winterstein’s last hours at a St. Catharines, Ont., hospital were presented.

For Francine, who lost her 24-year-old daughter in 2021 due to septic shock, avoiding the distressing content of those videos – including one where Winterstein collapses in the emergency department waiting room – wasn’t an option.

She felt it was essential to understand what transpired – the world needed to know.

“It haunts my dreams,” she shared with CBC during an interview from her warm kitchen in St. Catharines, just about three weeks after the inquest wrapped up with multiple recommendations.

“I have nightmares as a result of seeing the video and hearing the testimony.”

The three-week inquiry revealed that Winterstein, an Indigenous woman, sought help at the hospital’s emergency department two consecutive days due to severe body pain.

The doctor who examined her on December 9, 2021, dismissed her symptoms as stemming from “social issues,” noting a history of substance use and anxiety disorder in his records. She left with just Tylenol and a bus ticket, instructed to return if her condition worsened.

The following day, she returned by ambulance suffering excruciating pain. The inquiry found that the triage nurse only looked at Winterstein for three to five seconds from afar during assessment. She was then sent back to the waiting area where she waited for 2½ hours before collapsing.

Despite hospital guidelines stating that patients like Winterstein should be reassessed every 15 minutes if their condition could worsen, this protocol wasn’t followed even once.

The family’s ongoing quest for answers

Winterstein’s family campaigned for years for an inquest to uncover how and why she died. Heather was part of the Cayuga Nation connected to Six Nations of the Grand River.

“I knew that something was wrong on that night she died,” said Shimizu-Orgar. “I felt it in my heart. I feel vindicated.”

Heather Winterstein, 24, first sought hospital emergency care while experiencing body pain. Her death resulted in a weeks-long inquest last month. (Submitted by Jill Lunn)

Inquest juries can only classify causes of death into five categories: natural causes, suicide, homicide, undetermined or accident. In this case, Winterstein’s death was deemed accidental. The jury also concluded that she succumbed to septic shock – which is caused by a bacterial infection – and recognized that delayed treatment contributed significantly to her demise.

Shimizu-Orgar had hoped the jury’s findings would bring her some peace.

“But hearing what actually occurred will haunt me forever,” she remarked. “You can’t unhear what you’ve heard. You can’t unsee what you’ve seen.”

“This is going to stay with me forever.”

Nevertheless, she stressed how crucial it was for her and her family to witness all parts of the inquiry proceedings along with that final video.

“If it wasn’t seen then her voice would never have been heard; nothing would have come out.”

Concerns about potential anti-Indigenous bias

Shimizu-Orgar believes biases against Indigenous peoples and factors related to homelessness and substance use influenced Winterstein’s care leading up to her death.

Lynn Guerriero, president and CEO of Niagara Health-which operates what’s now referred to as Marotta Family Hospital-testified during the inquiry that identifying anti-Indigenous racism as part of Winterstein’s experience proved difficult since front-line staff consistently stated they didn’t know about her background.

However,, Guerriero admitted there is “absolutely systemic racism and Indigenous racism within healthcare.” She mentioned still questioning whether “unconscious bias” linked to drug use or housing instability played larger roles in how Winterstein received care.
We’re going to work for change. Our work isn’t done.- Francine Shimizu-Orgar , Heather Wintersteins mother

Following Winterstein’s passing-and before the inquiry-Niagara Health already started taking steps towards reforming their practices:
They became Ontario’s first hospital formalizing an agreement with the Indigenous Primary Health Care Council aimed at enhancing health outcomes among Indigenous populations.
They established an Indigenous Health Services & Reconciliation Team.
Indigenous artwork has been placed across its hospitals and urgent-care facilities.
The jury provided 68 recommendations directed towards various bodies including but not limited too Ministry Of Health, Nigara health, Nigara regional paramedic service, Nigara regional police , and College Of Nurses Of Ontario. The majority targets Niagra Health independently or alongside others agencies...

Níagara health released a statement addressing Friday acknowledging," Heather winterstien' s passing represents tragedy hence why we fully engaged into coroner' s investigation. the jury determined manner regarding accidently involved therefore we accepted all suggestions made within this report&quote;. Action plans implementing these changes are already underway."

A foundation honoring Heather

Wintersteins brother Ronan Shimizu-Obee aged 22 expressed he has found " a bit of peace" now since details about his sisters passing are finally publicized.<Ronan shimizu obee left says they’ll continue advocating better health services indigenous people niagara region honor legacy

" Its really frightening knowing we stayed uninformed four long years. We were completely unaware.”

" This could happen anyone. With our systems operation its far more than issue indigenous peoples -this matters everyone.&quote;

Francine along with son plan establishing foundation dedicated Heathers memory which includes scholarships aiding young individuals aspiring improve healthcare services addressing indigenous needs.

The family hopes lessons learned through loss coupled sweeping recommendations will aid preventing similar tragedies other families face losing loved ones like winterstin.

" Its hard imagine another family going through ordeal,", said francine&quote.;“Hope none ever need endure such trauma”.

Shed added theyll persist speaking up aim improving medical outcomes hospitals.

" Were committed pursuing change. Work isn’t finished& quote;

Francine remarked “Daughter fought until end get necessary treatment.”

“She did everything possible herself. I’m so proud see fighting spirit”.

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