1 2 3 IPPERWASH PUBLIC INQUIRY 4 5 6 7 ******************** 8 9 10 BEFORE: THE HONOURABLE JUSTICE SIDNEY LINDEN, 11 COMMISSIONER 12 13 14 15 16 Held at: Forest Community Centre 17 Kimball Hall 18 Forest, Ontario 19 20 21 ******************** 22 23 24 May 9th, 2005 25

2
  1                        Appearances
  2  Derry Millar      )             Commission Counsel
  3  Susan Vella        )
  4  Donald Worme, Q. C )    (np)
  5  Katherine Hensel  )
  6  Jodi-Lynn Waddilove )   (np)
  7  
  8  Murray Klippenstein )  (np)      The Estate of Dudley 
  9  Vilko Zbogar       )   (np)     George and George
 10  Andrew Orkin       )            Family Group
 11  Basil Alexander    )            Student-at-Law
 12  
 13  Peter Rosenthal  )              Aazhoodena and George
 14  Jackie Esmonde   )   (np)       Family Group
 15  
 16  Anthony Ross     )              Residents of 
 17  Kevin Scullion   )              Aazhoodena  (Army Camp)
 18  William Henderson )              Kettle Point & Stony
 19  Jonathon George  )              Point First Nation
 20  Colleen Johnson  )   (np)
 21  
 22  Kim Twohig       )   (np)       Government of Ontario
 23  Walter Myrka     )   (np)
 24  Susan Freeborn   )   (np)
 25  Michelle Pong    )

3
  1                   APPEARANCES (cont'd)
  2  Janet Clermont   )              Municipality of 
  3  David Nash       )   (np)       Lambton Shores
  4  
  5  Peter Downard    )   (np)       The Honourable Michael
  6  Bill Hourigan    )   (np)       Harris
  7  Jennifer McAleer )
  8  
  9  Ian Smith        )   (np)       Robert Runciman
 10  Alice Mrozek     )   (np)
 11  Harvey Stosberg  )   (np)       Charles Harnick
 12  Jacqueline Horvat )   (np)
 13  Douglas Sulman, Q.C. )           Marcel Beaubien
 14  Trevor Hinnegan     )
 15  
 16  Mark Sandler       ) (np)       Ontario Provincial 
 17  Andrea Tuck-Jackson )            Police
 18  Leslie Kaufman     )  (np)
 19  
 20  Ian Roland       )   (np)       Ontario Provincial 
 21  Karen Jones      )              Police Association &
 22  Debra Newell     )   (np)       K. Deane
 23  Ian McGilp       )   (np)
 24  Annie Leeks      )
 25

4
  1                   APPEARANCES (cont'd)
  2  
  3  Julian Falconer  )   (np)       Aboriginal Legal 
  4  Brian Eyolfson   )              Services of Toronto
  5  Julian Roy       )   (np)
  6  Clem Nabigon     )   (np)
  7  Adriel Weaver     )   (np)       Student-at-Law
  8  
  9  Al J.C. O'Marra  )              Office of the Chief
 10  Robert Ash, Q.C. )    (np)       Coroner
 11  
 12  William Horton   )   (np)       Chiefs of Ontario
 13  Matthew Horner   )   (np)
 14  Kathleen Lickers )   (np)
 15  
 16  Mark Frederick   )   (np)       Christopher Hodgson
 17  Craig Mills      )   (np)
 18  Megan Mackey     )
 19  
 20  David Roebuck    )   (np)       Debbie Hutton
 21  Anna Perschy     )   (np)
 22  Melissa Panjer   )   (np)
 23  Danya Cohen-Nehemia ) (np)
 24  
 25

1 APPEARANCES (cont'd) 2 3 Ron LeClair ) Jacqueline Derbyshire 4 Marlene Bergman 5 Glenna Ladell 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

1 TABLE OF CONTENTS 2 Page 3 Exhibits 6 4 5 GLENNA MAUREEN LADELL, Sworn 6 Examination-In-Chief by Ms. Katherine Hensel 11 7 Cross-Examination by Ms. Karen Jones 48 8 9 MARLENE BERGMAN, Sworn 10 Examination-In-Chief by Ms. Katherine Hensel 58 11 12 JACKALINE PATRICIA DERBYSHIRE, Affirmed 13 Examination-In-Chief by Ms. Susan Vella 80 14 Cross-Examination by Mr. Andrew Orkin 168 15 Cross-Examination by Mr. Peter Rosenthal 173 16 Cross-Examination by Ms. Karen Jones 178 17 Cross-Examination by Mr. Al O'Marra 193 18 Re-Direct Examination by Ms. Susan Vella 197 19 20 Certificate of Transcript 202 21 22 23 24 25

1 EXHIBITS 2 No. Description Page 3 P-382 Document Number 50002248, Nurse 4 Glenna Ladell's notes, Sept. 07/95 5 Re: Mr. Anthony George 37 6 P-383 Document Number 5000249, Nurse Glenna 7 Ladell's notes, Dept. 07/95 Re: Mr. 8 Anthony George 37 9 P-384 Document Number 5000245, Code Blue 10 record of Dudley George made by Nurse 11 Glenna Ladell, Sept. 07/95 Cardiopulmonary 12 resuscitation record. 38 13 P-385 Document Number 5000246, Record of Dudley 14 George's death, September 07/95. 15 Pronounced dead by Dr. Marr at 00:20 16 hours. 38 17 P-386 Document Number 5000247, Nurse Glenna 18 Ladell's notes September 07/95 Re: Mr. 19 Anthony George. 50 20 P-387 Document Number 1000047, Strathroy 21 Middlesex General Hospital Documentation 22 of Mr. Cecil Bernard George, pages 318 23 to 364, September 07/95. 115 24 25

1 EXHIBITS (continued) 2 Exhibit No. Description Page No. 3 P-388 Document Number 5000243, Emergency 4 and Outpatient Record of Mr. Anthony 5 George, September 07/95. 125 6 P-389 Document Number 5000250, Pages 2924 to 7 2930, ECG strip of Mr. Anthony George. 141 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

1 --- Upon convening at 10:30 a.m. 2 3 THE REGISTRAR: This Public Inquiry is 4 now in session. The Honourable Mr. Justice Linden 5 presiding. Please be seated. 6 MR. DERRY MILLAR: Good morning, 7 Commissioner. 8 COMMISSIONER SIDNEY LINDEN: Good 9 morning, everybody. 10 MR. DERRY MILLAR: Before we start, I 11 thought I would just take a moment to welcome a guest 12 that we have today with us. 13 COMMISSIONER SIDNEY LINDEN: I recognize 14 him. I do recognize him. 15 MR. DERRY MILLAR: It's your brother, Mr. 16 Justice Allan Linden of the Federal Court of Appeal has 17 come down to visit us for this morning. 18 COMMISSIONER SIDNEY LINDEN: Check up on 19 his brother. 20 MR. DERRY MILLAR: He never said that, 21 actually. 22 COMMISSIONER SIDNEY LINDEN: No. 23 MR. DERRY MILLAR: Now, Commissioner, 24 before we start, I just wanted to tell the parties -- 25 I've put out on the -- we put out on the desk this

1 morning, two (2) volumes of materials and the two (2) 2 volumes are transcripts of postal codes. And they've 3 been tabbed actually to -- the numbers are supposed to 4 conform to the numbers on the schedules that I've 5 provided to the parties last week. 6 So if people are wondering what the tab 7 numbers refer to, that's what they refer to. 8 And just so everyone knows this morning, 9 we're going to -- today we're going to be dealing with 10 the three (3) nurses, Ms. Ladell, Ms. Bergman, and Ms. 11 Derbyshire, tomorrow morning Dr. McCallum and then Deputy 12 Commissioner, of course. 13 And I understand this morning we'll break 14 at 12:30 for lunch? 15 COMMISSIONER SIDNEY LINDEN: If that's 16 okay, yes, at 12:30. 17 MR. DERRY MILLAR: Thank you. 18 MS. KATHERINE HENSEL: Good morning, 19 Commissioner, the Commission calls, as its next witness, 20 Mrs. Glenna Ladell. 21 22 (BRIEF PAUSE) 23 24 THE REGISTRAR: Good morning, Mrs. 25 Ladell.

1 MS. GLENNA LADELL: Good morning. 2 THE REGISTRAR: Mrs. Ladell, do you 3 prefer to swear on the Bible or affirm this morning? 4 MS. GLENNA LADELL: The Bible's fine. 5 THE REGISTRAR: Very good. Would you 6 take the Bible in your right hand, please. And state 7 your name in full for us please, for the record. 8 MS. GLENNA LADELL: Glenna Maureen 9 Ladell. 10 THE REGISTRAR: Thank you. 11 12 GLENNA MAUREEN LADELL, Sworn: 13 14 THE REGISTRAR: Thank you. 15 16 EXAMINATION-IN-CHIEF BY MS. KATHERINE HENSEL: 17 Q: Good morning, Mrs. Ladell. 18 A: Good morning. 19 Q: Just for the record, your date of 20 birth is August 31st, 1939? 21 A: Yes. 22 Q: And you are -- or you were, in your 23 professional career, a registered nurse? 24 A: Yes. 25 Q: And you graduated from the Toronto

1 Western Hospital School of Nursing in 1960, I understand? 2 A: That's correct. 3 Q: And you subsequently worked for one 4 (1) year at that hospital? 5 A: That is right. 6 Q: You then received your Bachelor of 7 Science and Nursing in 1965? 8 A: Right. 9 Q: From the University of Western 10 Ontario? 11 A: That's correct. 12 Q: And that was a three (3) year 13 program? 14 A: No. 15 Q: Oh. 16 A: Two (2) year. 17 Q: Two (2) year program. Thank you. 18 And upon graduating from that program, you 19 started working at the Strathroy Middlesex General 20 Hospital in August of 1965? 21 A: That's correct. 22 Q: And you worked there until January of 23 2000 when you retired? 24 A: That's right. 25 Q: I also understand that you became a

1 nursing supervisor in 1966? 2 A: That's right. 3 Q: And you served in that capacity until 4 your retirement in 2000? 5 A: Yes, that's right. 6 Q: In 1995, you were working as a 7 nursing supervisor, then? 8 A: That's right. 9 Q: And, you were working in a part-time 10 capacity at that time? 11 A: Yes. 12 Q: Can you describe for us, Mrs. Ladell, 13 the general duties of a nursing supervisor? 14 A: As a nursing soper -- supervisor, 15 particularly when I worked mainly on the 3:00 to 11:00 16 shift, I was responsible for the hospital as a total. 17 Especially after 5:00 p.m. on the -- on the particular 18 day, as none of the administration staff were there, a 19 lot of the hospital departments, for -- for example, 20 pharmacy, stores, business office, they were all closed. 21 So we had access to those departments, as 22 required, to get whatever the staff might require or 23 information that was required of any other people during 24 that time. 25 Q: So, it did fall on your shoulders to

1 keep the hospital running smoothly, particularly after 2 5:00 p.m.? 3 A: That's right. 4 Q: Turning now to September 6th, 1995, I 5 understand that on that day you were working as a nursing 6 supervisor at the Strathroy Middlesex General Hospital 7 and that you were scheduled to work from 3:00 to 11:00 8 p.m.? 9 A: That's right. 10 Q: And you did in fact work that shift-- 11 A: Yes, I did. 12 Q: -- from 3:00 to 11:00? 13 A: Yes, I did. 14 Q: Okay. And, at some point during your 15 shift, perhaps towards the end of it, did you receive 16 information that something unusual was going to happen? 17 A: Yes, Lisa Seeley, the Emergency Nurse 18 for 3:00 to 11:00, in the Emergency Department, had 19 received a phone call and I believe it was from 20 Wallaceburg Dispatch, to say that there was something 21 happening. 22 And because we were the closest hospital, 23 they say we possibly could be getting some patients if, 24 you know -- if something did happen. 25 Q: And, did you receive any specific

1 information about what might be happening? 2 A: Not particularly that I recall. 3 Q: Okay. Were you aware that -- what 4 might be happening -- happening -- might be related to 5 events occurring at Ipperwash Provincial Park? 6 A: I don't recall really other than that 7 there was something going on, but I don't remember any 8 specific details. 9 Q: Okay. And at that time, were you 10 aware in general terms that there was an occupation 11 occurring at Ipperwash Provincial Park? 12 A: Not particularly. 13 Q: All right. So as a result of the 14 information that you received from Ms. Seeley what did 15 you do? 16 A: I was giving, as we usually did, 17 Marlene Bergman, the night supervisor comes in at 11:00 18 and so I would give her a report. And because something 19 was happening and there aren't a lot of people working 20 the night shift, then I decided that maybe I should stay 21 for a while just to see if my assistance was needed as an 22 extra pair of hands. 23 Q: All right. And at that time, were 24 you were working in the Emergency Department or were 25 you --

1 A: We worked there as required. 2 Q: Okay. 3 A: But, like a -- from eleven o'clock 4 til -- I would give report to the night supervisor, 5 Marlene. 6 Q: All right. And as a result of the 7 information you received, did you yourself, participate 8 in any preparations for the arrival of patients, or 9 anticipating the arrival of patients? 10 A: I believe that we were notified in 11 the -- in the place that we were giving report to each 12 other and I think it was -- I think in the notes 13 somewhere it says about a quarter -- I don't know, twenty 14 (20) or a quarter to 12:00 at that time, we would go to 15 the Emergency and assist with any additional preparation 16 that was required. 17 But the nurse in Emerg. would already have 18 started -- we get a, what we call the OR room or the 19 Emergency room ready for any -- any particular -- well, 20 like, you start -- get the intravenous set up and -- and 21 get a stretcher ready and so on. 22 Get the room kind of organized for 23 whatever might turn up. It's better to be prepared. 24 Q: Of course. All right. So were you 25 in the Emergency Department when the first patient coming

1 from the events at Ipperwash Provincial Park arrived? 2 A: Yes, I was. 3 Q: Okay. And we understand from other 4 witnesses that that was Mr. Nicholus Cotrelle -- 5 A: That's right. 6 Q: -- the young man who was aged sixteen 7 (16) at the time. 8 A: Right. 9 Q: Do you recall -- well, first of all, 10 do you recall what time he arrived? 11 A: 12:04. 12 Q: 12:04. And what can you tell us 13 about the circumstances of his arrival and your 14 observation of him? 15 A: He arrived by ambulance and I did a 16 little initial charting on time, either what I was -- 17 what I saw or what I was told. 18 Q: Hmm hmm. 19 A: I didn't really have any conversation 20 with him per se. I just -- I was recording and that was 21 my job, to record what was happening. 22 Q: Okay. And where were you located at 23 that -- situated at that time in the department? 24 A: I'd be right by his stretcher in the 25 Emergency room.

