A triage nurse at a St. Catharines, Ontario hospital admitted during a coroner's inquest this week that she spent only three to five seconds looking at Heather Winterstein before the 24-year-old died of sepsis — and never actually spoke to her or took her vital signs.
Andrea Demery testified Thursday that her entire patient interaction with Winterstein consisted of a brief glance across the emergency department after speaking with paramedics who had just transported her by ambulance. Winterstein was waiting in a wheelchair, complaining of severe pain with her heart rate elevated to 130 beats per minute.
"I probably looked at her for three to five seconds," Demery said. "I didn't give her any opportunity" to ask questions during the assessment process.
The inquest, which began March 30 and is expected to hear from over 20 witnesses, is examining the circumstances surrounding Winterstein's death on December 10, 2021 — the second consecutive day she had sought emergency care at the hospital.
Staffing Crisis at Breaking Point
Demery explained to inquiry lawyer Julian Roy that the emergency department was dangerously understaffed during the height of the COVID-19 pandemic. Many nurses had been sent home after showing COVID-19 symptoms, leaving the unit stretched beyond capacity.
"We were always short. That became the norm," Demery testified. When asked why critical protocols weren't followed, she said bluntly: "Nurses are burned out. Nurses are exhausted."
Despite being required to reassess patients every 15 minutes while they waited for physician evaluation, Demery did not check on Winterstein again during her 2½-hour wait in the emergency unit. After that period, Winterstein collapsed. Despite resuscitation efforts by medical staff, she was pronounced dead the same day.
Missed Warning Signs
Winterstein had first arrived at the hospital on December 9 after reportedly falling down a flight of stairs. She was given acetaminophen and discharged with instructions to return if her condition worsened. The emergency physician who assessed her that day attributed her hospital visit to "social issues," according to previous inquest testimony.
When she returned by ambulance the following day, her condition had deteriorated dramatically. Paramedic Brandon St. Angelo reported that Winterstein's pain had escalated to 10 out of 10 on the pain scale. He also informed Demery that Winterstein had mentioned possible fentanyl withdrawal.
Demery acknowledged that while Winterstein's heart rate of 130 was elevated, she attributed it to pain or potential withdrawal rather than investigating further — a critical oversight that the inquest is examining as part of the broader circumstances leading to her death from sepsis, a life-threatening systemic infection that causes the body's tissues and organs to fail.
What the Inquest Will Determine
An Ontario coroner's jury will review all evidence presented during the 13-day virtual hearing to determine the facts surrounding Winterstein's death and may make recommendations aimed at preventing similar deaths. The jury is not tasked with assigning blame or determining guilt or innocence.
The inquest highlights ongoing concerns about emergency department capacity, nurse burnout, and whether adequate protocols for patient reassessment can be maintained during periods of severe staffing shortages — issues that continue to affect hospitals across Canada.
This reporting is based on testimony from the ongoing coroner's inquest into the death of Heather Winterstein. The inquest proceedings are public record.