Coroner's office now probing death of woman after paramedics couldn't reach her in time

The Ontario coroner’s office is investigating after a Hamilton senior died alone on her apartment floor while waiting nearly half an hour for paramedics.

Catherine Terry, 71, of Hamilton died of a heart attack during a code zero alert

Catherine Terry, 71, died of a heart attack inside her central Hamilton apartment on July 10 while waiting for paramedics to save her. (Paige Sutherland)

The Ontario coroner's office has launched an investigation after a Hamilton senior died alone on her apartment floor while waiting nearly half an hour for paramedics.

The investigation comes in the wake of a CBC News story that showed Catherine Terry, 71, died of a heart attack during a code zero alert on July 10. A code zero is when "one or less" ambulances across the service's entire fleet are available for a call.

Premier Kathleen Wynne has written to the Terry family, saying the provincial government is aware of the ambulance shortage and is taking the matter "very seriously." 

Ambulance shortages have been happening more frequently, leaving Hamiltonians in medical distress, and at risk of having no one available to help them when they need it most.

If the paramedics weren't so tied up at her hospitals, my mom would still be here.- Paige Sutherland, daughter

Cherl Mahyr, spokesperson for the Office of the Chief Coroner, on Monday confirmed the investigation.

That's welcome news to Terry's daughter, Paige Sutherland.

"To have them react to the article and actually take action, that's exactly what we wanted," she said.

In an email, Maher pointed to Sec. 10 of the Coroner's Act as to why Terry's death met the criteria for investigation. The section deals with people who have died as a result of negligence, misconduct or malpractice.

'She's passing the buck'

Hospital records viewed by CBC News show an emergency call was first placed through Terry's Lifeline system at 9:36 p.m. on July 10. No ambulances were immediately available in Hamilton that night and the call was originally categorized as a fall (which is considered a lower priority), so firefighters were first on scene at 9:54 p.m.

They discovered Terry's heart wasn't beating, and the call was updated. Paramedics then finally got inside her apartment at 10:04 p.m. — 28 minutes after Lifeline first called for help.

The provincial benchmark for arrival times that paramedics strive to hit on non-emergency calls is 25 minutes. For the most urgent calls requiring resuscitation, it's six minutes.

In a letter to the family, Ontario Premier Kathleen Wynne offered her condolences, and said the provincial government is treating the matter seriously.

Paige Sutherland, left, and her sister Alison Terry are pushing for change after their mother's death. (Adam Carter/CBC)

"An investigation into the incident was opened on August 30, 2017, and the appropriate next steps will be identified and taken swiftly at its conclusion," she said.

In the letter, Wynne said the province is committed to enhancing and modernizing the emergency health services system in Ontario, but she also noted that the city is responsible for establishing levels of service, which includes ambulance deployment strategies.

"She's passing the buck to the city," Sutherland said, noting a massive part of the problem is offloading delays at local hospitals, which in turn jam up paramedics and cause code zeros.

"If the paramedics weren't so tied up at her hospitals, my mom would still be here."

Call volume increase straining system

The city says hospital offloading times directly influence code zeros.

The province recommends 90 per cent of patients be offloaded from an ambulance within 30 minutes of reaching a hospital, says the Hamilton Paramedic Service's annual report for 2016. The Ontario average last December was 46 minutes.

Code zero incidents are rising in Hamilton, statistics show. (CBC)

In Hamilton, it took a lot longer. In December 2016, it took 107 minutes for patients to be offloaded at Hamilton General, 112 minutes at Juravinski and 91 minutes at St. Joe's.

The city says every code zero event this year is associated with a day where the paramedic service had 10 or more offload delays longer than two hours.

The paramedic service says an increase in calls for service is also impacting resources.

About the Author

Adam Carter

Reporter, CBC Hamilton

Adam Carter is a Newfoundlander who now calls Hamilton home. He enjoys a good story and playing loud music in dank bars. You can follow him on Twitter @AdamCarterCBC or drop him an email at


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