1 Q: In the Emergency room? 2 A: Yes. 3 Q: Was that the room that we have heard 4 others refer to as the OR or -- 5 A: Yes. 6 Q: And OR stands for? 7 A: Operating room. 8 Q: Operating room. 9 A: But it was just -- and it was an 10 operating room at times, but we also, because it was a 11 large room, that's where we would put any trauma 12 patients, because there was more room and the equipment 13 was right near at hand, that we might require to treat 14 such a patient. 15 Q: And if I could take you, Mrs. 16 Liddell, to Tab 1 of the brief of hospital records, 17 actually, which is the other binder. Well, it says 18 "Hospital Records: Nurse Witnesses" on the front. 19 A: Yes. 20 Q: And, for the record, I am referring 21 to a document that's been identified in these Proceedings 22 as Exhibit P-356. It's Inquiry Document Number 100043, 23 the medical records of Nicholus Cotrelle from Strathroy 24 Middlesex General Hospital. 25 A: Yes.

1 Q: And if I could take you to the nurses 2 notes which, I believe, are the third page of the tab in 3 front of you. 4 A: Yes. 5 Q: And for people looking for them in 6 the database, they are at Front 284, 000284. 7 Now, do you recognize your handwriting 8 amongst any of the notes that appear there? 9 A: Yes, the initial nurses' notes are 10 done by me. 11 Q: And do you recall making those notes? 12 A: Yes, I do. 13 Q: And you note there that the patient, 14 as you've already observed, arrived at 00:04. 15 A: Yes. 16 Q: Four (4) minutes after midnight. 17 A: Yes. 18 Q: And that he had a gunshot to his 19 right posterior back? 20 A: Yes. And that would have been told 21 to me either -- likely he arrived by ambulance and so the 22 -- usually when the ambulance personnel bring a patient 23 into us, they will have some documentation of history 24 that they have gotten from the patient. 25 And they will tell us exactly, you know,

1 where the injury is, what's kind of taken place and so 2 that's where I would get that information. 3 Q: So it wasn't based on your direct 4 observation of his injuries. 5 A: Not necessarily. It would likely be 6 from what the ambulance attendant had told me. 7 Q: You -- You note further that it's a 8 male patient admitted per ambulance as you've already 9 described. "Laceration to left back and abrasion left 10 wrist." 11 A: Yes. 12 Q: Is that -- am I making out your 13 handwriting correctly here? 14 A: Yes. That's right. That's right. 15 Q: And you would have obtained that 16 information on the same basis that you described? 17 A: Yes. Like partly I -- I would see 18 but they would also -- as they were saying I maybe would 19 be observing as well and so then I would write it down. 20 Q: And you also note, pain both sides of 21 back? 22 A: Yes. And that's likely something I 23 would have been told. Not necessarily I would hear the 24 patient say per se. 25 Q: You note further, "Got hit while

1 standing outside of car"? 2 A: And that -- and that's likely what 3 the ambulance had told me because they had already talked 4 to Nicholas 5 Q: All right. And you don't -- you 6 don't recall him -- 7 A: No, I don't remember having any 8 conversation with Nicholas at all. 9 Q: And you note that his blood pressure 10 is 128 over 90? 11 A: And someone would have taken it and I 12 was merely recording. 13 Q: And you also note, "Question mark, 14 223 rifle shell in right back." 15 A: And someone would have said that 16 because I know nothing about shells. 17 Q: And do you -- do you recall today who 18 -- who advised you of that? 19 A: No, I don't. I'm not sure. I don't 20 recall. 21 Q: And just to finish with your notes, 22 examined by Dr. Marr? 23 A: Yes. 24 Q: And your note there, "G. Ladell, 25 R.N.," does that merely signify that you've made these

1 notes? 2 A: Yes, that's right. That's what we 3 are required to do, to sign -- to sign anything that we 4 had documented. 5 Q: And finally, you've noted below it, 6 it appears -- appears to be your handwriting -- 7 A: Yes, it is. 8 Q: "Collar on but no neck pain." 9 A: And that's something the ambulance do 10 -- they put a neck collar on for -- to make -- to prevent 11 injuries. Like it's just a cautionary kind of thing that 12 they put on. 13 Q: And is there anything else that you 14 can recall about the arrival of Mr. Cotrelle that -- that 15 you should -- you feel you should share with us? 16 A: No, I don't. 17 Q: All right. We understand that two 18 (2) other patients arrived shortly afterwards? 19 A: That's correct. 20 Q: And namely, Mr. Anthony George or 21 Dudley George -- 22 A: Yes. 23 Q: -- and Cecil Bernard George? 24 A: Right. 25 Q: Do you recall the order in which they

1 arrived or in which you observed them arriving? 2 A: They came about the -- the same time. 3 But I'm not sure which one actually cam in first. 4 Q: All right. And when they arrived, 5 you were in the OR? 6 A: Yes, I was with Nicholus and then 7 they -- the ambulance and people would bring them right 8 into that same room. And so then I -- I kind of went 9 from -- left Nicholus and went to the -- you go to the 10 most seriously injured. And I went to Dudley George or 11 Anthony George. 12 Q: And did you have anything to do with 13 the treatment of Cecil Bernard George? 14 A: No, I did not. 15 Q: And did you observe -- what were your 16 observations concerning Cecil Bernard George? 17 A: I don't recall anything because I 18 didn't really have anything to do with him. We kind of 19 would stick with, you know, go with another patient 20 instead of trying to see them all at once. 21 Q: So at that point there were three (3) 22 patients in the room? 23 A: That's right. 24 Q: Nicholus Cotrelle, Cecil Bernard 25 George, and Anthony Dudley George?

1 A: Right. 2 Q: Can you describe for us if you will, 3 your observations of Mr. Anthony Dudley George's 4 condition on his arrival? 5 A: He was unresponsive, no movement. 6 His eyes were fixed. There was some bleeding from his 7 chest where he had a wound. But, like, he just -- he was 8 unconscious. There was just no reaction whatsoever. 9 Q: And did you make any direct -- did 10 you participate in taking his vital signs or any other 11 treatment or assessment, directly of Mr. George? 12 A: No, I -- I just mainly recorded. 13 Q: Okay. 14 A: I would maybe help set up, maybe get 15 the doctor oxygen or an endotrachial tube or those kinds 16 of things. I don't remember exactly what I did, but I 17 didn't start the intravenous, I didn't put the monitor 18 on. I didn't, you know, take his vital signs. 19 Q: Okay. And I understand that a code 20 blue was called -- 21 A: That's right. 22 Q: -- shortly after his arrival? 23 A: That's right, because of his 24 condition. That's what we do, we call a code blue which 25 brings extra people to the department and those people

1 each have a specific job. 2 One (1) will be for doing the medication, 3 some will be doing the compressions, some -- you know, 4 they each their specific jobs. And as my job, as the 5 supervisor, I was to be the recorder; that was my main 6 job. 7 Q: Okay. And if I could actually take 8 you to Tab 7 of the same brief of documents. And, for 9 the record, there's two (2) documents that -- that I will 10 be referring Mrs. Liddell to, Inquiry Document number 11 5000248 and 5000249. 12 First of all, if I could take you to 13 Document 5000249, which is the second page -- 14 A: Yes. 15 Q: -- in that tab for you. 16 A: Yes. 17 Q: Do you recognize your handwriting 18 anywhere on that page? 19 A: Yes, approximately the middle -- 20 Q: Hmm hmm. 21 A: -- where I've said the above -- 22 Q: Hmm hmm. 23 A: -- notes were rewritten on September 24 the 7th. 25 Q: Hmm hmm.

1 A: And I've signed it and dated it and 2 the time. 3 Q: Okay. And what was the time? 4 A: At -- September the 8th at 14:45. 5 Q: Okay. 6 A: Which would be the next day. 7 Q: Okay. And can you explain for us 8 what -- what that notation in your charting means? 9 A: It just means that I have given a 10 little better description of what actually happened the 11 night of -- 12 Q: Hmm hmm. 13 A: -- the 7th. 14 Q: Okay. 15 A: I suppose when you're not in the 16 situation, like when you have a crisis like that with 17 three (3) patients, then a lot of things happen and you 18 don't always have time to record everything you likely 19 should have. So I was given the opportunity the next day 20 to more clearly describe what actually happened -- 21 Q: Hmm hmm. 22 A: -- the night that he -- that Dudley 23 George arrived. 24 Q: Okay. And if I could take you to the 25 previous page --

1 A: Yes. 2 Q: -- which is Inquiry Document Number 3 5000248. 4 A: Yes. 5 Q: Do you recognize your notes anywhere 6 on that page? 7 A: Those notes are all mine. 8 Q: Okay. And would you have made those 9 notes at the time on September 7th, at for example, 00:08 10 hours or would they have been made -- 11 A: I -- I rewrote them the next day. 12 Q: Okay. And -- 13 A: And that's what happened, but I had 14 written it all exactly like that. 15 Q: Okay, so you were working, at the 16 time, from another set of notes that would have contained 17 less information, in other -- 18 A: Right. 19 Q: -- words. Okay -- 20 A: Right, and my memory was better then. 21 Q: Okay. And in those notes, you have 22 recorded at 00:08, "Male patient, native Canadian brought 23 in by ? car by ? family"? 24 A: I was in the OR room as you're 25 calling it --

1 Q: Hmm hmm. 2 A: -- and I was not -- I did not 3 personally see how he came or who came with him. 4 Q: Hmm hmm. 5 A: So I am going by what I was told -- 6 Q: Hmm hmm. 7 A: -- that's why the question mark. 8 Q: Hmm hmm. Okay, and you also note 9 that the patient was unresponsive, which you also -- 10 A: Yes. 11 Q: -- observed to us -- 12 A: That's right. 13 Q: "No vital signs visible", that he was 14 attached to monitors? 15 A: Yes, there's a monitor -- 16 Q: Hmm hmm. 17 A: -- with leads that we put on and that 18 gives us an idea of his heart activity -- 19 Q: Hmm hmm. 20 A: And I recall that there was, like, a 21 straight line which would indicate no activity. 22 Q: Okay, all right. And did you 23 participate in the attaching of those monitors yourself 24 or -- 25 A: No, I did not.

1 Q: You were focussed on recording -- 2 A: Yes. 3 Q: -- as you observed. And you also 4 note further on that: 5 "? gunshot wound, no obvious outlet for 6 bullet?" 7 A: And -- yes, and I was told that -- 8 see, that's why the question mark again? I was told that 9 it was a gunshot wound and he had been examined. Like, 10 that's one (1) thing they were looking for, to see if 11 they could find out what -- if it had gone right through 12 and so they had -- I was told that they couldn't find 13 any. It's not because I saw it particularly, it's 14 because it was what I was told. 15 Q: All right. And, finally, no movement 16 by patient. Did you observe Mr. George moving at any 17 point while he was in the ER? 18 A: No. 19 Q: Or, OR? 20 A: No. 21 Q: Can you describe for us any medical 22 treatment administered to Mr. George in an attempt to 23 revive him? 24 A: We did -- we called the Code Blue, 25 and so then we would do compressions on his chest, we

1 would have oxygen on him. We put an endotrachial tube 2 down and -- and that is a better way to give him oxygen 3 deep down. Like, the tube goes down into your throat and 4 you have an oxygen bag on top where you can pump air 5 right down into his chest. 6 We'd start the intravenous, which 7 would give him extra fluid, which would help as well, 8 because he -- there was a fair amount of bleeding from 9 his wounds, so this would increase his body fluids, which 10 is another way to try to revive him. 11 Q: And can you recall how soon after his 12 arrival at 00:08 these -- these efforts began? 13 A: They start immediately. As soon as 14 he comes in the room you immediately do everything you 15 can possibly do to revive a patient. 16 Q: Okay. And if I could take you to Tab 17 4 of the book in front of you, which is Inquiry Document 18 Number 5000248? No, sorry, 5000245. 19 A: Right. 20 Q: Can you tell me what -- what that 21 document is? 22 A: It's called -- what I would call the 23 "Code Blue Record" -- 24 Q: Hmm hmm. 25 A: -- and it's a record that I made at

1 the time that the code was being done. 2 Like, you give events as to what you know, 3 what happened, what date, what time, where, and the two 4 (2) physicians that were present, and, as I say, like the 5 respiration, the bag and the mask and the endotrachial 6 tube, which I talked about and who put it in, which was 7 Dr. Marr and then the closed-chest massage, which is the 8 compressions that were being done. 9 The intravenous, we had two (2) 10 intravenouses, which is what we usually do for someone 11 like this and the -- what the fluid was and who started 12 them. And then there's a place for vital signs. And I'd 13 done it three (3) times during that code procedure and 14 there was no activity; pulse, blood pressure, or anything 15 during that entire code time. 16 And I've also noted over there that at 17 00:19 that the pupils were fixed and dilated, which they 18 had been from when he came in through this whole 19 procedure. 20 And I've also, just for information, noted 21 that no CPR or resuscitation efforts were done during 22 transport to the hospital. Like, if he'd been in an 23 ambulance, then they -- we usually would do that on the 24 transport to the hospital. 25 And then I have the time that he died and

1 who the physician in charge, the nurse in charge, which 2 is always the Emergency nurse or when it's in the 3 Emergency Department. Then I had my name as a recorder. 4 Q: Okay. And the Charge Nurse would 5 have been -- 6 A: Jackie Derbyshire, because she was 7 the Charge Nurse in Emergency that night. 8 Q: Okay. Just -- just to take you back 9 a little bit. 10 A: Yes? 11 Q: You note here the time 00:11? What 12 does that time signify, that's towards the top right 13 beside Dr. Marr's name? 14 A: That is the time she got the 15 endotrachial tube inserted. 16 Q: Okay. 17 A: So he would have had oxygen by mask 18 prior to that because it takes a minute or so to get the 19 endotrachial tube in. So, we always note the time that 20 it's actually inserted. 21 Q: All right. And with respect to your 22 note here at 00:19 that pupils were fixed and dilated and 23 -- did -- so, that would have been information that you 24 were told -- 25 A: Yes.

