Inquest into the Death of Heather Winchester

Informed Consent, Clinical Systems and Misleading Documentation

By Sebastian Cannavo

Senior Associate

The February 2025 findings of the NSW Deputy State Coroner in the Inquest into the death of Heather Winchester provide a detailed and sobering examination of informed consent, advance care planning and clinical decision‑making, particularly where religious beliefs intersect with emergency medical care.

While the inquest did not attribute civil or criminal liability, it offers important guidance for health services, clinicians, and legal practitioners advising on informed consent, documentation, and system design, especially when taking into account patients’ religious beliefs.

Background

Heather Winchester, aged 75, died on 27 September 2019 at John Hunter Hospital, in Newcastle, following complications from an elective hysterectomy performed at Maitland Hospital. The Deputy State Coroner, Magistrate David O’Neil, found that her death was caused by multiple organ failure due to severe anaemia, secondary to blood loss following surgery, with contributing comorbidities, including ischaemic heart disease, chronic kidney injury and diabetes.

Mrs Winchester was a devout Jehovah’s Witness and had consistently expressed a refusal to accept blood transfusions, which is common amongst Jehovah’s Witnesses. However, the inquest revealed significant ambiguity and inconsistency in how her wishes were recorded by hospital staff, and interpreted and communicated across treating teams.

Treatment

Mrs Winchester underwent an elective hysterectomy on 25 September 2019. Post‑operatively, she suffered significant internal bleeding, with imaging revealing a large pelvic haematoma and ongoing arterial haemorrhage. Over the next 48 hours, she underwent two further surgical procedures in an attempt to control the bleeding.

By this time, Mrs Winchester had lost approximately one litre of blood and required intensive care. Clinicians repeatedly assessed whether blood transfusion could be administered, given the life‑threatening circumstances. Mrs Winchester, when lucid, clearly and repeatedly refused transfusion of whole blood and primary blood components, even when informed that refusal was likely to result in death. She subsequently died on 27 September 2019.

Conflicting Understandings of Consent

A central focus of the inquest was the disconnect between different clinicians’ understandings of Mrs Winchester’s consent. Prior to surgery, she had completed hospital consent forms, refusing blood transfusions. She had also completed worksheets produced by the Jehovah’s Witness organisation, indicating acceptance of certain blood fractions, including haemoglobin‑based products.

Crucially, the inquest established that the products identified as acceptable in those worksheets were not available anywhere in New South Wales at the relevant time. The Deputy State Coroner described the documents as “misleading” and “inappropriate for use in New South Wales”, noting they were produced in the United States without regard to local clinical realities. In other words, it would have been impossible for Mrs Winchester to receive these medical products in New South Wales.

As a result, different members of the treating team formed different conclusions as to whether Mrs Winchester would accept packed red blood cells in an emergency. This lack of clarity contributed to confusion, stress and delay during a rapidly evolving clinical crisis following her surgery.

Legal and Systemic Issues Identified

The Coroner emphasised that the purpose of an inquest is not to attribute blame, but to identify systemic lessons, to mitigate the risk of similar issues occurring in the future. Several key legal and governance issues emerged.

1. Informed Consent Must Be Practically Informed

While Mrs Winchester’s refusal of blood was ultimately upheld as informed and valid, the Coroner was critical of consent processes that relied on theoretical treatment options that were not clinically available in NSW. Consent cannot be meaningfully informed if patients are not told that nominated alternatives do not exist in the relevant health system. In other words, it should have been explained to Mrs Winchester that blood fractions, including haemoglobin‑based products, were not available in NSW, and then her consent obtained.

2. Documentation Must Be Clear, Accessible and Consistent

The inquest highlighted failures in ensuring that all clinicians had access to, and reviewed, the same documentation. Some clinicians relied on worksheets, whilst others relied on advance care directives or verbal discussions. The Coroner noted that inconsistencies across forms, progress notes and electronic records significantly increased risk in emergency decision‑making.

3. Respect for Autonomy Does Not Eliminate System Responsibility

Although Mrs Winchester’s autonomy was respected, the Coroner made clear that health systems retain responsibility to design processes that reduce ambiguity. This includes ensuring clinicians are not placed in ethically or legally precarious positions due to poor documentation or unclear policies.

Recommendations

Pursuant to section 82 of the Coroners Act 2009 (NSW), the Deputy State Coroner made 14 recommendations aimed at preventing similar deaths. Key recommendations included:

• Implementation of a standardised procedure for patients identifying as Jehovah’s Witnesses, including clear documentation of partial refusals and available treatment products.
• Development of checklists identifying blood products actually available at the treating facility, so any consent can be informed consent.
• Improved training for visiting medical officers and locums (temporary placed doctors) regarding access to, and responsibility to review, electronic medical records.
• Resumption of structured engagement between hospital services and Jehovah’s Witness Hospital Liaison Committees, to improve mutual understanding while ensuring clinical realism.
• Withdrawal of misleading or outdated medical worksheets by the Jehovah’s Witness Organisation, not aligned with Australian practice.

Key Takeaways

The Winchester inquest reinforces several enduring principles:

• Advance care directives and refusal‑of‑treatment documents must be locally appropriate, legally sound and clinically realistic. In other words, they must be based on the actual real and contemporaneous situation.
• Health services should proactively audit consent and advance care planning processes for high‑risk procedures, to avoid later panic during emergency situations.
• Religious or values‑based treatment refusals require early, detailed and repeated conversations, with outcomes clearly recorded and reconciled across all documentation, to ensure that they are properly understood and complied with.
• System failures, rather than individual errors, are often the greatest source of legal and ethical risk.

If you, or a family member, have concerns that medical treatment may have fallen below an acceptable standard of care, our Injury Compensation Department can provide confidential advice about your options.