CBC Lite Sections News • Canada • Hamilton WINTERSTEIN INQUEST Woman collapses in ER waiting room in video shown at Ontario inquest into her sepsis death livePosted: April 17, 2026 12:58 PM | Last Updated: Just now Heather Winterstein, 24, died on the 2nd day she sought help at St. Catharines hospital in 2021 Image | Heather Winterstein, 24, first sought hospital ER care while experiencing body pain after a fall. The inquest into her sepsis death began March 30. (Submitted by Jill Lunn) (BUTTON) Load image Open image in new tab The Latest * A virtual coroner’s inquest examining the circumstances of Heather Winterstein’s death from sepsis in a St. Catharines, Ont., hospital is in its 13th day. * Winterstein, a member of the Cayuga Nation with ties to Six Nations of the Grand River, had been trying to get help over two days in the hospital emergency room before she died in 2021. * Today, an inquest lawyer showed hours of video of Winterstein struggling to get comfortable and getting out of a wheelchair in the ER. Another video showed her later collapsing. * Family and community groups have expressed concern that addiction discrimination and anti-Indigenous racism may have played a role in Winterstein's treatment. * A commander with Niagara EMS told the inquest certain information about Winterstein, including grey skin and shortness of breath, wasn’t relayed to paramedics. Updates 📌 Pinned Updates 📌 Pinned 8 hours ago What to know about today’s inquest proceedings Paul Forsyth Image | Heather Winterstein with mom and brother (1) (Submitted by Jill Lunn) (BUTTON) Load image Open image in new tab Testimony in the coroner’s inquest for Heather Winterstein is nearing its end, with proceedings today expected to hear again from an EMS commander who spoke yesterday about how busy the ambulance service was on Dec. 10, 2021. Ryan Pearson testified the paramedic service was being overloaded with calls around that time. The inquest, which began March 30, previously heard that the COVID-19 pandemic had led to increasing patient loads and understaffing. Winterstein, 24, was taken by ambulance to hospital twice, on Dec. 9 and 10, and faced lengthy emergency department waits. She died hours after collapsing while waiting to see a doctor. During testimony by a triage nurse, it was learned that Winterstein had been suffering body pain for six days after a fall. A hospital official was questioned yesterday about the ER doctor who saw Winterstein during her first hospital visit and sent her home with Tylenol, telling her to return to the hospital if she got worse. Family, friends and a physician previously said they believe racism and bias affected the quality of care Winterstein received. Also yesterday, Dr. Rafi Setrak, the regional chief of emergency medicine at Niagara Health, which runs the hospital (now named Marotta Family Hospital), testified the health system "failed" Winterstein. Earlier this week, Niagara Health president and CEO Lynn Guerriero said, "There's absolutely systemic racism and Indigenous racism in health care.” But she said she's struggling to accept that anti-Indigenous racism played a part in Winterstein's death, because front-line medical staff who were involved in her care have said they didn't know she was Indigenous. Scott Cronkwright, a peer support navigator who interacted with Winterstein on both Dec. 9 and 10 at the hospital, described how much pain she was in when he found her lying on the floor of the emergency waiting room on Dec. 10. He said it was obvious Winterstein's condition was extremely serious and she should have had a bed instead of being in the waiting room. The inquest was originally scheduled to hear witnesses for 13 days. It's not clear if testimony will conclude today or if it will stretch to Monday, when the charge to the jury is expected to take place. Timeline 8 hours ago What to know about today’s inquest proceedings Paul Forsyth Image | Heather Winterstein with mom and brother (1) (Submitted by Jill Lunn) (BUTTON) Load image Open image in new tab Testimony in the coroner’s inquest for Heather Winterstein is nearing its end, with proceedings today expected to hear again from an EMS commander who spoke yesterday about how busy the ambulance service was on Dec. 10, 2021. Ryan Pearson testified the paramedic service was being overloaded with calls around that time. The inquest, which began March 30, previously heard that the COVID-19 pandemic had led to increasing patient loads and understaffing. Winterstein, 24, was taken by ambulance to hospital twice, on Dec. 9 and 10, and faced lengthy emergency department waits. She died hours after collapsing while waiting to see a doctor. During testimony by a triage nurse, it was learned that Winterstein had been suffering body pain for six days after a fall. A hospital official was questioned yesterday about the ER doctor who saw Winterstein during her first hospital visit and sent her home with Tylenol, telling her to return to the hospital if she got worse. Family, friends and a physician previously said they believe racism and bias affected the quality of care Winterstein received. Also yesterday, Dr. Rafi Setrak, the regional chief of emergency medicine at Niagara Health, which runs the hospital (now named Marotta Family Hospital), testified the health system "failed" Winterstein. Earlier this week, Niagara Health president and CEO Lynn Guerriero said, "There's absolutely systemic racism and Indigenous racism in health care.” But she said she's struggling to accept that anti-Indigenous racism played a part in Winterstein's death, because front-line medical staff who were involved in her care have said they didn't know she was Indigenous. Scott Cronkwright, a peer support navigator who interacted with Winterstein on both Dec. 9 and 10 at the hospital, described how much pain she was in when he found her lying on the floor of the emergency waiting room on Dec. 10. He said it was obvious Winterstein's condition was extremely serious and she should have had a bed instead of being in the waiting room. The inquest was originally scheduled to hear witnesses for 13 days. It's not clear if testimony will conclude today or if it will stretch to Monday, when the charge to the jury is expected to take place. 