THE OLD GUARDIAN INVESTIGATES
The death of Brigitte Stegemann at a Belleville-area long-term care home raises two unresolved legal questions. The people positioned to answer them have not.
By Chris Allen | The Old Guardian | September 17, 2026
THREE OPPORTUNITIES, THREE SILENCES
Brigitte Stegemann, known to her family as GG, died on July 10, 2026, at The Pearl, a 41-bed long-term care home in Cannifton, Ontario, formerly operated as E.J. McQuigge Lodge. She was 83 years old and had been diagnosed five months earlier with stage IV stomach cancer. Her death was provided under Canada’s medical assistance in dying program.
On August 17, 2026, her granddaughter and Power of Attorney for personal care, Brigitte Kranendonk, filed a formal complaint with Ontario’s Chief Coroner, requesting review by the province’s MAiD Death Review Team. The complaint asks the Coroner to examine whether the process that led to GG’s death complied with the Coroners Act and the Criminal Code.
In the month since, The Old Guardian has given three parties direct, repeated, and specific opportunity to respond to the questions this complaint raises. Pearl Care Homes Inc., which operates the facility, was contacted on August 14 and again on August 24, with a total of six specific questions about the events leading to GG’s death. Neither message received a reply. Dr. Catherine Koester, the physician who provided the procedure, was contacted on August 24 with five specific questions and given until September 5 to respond. That deadline passed without a reply.
On September 9, both parties were sent a final, explicit right-of-reply notice, listing the specific claims that would appear in this report and setting a final deadline of September 16. Pearl Care Homes’ first point of contact returned a delivery failure; the notice was redirected the same day to the facility’s administrator and two other staff members. As of publication, no response has been received from Pearl Care Homes Inc., from Dr. Koester, or from anyone acting on their behalf, at any address, at any point in this five-week window.
That silence does not, on its own, prove anything happened the way GG’s family says it did. It does mean this report proceeds without the benefit of an account from either party positioned to explain what the documented record does not.
WHAT THE RECORD SHOWS
Some of this is not in dispute.
Pearl Care Homes Inc., Ontario Corporation Number 1634259, was formed by amalgamation on January 1, 2005, from Keay Nursing Homes Inc. and 854822 Ontario Inc. It is licensed by the Ontario Ministry of Long-Term Care and managed by UniversalCare Canada Inc. The facility’s Ministry inspection record over the relevant period shows no findings specific to consent. A Critical Incident inspection on January 8, 2026, addressed a complaint about POA communication, logged as intake #00163634, but the complaint was not substantiated at the level of a written notification; that inspection window overlaps with the period the family says MAiD discussions with GG were privately restarted. Ministry inspections of long-term care homes assess compliance with care standards; they are not designed to evaluate the specific process by which MAiD consent is obtained, which is a separate legal and medical framework. The absence of an inspection finding here answers a narrower question than it might appear to.
Dr. Koester has practiced independently in family medicine since June 2008, through her professional corporation, Kate Koester Medicine Professional Corporation, based out of a clinic in Newburgh, Ontario, serving Lennox and Addington County, which includes Cannifton. She holds no hospital privileges and has no prior record of discipline with the College of Physicians and Surgeons of Ontario. The coroner’s complaint against her, filed August 17, is the first documented regulatory action of any kind involving her practice.
Her name has appeared inconsistently across public accounts of this case, including in the family’s own written complaint. To be precise: the physician identified here is Catherine Louise Koester, CPSO registration number 84550, confirmed directly against the College’s public register. A separate, unrelated physician registered under the surname Kester, CPSO registration number 72393, practices at Sunnybrook Health Sciences Centre in Toronto and has no connection whatsoever to this case.
WHAT THE FAMILY SAYS HAPPENED
Everything beyond the documented record above originates with reporting by Kelsi Sheren, a Canadian veteran, author, and MAiD-focused commentator who has published two detailed accounts of this case on her Substack since late July. Her reporting is based on an eighty-minute interview she conducted with Brigitte Kranendonk on July 22, a written statement the family posted publicly to Facebook, and the family’s written complaint to the coroner, which Kranendonk provided to her directly. The Old Guardian’s own contact with Kranendonk began in July and stalled in August after an initial exchange; this report does not have an independent account from her. What follows should be read as exactly that: one family’s account, filtered through one other outlet’s reporting, of events they were not present for in full, made public while a coroner’s investigation remains open.
According to that reporting, staff at The Pearl privately restarted conversations with GG about medical assistance in dying during a roughly ten-day period when Kranendonk was away, and these conversations were not disclosed to her at the time. GG is described in this reporting as profoundly hearing-impaired, completely deaf in one ear with limited hearing in the other, and as experiencing frequent periods of lethargy and unresponsiveness in her final months, a detail relevant to any account of what she could hear or process during this period. Formal eligibility assessments took place on July 6 and 7, attended by GG’s daughter, son-in-law, and Kranendonk herself, and the reporting describes GG as unable to recall basic facts about her own family during at least one of these sessions. On the morning of July 10, Kranendonk reportedly told her grandmother directly that she still had the right to refuse. GG is described as having remained silent through the procedure that followed, giving no verbal confirmation of consent. Separately, the reporting states that paperwork related to the MAiD application was completed by a member of facility management after a provision date had already been scheduled, that the date was then moved forward by one day to accommodate the physician’s schedule without consulting the family, and that GG had, months earlier, explicitly declined MAiD on the basis of her Christian faith.