1 Q: -- rather than what you observed 2 yourself? 3 A: Yes, because it's hard with everybody 4 moving for me to be right up there looking into his 5 pupils because his eyes would have been shut. 6 Q: And, with respect to your note, "No 7 CPR done during transport here," -- 8 A: And I was told that -- like I was 9 told that he had come likely -- by -- by the car, and 10 that nothing had been done. And that's information that 11 I would have been given. 12 Q: Okay. And do you recall who gave you 13 that information? 14 A: No, I do not. 15 Q: Do you recall inquiries being made at 16 the time by the physicians as to the history of his 17 injuries? 18 A: I believe Dr. Marr would try to find 19 that out as part of -- like when she would write up her 20 notes on this case, she would try to find out any 21 background information. But I personally didn't get it. 22 Q: Okay. And you said that she would -- 23 do -- do you recall her actually making inquiries of the 24 nursing staff, or anyone else? 25 A: No, I do not.

1 Q: Okay. And during the time that we've 2 been discussing here, do you recall the presence of any 3 police officers in the -- first of all in the Emergency 4 Department or hospital? 5 A: There were certainly some in the 6 hospital. I don't recall if there was one (1) in the OR 7 at the time that this was going on, but there certainly 8 were police in the hospital. 9 Q: Were there police in the hospital 10 prior to the arrival of any of these patients? 11 A: I do not recall. I do not recall. 12 Q: And the officers that you did 13 observe, they would have been in the Emergency 14 Department, that you observed them? 15 A: There were some in the Emergency 16 Department, and then just across the hall is what we call 17 the admitting office, and there were some in there. 18 Q: Okay. And do you recall roughly how 19 many officers were present? 20 A: No, I don't. I know there were quite 21 a few, but I have no idea as to number. 22 Q: Okay. Were you given any explanation 23 as to the reason for their presence there? 24 A: Well, something like this there 25 usually are police around but I -- I don't -- I don't

1 recall exactly, you know, the circumstances, exactly the 2 extent of what was really taking place. 3 Q: Okay. And -- and you did say 4 something like this, can you be a little more specific 5 about what you meant there? 6 A: I think at the time this was 7 happening, I didn't realize and -- and this is likely why 8 they had given me the next day the opportunity to rewrite 9 my notes, as I think at that time, I didn't realize the 10 extent as to, you know, that it would carry on and -- and 11 go on. 12 Q: Okay. And do you recall how the 13 police officers were dressed that were present in the 14 department? 15 A: Just in police uniform. 16 Q: Were they wearing any extra 17 protective gear? 18 A: They often do have, like, a vest over 19 top, but that's all I remember. 20 Q: And did the presence of police 21 officers in the department have any effect on you, as you 22 went about your work -- 23 A: No. 24 Q: -- with respect to these patients? 25 A: No. My job was to help the patients

1 to the best of my ability, and police do not bother me 2 that way. I guess I've worked enough with them that -- 3 no, they don't affect, you know, make me nervous or 4 anything like that, no. 5 Q: And they didn't pose any impediment 6 at the time? 7 A: No. No, they did not. 8 Q: And did their presence in the -- in 9 the hospital cause you to have any concerns for your 10 safety? 11 A: No. 12 Q: Okay. If I could take -- just to 13 continue with -- with Mr. George, Anthony Dudley George, 14 did you observe him being pronounced dead? 15 A: Yes, I did. That was just at the end 16 of the code. Like I've got 00:19 pupils fixed and 17 dilated, and then just -- 00:20 Dr. Marr pronounced him. 18 And yes, I was right there when she did that and recorded 19 the time. 20 Q: Okay. And if I could just take you 21 to the next tab, that's Tab 5 in the Brief of Documents 22 in front of you, which is Inquiry Document Number 23 5000246 -- 24 A: Yes. 25 Q: -- for the record?

1 A: Yes. 2 Q: And just as a housekeeping matter, I 3 should at this point pause and ask to have entered as 4 exhibits, the nurse's notes that appear at Document 5 Number 5000248. 6 THE REGISTRAR: P-382, Your Honour. 7 COMMISSIONER SIDNEY LINDEN: Okay. 8 9 --- EXHIBIT NO. P-382: Document Number 50002248, 10 Nurse Glenna Ladell's notes, 11 Sept. 07/95 Re: Mr. Anthony 12 George 13 14 MS. KATHERINE HENSEL: And at 5000249. 15 THE REGISTRAR: P-383, Your Honour. 16 THE CHAIRPERSON: 383. 17 18 --- EXHIBIT NO. P-383: Document Number 5000249, 19 Nurse Glenna Ladell's notes, 20 Dept. 07/95 Re: Mr. Anthony 21 George 22 23 MS. KATHERINE HENSEL: And as well, what 24 Mrs. Ladell has described as the Code Blue sheet which is 25 titled Cardio Pulmonary Resuscitation Record which is

1 Inquiry Document Number 5000245. 2 REGISTRAR: P-384, Your Honour. 3 4 --- EXHIBIT NO. P-384: Document Number 5000245, Code 5 Blue record of Dudley George 6 made by Nurse Glenna Ladell, 7 Sept. 07/95 Cardiopulmonary 8 resuscitation record. 9 10 MS. KATHERINE HENSEL: Okay, turning to 11 the next document, which is Inquiry Document Number 12 5000246 for the record. And if I could ask that this be 13 entered as the next exhibit? 14 REGISTRAR: P-385. 15 16 --- EXHIBIT NO. P-385: Document Number 5000246, 17 Record of Dudley George's 18 death, September 07/95. 19 Pronounced dead by Dr. Marr 20 at 00:20 hours. 21 22 MS. KATHERINE HENSEL: Thank you. 23 THE CHAIRPERSON: P-385. 24 25 CONTINUED BY MS. KATHERINE HENSEL:

1 Q: Mrs. Ladell, do you recognize that 2 document? 3 A: Yes, I have completed the top half, 4 which was my requirement. 5 Q: Your -- your requirement -- 6 A: As a supervisor, and because I was 7 looking after him and Mrs. Bergman was busy with other 8 matters, then I just carried on and -- and did it as if I 9 was supervisor at that time. 10 Q: Okay. All right. Okay, do you 11 recall once Mr. George was pronounced dead -- 12 A: Yes. 13 Q: -- what happened next? 14 A: We would try to notify his next of 15 kin, which I have on this Document 5000246, I've said 16 that I -- that they had come in and that they were 17 notified at 00:55. 18 Q: Okay. 19 A: And then at -- at 1:00, then I 20 notified the Coroner, Dr. Perkin, which is something we 21 do for deaths of -- of this type. 22 Then Dr. Marr would say to me that the 23 Coroner needed to be called, and -- and that was another 24 job a supervisor would do, so I have carried and done 25 that same thing as well.

1 Q: Okay, and when you say deaths of this 2 type, what do you mean by that? 3 A: Suspicious or unknown cause -- deaths 4 in an emergency like this, unless it's something that we 5 know -- have a big history on, then the Coroner is always 6 called. 7 Q: Okay. All right, at any point was 8 Mr. George identified to you as Anthony George? 9 A: Yes, he was identified by his 10 brother, Maynard George, and by his sister, Pamela George 11 to me. 12 Q: Okay? 13 A: And this is a requirement as well. 14 We have to have possible -- positive identification of 15 the patients, and this is -- was one (1) of my jobs, and 16 it was done to me. 17 Q: Okay. And where did that take place? 18 A: It would take place -- I don't recall 19 whether he -- I would think that likely, by this time, we 20 had moved him to the small room on the side, but I don't 21 recall exactly. 22 Q: Okay. All right. And had Dr. Perkin 23 arrived at the hospital by that point? 24 A: He didn't arrive until about quarter 25 to 2:00.

1 Q: Okay. 2 A: I had called him at 1:00. He lives 3 out of Strathroy, so it took him a few minutes to get to 4 the hospital. 5 Q: Okay. And can you describe your 6 conversations with him once he did arrive? 7 A: Well, I -- I would just, you know, 8 tell -- when -- over the phone I would tell him that, you 9 know, we had this patient and that Dr. Marr had asked for 10 me to call him. 11 And when he came in, usually he will talk 12 -- well, I -- he -- I -- I'm not -- I don't recall 13 exactly what he said to me at that point, but he would 14 have a discussion with the doctor in charge, which would 15 be Dr. Marr, to find out all of the particulars about 16 what has happened. 17 And then I would identify the patient to 18 him, and he -- the two (2) of us together in the room, he 19 would examine the body and I would be in the presence. 20 Q: And your identification of Mr. 21 George, to Dr. Perkin, would have been based on his 22 family members -- 23 A: Yes. 24 Q: -- Maynard George's --? 25 A: I have to have a positive

1 identification to me, and then I identify the body to the 2 Coroner. 3 Q: Okay. Now, taking you back, for a 4 moment, to your conversation with Maynard George and 5 Pamela George, -- 6 A: Yes. 7 Q: -- was it you that notified them of 8 Mr. George's death? 9 A: Yes, I did. And that was also a job 10 that we did as a supervisor. 11 Q: Okay. After the arrival of Dr. 12 Perkins, can you describe what went on in relation to -- 13 to Mr. George? 14 A: Well, I would take him into the room 15 where Dudley George was, and positively identify the 16 patient to him, and then he examines the body. 17 Q: Okay. Now, we have heard evidence 18 here, Mrs. Ladell, that Mr. George's family did conduct a 19 smudging ceremony with -- 20 A: Yes -- 21 Q: -- his -- 22 A: -- they did. 23 Q: Were you present for that? 24 A: No, I was not allowed to be in the 25 room.

1 Q: Okay. And did you have any 2 conversations with any of his family members about that 3 ceremony? 4 A: No, they -- well, they just said that 5 they wanted to do it, and I kind of wanted to go in 6 because I felt that he was still my responsibility. 7 Q: Hmm hmm. 8 A: And they wouldn't allow me to go in, 9 so I had to wait outside the door, but I don't remember 10 who I spoke to. 11 Q: Okay. And if I could take you to -- 12 first of all, was there anyone else present, other than 13 his family members at the time? 14 A: For that service? 15 Q: Yes. 16 A: There were several people in there, I 17 have no idea who they were. 18 Q: Okay. If I could take you to Tab 7 19 which has been identified as -- the document there has 20 been identified as Exhibit P-382. 21 Now, there you have noted, 22 "Religious native rights performed by 23 family in presence of Constable 24 Murphy." 25 Is that a correct interpretation of your

1 handwriting? 2 A: Yes, that's my handwriting. 3 Q: Okay. 4 A: Yes. 5 Q: Does that refresh your memory as to 6 who was in the room at the time? 7 A: No, I just remember there were 8 several people around, but I have no idea who they all 9 were. 10 Q: Okay. Did you have any further 11 conversations with any members of Mr. George's family 12 after that time? 13 A: Not that I recall. 14 Q: Okay. And do you recall -- with 15 respect to the -- to the ceremony that you referred to 16 earlier, do you recall any concerns being raised, or 17 experienced by you, concerning the presence of oxygen in 18 the hospital, or oxygen lines and open flame? 19 A: I don't remember. 20 Q: You don't recall? 21 A: I don't remember. 22 Q: And -- all right. And then we 23 understand that Mr. George's body would then have been 24 taken to the morgue, is that correct? 25 A: Yeah, well it was first after --

1 Q: Hmm hmm. 2 A: -- Dr. Perkin examined the body -- 3 Q: Hmm hmm. 4 A: He and the constable took the body to 5 x-ray, to have some x-rays, which is not unusual either-- 6 Q: Hmm hmm. 7 A: -- to give a little more clarity to 8 exactly, you know, for Dr. Perkin's records, exactly what 9 had taken place. 10 And then he was brought back to the 11 Emergency Department. And then at three o'clock, Marlene 12 and I took the body to the morgue, which is another 13 nursing supervisor job. 14 Q: Okay, and by "Marlene" you mean 15 Marlene Bergman? 16 A: Marlene Bergman, yes. 17 Q: Okay. And do you recall taking any 18 of Mr. George's effects with him to the morgue? 19 A: His clothes went with him. Any 20 valuables were taken to the business office -- 21 Q: Okay. 22 A: -- which is ordinary procedure as 23 well. 24 Q: Okay. Do you recall if -- taking any 25 valuables to -- to the business office in this case?

1 A: I think Marlene took those. 2 Q: Okay. 3 A: Marlene Bergman took those. 4 Q: All right. Okay. And did you have 5 any further involvement with Mr. George or his family 6 that evening? 7 A: No. 8 Q: Did you have any further involvement 9 with any of the other patients that had come in, Mr. 10 Cotrelle or Cecil Bernard George? 11 A: I took -- I helped take one (1) end 12 of the stretcher when Nicholus Cotrelle was admitted to 13 2-South -- 14 Q: Hmm hmm. 15 A: And that was, I think, about 2:30. 16 Q: Okay. Right, I just have one (1) 17 further area of questioning. Just to go back to the time 18 when resuscitation efforts were being conducted on Mr. 19 George, do you call whether Mr. Cotrelle was moved out of 20 the room at anytime? 21 A: Yes, he was. 22 Q: Okay. We've heard evidence from Mr. 23 Cotrelle that he was actually present in the room for 24 quite some time. Do you recall when he would have been 25 moved out?

