A long-awaited coroner’s inquest into the 2021 death of Heather Winterstein at a hospital in St. Catharines, Ont., got underway on Monday, with Winterstein’s mother telling the five-person jury about the torment she feels over her daughter’s death.
Francine Shimizu-Orgar said as a registered nurse, she suffers from terrible guilt for not being able to help her 24-year-old daughter before her death in December, 2021.
“How does a registered nurse not help her dying child?” she asked. “There isn’t a day that goes by that I don’t blame myself for what happened. The guilt I feel for not saving my daughter is so immense.”
The inquest before coroner and inquiry presiding officer Dr. David Eden is being held virtually, and is expected to take place over about 13 days with about 22 witnesses.
On Monday, Shimizu-Orgar said having to live 1,571 days without proper answers about how her daughter died has been “absolute torture” for her.
Winterstein’s family had a slideshow presented at the inquest, showing Winterstein as a blonde-haired kindergarten student, in a pink prom dress, at her Grade 8 graduation, riding on an elephant at African Lion Safari and with her dad Mark Winterstein at the Butterfly Conservatory in Niagara Falls.
Mark fought tears as he recalled taking his daughter on bike rides in the basket on the front of his bike, taking her to the playground and going hiking with her.
“Every day reminds me I no longer have my daughter,” he said.
Winterstein’s brother, Ronan Shimizu-Obee, said it hurts not being able to go to his big sister, who he used to share 7-Eleven slurpies and video games with, for advice.
“I feel there’s a massive hole in my life because of Heather’s absence,” he said. “I don’t know what’s worse: her being gone or not knowing fully what happened to her.”
Winterstein, an Indigenous woman, had tried to get care at what is now called the Marotta Family Hospital over two days on Dec. 9 and 10, 2021, after she’d fallen down stairs two days earlier.
She was taken by ambulance on Dec. 9 with severe back pain. But she was just given a Tylenol and sent home with a bus ticket, the Office of the Chief Coroner said in a report in February. The office said the physician determined “social issues” were behind her trip to the hospital.
She returned to the hospital by ambulance the next day. After waiting for hours in the emergency department waiting room, Winterstein collapsed on the floor. The coroner’s office said she was taken to the intensive care unit where efforts to resuscitate her failed.
An autopsy found Winterstein died from sepsis, an extreme response due to an infection, due to streptococcus pyogenes and staphylococcus aureus bacteria, the coroner’s office said.
Winterstein’s mother said her daughter had opened up to her about an addiction to heroin and fentanyl. Her family previously said they worried that may have impacted the care she received.
Winterstein’s stepmother, Rosemary Ripper, told the inquiry that on the evening of Dec. 9 after Winterstein returned from the hospital to the St. Catharines apartment of Ripper and Mark where she was living, Winterstein looked very weak, her eyes were cloudy, her skin was grey and she had to lean against the wall.
“She said she had bone pain throughout her body,” Ripper said.
By the next morning, Ripper said Winterstein’s condition had worsened.
“She was terrible,” she told the inquiry. “She was in bed and she was rolling back and forth in pain. She was moaning a lot.”
Mark, a trucker, told the inquiry that he returned home to his apartment from a long-distance trucking run early in the morning of Dec. 10 and heard his daughter moaning inside.
He said he’d assumed she’d received medical attention at her hospital visit.
Later that morning he spoke to her again and she asked him to call 911 at about 10:31 a.m.
He said she was “agonized.”
In the 911 call recording played at the inquiry, Winterstein said she’d fallen about two-thirds of the way down the apartment’s exterior staircase two days earlier while carrying bags for Goodwill. Her speech was noticeably slow and weak.
The 911 dispatcher said based on how Mark described his daughter’s condition, it “doesn’t appear to be immediately life-threatening.”
Once a female and male paramedic arrived, Mark said the male paramedic suggested his daughter just needed to stay home and rest.
“And he told her if she went to the hospital she’d have to go to the Fort Erie hospital and wait for eight hours,” he said.
“I actually thought they were trying to discourage her from going,” said Mark. “They were trying to scare her.”
Mark said the paramedics did not bring a stretcher or equipment to bring her down the stairs, did no physical assessment of her and did not appear to take her vital signs.
He said the paramedics had his daughter walk down the stairs under her own power. At that point, Mark said his daughter assured him she had his phone number.
“That was the last time I saw her alive,” he said. “I thought she was in good hands.”
After going back to sleep, Mark called Niagara Health to check on his daughter. “They said ‘you need to come to the hospital right away.’ “
He and Ripper drove to the St. Catharines hospital and a woman there told them that Winterstein had died.
The lawyers for the paramedic service said they had no questions for Mark.
The inquest continues Tuesday.