23 minutes ago Triage nurse says more nurse, doctor staffing key to improving patient care Paul Forsyth Hayward is asked about recommendations she may have that would improve patients’ experiences in the hospital emergency department. Full staffing in the ER area is critical to patient safety. "You can't close your doors" when short-staffed, she says. She says making emergency department staffing is key. Other ways to address staffing challenges could include having the charge nurse help with triage assessments and registered practical nurses aid in waiting room reassessments. Increasing doctor staffing would help in getting patients seen in a timely manner, says Hayward, as would having a doctor in the triage or waiting room. Hayward says she supports Niagara Health's addition to IV drug use as a criteria for sepsis screening. 51 minutes ago Paul Forsyth Varrette asks Hayward about how staffing affects the triage process. Hayward says being short-staffed by even one nurse means it’s difficult to do the process and medical directives, and to check patients in the waiting room, she says. Previously, the inqest heard from a triage nurse that the emergency department was short-staffed the day Winterstein died, at a time when the pandemic was causing overwhelming demand for care and nurses presenting any COVID-19 symptoms weren’t able to come to work. Hayward says she has experienced burnout working in an emergency department setting. 1 hour ago Paul Forsyth Varrette questions Hayward about medical directives, which allow nurses to do procedures that would normally be out of their scope of practice, so wouldn’t need approval from a doctor. Procedures that doctors would normally do including an electrocardiogram for someone with chest pains, says Hayward. Having a clear picture of whether a medical directive would apply to a patient is important, she says. Medical directives can help the triage nurse to relay important information to doctors, such as low hemoglobin uncovered in a blood test, says Hayward. 1 hour ago Paul Forsyth Hayward says a change in a patient's skin colour or level of pain would raise her concern for a patient in a waiting room. Under questioning, she adds she doesn't think frequent repositioning by the patient would raise an alarm bell as much. Varrette, the inquest lawyer, asks if she would use a patient's prior emergency department visit the day before as part of her assessment. Hayward says that may help staff learn more about a patient’s medical history. "It can be helpful to determine if I need to be more concerned." Asked if she'd take extra steps for a person with a history of substance use, Hayward says that could be a concern for sepsis. "It can be a source of infection." 1 hour ago Paul Forsyth For patients with more worrying signs, such as a fast heartbeat or high blood pressure, "anything abnormal is something to pay attention to," testifies Hayward. On a low-volume day, it's easy to reassess in a timely manner, she says. "On a day that's very backlogged … it is very easy to lose track of those 15 minutes. "You just have to be constantly aware" of time passing by between reassessments. Hayward says raising alarms too frequently may lead to nurses feeling “alarm fatigue,” meaning they’d stop listening to them. This has been backed by research, she says. "It might not be possible some days" to meet reassessment time requirements. 1 hour ago Reassessment of a patient can be ‘quite quick,’ triage nurse says Paul Forsyth Image | A triage nurse testifying at the inquest works at Hamilton General Hospital, shown here. (Bobby Hristova/CBC) (BUTTON) Load image Open image in new tab Hayward is explaining how the CTAS score of severity is determined. She says nurses at Hamilton General Hospital where she works have the authority to increase the CTAS score based on certain modifiers. A patient given a CTAS 2 score, as Winterstein was, should see a doctor within 15 minutes of arriving, but that doesn't always happen, she says. They should be reassessed every 15 minutes, she adds. "Any patient in the waiting room is the responsibility of the triage nurses.” The inquest has heard Winterstein was not reassessed in the 2½ hours that she waited in the waiting room until she collapsed. A reassessment can be as simple as glancing into the waiting room to visually gauge if the patient is not in distress, or asking them a quick question, says Hayward. "It doesn't have to be extensive and lengthy. It can be quite quick." 2 hours ago Paul Forsyth Hayward says that if patients coming into the emergency department aren’t hooked up to paramedic service monitors, which the triage nurse can use to confirm their vital signs, she would take their vital signs. She says she normally gets verbal reports from paramedics, not ambulance call reports. Typically, patients arrive in a stretcher, except for uncommon cases when patients refuse to get on one, says Hayward. She says triage nurses also assign a CTAS (Canadian Triage Acuity Scale) score to patients, ranging from Level 1 to 5, with Level 1 being the most serious. "I work on a trust, but verify principle when it comes to working with paramedics,” says Hayward. “I will always verify that information. It's part of my process to confirm the information I've received is true." That can be done by asking the patient questions, she says, noting she would walk up to the patient on the stretcher to do that. The inquest has heard the triage nurse on Dec. 10, Winterstein’s second day in the ER, didn’t speak to her, and only looked towards her for two or three seconds as part of her assessment. 