1 A: I don't know the exact time. I know 2 he was moved out, but I don't know exactly what time he 3 was moved out. 4 Q: Okay. Do you know when he would have 5 been moved out in relation to Mr. George being 6 pronounced? 7 A: No. 8 Q: Okay. 9 A: I don't recall. 10 Q: Okay. All right. Thank you, Mrs. 11 Ladell,-- 12 A: You're welcome. 13 Q: -- those are all my questions. 14 A: Thank you. 15 Q: My Friends -- Counsel for the parties 16 may have some further questions for you, all right? 17 A: Thank you. 18 COMMISSIONER SIDNEY LINDEN: Does anybody 19 wish to examine this witness? Ms. Jones? How long do 20 you anticipate you might be? 21 MS. KAREN JONES: About two (2) minutes. 22 COMMISSIONER SIDNEY LINDEN: Fine. 23 24 (BRIEF PAUSE) 25

1 MS. KAREN JONES: Good morning, Mr. 2 Commissioner. 3 COMMISSIONER SIDNEY LINDEN: Good 4 morning. 5 6 CROSS-EXAMINATION BY MS. KAREN JONES. 7 Q: Good morning, Ms. Ladell. 8 A: Good morning. 9 Q: My name's Karen Jones and I'm one (1) 10 of the lawyers for the Ontario Provincial Police 11 Association. 12 A: Yes. 13 Q: I just have a couple of things that I 14 wanted to make sure were clear. You were earlier taken 15 to the records of Mr. Anthony Dudley George -- 16 A: Yes. 17 Q: -- in the binder? 18 A: Yes. 19 Q: And you were asked to look at two (2) 20 pages, and the numbers were Inquiry Document Number 21 5000248 and 249. And you told us that those were the 22 notes that you made after the fact? 23 A: That's correct. 24 Q: And I take it if you turn -- do -- do 25 you have -- do you have the document numbered 5000247 in

1 that binder in front of you? It's at Tab 6 I think, of 2 your book. 3 A: Yes, I have it. 4 Q: Okay. Do you see the document number 5 at the very top? 6 A: Yes, I do. 7 Q: And the ending 247? 8 A: Yes. 9 Q: And there's a note there dated 10 September 7th, 1995 at 0:08? I take it that that is your 11 original note? 12 A: That is correct. 13 Q: Okay. Is that -- 14 A: And I've stroked -- see I've stroked 15 out ambulance because I wasn't sure how he came, and then 16 later I learned that he came by car, and that's why that 17 error is there. 18 Q: Right. And Mr. Commissioner, I 19 wonder just for the sake for completeness, if we could 20 have all of Ms. Ladells's records in -- for her nursing 21 notes? And I'm not sure if it makes sense to add this as 22 a new exhibit or to have it included in the two (2) 23 previous pages that were her notes? 24 Okay. That sounds like it would be a 25 separate exhibit.

1 COMMISSIONER SIDNEY LINDEN: Separate 2 exhibit? That's fine. 3 THE REGISTRAR: P-386, Your Honour. 4 COMMISSIONER SIDNEY LINDEN: P-386. 5 MS. KAREN JONES: Thank you. 6 7 --- EXHIBIT NO. P-386: Document Number 5000247, 8 Nurse Glenna Ladell's notes 9 September 07/95 Re: Mr. 10 Anthony George 11 12 CONTINUED BY MS. KAREN JONES. 13 Q: And I just had one (1) question, or a 14 couple of questions to ask you about the notes that you 15 made with Mr. Nicholas Cotrelle. And I think those are 16 in the binder in front of you too. 17 And we had looked at your -- 18 A: Excuse me, what tab are we looking 19 at? 20 Q: It's Tab 1 in your book. 21 A: Oh, is it number 1? 22 Q: Yes, I think so. 23 A: Yes. 24 Q: And then looking at the first page of 25 the nurses notes --

1 A: Yes. 2 Q: -- which is Inquiry Document 100043. 3 A: Yes. 4 Q: You -- we had earlier had up on the 5 screen, your note that -- it looks like it's dated 00 -- 6 it looks like originally eight (8) and then a written 7 over four (4), can you help us with that? 8 A: The clocks aren't always the same, 9 and so we try to co-ordinate everything to have it in 10 better chronological sequence. 11 Q: Okay. 12 A: And so I'm not sure exactly what was 13 there initially. 14 Q: Okay. Something was there and then 15 you wrote a 4 over it, is that right? 16 A: Yes. Yes, I did. 17 Q: Okay. And then that leads to my next 18 question which is that -- can you help us understand, 19 when you put a time down on a chart -- 20 A: Yes. 21 Q: -- are you referring to the time you 22 take from your watch or the time you take from the clock 23 in the room or something else? 24 A: I never wore a watch. 25 Q: Okay.

1 A: It would be the clock in the room. 2 Q: Okay. And so when you talk about a 3 discrepancy in clocks and time and -- and you're not sure 4 what the original entry was there, can you help us with 5 what you would have been looking at at first to get the 6 original time because you then subsequently changed it to 7 something else. 8 A: Part of it is -- and I'm not sure 9 whether it's here. Yes, there's another exhibit, 10 1000043; it's two (2) pages in front of that. 11 Q: Yes? 12 A: And it is the Emergency and 13 Outpatient Record. 14 Q: Yes. 15 A: And so, we try to have that time -- 16 Q: Okay. 17 A: -- and our time the same. 18 Q: Okay. 19 A: So, whenever they come in, then the 20 admitting people will put a time of entry. 21 Q: Yes. 22 A: And so that's that time. So, we -- 23 we had that time to correspond with this time -- 24 Q: Okay. 25 A: -- so that they're all the same.

1 Q: Okay. And so, at some -- I'm sorry, 2 and I don't want to make this more confusing. 3 A: That's okay. 4 Q: If you can help us with process on 5 evenings or nights, when someone comes into the Emergency 6 Department who would fill out the Emergency and 7 Outpatient Record? 8 A: This emergency? 9 Q: Yes. 10 A: The top part is filled out by the 11 admitting person. 12 Q: Okay. 13 A: And then where Marlene Bergman has 14 signed -- 15 Q: Yeah. 16 A: -- then someone in the Emergency part 17 or whoever is looking after as a nurse -- 18 Q: Yeah. 19 A: -- the nurse's assessment that's -- 20 and she would fill in the attending doctor -- 21 Q: Okay. 22 A: -- and then the latter part is done 23 by the attending doctor. 24 Q: Okay. And do you have a person who 25 works at the desk in the Emergency Department twenty-four

1 (24) hours to do -- 2 A: Like a secretary? 3 Q: Yeah, to fill out -- 4 A: No. 5 Q: Okay. Who -- 6 A: We only have them and they only work 7 the day shift -- 8 Q: Okay. 9 A: -- unless it's changed, but when I 10 was there it was only the day shift. 11 Q: Okay. 12 A: So, this top part is always done by 13 the admitting person and there is one (1) -- someone 14 there twenty-four (24) hours a day. 15 Q: And by "the admitting person," do you 16 mean the nurse who would have done the admitting or who-- 17 A: No, no. This -- this -- this typed 18 part -- 19 Q: Yes. 20 A: -- at the top is done by Admitting -- 21 I guess you'd call her an officer. She is not a nurse. 22 Q: Okay. 23 A: She looks after the switchboard, she 24 looks after these admissions. Particular, like in the 25 night, she's the only person in that office.

1 Q: Okay. 2 A: And then, she brings this chart over 3 to the Emergency Room, which is just across the hall. 4 Q: Okay. 5 A: And then, it is the responsible of 6 the nurse and the doctor to complete that document. 7 Q: Okay. And so, do I take it from what 8 you've said, then, that you would have seen the Emergency 9 and Outpatient Record with the time of 00:04 on it? 10 A: Yes. 11 Q: And then, you would have changed the 12 time -- 13 A: That's right. 14 Q: -- in your own documentation -- 15 A: That's right. 16 Q: -- so that it was the same as that? 17 A: Corresponding, right. 18 Q: Okay. So, it -- that time of 00:04 19 corresponds to whatever the admitting person was looking 20 at -- 21 A: That's right. 22 Q: -- not with the clock in the OR? 23 A: Because likely, her clock is a -- a 24 minute or two (2) off my clock. 25 Q: Okay.

1 A: They are supposed to be all the same, 2 but that's very hard to do -- 3 Q: Yeah. Yes. 4 A: -- in a large place. 5 Q: Okay. 6 A: To have them all exactly the same 7 time. 8 Q: Right. Okay. And those are my 9 questions. Thank you very much. 10 A: Thank you. 11 COMMISSIONER SIDNEY LINDEN: Thank you 12 very much, Ms. Jones. Thank you very much, Mrs. Ladell. 13 MS. KATHERINE HENSEL: Thank you, Mrs. 14 Ladell. 15 16 (WITNESS STANDS DOWN) 17 18 MS. KATHERINE HENSEL: I believe these 19 Witnesses' Counsel -- actually I should have introduced 20 him while he was here, but I will when he comes back in, 21 has gone to locate the next witness, Marlene Bergman, 22 she's on the premises. 23 COMMISSIONER SIDNEY LINDEN: Is she here 24 or should we take a short break? 25 MS. KATHERINE HENSEL: Yeah. Yeah, we

1 can -- if we take a short break that would be... 2 COMMISSIONER SIDNEY LINDEN: We can take 3 a short break now. 4 MS. KATHERINE HENSEL: Okay. Thank you. 5 THE REGISTRAR: This Inquiry will recess 6 for ten (1) minutes. 7 8 --- Upon recessing at 11:20 a.m. 9 --- Upon resuming at 11:35 a.m. 10 11 THE REGISTRAR: This Inquiry is now 12 resumed, please be seated. 13 MS. KATHERINE HENSEL: Thank you, 14 Commissioner, I was remiss this morning in not 15 introducing Counsel for the witnesses today, Ron LeClair, 16 who is seated back -- 17 COMMISSIONER SIDNEY LINDEN: Good 18 morning. 19 MS. KATHERINE HENSEL: -- a few tables 20 back. 21 MR. RON LECLAIR: Good morning. 22 MS. KATHERINE HENSEL: The Commission 23 calls, as its next witness, Marlene Bergman. 24 THE REGISTRAR: Good morning, Ms. 25 Bergman. How are you this morning? Do you prefer to

1 swear on the bible or affirm? 2 MS. MARLENE BERGMAN: Bible. 3 4 MARLENE BERGMAN, Sworn: 5 6 EXAMINATION IN-CHIEF BY MS. KATHERINE HENSEL: 7 Q: Good morning, Mrs. Bergman. 8 A: Good morning. 9 Q: I should remind you before we begin 10 to speak directly into the mic, and you might want to 11 move it a little bit closer to you, if you're... 12 13 (BRIEF PAUSE) 14 15 Q: Our court officer will help you with 16 that. 17 18 (BRIEF PAUSE) 19 20 Q: Thank you. Just for the record, Mrs. 21 Bergman, your date of birth is May 16th, 1941? 22 A: Yes. 23 Q: And I understand that you graduated 24 from the St. Thomas Elgin Hospital School of Nursing 25 Program in 1962?

1 A: That's right. 2 Q: And that was a three (3) year 3 program? 4 A: Yes. 5 Q: Shortly afterwards you started 6 working with the Strathroy Middlesex General Hospital as 7 a registered nurse? 8 A: Correct. 9 Q: And that was also in 1962? 10 A: Yes. 11 Q: And in 1973 you became a nursing 12 supervisor at the same hospital? 13 A: Yes. 14 Q: And you served in that capacity until 15 your retirement in 1996? 16 A: Yes, that's right. 17 Q: And I understand that as a nursing 18 supervisor, you were responsible for supervising nursing 19 operations throughout the hospital? 20 A: That's correct. 21 Q: And also you pitched in and assisted 22 other nurses when you were required? 23 A: That's correct. 24 Q: Now, turning now to September 6th, 25 1995, I understand that you went on duty at 11:00 p.m.

1 that night? 2 A: Yes, that's correct. 3 Q: And that you received information 4 around that time that you might -- your hospital might be 5 receiving some patients? 6 A: Correct. 7 Q: Okay. Can you tell us where you 8 received that information? 9 A: In the nursing office. 10 Q: Hmm hmm, okay. And was there a 11 particular nurse that gave you that information, that you 12 can recall? 13 A: Yes, Lisa Seeley. 14 Q: Okay, and what did she tell you? 15 A: That dispatch had phoned and there 16 was ambulances at the Ipperwash Park area -- 17 Q: Hmm hmm. 18 A: -- and we were the closest hospital. 19 Q: And did she get any information or 20 did you get any information about the number of patients 21 that might be coming? 22 A: No. 23 Q: Okay. After that phone call, did you 24 receive any further information about the patients that 25 might be coming in?

1 A: Not until the Emergency nurse called 2 me. 3 Q: Okay. 4 A: And she had received a dispatch. 5 Q: Okay, and what was that dispatch? 6 A: That we would be receiving at least 7 two (2) patients, one (1) by ambulance and one (1) by 8 car. 9 Q: Okay. Do you remember about what 10 time that would have occurred? 11 A: About twelve (12) -- 11:20 or -- no, 12 sorry, 11:40, about that time. 13 Q: And we've also heard from your 14 colleague, Mrs. Glenna Ladell earlier today that she 15 stayed on -- on duty, that she was the nursing supervisor 16 for the shift before, and that she stayed on duty? 17 A: That's correct. 18 Q: Okay, and that she provided you with 19 a report of what had happened during the day and also a 20 briefing on -- on the information she had also received 21 from Ms. Seeley? 22 A: Yes. 23 Q: Prior to the arrival of any patients, 24 do you recall whether there were police officers present 25 at the hospital?

