On Dec. 9, 2021, Heather Winterstein, a 24-year-old Cayuga woman, went to the emergency department in St. Catharines, Ont., with severe back pain, was sent home with Tylenol and returned by ambulance the following day. After waiting more than two hours, she collapsed and died of septic shock. At the coroner’s inquest, clinicians testified they had not known she was Indigenous. The inquest issued 68 recommendations addressing cultural safety, clinical assessment and emergency department procedures.