2 hours ago Paul Forsyth Hayward says ER patients are asked screening questions and staff get information gathered by paramedics. She says she verifies patients’ vital signs taken earlier by paramedics to check if they are accurate, delves into allergies, current medications and medical history, and will ask patients questions to clarify questions she might have. Hayward says rechecking vitals is important because vitals can change quickly. "I like to verify that these things are true." She also confirms the respiratory rate because that's often inaccurately reported, she says. The inquest has heard the triage nurse who was in the ER when Winterstein was there on the day she died didn't take her vital signs, relying instead on vitals taken by the paramedics. 2 hours ago Expert testifies on best way to triage patients brought by ambulance Paul Forsyth Rebecca Hayward, a registered nurse with Hamilton General Hospital's emergency department, is now under questioning by inquiry lawyer Christina Varrette. Hayward is a trained triage nurse with expertise in reassessing patients in a hospital emergency department. Varrette asks her about triage best practices. The term triage has been used repeatedly throughout the inquest. It’s the process of quickly assessing and prioritizing patients or medical problems based on how severe they are, to determine the order people should be treated. In the case of Winterstein, the triage process has been a focus in terms of assessing and other protocol for patient treatment. A triage nurse testified previously that the ER wait room was so busy, in part due to the COVID-19 pandemic, that some protocols weren’t followed. 3 hours ago After minutes struggling in her wheelchair, Winterstein collapses, video shows Paul Forsyth In an about seven-minute video, starting around 2:28 p.m., a man in a checkered shirt pushes her wheelchair to the triage area, then walks away. Winterstein is sitting for a time, and a person walks over to her and speaks for a few seconds before leaving as other people walk past her. Winterstein’s head slumps forward onto her legs and she collapses onto the floor. A woman and a security guard walk by. Several people, some in hospital gowns, bend down to help her. The video shows her being wheeled through a set of double doors. Winterstein is lying completely still. Nurses in hospital gowns appear and Winterstein is placed on the gurney, which is wheeled through the double doors. There’s now a 15-minute break in the proceedings. 3 hours ago Woman’s last minutes before collapse shown in videos Paul Forsyth The inquest resumes with a video shown from 2:21 p.m. on Dec. 10, 2021. It shows Winterstein in a wheelchair in the emergency wait room. She appears to be moving her wheelchair with difficulty. A man in a checkered shirt approaches, then wheels her out of frame. 4 hours ago Video will show woman collapsing in ER wait room, inquest lawyer says Paul Forsyth The final video shown to the inquest jurors was taken at 2:01 p.m. Winterstein is seen speaking briefly to peer support navigator Scott Cronkwright. Inquest lawyer Christina Varrette says there are two more videos to watch, including one showing when Winterstein collapsed. Presiding inquest officer Dr. David Eden said "we can appreciate these are tough to watch." There’s now a lunch break. 4 hours ago Paul Forsyth The next video, at 1:49 p.m., shows Winterstein lying on her back on the floor. A security guard stops briefly, then two security guards lift her up onto her wheelchair. She appears unsteady on her feet. The guards leave then before one returns briefly, picking up her blanket and putting it on her. 4 hours ago Paul Forsyth Image | In video played at the inquest, Winterstein appears uncomfortable during her time in the emergency room. (Submitted by Jill Lunn) (BUTTON) Load image Open image in new tab At 12:56 p.m., in a video that’s just over five minutes long, Winterstein gets up and walks a short distance with her blanket to a chair next to a table along the wall of the waiting room area. She places her blanket on the table and leans forward, resting her head on the table briefly. She then places her right leg on the table, trying to get comfortable. She moves her leg off the table and leans her head on it again briefly before placing her right leg on it. The next video, starting at 1:30 p.m., is about three minutes long and shows Winterstein leaning forward on the table. She gets up, then takes her blanket and places it on the floor, appearing to have difficulty lying down on the blanket next to her wheelchair. 5 hours ago Paul Forsyth In a 12:28 p.m. video that’s a little under three minutes long, she sits up in her chair, bends over briefly, then gets up with her white blanket. She walks slowly to a nearby area in the ER wait room and lies down on the floor. The next video, a little over 13 minutes long and starting at 12:30 p.m., shows Winterstein lying on the floor. She’s approached by a security guard who appears to check up on her. A man in scrubs then approaches her before walking away. Two security guards come to help her up into her wheelchair and she is left pointing towards a wall. The man in scrubs returns briefly then leaves and returns with a clean blanket. 