1 A: No. 2 Q: We've heard from Mrs. Ladell and 3 other witnesses that the first patient to arrive in the 4 Emergency Department was Nicholus Cotrelle, and that he 5 arrived at approximately four (4) minutes after midnight? 6 A: That's correct. 7 Q: And can you recall observing his 8 condition at that time, when he arrived? 9 A: He -- he arrived by ambulance, and 10 his condition -- he was conscious. 11 Q: Hmm hmm, okay. Did you see him 12 actually come into the hospital? 13 A: Yes, I did. 14 Q: Okay. Were -- where were you when he 15 arrived? 16 A: I was in the Emergency Department. 17 Q: Okay, and he was conscious. Was 18 there anything else significant about his medical 19 condition that you can recall? 20 A: On arrival? 21 Q: Hmm hmm? 22 A: When he came in the door -- 23 Q: Yes? 24 A: -- he was on the stretcher -- 25 Q: Okay?

1 A: -- and -- and we took him straight 2 into the trauma room, or the OR we call it. 3 Q: Okay, and what happened then? 4 A: He was examined by Dr. Marr, who was 5 in the hospital. 6 Q: Hmm hmm. Okay, do you recall having 7 any conversations with Mr. Cotrelle or hearing him speak 8 to anyone? 9 A: I -- I heard him say that he was in a 10 car with glass crashing around him. 11 Q: Okay. And was that -- when he was 12 speaking, was he describing -- was that in reference to 13 how his injuries may have occurred? 14 A: Yes, I think so. 15 Q: Okay. And can you describe Mr. 16 Cotrelle's -- as far as you were able to observe, his 17 emotional or psychological state when he arrived? 18 A: He -- 19 Q: Did he appear calm? 20 A: -- was quite calm when he arrived. 21 Q: Okay, and we understand that shortly 22 after Mr. Cotrelle's arrival, two (2) other patients 23 arrived at the hospital? 24 A: That's correct. 25 Q: Okay. Did you observe the arrival of

1 those two (2) patients? 2 A: I did. 3 Q: Okay, we have heard evidence that 4 Cecil Bernard George and Anthony Dudley George arrived at 5 the hospital. 6 Where were you located when they arrived? 7 A: I -- I was in the emergency room -- 8 Q: Hmm hmm? 9 A: -- but my contact with them was with 10 Mr. Anthony George first, and Mr. Cecil George second. 11 Q: Okay, and did you observe them being 12 brought into the -- when you said you were in the ER, or 13 the Emergency room do you mean the trauma room, or we've 14 heard it described as the OR as well? 15 A: I -- yes, I think I was in that room 16 at -- with the other patient. 17 Q: Okay. And just in terms of their 18 arrival, did you note the order that they were brought 19 in? 20 A: That's not -- they were just one (1) 21 after the other. 22 Q: Okay, in -- in quick succession would 23 you say? 24 A: Yes, fairly quick. 25 Q: So, do you recall who was brought in

1 first? 2 A: No, just my contact with them -- 3 Q: Hmm hmm, okay? 4 A: -- which one (1) was first. 5 Q: Okay, and which patient did you first 6 have contact with after Mr. Cotrelle? 7 A: Mr. Anthony George. 8 Q: Okay, and can you describe the nature 9 of that contact? 10 A: It was -- I assisted in putting the 11 leads on Mr. George. 12 Q: Okay. Did you observe his condition 13 when he first arrived? 14 A: He wasn't breathing. 15 Q: Okay. And Mrs. Ladell described to 16 us this morning the calling of a code blue? 17 A: Yes. 18 Q: Do you recall that? 19 A: Yes. 20 Q: And she also described for us that 21 under code blue circumstances each member of the nursing 22 team would take on different roles? 23 A: Correct. 24 Q: And can you describe for us your role 25 on the team that was treating Mr. George?

1 A: My role would have been the recorder 2 but -- 3 Q: Hmm hmm? 4 A: -- but Mrs. Ladell was there, and she 5 took over role, but I went right next to Mr. Cecil 6 George. 7 Q: Okay. So, you mentioned that you put 8 leads on -- on Mr. George -- Anthony George -- 9 A: Yes. 10 Q: -- monitors. What was the -- the 11 purpose of those monitors? 12 A: It -- the purpose of the monitors is 13 -- is to give us the heart activity. 14 Q: Hmm hmm. Okay. And did you engage 15 in any other treatment or assessment of Mr. George? 16 A: No, I didn't. 17 Q: Okay. All right. You mentioned 18 earlier that you then turned to Mr. Cecil Bernard George? 19 A: Yes. 20 Q: Okay. Were you aware at the time of 21 the circumstances surrounding his arrival at the 22 hospital; how he came to be at the hospital? 23 A: No. 24 Q: Okay. Do you know who had delivered 25 him to the hospital?

1 A: He came into the room by stretcher -- 2 Q: Okay. 3 A: -- with the ambulance attendant. 4 Q: All right. And did you know why the 5 ambulance -- or did you know any of the ambulance 6 attendants that brought Cecil Bernard George in? 7 A: No, I didn't. 8 Q: Okay. Were you aware that they were 9 St. John Ambulance attendants? 10 A: Not at the time. 11 Q: Okay. Would it be unusual for you -- 12 for a St. John Ambulance driver to deliver a patient to 13 your hospital, in your experience? 14 A: Not unusual, but not too often. 15 Q: Okay. Describe for us, if you will, 16 what Cecil Bernard George's condition was as far as you 17 observed it when you first encountered him? 18 A: When I first observed him, he -- he 19 was conscious. He was a bit vague and -- and but he 20 would react to verbal command. 21 Q: Okay. And when you say, "vague," can 22 you expand on that a little bit? 23 A: On the conscious of the patient? 24 Q: Hmm hmm. Well, you -- you mentioned 25 that he was vague, does that mean that he...

1 A: You would ask him a question and he 2 might say, "yes" and then "no." 3 Q: To the same question? 4 A: Yes. 5 Q: All right. And that he would respond 6 to a verbal command? 7 A: If you asked him to move his arm or - 8 - or his leg, he would. 9 Q: Did he complain of any injuries at 10 that time? 11 A: The ambulance drivers were the ones 12 that told me he had a head injury and abdominal injuries. 13 I can't recall him telling -- verbally coming from him at 14 the time. 15 Q: Okay. And was he -- did he have a 16 neck collar -- 17 A: Yes. 18 Q: -- at the time? All right. 19 A: Yes. 20 Q: Okay. We -- we have heard from other 21 witnesses, Mrs. Bergman, that he -- he didn't know a neck 22 collar was put on his neck to -- to brace him. 23 A: He didn't know? 24 Q: No. No, he -- that he wasn't wearing 25 a collar.

1 A: Oh, okay. 2 Q: But you can recall him wearing a 3 collar? 4 A: It would be in my notes if he... 5 6 (BRIEF PAUSE) 7 8 Q: If I could take you, Mrs. Bergman, to 9 the other binder that's in front of you, the black 10 binder. 11 A: The black binder? 12 Q: There's tabs. Not the one that -- 13 that we provided to you earlier -- 14 A: Oh. 15 Q: -- it's the one that's on the desk 16 there. It just contains copies of the -- the nursing 17 notes that we did provide to you -- 18 A: Hmm hmm. 19 Q: -- last week. If you could turn to 20 Tab 2 of that and for the record, that's Inquiry Document 21 Number 1000047, and that would be the third page; nursing 22 notes do appear there. 23 A: Hmm hmm. I have written he has a 24 neck collar on. 25 Q: Okay. All right. And that accords

1 with your memory at the time? 2 A: Yes. 3 Q: And, for the record, that was on -- 4 the page number is front 338. 5 A: Okay. 6 Q: Did you -- did you observe any 7 lacerations or any other types of injuries on Mr. George? 8 A: He had a cut to his upper right lip. 9 Q: Okay. Any others? 10 A: And -- and I didn't note the one that 11 was on the back of his head. 12 Q: Okay. And were they bleeding at the 13 time? 14 A: Not profusely. 15 Q: And what did you do to treat Mr. 16 George for his injuries at that time? 17 A: At that time, I started an IV, did 18 his blood pressure and his vitals. 19 Q: Okay. 20 A: And by that time, another nurse had 21 come on and -- and she was a primary nurse for him then. 22 Q: And who was that nurse? 23 A: Dawn Wolf. 24 Q: Okay, and I understand also that Dr. 25 Marr -- both Dr. Marr and Dr. Saettler also then treated

1 Mr. George? 2 A: Yes. 3 Q: Okay. While you were treating Cecil 4 Bernard George, I understand that there were also 5 resusitative efforts going on with respect to Anthony 6 Dudley George -- 7 A: Yes. 8 Q: -- and that he was eventually 9 declared -- declared dead at twenty (20) minutes after 10 midnight. 11 Did you observe any of that going on at 12 the time? 13 A: No. 14 Q: Okay. Were you focussed on -- 15 A: I was focussed on the patient I was 16 with. 17 Q: Okay, and that was -- 18 A: You would see in the room the action, 19 but -- or if they needed you for something. 20 Q: Okay. Okay, and I understand also 21 that Cecil Bernard George was eventually moved out of the 22 emergency department? 23 A: Yes. 24 Q: Did you have anything to do with 25 that, or...

1 A: Not Cecil Bernard, no. 2 Q: Okay. And can you describe Mr. 3 George's state, his manner, during the time that you had 4 interactions with him? 5 A: He was calm. 6 Q: He was calm? Right -- 7 A: Hmm hmm. 8 Q: You'd also earlier described a 9 certain vagueness? 10 A: Yes. 11 Q: Okay. And while you were in the 12 trauma room or OR, were there police officers present in 13 that room? 14 A: At the time I wasn't aware of it, but 15 there were after. 16 Q: Okay. And after -- after when? 17 A: After the code was called and it -- 18 things were back to a little bit normal. 19 Q: All right, so -- and was it your 20 impression at the time that either Nicholus Cotrelle or 21 Cecil Bernard George were in police custody? 22 A: I wasn't aware of it at the time? 23 Q: Okay. Did you observe police 24 officers staying fairly close to those two (2) patients 25 during your time there?

1 A: I really wasn't watching them. 2 Q: Okay. You were focussed on the 3 patients at -- 4 A: Yes. 5 Q: -- the time? Okay, did you have any 6 interactions with any members of Mr. George's -- by that, 7 I mean Cecil Bernard George's family that evening? 8 A: No. Oh, I -- I -- 9 Q: Hmm hmm. 10 A: -- recall a telephone call from a 11 brother and it's recorded. 12 Q: A brother of Cecil Bernard George 13 or -- 14 A: Yes. 15 Q: -- Anthony George? 16 A: Oh, I'm sorry. It's Anthony George. 17 Q: Okay. 18 A: Okay. 19 Q: And can you describe that telephone 20 call for us? 21 A: I can't describe the exact words but 22 he -- 23 Q: Hmm hmm. 24 A: -- was inquiring about Anthony George 25 and he said he was a brother --

1 Q: Hmm hmm. 2 A: -- that was later, and the family had 3 come and been there and gone, so I referred them to the 4 family. 5 Q: Okay. And that -- would that be 6 standard procedure, if family -- 7 A: Once the family's notified. 8 Q: Okay, you refer other members of the 9 family to those family members -- 10 A: To family -- 11 Q: -- who -- 12 A: Yes. 13 Q: -- were notified? Okay. Okay, and 14 do you recall the arrival of the Coroner at the hospital? 15 A: I didn't see him come in the door, 16 but I knew he was there. 17 Q: Okay. And that was in relation to 18 Anthony -- he was there in relation to -- 19 A: Yes. 20 Q: -- George? 21 A: Yes. 22 Q: Okay. Did you participate in the 23 identification of Mr. George by his family members? 24 A: No, I did not. 25 Q: Okay. Did you assist the Coroner or

1 interact with the coroner in any way once he had arrived? 2 A: No. 3 Q: Okay. Were you aware of what he was 4 doing while he was there? 5 A: No. 6 Q: Okay. And Mrs. Ladell testified 7 earlier that Mr. George -- Anthony Dudley George was 8 eventually moved to morgue -- 9 A: Hmm hmm. 10 Q: Do you recall -- did you participate 11 in transporting his body to the morgue? 12 A: Yes. 13 Q: Okay. And were you accompanied, at 14 that time, by a police officer? 15 A: Yes. 16 Q: And beyond accompanying you, did that 17 police officer do anything in relation to Mr. George's 18 body? 19 A: Not that I recall. 20 Q: Do you recall him doing any 21 fingerprinting on Mr. George? 22 A: There was another officer that came 23 in for the fingerprinting but I just directed him down 24 there. 25 Q: Okay. So you weren't present when

1 that happened? 2 A: No. 3 Q: And just one (1) final question, Mrs. 4 Bergman, in terms of your -- you performing your nursing 5 duties that evening or over that night in the hospital, 6 did the presence of police, at any time, interfere with 7 your performance of those duties? 8 A: No. 9 Q: Did it -- I'm sorry to interrupt 10 you, please continue. 11 A: Not that I recall. 12 Q: And did -- did their presence give 13 rise to any concern on your part as to how events were 14 unfolding either at the hospital or anywhere else? 15 A: Not -- like were we anxious? Is that 16 what you're referring to? 17 Q: Yeah or did experience any -- any 18 concern about their presence, in terms of you performing 19 your duties or perhaps your personal safety? 20 A: Not interfering with our duties, no. 21 Q: All right. Thank you, Mrs. Bergman, 22 those are all my questions. 23 A: Okay. 24 COMMISSIONER SIDNEY LINDEN: Thank you 25 very much.