Each of these claims was put directly to Pearl Care Homes and, where relevant, to Dr. Koester, in the right-of-reply notices sent September 9. Neither responded to any of them. Sheren’s own reporting notes a parallel outcome: she states that she independently requested the death certificate, both required eligibility assessments, the signed MAiD request and its witness, and any waiver of final consent, and that none had been produced as of her July 27 report.
THE TWO QUESTIONS NOBODY WILL ANSWER
Two specific, resolvable facts sit underneath everything else in this case, and both remain unknown because the only two people positioned to answer them have not.
The first is whether a written Waiver of Final Consent existed for GG, under section 241.2(3.2) of the Criminal Code. This matters because the law does not, in every case, require a verbal confirmation of consent immediately before a MAiD provision. A person assessed as eligible under Track 1 can sign a written arrangement in advance, waiving that final verbal step, specifically to cover situations where they may lose the capacity to confirm it later. If such a waiver existed for GG, and was properly obtained, her silence on July 10 would not, on its own, indicate anything went wrong. If no such waiver existed, the law required her active consent that day, and her family’s account describes a procedure that proceeded without it. This is not a peripheral detail. It is close to the entire legal question the case turns on, and it was asked of Dr. Koester directly, in writing, twice. She has not answered.
The second is the identity of the second independent assessor. Canadian law requires two separate, independent clinicians to confirm a patient’s eligibility for MAiD. Nowhere in the record, the family’s account, the coroner’s complaint, or anything provided by Pearl Care Homes or Dr. Koester, is that second assessor named. This is not a hypothetical concern. A January 2021 Ministry of Health Decision Briefing Note, obtained separately through a British Columbia freedom of information request, describes an unnamed B.C. physician whose MAiD report lacked a required second assessment confirming eligibility. The Ministry’s own briefing note recommended referring that case to both the police and the physician’s regulatory college. It is not known whether that recommendation was acted on. What it establishes is that a missing second assessment is not a paperwork technicality in the eyes of the system meant to catch it. It is something a Ministry of Health, in at least one other documented instance, has treated as serious enough to warrant a criminal referral.
A PATTERN, NOT AN ISOLATED CASE
GG’s case does not exist in isolation, and the questions it raises are not unique to one facility or one physician.
Ontario’s own MAiD Death Review Committee published a report in 2024 examining waivers of final consent specifically, drawing on a sixteen-member panel of physicians, ethicists, lawyers, and disability advocates whose job is to review these cases after the fact. That committee could not agree on a consistent standard for how capacity should be evaluated before a waiver is signed. In one case it reviewed, a man with dementia gave no verbal response at all during his provision, and the committee found that silence alone, absent any sign of refusal, was sufficient under the law. In another, a financial beneficiary had signed a waiver on the patient’s behalf, which the committee flagged specifically because the signer had a stake in the outcome, and it recommended using independent third parties for exactly that reason. The same report notes that a family’s involvement in a waiver can lapse entirely over time, and that family members may remain unaware such an arrangement exists at all, because a capable adult’s decision to enter into one is legally their own, and provincial privacy law can prevent a facility from disclosing it without that person’s consent. Every element of GG’s case sits inside the exact set of gaps this report already identified, in the province where she died, before she died.
A separate and unrelated set of documents, obtained through freedom of information requests in British Columbia, shows the same underlying incentive at work in a different oversight structure entirely. An internal memo to that province’s Deputy Minister of Health in November 2023, which he approved, recommended building a system to weigh MAiD-related referrals specifically because, in the memo’s own words, referring cases too readily “may discourage physicians or nurse practitioners from providing MAiD despite high demand.” Since 2018, that province has referred only 22 cases to regulatory colleges and two to law enforcement, out of thousands reviewed, a rate under 0.2 percent. In several of those rare referrals, the assessor had declared the patient eligible even though their own written assessment did not find all eligibility criteria were met. British Columbia’s MAiD program and Ontario’s are governed separately, by different oversight bodies, but the documents from both provinces describe a system built primarily to expand access, with review mechanisms that consistently treat caution as a cost to be weighed against volume, not a floor to be enforced regardless of it.
That is the system GG’s case moved through. Whether it worked as intended, or failed her specifically, is a question with a real answer. Three parties who could supply it have been asked directly, repeatedly, and in writing. None of them have.
EDITOR’S NOTE
This report relies on the formal coroner’s complaint filed by Brigitte Kranendonk on August 17, 2026; Ontario Ministry of Long-Term Care inspection records for The Pearl; corporate registry records for Pearl Care Homes Inc.; the College of Physicians and Surgeons of Ontario’s public register; Ontario’s 2024 MAiD Death Review Committee report on Waivers of Final Consent; and freedom of information documents obtained by The B.C. Catholic (July 2025) and Canadian Catholic News (July 2026) regarding oversight of British Columbia’s MAiD program. The account of events attributed to the Stegemann family in this report is drawn from reporting published by Kelsi Sheren, based on her own interview with Brigitte Kranendonk and documents the family provided to her directly; it is not independent reporting by this outlet, has not been independently verified beyond what is stated here, and the coroner’s investigation into this matter remains open. Pearl Care Homes Inc. and Dr. Catherine Koester were each given multiple, specific opportunities to respond between August 14 and September 16, 2026, and did not.