5 hours ago Paul Forsyth In a 12:28 p.m. video that’s a little under three minutes long, she sits up in her chair, bends over briefly, then gets up with her white blanket. She walks slowly to a nearby area in the ER wait room and lies down on the floor. The next video, a little over 13 minutes long and starting at 12:30 p.m., shows Winterstein lying on the floor. She’s approached by a security guard. Two security guards then come to help her up into her chair. 5 hours ago Paul Forsyth Image | Winterstein visited the ER twice. (Submitted by Jill Lunn) (BUTTON) Load image Open image in new tab Another video, at 12:21 p.m., is played in fast motion. It shows Winterstein trying to get comfortable in her chair as she keeps shifting and lifting her legs, lying down then sitting up, then lying back down again. The same video is then played at regular speed. 5 hours ago Paul Forsyth The next video, timed at 12:15 p.m., lasts about four minutes and shows Winterstein walking across the waiting room towards the triage area, out of view. She then reappears, walking slowly. The next video shows Winterstein returning to the seating area at 12:19 p.m. She gets back in her chair and uses a thin blanket as a pillow on the metal arm rest while lying down and putting her legs on the wheelchair. 5 hours ago Video evidence shows Winterstein in a wheelchair Paul Forsyth A video taken at about 11 a.m. shows an ambulance pulling into the ambulance bay and a paramedic bringing a wheelchair. Winterstein is wheeled into the emergency department. Another video shows Winterstein being taken through double doors, and another shows her at 12:10 p.m. being taken into the emergency department waiting room. She gets out of her wheelchair after the paramedic leaves and, with difficulty, gets into a chair next to it. She tries to lie down in the chair, putting her legs on the wheelchair, and then what appears to be a staff member walks over and talks to her briefly. She then removes her legs from the wheelchair, stands and walks unsteadily across the waiting room. 5 hours ago Image | The Marotta Family Hospital, formerly the St. Catharines Hospital, is pictured yesterday. (Diona Macalinga/CBC) (BUTTON) Load image Open image in new tab Pearson's testimony wraps up after he answers some juror questions. Some videos are now being played at the hearing. They’re from the St. Catharines hospital on Dec. 10. 6 hours ago Paul Forsyth Search asks if EMS has supports for paramedics who have experienced traumatic experiences while on calls. Pearson said paramedics can be pulled off the road to get peer support and have their mental state assessed. More traumatic calls can also be monitored, for check-ins by superintendents of paramedics. Pearson says each supervisor goes out each year and watches paramedics on a call, doing a comprehensive evaluation and ensuring compliance rules are all being followed. The inquest is on a short break while the jury ponders questions for Pearson. 6 hours ago What else EMS now does in wake of death Paul Forsyth Pearson says EMS has introduced mandatory training in areas such as bias, diversity, equity, inclusivity, implicit bias, people experiencing mental health or addiction issues, racism and Indigenous perspectives. Superintendents and managers have also taken part in Indigenous experiences training, he says. EMS is also working with Niagara Health's new Indigenous health council, and has full-time staff at the safe drug consumption site in St. Catharines who can respond to overdoses, Pearson adds. 6 hours ago More ambulances added due to call volumes Paul Forsyth Image | Daina Search is a lawyer for Niagara EMS. (LinkedIn) (BUTTON) Load image Open image in new tab Daina Search, lawyer for Niagara EMS, is now questioning Pearson. He says that in response to increased call volumes, EMS added additional ambulances, moved bases so ambulances can be resupplied more efficiently, and increased the number of full-time staff. "It certainly has improved," he says. Search asks if EMS staff are protected under law when taking part in internal quality reviews, the way hospital staff are. Pearson says no. 6 hours ago EMS head questioned on Winterstein’s slow speech Paul Forsyth Natai Shelsen, lawyer for the Winterstein family, is now asking Pearson questions. Shelsen notes the report of Winterstein’s grey skin not making its way to the paramedics on Dec. 10, and adds that reports she was having slow speech did appear to make it to the paramedics. But, she adds, in the ensuing paramedic report, there’s no mention of slow speech and it should have made its way to clinicians. "The documentation lacked in certain details," Pearson concedes. Featured Media Embed | Niagara Health CEO acknowledges racism in health care at ER death inquest | Hanomansing Tonight Open full embed in new tab Loading external pages may require significantly more data usage than loading CBC Lite story pages. For images and videos read the full story. CBC Lite is a low-bandwidth website. To see what's new, check out our release notes. For high quality images, media, comments, and other additional features visit the full version of this story. We and select advertising partners use trackers to collect some of your data in order to enhance your experience and to deliver personalized content and advertising. If you are not comfortable with the use of this information, please review your device and browser privacy settings before continuing your visit. 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