1 MS. KATHERINE HENSEL: Counsel for the 2 other parties may have some questions for you. 3 COMMISSIONER SIDNEY LINDEN: Does anybody 4 have any questions for this witness? I think -- 5 MS. KATHERINE HENSEL: We're all done. 6 COMMISSIONER SIDNEY LINDEN: I think this 7 is a first for us, isn't it? 8 MS. KATHERINE HENSEL: Hmm hmm. 9 COMMISSIONER SIDNEY LINDEN: Thank you 10 very much, Mrs. Bergman -- 11 THE WITNESS: Thank you. 12 COMMISSIONER SIDNEY LINDEN: -- for 13 coming and giving your evidence. And that concludes the 14 -- your evidence today. 15 THE WITNESS: Thank you. 16 17 (WITNESS STANDS DOWN) 18 19 MS. KATHERINE HENSEL: Now I understand 20 our next witness, Mrs. Derbyshire is en route. Do we 21 have an arrival time for her? 22 COMMISSIONER SIDNEY LINDEN: Yes, Ms. 23 Vella? 24 MS. SUSAN VELLA: Yes, Commissioner. As 25 you know we have a third witness scheduled for today. We

1 anticipated that she would not be reached until after 2 lunch and accordingly, she's en route from Strathroy. I 3 tried to get her a little earlier but was unable to do 4 that when I saw the pace of the witness testimony. 5 COMMISSIONER SIDNEY LINDEN: Let the 6 record show that we're speeding right along. 7 MS. SUSAN VELLA: Therefore I 8 respectfully request that we break for lunch early and 9 perhaps we can also come back correspondingly earlier. 10 COMMISSIONER SIDNEY LINDEN: That's fine. 11 We'll break for lunch now, our usual hour and fifteen 12 (15) minutes. We'll adjourn for lunch. 13 THE REGISTRAR: This Inquiry stands 14 adjourned until 1:15 p.m. 15 16 --- Upon adjourning at 12:00 p.m. 17 --- Upon resuming at 1:22 p.m. 18 19 THE REGISTRAR: This Inquiry is now 20 resumed. Please be seated. 21 COMMISSIONER SIDNEY LINDEN: Good 22 afternoon. 23 MS. SUSAN VELLA: Good afternoon. 24 Commissioner, just before I call the next witness I just 25 want to advise Counsel that we distributed, at lunch

1 time, an article from the New England Journal of 2 Medicine. It's an article that Dr. McCallum will be 3 referring to tomorrow during his examination. We sent an 4 abstract of it last week. 5 COMMISSIONER SIDNEY LINDEN: Okay. 6 MS. SUSAN VELLA: The Commission calls, 7 as its next witness, Jacqueline Derbyshire, please. 8 9 (BRIEF PAUSE) 10 11 THE REGISTRAR: Good afternoon, Ms. 12 Derbyshire. 13 MS. JACKALINE DERBYSHIRE: Hi. 14 THE REGISTRAR: Do you prefer to swear on 15 the Bible or affirm? 16 MS. JACKALINE DERBYSHIRE: I'll affirm. 17 THE REGISTRAR: Very good. Could you 18 give us your name in full please for the record? 19 MS. JACKALINE DERBYSHIRE: Jacqueline 20 Patricia Derbyshire. 21 THE REGISTRAR: And could you spell your 22 first name for us please? 23 MS. JACKALINE DERBYSHIRE: J-A-C-K-A-L-I- 24 N-E. 25 REGISTRAR: Thank you very much.

1 2 JACKALINE PATRICIA DERBYSHIRE, Affirmed: 3 4 REGISTRAR: Thank you. 5 6 EXAMINATION-IN-CHIEF BY MS. SUSAN VELLA: 7 Q: Ms. Derbyshire, I understand that you 8 were born on November the 11th, 1946? 9 A: Yes. 10 Q: What is your current employment 11 position? 12 A: I'm currently employed as a 13 Registered Nurse, Strathroy Hospital in the Emergency 14 Department, and -- 15 16 (BRIEF PAUSE) 17 18 Q: Thank you. When you say that you are a 19 job sharer, what does that mean? 20 A: It means that essentially I'm 21 employed half the full time position. There's two (2) of 22 us that share the hours of a full-time position, in the 23 Emergency Department, as far as hours. 24 Q: All right. And what are you -- what 25 is your regular shift?

1 A: My shift is actually rotating -- a 2 rotating type of shift. It's a -- I believe it's a seven 3 (7) week rotation, and we take the number of hours and 4 days in that rotation, and -- and the -- my job sharer 5 and I split it up between ourselves however we actually 6 want to split it up, so long as it's fair and even. 7 And we do -- at the present time, we do 8 twelve (12) hour days, twelve (12) hour nights, and I 9 think there's a couple of eight (8) hour shifts, kind of, 10 to make up the hours. 11 Q: All right. And how long have you 12 worked at the Strathroy Middlesex General Hospital in the 13 Emergency Department? 14 A: I started in the Emergency Department 15 in 1981. 16 Q: And your employment there has been 17 continuance -- continuous since then? 18 A: Yes, it has. 19 Q: I understand you received your 20 nursing diploma from the Ontario Nurse's Association in 21 1968? 22 A: The Ontario College of Nurses. 23 Q: College of Nurses, yes? 24 A: 1968. 25 Q: Thank you. And at that time, did you

1 receive the designation of Registered Nurse? 2 A: Yes. Yes. 3 Q: I understand that you completed your 4 nurse's training at the Sarnia General Hospital, and that 5 that was a three (3) year period? 6 A: That's right. 7 Q: During the course of your three (3) 8 years of training, what areas of nursing did you 9 complete? 10 A: We completed all areas of nursing. 11 Now, that would include medical nursing, surgical 12 nursing, psychiatric, pediatric, operating room, chronic 13 nursing, and medical. 14 Q: I understand that you worked also in 15 the Intensive Care Unit, chronic care, at the Sarnia 16 General Hospital during the course of your training? 17 A: Yes. Actually, the Intensive Care 18 was -- we didn't actually work as staff in the Intensive 19 Care. We did observe, but post -- post my registered 20 nursing, I worked on a surgical floor and floated. In 21 other words, when they were busy in the Intensive Care I 22 would go in, and help in there as well. 23 Q: And over what -- what years did you 24 work at the Sarnia General Hospital then? 25 A: We moved to Strathroy in 1974, and

1 until that time I had been at Sarnia General. 2 Q: So, 1968 to 1974 approximately? 3 A: Yes. 4 Q: Thank you. And when did you move -- 5 you moved into the Emergency Department at -- in 1981? 6 A: That's right. 7 Q: Prior to that, what unit did you work 8 in at the Strathroy Hospital? 9 A: When I first went there in 1974, I 10 actually floated. Now, floated means that you went 11 wherever they needed to have some help. 12 At that time, they -- they were building a 13 new Intensive Care in that hospital, and they were 14 pleased to have someone that had worked in an Intensive 15 Care, and asked me would I mind waiting until it was 16 opened, to actually go into a position there. 17 So -- so for the first few months I 18 floated, and then I went to the intensive care. 19 Q: And did you stay in that unit until 20 1981? 21 A: I did. 22 Q: I understand that when you became a 23 registered nurse, there was no formal training specific 24 to Emergency nursing, or Emergency Department nursing; is 25 that right?

1 A: There was nothing specific. You 2 floated through all the areas of the hospital at some 3 point in time during your training, but there wasn't any 4 intense training in any of the areas. It was more or 5 less to give you an overview of all areas. 6 Q: Is there currently a specific program 7 to -- to -- for Emergency Department nursing? 8 A: Yes, actually there's several -- 9 several courses available. There is a course whereby you 10 can actually go and attend a college and become a 11 specialist in Emergency nursing. And then as a nurse in 12 the Emergency Department, of course, as anywhere else, 13 there's always upgrading and continuing education. 14 But there are specific courses just for 15 the nurses that work in the speciality areas, including 16 the Emergency Room, that is, -- there's a trauma course 17 an -- a trauma nursing care course, and that involves all 18 aspects of trauma. 19 There's also an Advanced Cardiac Life 20 Support, ACLS course, and that of course has to do with 21 your cardiology, and then there's also a course in 22 pediatrics, which offers both trauma and -- trauma and 23 cardiology and pediatric speciality -- just care. 24 Q: Did you receive any diploma 25 recognizing the specialty of Emergency Department

1 nursing? 2 A: Yes. 3 Q: When did you receive that diploma? 4 A: I think it was 1997, and it was from 5 Humber College. 6 Q: Was this a mandatory program? 7 A: No. 8 Q: And I understand you also teach 9 Emergency nursing candidates? 10 A: Yes, I do. 11 Q: Can you explain the basic skills 12 which are required of Emergency Department nurses? 13 A: Emergency Department nurses must be 14 skilled in the areas of trauma, resuscitation of 15 patients. They have to be able to be in charge of a 16 situation or often in charge of the department -- 17 Q: Hmm hmm. 18 A: -- on and off shift. I don't mean 19 off shift, I mean they have to be able to do that when 20 they're on shift. 21 They have to maintain certain standards of 22 practice, and be re-certified in these once a year. And 23 they are expected -- expected to upgrade and continue 24 with their education, as things progress. 25 Q: All right. Since 1981 have you also

1 -- have you participated in any upgrading programs aside 2 from the specialty diploma you received in 1997? 3 A: Yes. Yes. Once -- 4 Q: What -- 5 A: -- a year, or twice a year, I usually 6 try to go to some type of a conference, and these are 7 offered for all medical personnel including, you know, 8 your doctors, nurses and -- and they usually offer a good 9 review, and an update of all the latest treatments and 10 interventions. 11 Q: Were you on duty at the Emergency 12 Department of the Strathroy Middlesex General Hospital on 13 the evening of September the 6th, 1995? 14 A: Yes, I was. 15 Q: What time did you come on duty? 16 A: 11:00 p.m., 23:00. 17 Q: Did you arrive early that evening? 18 A: I may have. Usually we try to be 19 there ten (10) minutes or so early. 20 Q: I understand that you were the charge 21 nurse in the Emergency Department that evening? 22 A: Yes. 23 Q: What are the key duties of the charge 24 nurse? 25 A: A charge nurse, on any shift, acts as

1 a coordinator. Patient care is -- is her uppermost 2 concern and standards of practice for patient care being 3 maintained. She also may assign other nurses specific 4 duties. 5 She's available to Administration, if 6 there were to be any questions that they wanted answered 7 throughout the department. She may -- may be requested 8 to deal with the public. She may be requested to deal 9 with any outside matters, and generally, she runs the 10 place. 11 Q: Now, were there any other Emergency 12 nurses on duty that evening? 13 A: No, there's -- there -- at that time 14 there was only one (1) -- one (1) RN on the night shift. 15 Q: For the -- 16 A: In the -- in the Emergency 17 Department, yes. 18 Q: Is that the same now? 19 A: No, now there's two (2), just due to 20 volume. 21 Q: Had you been the charge nurse before? 22 A: Oh, yes. 23 Q: Basically, every shift that you would 24 take, would you be the charge nurse for the Emergency 25 Department?

1 A: Not necessarily. The charge nurse -- 2 the -- the nurse that is in charge is actually based on 3 seniority, seniority is based on -- it goes up by hours 4 of work. 5 So, even though I'd been there a long 6 time, I may not necessarily, because being a job share, 7 of course, I wouldn't have the hours. So, there's --it's 8 always the senior nurse, in hours, that will be the 9 charge nurse, except on days, and then there is a charge 10 nurse who works days. 11 Q: Okay. In a nutshell, you were 12 responsible for the administration of the Emergency 13 Department that evening from the nursing perspective? 14 A: Yes. 15 Q: Prior to coming onto your shift that 16 night, were you aware of the Ipperwash Park occupation by 17 Aboriginal people? 18 A: I was aware of it through the news 19 media. 20 Q: Were there any contingency plans, 21 made in advance, specific to possible Emergency services 22 that might be required with respect to the Park 23 occupation at the hospital? 24 A: When? 25 Q: Prior to September the 6th, to your

1 knowledge? 2 A: No. No, you mean was there sort of a 3 plan if -- if there should be -- no, not that I was aware 4 of. 5 Q: All right. So, when you came on for 6 your shift that evening, as far as you were concerned, 7 this was just another night? 8 A: Hmm hmm. Yes, just another night. 9 Q: did that change? 10 A: It certainly did. 11 Q: When? 12 A: When -- actually, when I came on 13 duty, and there's usually the nurse going off of duty, 14 will give you a report on any patients that are left for 15 your shift or anything that is pertinent that she wishes 16 you to know. 17 And -- and one (1) of the nurses that 18 evening told me that -- that she had received a phone 19 call and that several ambulances had been dispersed to 20 the Ipperwash area. 21 Q: Who was that nurse? 22 A: Lisa Seeley. 23 Q: And, you would have received this 24 information, then, around 23:00 hours -- 25 A: Yes.

1 Q: -- at the switch-over? 2 A: Yes. 3 Q: Did she advise you who she received 4 the call from with respect to the dispatch of ambulances? 5 A: She had received it from Wallaceburg. 6 Q: All right. Did you often receive 7 calls from the Wallaceburg Ambulance Dispatch? 8 A: No. No, they're not in our 9 jurisdiction. 10 Q: Now, at this time were you provided 11 with any specific details of specific casualties? 12 A: No. 13 Q: So, this was essentially a -- a 14 warning or a notice that there might be -- 15 A: Hmm hmm. 16 Q: -- casualties that evening? 17 A: Yes, we really still had no knowledge 18 of anything specific. 19 Q: Was there any indication provided 20 through Lisa Seeley, that the casualties, the possible 21 casualties, could include gunshot wounds? 22 A: No. I -- at least I don't 23 remember her saying that. 24 Q: Or that there could be multiple 25 serious casualties?

