The triage nurse who initially assessed Heather Winterstein on the day she died of sepsis in 2021 says she never spoke to the 24-year-old patient and didn’t take her vital signs after paramedics had, explaining to a coroner’s inquest that staff were overwhelmingly busy.

Andrea Demery testified Thursday that her only engagement with Winterstein was to glance at her briefly in her wheelchair from across the room after speaking with one of the paramedics who’d just brought her there by ambulance.  

“I probably looked at her for three to five seconds,” Demery said.

She also said she didn’t reassess Winterstein while the patient was waiting in the emergency unit for a doctor, something Demery was supposed to do every 15 minutes to determine if her condition was deteriorating.

“Nurses are burned out. Nurses are exhausted,” Demery told inquiry lawyer Julian Roy when asked why certain protocols weren’t done.

After a 2½-hour wait, Winterstein collapsed. Efforts by medical staff to resuscitate her failed and she was pronounced dead on Dec. 10, 2021 — the second day in a row that she’d sought help at the hospital. She’d developed an extreme reaction to a bacterial infection, resulting in sepsis, a life-threatening condition that damages the body’s own tissues and organs. 

Winterstein first arrived at the hospital on Dec. 9 by ambulance, complaining of pain after reportedly falling down a flight of stairs the day before. She was given a Tylenol and sent home with instructions to return to the emergency department if her condition worsened. The emergency physician who assessed her determined “social issues” were behind her hospital visit, the inquest previously heard.

Demery is among witnesses who’ve described the events leading up to Winterstein’s death since the inquest began March 30. A total of over 20 people are expected to testify over 13 days during the virtual hearings. 

An Ontario coroner’s jury takes into account such evidence to determine the facts in a case and may make recommendations to prevent similar deaths, but isn’t tasked with assigning blame or making findings of guilt or innocence. 

Patient not given opportunity to ask questions, inquest told

Winterstein was transported by ambulance just after noon on Dec. 10 to the emergency department of what’s now known as the Marotta Family Hospital. Demery said she only spoke with paramedic Brandon St. Angelo, who reported Winterstein’s pain had worsened to 10 out of 10 on the pain scale.

Triage nurses have advanced experience and make initial assessments of patients, prioritizing care based on severity rather than arrival time. 

Demery said Winterstein wasn’t given the chance to ask her any questions during the assessment process, adding, “I didn’t give her any opportunity.” 

St. Angelo also informed Demery that Winterstein said she might be suffering from withdrawal from fentanyl.

Demery, who relied on vital signs taken by the paramedics, noted Winterstein had an elevated heart rate of 130, but said she thought that could have been from pain or from fentanyl withdrawal.

“I attributed it mostly” to withdrawal symptoms, she said.

“The withdrawal symptoms are so horrendous. It’s just such a terrible feeling throughout the body.”

Demery said she was not aware at the time that standards at Niagara Health, which runs the hospital, dictated triage nurses were supposed to always take vital sign readings themselves.

“It was a standard of our department that wasn’t being enforced. It was never brought to our attention that we were doing it wrong.”

Because Winterstein was put at the second highest of five levels under the Canadian Triage and Acuity Scale (CTAS), hospital protocols dictated that Demery was responsible for reassessing her every 15 minutes.

“We know their condition can deteriorate very quickly,” said Demery.

But Winterstein wasn’t reassessed at all over the 2½ hours she waited, she added. 

“She should have had at least 10 reassessments.”

‘We just can’t do it all,’ nurse testifies

Roy, one of the inquest’s counsel, asked Demery why Winterstein wasn’t reassessed. 

Demery said front-line triage staff were overwhelmed, with 47 patients waiting to be seen in the emergency department and only three triage nurses working instead of the normal four. She said nurses who had been delaying their breaks for hours had to finally take them, and one nurse had to spend time answering phones and handling new patient arrivals. 

Fighting back tears, Demery said, “Every time you open the door to the waiting room, and you see all these people and there’s a baby that’s three days old, and there’s somebody that’s clutching their chest and somebody else is puffing away on their Ventolin [inhaler], and you have to see all those people, you have to triage them and try to figure out how sick they are, then our standard of care deteriorates and it’s not because we want it to deteriorate. We just can’t do it all.”

Demery said she opted to have Winterstein sent to the waiting room rather than another area where she might have been seen by a doctor more quickly.

“She looked relatively comfortable in her wheelchair. She didn’t [look] in obvious distress.”

Roy asked Demery if nurses have a way to voice concerns over patient safety at the hospital, given limited resources. She said most nurses simply give up trying to ring the alarm bell.

“There comes a fatigue from expressing this over, and over and over again,” she said. 

“You get exhausted with trying to fight for the department.”

Staff administered host of treatments

After Winterstein collapsed at 2:41 p.m. ET on Dec. 10, Demery said, she rushed to the waiting room along with other medical staff.

Doctors spent hours trying to resuscitate her and save her life, the inquest heard.

Dr. Jennifer Tsang, a specialist in the hospital’s intensive-care unit, testified Winterstein’s blood had become dangerously acidic — known as metabolic acidosis — and her blood pressure had plummeted to dangerously low levels. Tests also showed her levels of hemoglobin, which transports oxygen to organs and tissues, had dropped sharply. Her pulse was high and her breathing was shallow.

“She was in a severe shock state,” said Tsang. “That could lead to multiple organ failure and death.”

Over two hours, the doctor administered a host of treatments, including various fluids and antibiotics, even though Winterstein didn’t show signs of infection.

“When someone is this sick, [you] throw the kitchen sink at them to try to keep them alive,” said Tsang.

Winterstein was rushed to intensive care, where her mother agreed to halt resuscitation attempts and she was pronounced dead at 8:42 p.m., she added.

What’s changed at hospital since Winterstein’s death

Demery said the hospital has made a number of “important changes” in the emergency department since Winterstein’s death.

She said they’ve added a nurse practitioner and personal support worker to monitor patients in the waiting room, a new lead nurse in what’s known as the rapid assessment zone to help with patient flow, and a technician for tasks such as blood work and taking electrocardiogram readings, so triage nurses can concentrate on doing patient assessments.

But, Demery added, CTAS 2 patients still aren’t always getting regular reassessments every 15 minutes. 

“I still don’t feel there’s enough resources to complete that task.”

Winterstein was a member of the Cayuga Nation, with ties to Six Nations of the Grand River. Since her death, family members and community organizations have expressed concern that addiction discrimination and anti-Indigenous racism may have played a role in how she was treated.

Demery, who said she was not aware Winterstein was Indigenous, addressed the family while testifying virtually, saying she hopes her death will help ignite a “revolution” in the health-care system.

“I am so sorry she was taken from you at such a young age and [it] has left such a painful hole in all of your lives.”