A family in Winnipeg spent eight months waiting for a report. When it arrived this month, CTV News reported that they were left with more questions than answers.
Stacey Ross was 55, an educational assistant. In early January 2026 she went to the emergency department at St. Boniface Hospital with chest pain, a cough, and trouble breathing. She waited roughly twelve hours and was sent home. Eleven days later she was taken back by ambulance from work. She waited about eleven hours for a bed, was finally admitted late on January 15, and died the following day. The hospital opened a critical incident review. Her sister, Sheri Ross, has been the family’s voice throughout, and the family has called for a public inquiry rather than an internal process.
That story is out of Manitoba, and the details of what the report found have not been published in a form I can verify. Nothing about the Manitoba process governs Ontario. But the shape of it is familiar to anyone who does this work here, and it is worth using as the occasion to answer a question Ontario families ask constantly: what is an internal hospital investigation actually going to give me, and what is it never going to give me?
Ontario Is Not a Bystander to This Problem
Before the legal machinery, the context. Ontario emergency departments are under the same pressure.
In April 2026, Ontario Health data showed that patients requiring admission spent an average of 17.2 hours in the emergency department, more than double the province’s eight-hour target, with only about 30 percent admitted within that target. The Canadian Centre for Policy Alternatives, in a May 2026 analysis, reported that Ontario’s 90th percentile wait just to be seen by a physician rose to 4.5 hours in 2024/25 from 2.7 hours in 2020/21, and that the 90th percentile wait for admission rose to 44 hours from 29. The Canadian Institute for Health Information reported in June 2026 that roughly one in ten admitted patients nationally, about 180,000 people, spent more than 48 hours in an emergency department in 2024/25 waiting for an inpatient bed.
Those figures come from administrative performance data and a think tank analysis respectively, not from any court, and the province disputes the framing. They describe a system, not a standard of care. But they explain why the failure mode in the Ross case, a patient deteriorating during a long wait for a bed that does not exist, is not a Manitoba peculiarity.
Ontario has produced its own version. The inquest into the death of Heather Winterstein, a 24-year-old member of the Cayuga Nation who died of septic shock in December 2021 after presenting twice to the emergency department in St. Catharines, returned its verdict on April 22, 2026. The jury classified the death as an accident and attributed it to septic shock with delayed treatment. It made 68 recommendations. The family had asked the jury to classify the death as a homicide and did not get that. Which is itself the point of this article: each of these processes answers some questions and refuses others.
What a Critical Incident Review Is
In Ontario, a serious unexpected harm or death in hospital care that does not flow primarily from the patient’s underlying condition or a known inherent risk is a critical incident. Hospitals are required to investigate. The governing framework is the Quality of Care Information Protection Act, 2016, which replaced the 2004 version effective July 1, 2017, together with the hospital management regulation under the Public Hospitals Act.
QCIPA does two things that pull in opposite directions, and understanding the split is most of what a family needs.
It protects the review itself. Information created by or for a designated quality of care committee, the deliberations, the opinions expressed, the committee’s own analysis, is shielded from disclosure and generally cannot be compelled in a legal proceeding. The policy rationale is that clinicians will not speak candidly about what went wrong if their words become a plaintiff’s exhibit. Reasonable people disagree about whether that trade is worth it. It is the law either way.
It requires disclosure to the family. The 2016 version was amended precisely because the 2004 version was being used as a shield. Hospitals must now tell the patient or the family the material facts of what happened, the consequences, the actions taken or recommended as a result, and the identified cause or causes. A hospital that hands a family a letter saying only that a review occurred and improvements were made is not complying.
The distinction that matters most, and the one families most often misunderstand: QCIPA does not protect the underlying facts. The chart, the triage record, the CTAS score and the times attached to it, the vital signs, the lab results, the troponin values, the nursing notes, the physician notes, the bed management records: none of that becomes privileged because a quality committee later looked at it. It was created in the course of care, not for the committee. It remains fully obtainable, and it is the material a claim is actually built on. If you take one thing from this article, take that.
What It Will Never Give You
A critical incident review is a quality improvement exercise. It is designed to prevent the next death. It is not designed to assign responsibility for this one, and it does not.
It is not a finding of negligence. A hospital official who tells a family at a meeting that something was “missed” is describing a clinical event in a patient relations setting. That is meaningful, and it is often the first honest account a family receives, but it is not an admission of liability, it is not evidence in the form a court needs, and it does not establish that the missed step caused the death.
It is not a finding of causation either. Establishing that a delay caused a death requires expert medical evidence measured against the “but for” standard, weighing the patient’s underlying condition, the natural history of the illness, and what would have happened on the counterfactual timeline where the patient was seen and admitted promptly. A review does not do that analysis and is not built to.