1 A: No. 2 Q: Do you recall how many nurses were on 3 duty at the hospital for that evening shift? 4 A: I -- I really wouldn't have any idea 5 of how many were in the hospital, like, I think some of 6 the floors, it varies on the number of patients as to how 7 many they staff with per -- per evening and per night 8 shift, so I wouldn't be aware of the total number, but it 9 certainly -- it certainly is bare bones. 10 Q: Bare bones staff? 11 A: Yeah, on the night shift. 12 Q: Okay. Were there any doctors on duty 13 that night? 14 A: Yes. 15 Q: Do you know how many? 16 A: Two, (2) that I know of. 17 Q: And who were they? 18 A: Dr. Marr, she was the doctor on call 19 in the Emergency Department, and Dr. Saettler was the 20 surgeon on call that evening -- or, that night. 21 Q: Did you take any preparative -- 22 preparation steps for the Emergency Room Department as a 23 result of the call from Wallaceburg? 24 A: Just to make the -- just to make the 25 supervisor aware that there was something.

1 Q: And who was the supervisor who you 2 spoke with? 3 A: Marlene Bergman. 4 Q: Did you communicate any requests of 5 Marlene Bergman with respect to precautionary steps or 6 requirements that should be taken? 7 A: Well, I said to her that we -- we had 8 to think about staffing, as to who we may be able to pull 9 from the other floors, if we were to need them, but I 10 really had no idea -- I couldn't ask for anything 11 specific because I didn't know myself. 12 Q: All right. Did -- did that standby 13 situation change at some point? 14 A: Yes. 15 Q: Do you recall when? 16 A: I think it was maybe a half an hour 17 or so later. Just -- now, it was getting on toward 18 midnight, maybe twenty (20) to or a quarter to, then we 19 did get -- I did get a call from the London Dispatch -- 20 Q: Hmm hmm. 21 A: -- which is -- which is our area. 22 Q: All right. Is this the London 23 Ambulance Dispatch? 24 A: Yes. 25 Q: And you took this call?

1 A: Yes. 2 Q: What were you told? 3 A: I was told that we were getting two 4 (2) injuries, gunshot wound, and that one (1) was coming 5 by ambulance, the other was possibly coming by car. 6 Q: All right. Now, in the statement 7 that you gave to the OPP, do you recall being interviewed 8 by them on September the 13th, 1995, approximately? 9 A: I was interviewed but I -- if it was 10 the 13th I can't really remember the -- but I was 11 interviewed, yes. 12 Q: Relatively shortly after the events? 13 A: Yes. 14 Q: And in that interview you advised 15 that -- that this call occurred somewhere around 23:40 to 16 23:45, so is that -- 17 A: Okay, yeah. That would be right. 18 Q: Thank you. Did you document this 19 call at all? 20 A: I don't think I did. 21 Q: And were you advised by London 22 Dispatch with respect to the severity of the gunshot 23 wounds? 24 A: No, no. 25 Q: And just for clarification, were you

1 advised as to the number of gunshot wound victims you 2 were expecting to receive? 3 A: Two (2). 4 Q: What did you do in preparation, if 5 anything, as a result of this call? 6 A: Now, I -- I wanted to get some stuff 7 down to the Emergency Department, so again, I spoke with 8 Marlene Bergman, the supervisor, and we decided that we 9 should prepare, and prepare for a fairly serious 10 situation, not knowing -- not knowing exactly what we 11 were dealing with. We'll prepare for the worst, and then 12 fine, if it's not that bad then you can always, you know, 13 back off. 14 Q: And it was your understanding that 15 one (1) of these victims would be coming in by ambulance 16 and the other by private vehicle? 17 A: Possibly. 18 Q: Possibly? Okay. Now, can you tell 19 us, in a general way, what basic care and treatment was 20 your department set up to give? 21 A: You mean that evening, or all the 22 time? 23 Q: Well, let's -- let's start with all 24 the time, and then you can tell me if something was 25 different that evening.

1 A: Okay. Our department is set up with 2 basically two (2) resuscitation rooms, and they're -- 3 they are the rooms where we would generally deal with 4 cardiology patients. 5 The third room that we have available, 6 that we specifically use for any type of trauma, serious 7 trauma, is what we refer to as our -- as our OR. 8 Now, this is -- it's called an OR because 9 it's actually a miniature type of operating room where 10 they can sew people up or tape, you know, little -- 11 little lesions off, this type of thing. 12 That room is also set up for a complete 13 resuscitation as far as what I would refer to as your 14 basic ABC's. In other words trying to keep the person 15 alive or resuscitate. "A" meaning their airway, "B" 16 meaning their breathing, and "C" meaning their 17 circulation. 18 So those three (3) letters actually cover 19 basically any type of trauma or any type of situation 20 where the person is -- appears not to be alive. And that 21 room is set up with IV poles, it's set up that you can 22 put the heart monitor on there, that you can -- all types 23 of airways. Anything that you would need for a 24 resuscitation is in that room. 25 Q: All right. And have you heard that

1 room sometimes referred to as the "trauma room"? 2 A: Yes. 3 Q: And you indicated that you could 4 carry out -- or at least that that room was capable of -- 5 of having minor surgery completed in it? 6 A: Yes. Yes. 7 Q: What about more significant 8 surgeries, such as cardiovascular surgery? 9 A: No. No. It wasn't an operating room 10 as in the -- the type of operating room where you have a 11 full anaesthetic, and all sterile technique, and 12 procedures being done that are quite invasive. No. It's 13 not that type of a room. 14 Q: And you indicated -- were there any - 15 - any different equipment brought into that room, if you 16 will, or capability on the evening of September the 6th? 17 A: Different as far as...? 18 Q: Well, in terms of your -- the basic 19 care and treatment capabilities of that room? 20 A: No. There wasn't anything 21 exceptional other than what we always use. 22 Q: All right. Now after the call from 23 London Dispatch and your conversation with Marlene 24 Bergman -- 25 A: Hmm hmm.

1 Q: -- what happened next? 2 A: I did have -- Marlene set out -- 3 Marlene Bergman, the supervisor, set out to -- to recruit 4 a number of nurses. In the meantime I did receive 5 another phone call from the London OPP. 6 And at that time they said that they would 7 be coming to the hospital, and I decided that when the 8 girls came to my department, I would speak to them, and 9 instruct them as to how I really wanted them to perform 10 that evening. 11 Q: All right. 12 A: Or that night. 13 Q: Do you recall the -- the name of the 14 OPP officer you spoke with? 15 A: I don't. 16 Q: And do you know approximately how 17 long after the call from London Dispatch, you received 18 the call from the OPP? 19 A: Maybe fifteen (15) -- fifteen (15), 20 twenty (20) minutes. Maybe in there. 21 Q: Now -- 22 A: I would say it -- it was right around 23 midnight anyway. 24 Q: Was it before or after midnight? 25 A: I think it was a little before.

1 Q: All right. Did the OPP officer 2 advise you with respect to why they would be coming to 3 your hospital that evening? 4 A: I think they said that it was to be 5 for security reasons. 6 Q: Security in relation to what? 7 A: The hospital. 8 Q: Yes. But why -- did they give you 9 understanding as to what you needed security from? 10 A: No. I don't even -- I don't even 11 think that we really -- I don't think we really even 12 talked about that. You know, as a -- as a nurse, I 13 wouldn't really be interested in what they were doing per 14 se. 15 You know, they're going to do their job, 16 I'm going to do my job basically. 17 Q: All right. 18 A: And all I knew was that they were 19 going to be coming to the hospital. 20 Q: Did they ask you any questions? 21 A: Yes, they did. They asked me if I 22 had any patients in the department at that present time. 23 If I did have any patients in the department, could they 24 be treated and released. 25 And if -- if there was someone that

1 couldn't be released, would we mind keeping them inside 2 the Emergency Department for the present time. 3 Q: And did you understand that this call 4 or these questions were in relation to the patients that 5 you were expecting from the Ipperwash situation? 6 A: Did they say that to me, you mean? 7 Q: Well, did you understand that? 8 A: Yes. 9 Q: Okay. You indicated that when the 10 other nurses came to your department, you had a 11 conversation with them about they wished -- how they 12 should perform that evening. 13 Can you tell me what it is you told them, 14 and why you gave these particular instructions? 15 A: I told them that they were to chart 16 meticulously, that they were to -- not ask the question 17 to the patient as to what had happened, or why -- why it 18 had happened, to only speak to them in relation to what 19 was wrong with them, physically. 20 It would -- not to -- not to just sort of 21 talk to them at random, but just to keep it very 22 professional, keep it pertinent to their injuries, chart 23 meticulously, and -- and to keep it in their mind that 24 possibly anything they were going to say or do that 25 evening would become a legal issue.

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1 Q: All right. 2 A: The reason that I did this is because 3 I was taking these girls from a floor where they're just 4 used to giving good nursing care, but they -- they aren't 5 in a position, very often, or probably rarely, to have to 6 deal with situations that may be of a legal consequence. 7 Q: All right. And the legal consequence 8 that you were referring to, is that assumed by virtue of 9 the -- the forthcoming police presence? 10 A: Yes. 11 Q: Were these nurses who had very much 12 Emergency Department experience? 13 A: No. 14 Q: And you said that you told them not 15 to ask any questions concerning the circumstances giving 16 rise to their injuries? Would that not be something 17 relevant for the doctor to know in terms of assessment 18 and treatment? 19 A: If it had -- if it was pertinent to 20 their injury, then the patient would volunteer that 21 information. But as far as asking -- like, you can 22 certainly ask the mechanism of injury or how it occurred, 23 the injury itself. You aren't really interested in the 24 circumstances around it or hearsay. 25 Q: So you wanted to ensure that the --

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1 this -- the more social conversation, if you would -- 2 A: That's right. 3 Q: -- that that wouldn't take place. 4 A: That's right. Just concentrate on 5 your patient care. 6 Q: All right. Did you receive any 7 patients that night from the Ipperwash Park incident? 8 A: Yes. 9 Q: How many in total? 10 A: Three (3). 11 Q: Do you recall approximately how far 12 apart they arrived at your Emergency Department? 13 A: I would say that all of them arrived 14 within fifteen (15) to twenty (20) minutes, in that 15 period of time -- 16 Q: Hmm hmm. 17 A: -- all three (3) of them would have 18 arrived. 19 Q: And relative to the OPP call, how 20 many minutes later did the first patient arrive, 21 approximately? 22 A: Oh, I think probably within about 23 five (5) or -- five (5) or six (6) minutes. It was 24 fairly shortly. 25 Q: Hmm hmm. Do you -- and do you know

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1 now who -- what the name of that patient was? 2 A: In the order that they came in? 3 Q: The first patient? 4 A: Now, the first patient was -- he was 5 a young boy. 6 Q: Young man? 7 A: Yeah, young man. 8 Q: teenage? 9 A: Sixteen (16) or seventeen (17) years 10 old. 11 Q: Hmm hmm. 12 A: And I believe he -- his name is 13 Cotrelle -- Cotrelle? 14 Q: Does Nicholus Cotrelle -- 15 A: Yeah -- 16 Q: -- ring a bell? 17 A: Yes. 18 Q: All right. 19 A: That's it. 20 Q: Thank you. And do you recall by what 21 means he arrived? 22 A: He arrived -- he arrived by 23 ambulance. 24 Q: All right. I wonder if you would go 25 to your Tab 1, this is in the hospital record, nurse

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1 witnesses, Tab 1, and it's been made Exhibit P-356. 2 If you go to the second page, and it's 3 Inquiry Document Number 1000043, this is the Emergency -- 4 A: Pardon me, Tab 1... 5 Q: Page 2. 6 A: Now, are these numbered at the 7 bottom? 8 Q: No, I'm afraid not. If you would 9 just -- 10 A: Okay. 11 Q: -- turn to the second page. 12 A: Oh, I see, okay. All right. Sorry. 13 Sorry. I was looking for a number on the page. Okay, 14 one (1), two (2) -- okay what are -- 15 Q: All right. You'll see in the top 16 right, or left corner there's a front number in the box, 17 it's 271, or 00000271? 18 A: Yes. Yes, I see it. 19 Q: And, it's the Emergency and 20 Outpatient Record for Nicholus Cotrelle? 21 A: Yes. Yes. I see that. 22 Q: All right. And these records, can 23 you tell us, is there a standard procedure in when these 24 records are made and who makes them? 25 A: Yes. The actual Emergency and

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1 Outpatient Record is -- this is made by the Outpatient 2 Department. We need to have something to chart on, so 3 basically like, if someone is coming into the Emergency 4 to make a visit, they would go to the Outpatient 5 Department first. 6 Well, they'd go to the Triage Nurse, but 7 they'd go to the Outpatient Department first. They type 8 in all their information, make us a chart, and bring it 9 over to the Emergency Department. 10 Q: And then, it's filled out, I see, by 11 -- would it be the Primary Care Nurse and perhaps the 12 doctor? 13 A: I see that, yes. 14 Q: And the doctor on call? 15 A: Hmm hmm. 16 Q: All right. And, according to this 17 record, it would appear that Mr. Cotrelle arrived in the 18 Outpatient Department or the Emergency Department, I 19 should say, at approximately 00:04 a.m.? 20 A: I see that, yes. 21 Q: On September the 7th, 1995? 22 A: Right. 23 Q: Does that seem about right to your 24 recollection? 25 A: That would seem -- yes. Yes, I would

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1 agree with that. 2 Q: All right. 3 4 (BRIEF PAUSE) 5 6 Q: Now, did you -- firstly, did you 7 observe Mr. Cotrelle as he came into the Emergency 8 Department? 9 A: Just very briefly. 10 Q: All right. 11 A: Just at a glance. 12 Q: And do you recall what your 13 preliminary observations or what your clinical 14 observations were at that time? 15 A: He -- he looked to me as though he 16 were fairly stable. His colour was good, he was 17 breathing fine, he was in a sitting position and he 18 certainly was, you know, looking around and -- 19 Q: Did your -- 20 A: -- I thought, you know, he's fine. 21 Q: All right. In other words, he was 22 stable; didn't require emergency treatment? 23 A: Right, yeah. Yeah, he wasn't a 24 resuscitation. 25 Q: Okay.

