A coroner’s inquest later determined that Winterstein died in 2021 at Niagara Health’s St. Catharines hospital – now called the Marotta Family Hospital – from septic shock caused by delayed treatment. The jury said staff decisions were affected by her Indigenous background, her history of substance use and her anxiety.

Following the inquest, Niagara Health conducted an internal review and a third‑party emergency‑department review. It accepted all 68 recommendations and, in 2024, launched its first Indigenous health services plan. The plan introduces mandatory cultural‑safety training, an Indigenous patient‑navigator team, Indigenous artwork, smudging ceremonies and a dedicated gathering room.

Charity Beland, a member of the Six Nations of the Grand River, serves as manager of Indigenous Health Services and Reconciliation at Niagara Health. She leads the team that designs and implements the new cultural‑safety initiatives.

Sean Longboat, chief executive officer of the Ontario Federation of Indigenous Friendship Centres, said the hospital’s steps are encouraging and should inspire other systems. However, he cautioned that rebuilding trust after the loss of a community member like Heather Winterstein will take time.

The case shows why addressing Indigenous mistrust matters: bias in care can delay treatment and increase the risk of death. By embedding cultural safety across all staff levels and giving Indigenous patients a voice, hospitals can improve safety, restore confidence and prevent future tragedies.