And it produces no compensation. No internal review, no complaint, and no inquest results in a dollar being paid to a family. Only a civil claim does that.
The same limits apply, in different shapes, to the other accountability routes. The coroner’s investigation or inquest determines who died, and when, where and by what means, and may make non-binding recommendations to prevent future deaths. Under the Coroners Act an inquest jury is expressly forbidden from making findings of legal responsibility. The Patient Ombudsman, created under the Excellent Care for All Act, 2010, can investigate complaints about public hospitals and make recommendations, but is a body of last resort and cannot award damages or discipline anyone. A complaint to the College of Physicians and Surgeons of Ontario can lead to discipline, which protects future patients and compensates no one.
Each of these is worth pursuing for what it offers. None of them substitutes for the others, and none of them is a claim.
The Clock Nobody Mentions
Here is the practical trap, and the reason this article exists.
Internal reviews take months. The Ross family waited about eight months. Ontario timelines are comparable, and inquests routinely take years to be called, let alone heard. Meanwhile the limitation period runs.
The general rule under the Limitations Act, 2002 is two years from the date the claim was discovered, which is not always the date of death and is a genuinely contested question in delayed diagnosis cases. But for a death, section 38 of the Trustee Act imposes a separate and much harder deadline: an estate claim must be brought within two years of the date of death, full stop, with no discoverability extension. Families who wait politely for the hospital’s report, then wait for the coroner, then start asking about a lawyer, sometimes find that the second anniversary has passed while they were being cooperative.
The right sequence is to run these tracks in parallel, not in series. Request the complete records immediately, including nursing notes, the triage record and the emergency department tracking data, which is often the single most important document in a wait time case and is the one most likely to be omitted from a routine records request. Attend the patient relations meeting and take careful notes of what is said, by whom. And get the file in front of counsel early enough that an independent assessment can happen before any deadline is in play.
Where a Claim Actually Comes From
If a wait time case is going to succeed in Ontario, it will not be because a report said something went wrong. It will be because expert evidence establishes that particular conduct fell below the standard of a reasonably competent practitioner or institution, and that the breach caused the harm.
Three separate pathways run against a hospital, and pleading strategy depends on distinguishing them. The hospital is vicariously liable for the negligence of its employees, which in the emergency department usually means the triage nurse and the nursing staff who did or did not reassess a waiting patient. The hospital may be directly liable for its own organizational failures, its staffing decisions, its triage and reassessment protocols, its bed management systems. And the emergency physician is usually an independent contractor with hospital privileges, not an employee, which means the hospital is generally not vicariously liable for the physician’s negligence and the physician must be sued directly.
That third point catches people out. It is also why the direct, systemic theory matters so much in boarding and overcrowding cases: when the failure is that no bed existed and nobody reassessed the patient for six hours, the negligence may be organizational rather than attributable to any individual clinician’s judgment.
Triage standards supply the measuring stick. The Canadian Triage and Acuity Scale, published by the Canadian Association of Emergency Physicians and most recently revised in 2016, sets five acuity levels with corresponding reassessment intervals: continuous for Level 1, every fifteen minutes for Level 2, every thirty for Level 3, hourly for Level 4, every two hours for Level 5. A documented failure to reassess on that schedule is powerful evidence. It is not automatically negligence. CTAS is a professional body guideline, not a statute, and the standard of care in any given case is a matter of expert opinion.
Which brings up something worth stating plainly: Ontario has no statutory maximum emergency department wait time. The eight-hour and four-hour figures are performance targets, not legal duties, and there is no statute requiring that a waiting patient be reassessed at all. Accountability for a long wait runs entirely through ordinary negligence principles. There is no provision to point to. That is a real gap, and it is why the question of when a delay becomes negligence has to be answered case by case, on the records, with experts.
For Families
If someone you love died after a long emergency department wait, the honest summary is this.
The hospital’s review will probably tell you more than you knew, and less than you want. You are entitled to the material facts, the consequences, the identified cause, and what is being changed. You are not entitled to the committee’s deliberations, and you will not get a finding that anyone was at fault, because that is not what the process does.
You are entitled to the entire medical record regardless, and that record, not the report, is where the answer lives.
The processes that explain and the process that compensates are different processes, and they run on different clocks. Pursuing one does not preserve the other.
None of that means a long wait is negligence. Emergency departments make defensible decisions under impossible pressure every day, and many bad outcomes after long waits involve no breach of the standard of care at all. But the only way to know which kind of case you have is to look at the records properly, early, with someone who reads them for a living.
Paul Cahill is a partner at Davidson Cahill Morrison LLP and a Law Society of Ontario Certified Specialist in Civil Litigation. He represents patients and families in medical malpractice claims across Ontario.
