The physician who treated Heather Winterstein the day before she died in hospital from a severe reaction to bacterial infection said he may have erred in diagnosing her condition as being due to “social issues.”

But the doctor also stressed that was a “working diagnosis,” not necessarily a definite or final diagnosis, and defended his assessment and treatment of Winterstein given what he knew at the time.

In a full day of testimony last week at the coroner’s inquest into Winterstein’s death on Dec. 10, 2021, Dr. Emad Nour said Winterstein didn’t seem to be in distress when he saw her sitting in a wheelchair in the St. Catharines hospital emergency department.

Nour didn’t order bloodwork for Winterstein despite examining her for signs of an infection, he told the inquest, which began on March 30. She was discharged and died the next day, after she returned to hospital.

While expressing sympathy for Winterstein’s family, Nour said he wouldn’t have done anything different in his assessment and treatment of her.

“This is a very unfortunate outcome,” Nour said. “I really express my sympathy and condolences to the patient’s family. It is a really sad situation.” 

He said he reflected at length on the case. “I reviewed this case many, many times,” he said. “If I had the same information … I would reach the same conclusion today.”

Nour insisted 24-year-old Winterstein did not seem to be suffering when he saw her. “The way she was talking to me, she was well,” he told the inquiry. “She was sitting comfortably, no distress whatsoever.

“She was not in pain at the time I was talking to her.”

In his physician notes from his assessment, presented at the inquiry, Nour noted Winterstein was suffering from “generalized body ache.” The note also mentioned a history of substance abuse disorder.

Winterstein’s mother, Francine Shimizu-Orgar, has testified her daughter had opened up to her about her addiction to heroin and fentanyl.

Winterstein’s family members and community organizations have expressed concern since her death that addiction discrimination and anti-Indigenous racism may have played a role in how Winterstein was treated.

Given Tylenol and sent home from hospital

Winterstein first went to the hospital by ambulance after flagging down a Niagara Regional Police officer on Dec. 9, complaining of pain.

On the first day of the inquest last week, she was heard saying in a 911 call made by her dad on Dec. 10 that two days earlier she’d fallen down a flight of stairs while carrying bags for Goodwill.

On Dec. 9 as she was discharged from the emergency room, 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.

Winterstein returned to the hospital by ambulance on Dec. 10. After spending hours waiting in the emergency room waiting area, she collapsed. Resuscitation attempts failed and she died that day.

An autopsy found Winterstein died from sepsis, an extreme response due to an infection, due to streptococcus pyogenes and staphylococcus aureus bacteria.

In testimony on March 31, Niagara Emergency Medical Services paramedic Paula Lagrotteria told the inquiry that Winterstein complained of pain all over her body but most notably in her right leg on Dec. 9. “She said it felt like it was in her bones,” the paramedic said.

Lagrotteria said Winterstein was walking hunched and slowly, had scabs on her hands, and had been experiencing diarrhea and loss of appetite. The paramedic also said Winterstein told her she’d used heroin earlier that day.

‘I couldn’t find the reason for the symptoms’

Nour, who said he hasn’t been working at the hospital since 2023, said on April 1 that when he saw Winterstein she declined to take off the hood she was wearing or the facemask she was wearing in the midst of the full-blown COVID-19 pandemic.

“How can I have good clinical judgment when the patient is covering the face and head?” he asked. But Nour said she didn’t have any breathing problems and her skin didn’t appear pale.

“The way she was talking to me, she was well,” he said.

Nour said medical records on Winterstein that he checked indicated a history of skin infections, generalized anxiety disorder and elevated pulse.

As part of his assessment of her, he said he examined her back over top of her clothing and rolled up her pants to examine her legs to about mid-thigh level.

He said he also examined her hands and arms, specifically areas such as near the elbows, wrists and hands that are common injection sites for people who use drugs that are injected.

“I was specifically looking for any signs of infection,” Nour said. “I didn’t find any red flag telling me this was infection.” 

Despite looking for signs of an infection, Nour said he did not order bloodwork. “She did not meet the criteria” for that, he said.

When he couldn’t find evidence of infection or trauma, Nour said he considered Winterstein might be suffering from muscle pain because he said people with a history of substance abuse can suffer from that.

Nour said he didn’t re-take her vital signs that were taken about two hours earlier by a triage nurse because Winterstein’s clinical status hadn’t changed. “There was no need to repeat the vitals at that time,” he said. 

In his physician notes, Nour noted “social issues” in a section noting the discharge diagnosis.

Under questioning, he said that was a “working diagnosis” and that issues such as a history of substance abuse, generalized anxiety and housing instability can contribute to symptoms such as fatigue and being unwell.

He conceded he “was wrong” about that diagnosis, but said he wonders if the infection that claimed her life could have happened after he treated her, in the 24 hours before her death.

Nour said he re-assessed Winterstein about 30 minutes after his initial assessment, after she was given Tylenol and Advil and some food and orange juice.

“I told her I couldn’t find the reason for the symptoms she was having,” he said.

On Dec. 16, seven days after he’d seen Winterstein and six days after she died, Nour filled out another document related to her examination. That document shown at the inquiry noted she had “no obvious redness, swelling or abscesses.” 

The inquiry lawyer wasn’t able to complete questioning of Nour on Wednesday and Nour was unavailable on Thursday.

He is expected to return to testimony later in the inquest, which continues Tuesday.