It was pounding rain outside the Sessions on the River recording studio in Fort Erie, Ont., Thursday night, but that did little to dampen the mood inside as friends, family and members of the community gathered to pay tribute to Heather Winterstein.

Her death at the St. Catharines hospital more than four years ago has raised questions about how Indigenous people and those with mental health and substance use issues are treated in the health-care system.

Just days before a coroner’s inquest is set to begin into Winterstein’s death in late 2021 at what is now called the Marotta Family Hospital, Thursday’s event was a celebration of the legacy the 24-year-old left behind.

“My niece was a person, a loved person with family,” her aunt Jill Lunn told CBC News. “We want to support Heather’s parents and remind people she was a beautiful, wonderful person who deserved better.”

Winterstein’s death came after she tried over two days in December of that year to access health care at the hospital. 

She was taken by ambulance to the hospital on Dec. 9, 2021, with severe back pain following a fall. But she was 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.

The next morning her family called emergency medical services when they noticed Winterstein’s skin appeared grey and she returned to the hospital.

Resuscitation attempts failed

After spending hours in the emergency department waiting room, Winterstein collapsed on the floor. The coroner’s office said she was rushed 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, Francine Shimizu-Orgar, is haunted by what her daughter endured in her final moments.

“One of the witnesses said she looked terrified,” she told CBC at Thursday’s event. “That’s not something a mother should hear.”

Shimizu-Orgar said Winterstein opened up to her that she was addicted to heroin and fentanyl, but said her daughter also experienced joy in life.

“Heather was a gentle person who loved animals,” she said, recalling her daughter’s budgies, cats, dogs, rabbits, Guinea pigs, hamsters and lizards. “I called her my little zookeeper.”

Inside the music studio Thursday evening, a solitary pink dress hung from a stand. Winterstein’s mom said it was her daughter’s prom dress from happier times.

Inquest begins Monday

The inquest into Winterstein’s death begins Monday and is expected to last about two weeks, with about 22 witnesses.

Shimizu-Orgar said people can expect to hear jarring testimony at the inquest about her daughter’s health care.

You are going to be outraged as I was.– Francine Shimizu-Orgar

“I want to give you fair warning that when you listen to the testimony, the evidence, you are going to be outraged as I was,” she told the gathering. 

Shimizu-Orgar hopes recommendations coming out of the inquest will help ensure how her daughter was treated won’t ever happen again.

“My whole goal is to stop this from happening to any other parent that has a child with addictions, that has an Indigenous child, that has a marginalized person in their family,” she said.

“I’m happy that the inquest is going to take place. I don’t want Heather’s death to be for nothing, and it won’t be for nothing. It’s going to be the start of something new and something powerful.”

The inquest was announced in 2024. It’s a public hearing “to inform the public about the circumstances of a death,” but does not assign blame or make findings of guilt or innocence. “The jury makes conclusions about the facts of the death and may make recommendations to prevent further deaths,” the province says.

Niagara Health, which runs the St. Catharines hospital, is one of the “parties with standing” at the inquest being headed by Dr. David Eden. Those are people or agencies with a “substantial and direct interest in the inquest,” including those who may be directly and uniquely affected by potential recommendations, the chief coroner’s office said.

In a previous statement to CBC News, Linda Boich, a vice-president at Niagara Health, described Winterstein’s death as “a tragedy.”

“We acknowledge the broader concerns about racism and bias in health care, including in hospitals like ours,” Boich said in an email.

“And we remain committed to confronting this and making meaningful, ongoing improvements.”

‘Tragic reminder’ of racism in health care

A third-party panel at the request of Niagara Health reviewed what happened at the hospital leading up to Winterstein’s death and found that despite Winterstein having abnormal vital signs at her first hospital visit, she was discharged without being assessed.

The panel noted there was concern that unconscious bias may have played a role in Winterstein’s care because she was labelled as experiencing both addiction and homelessness. The panel released their report in August 2023, making a series of recommendations.

Boich said Niagara Health accepted all the panel’s recommendations, such as making cultural safety training for staff mandatory, creating an Indigenous Health Services and Reconciliation team to support Indigenous patients, and beginning to recruit and retrain Indigenous employees, physicians and volunteers.

The Ontario Federation of Indigenous Friendship Centres said in a statement in February that the inquest is an important opportunity to examine systemic issues such as anti-Indigenous racism and mental health and addiction discrimination.

“Friendship Centres see firsthand the impact of the lack of cultural safety and the institutional and systemic racism continue to have on Indigenous people,” said Sean Longboat, executive director of the federation. “These realities must be understood if meaningful change is to follow.” 

The Chiefs of Ontario organization said the inquest must ask tough questions about bias in the health-care system to prevent similar tragedies in the future.

“Heather’s death is a tragic reminder of the systemic racism First Nations people continue to face in health care,” said Ontario Regional Chief Abram Benedict.

“It [inquest] is a critical moment to examine how systemic racism, stigma and bias, continue to shape the experiences of First Nations patients within hospitals and emergency departments within Ontario’s health-care system.”

The inquest begins at 9:30 a.m. and can be watched online.