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1 A: He needed nursing care, but not 2 resuscitation. 3 Q: All right. Did you receive any 4 advance notice with respect to the particulars of his 5 injuries, and his condition, while he was en route to the 6 hospital? 7 A: No. 8 Q: Would it be normal procedure for the 9 ambulance attendants to be patched through to you, or to 10 the Emergency Department en route, to give a -- give you, 11 I guess, a heads up -- 12 A: Yes. 13 Q: -- as to what you were dealing with? 14 A: Yes, we -- we usually did. 15 Q: And, do you know why it was you 16 didn't receive any such advance report from the ambulance 17 attendants on this call? 18 19 A: No, I don't. 20 Q: Did you assume that this was one (1) 21 of the two (2) gunshot victims that the London dispatch 22 had told you you might be receiving? 23 A: Yes, I did. 24 Q: Okay. 25 A: That's what we were -- as far as we

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1 knew, that's what we were expecting. 2 Q: By the time the -- Mr. Cotrelle 3 arrived, were there any OPP officers at the hospital, 4 that you noticed? 5 A: Oh, I -- I think they were, but I 6 really can't remember. 7 Q: Do you -- do you recall whether you - 8 - you spoke to any OPP officers at the hospital in 9 advance or at the time of Nick Cotrelle's arrival? 10 A: No. I remember I did. One (1) -- 11 one (1) officer came to the desk and said, we are going 12 to set up communications in the Outpatient Department. 13 That was -- that was it and I can't even tell you what 14 time that was. 15 Q: Now, these were policing 16 communications then? 17 A: Yes. 18 Q: All right. And, do you recall where, 19 then -- where Mr. Cotrelle was taken once he entered into 20 the Emergency Department? 21 A: He was taken to the Trauma Room. 22 Q: Can you -- 23 A: Or that little OR. 24 Q: Sorry, the OR? 25 A: The OR, yes.

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1 Q: Fair enough. And, can you just 2 describe, generally, the -- the basic layout and size of 3 the OR or Trauma Room? 4 A: I'm not very good at measurements, 5 I'm not sure. 6 Q: Okay. 7 A: -- for sure. It would be -- it would 8 probably be the size of this square area right here. 9 From you, over to the curtain, from possibly me to the 10 end of that desk there. 11 Q: To the Registrar's desk over here? 12 A: Yes. Yeah. It's not a huge room. 13 In the middle of the room is the natural operating room 14 table with the light above it. And then throughout the 15 room in -- in the -- in the parameter, we have various 16 types of equipment that we may be using. 17 Q: All right. 18 A: We have one (1) spare stretcher that 19 is along this wall. We have a door that goes actually 20 through to the front desk, and that's about it. We -- 21 when we get a trauma, from say a car accident or 22 something like that, we feel very comfortable setting up 23 for three (3) -- three (3) patients at a time. 24 Q: Three patients in the trauma room -- 25 A: Yes.

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1 Q: -- can accommodate obviously with -- 2 with other beds brought in? 3 A: Yes. That's right. 4 Q: And just -- you've used the word that 5 trauma a number of times. Can you just give us a sense 6 as to what you mean when -- when you describe a patient 7 who has suffered trauma? 8 A: When we refer to trauma, it means 9 that there has been some type of an injury -- an actual 10 injury, by some -- usually by some type of a force. 11 Q: All right. 12 A: And we will -- we will refer to 13 trauma from such a simple thing as being hit accidentally 14 with a back swing from a baseball bat, to a huge car 15 accident where there will be multiple injuries. 16 But, basically, it means some type of a -- 17 some type of a hitting or tumbling or -- 18 Q: So a physical injury caused by some 19 type of force? 20 A: Yes. 21 Q: All right. 22 A: Yes. 23 Q: Now was Dr. Marr in the OR at the 24 time of Mr. Cotrelle's arrival to your recollection? 25 A: I believe she was.

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1 Q: And did you have the full nursing 2 complement in -- in the department at the time of his 3 arrival? 4 A: Yes. 5 Q: And do you recall, right now, the 6 approximate total number of nurses who were present, 7 including yourself? 8 A: I know that -- oh, the total number 9 including myself. So there would be -- I think there was 10 probably six (6) or seven (7) initially. 11 Q: Yes. 12 A: And we were -- because we were 13 prepared to set up nursing care, one (1) on one (1), not 14 knowing what we were going to get. This is the -- this 15 is the way that we decided we would initially approach -- 16 Q: All right. 17 A: -- and then if we didn't need as many 18 as that, or things weren't of a nature that we needed to 19 have one (1) on one (1) nursing, we would send some of 20 the nurses back to the floors. 21 Q: All right. And I understand that, in 22 addition to yourself as a charge nurse, the -- there were 23 two (2) nursing supervisors? 24 A: That's right, yes. 25 Q: And normally would there be two (2)

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1 nursing supervisors? 2 A: No. There -- there wouldn't be. I 3 mean, at this time, of course it was a changeover of 4 shift for them as well, and -- and it wouldn't be unusual 5 for the evening supervisor to stay over. Even if there 6 was like an obstetrical delivery or something where, you 7 know, like the other one was going to be tied up. 8 Because, they too, like to be available, 9 you know, to come to an area if they -- they needed help. 10 So there were two (2) of them there that night. 11 Q: And one (1) was the -- was Ms. 12 Bergman -- 13 A: Yes. 14 Q: -- who was the one on duty that 15 night? 16 A: That's right. She was on the night 17 shift. 18 Q: And the other was who? 19 A: And Glenna Ladell was the evening one 20 that was supposed to go home. 21 Q: But didn't. 22 A: But didn't. 23 Q: And in addition to the -- those two 24 (2) and yourself, there were how many primary care nurses 25 from other floors then?

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1 A: I think initially I had asked for 2 four (4). 3 Q: Was Dr. Saettler in the OR at the 4 time of Mr. Cotrelle's arrival? 5 A: I don't believe that she was. 6 Q: Can you tell us, based on your 7 observations, what the first thing was -- what -- what 8 was done first on arrival of Mr. Cotrelle into the OR? 9 A: There would be -- initially there 10 would be what they call a head to toe assessment or 11 assessment at a glance. 12 And that is where you basically glance at 13 the -- at the person, and you can see whether they're 14 alert, you can see if they're breathing all right. You 15 can see what their colour's like. You can see their 16 demeanor; are they restless, are they, you know, are they 17 trying to communicate? Are they totally, sort of, 18 placid. Just at a glance, you totally assess that 19 person. 20 Q: All right. Did you conduct the head- 21 to-toe assessment? 22 A: No. 23 Q: Another nurse would have done that? 24 A: Yes. 25 Q: All right, but you were there?

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1 A: Yes. I was -- I was in and out of 2 the room over a period of time. 3 Q: Do you know what was determined as a 4 result of the head-to-toe assessment? 5 A: Well, there certainly weren't any 6 life-threatening injuries. 7 Q: All right. Did you provide any 8 primary care to Mr. Cotrelle? 9 A: No, I did not, no. 10 Q: Did you treat him at all that 11 evening? 12 A: No. 13 Q: But you know that he was attended 14 that evening, in the Trauma Room, by a nurse and by -- by 15 a doctor? 16 A: Yes. I know that they were both 17 there with him. 18 Q: Do you -- do you recall whether any 19 of Mr. Cotrelle's family arrived with him in the OR? 20 A: I don't believe so. I didn't see 21 anybody. 22 Q: And was any information received by 23 you, or your colleagues, to your knowledge, with respect 24 to the circumstances surrounding his apparent injuries? 25 A: There wasn't by me.

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1 Q: All right. Do you recall who arrived 2 next at the Emergency Department that evening? 3 A: I believe it was -- I think Cecil -- 4 Cecil -- 5 Q: Bernard? 6 A: George, is it? Yes, Cecil Bernard 7 George, is that his name? 8 Q: All right. 9 A: I didn't know his name at the time. 10 Q: Fair enough. 11 A: And just what I could recall from 12 that time. 13 Q: And approximately how many minutes 14 after Mr. Cotrelle arrived did Mr. Cecil Bernard George 15 arrive? 16 A: I would say he would probably be 17 within four (4) minutes. 18 Q: Approximately four (4) minutes? 19 A: I would think so. 20 Q: Is this to your recollection? 21 A: Yes. 22 Q: Would you look at Tab 2 of the 23 hospital records, and in particular, would you again look 24 at the second page. This is Inquiry Document Number 25 1000047 and it's the Emergency and Outpatient Record --

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1 A: Right. 2 Q: -- for Cecil Bernard George and I see 3 that the time of admission appears to be 00:06? 4 A: Yes, I think that's what -- it's 5 either that or it's an eight (8). I can't quite -- 6 Q: A six (6) or an eight (8)? 7 A: Yeah. 8 Q: Okay. And, does that accord with 9 your recollection, namely that Mr. Cotrelle came around 10 12:04, with Mr. George, Cecil Bernard George, coming 11 somewhere between 12:06 and 12:08? 12 A: I would -- I would believe so, yes. 13 Q: All right. Commissioner, I'd like, 14 at this time, to make the hospital chart of Cecil Bernard 15 George, Inquiry Document Number 1000047 the next exhibit. 16 THE REGISTRAR: P-387, Your Honour. 17 COMMISSIONER SIDNEY LINDEN: P-387. 18 19 --- EXHIBIT NO. P-387: Document Number 1000047, 20 Strathroy Middlesex General 21 Hospital Documentation of Mr. 22 Cecil Bernard George, pages 23 318 to 364, September 07/95 24 25 CONTINUED BY MS. SUSAN VELLA:

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1 Q: Do you know how or by what mode of 2 transportation Cecil Bernard George arrived at the 3 hospital? 4 A: He came by ambulance. 5 Q: Do you -- do you know what kind of 6 ambulance he arrived in? 7 A: I have no idea. 8 Q: All right. 9 A: I wouldn't -- we didn't have -- like 10 we don't see them from where we are. 11 Q: We have heard evidence, from the 12 ambulance attendants from that evening, that they are -- 13 they are from the St. John's Ambulance Service. 14 Now, have you ever received in your -- 15 during the course of your work at the Emergency 16 Department, injured patients via St. John's Ambulance? 17 A: Yes, I have. It would be usually 18 from a sporting event, or a festival, or -- you know, I - 19 - I just assumed that that type of an organization hires 20 them privately or -- but that would be the only 21 circumstance under which we would have a St. John's 22 Ambulance. 23 Q: All right. Did you make any initial 24 observations of Cecil Bernard George when he arrived in 25 the Emergency Department?

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1 A: Again, at -- at a glance, I didn't 2 directly care for him, either. 3 Q: All right. What were your clinical 4 impressions based on those observations? 5 A: He was not as alert. He wasn't 6 completely alert and orientated. He -- he seemed kind of 7 either confused or dazed, that type of thing. Wasn't 8 really focussing, and certainly wasn't verbalizing. 9 Q: And what, if anything, does that tell 10 you about this patient, in terms of treatment needs? 11 A: He has to -- he has to be given a 12 thorough assessment. Quickly. 13 Q: And relative to Mr. Cotrelle, how 14 would characterize the nature of his injuries? 15 A: His certainly was -- his certainly 16 was of a higher priority that Mr. Cotrelle's. 17 Q: Did you also observe any visible 18 injuries on his body? 19 A: Yes, he actually -- he had a -- cut 20 his lip. There was a -- quite a gash on his lip. That 21 was -- that was noticeable, like, right away. And I 22 don't really -- I don't really recall seeing any other 23 injuries, but that one was fairly obvious. 24 Q: All right, did you come to understand 25 that he also had an injury on his head, another injury on

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1 his head? 2 A: I did, yeah. 3 Q: And of what nature? 4 A: I think there was a small laceration 5 on the back of his head, that they did end up treating or 6 stitching or -- 7 Q: All right. 8 A: -- stapling. More -- what I more 9 noticed more myself with him, as you know -- as you walk 10 by, you can see like he's -- he's not taking in his 11 surroundings, he is not trying to communicate. He was 12 just like someone that you would say was confused. 13 Q: All right. And what, if anything 14 does that tell you might be wrong with the patient, when 15 you see him in that kind of state, then, given his 16 visible injuries? 17 A: Well, right away -- right away what 18 would come to mind is a head injury. The other thing 19 that would always come to mind is that he would have -- 20 be bleeding somewhere. 21 For whatever reason -- reason a person 22 would be confused would be lack of oxygen or swelling in 23 the -- in the brain. 24 Q: Hmm hmm. 25 A: And they're the -- they're the two

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1 (2) things that a nurse would twik in on. Now, a doctor 2 maybe more, you know, they might think a little deeper. 3 But as -- as to while you're trying to think of what 4 nursing care you're going to give, that's the two (2) 5 things that would come into your mind. 6 Q: All right, and is it fair to say that 7 -- that either of those conditions can be potentially -- 8 can those be potentially life threatening? 9 A: Yes, certainly they can. 10 Q: All right. Now did you receive any 11 advance notice from the ambulance attendants en route to 12 -- to the hospital concerning the nature of the injuries 13 and/or the condition of this patient en route? 14 A: No. 15 Q: Again, is this unusual? 16 A: Yes. 17 Q: And what is the advantage of -- of 18 receiving such information in advance? 19 A: You can definitely be -- be set up 20 with whatever you think you may be needing for this 21 patient. 22 Q: All right. 23 A: You know, you can have a monitor, you 24 can have intravenous ready, you can have splints at least 25 set out. If you think they're going to need some

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1 stiches, you can have tray ready. If you think they have 2 a chest wound, you can have a chest tube tray ready. 3 It just really helps you -- it saves time, 4 and in any trauma situation, the sooner that you can 5 intervene and re-balance the body situation, the better 6 the outcome -- 7 Q: All right. 8 A: -- for that patient. 9 Q: the better the rate of survival? 10 A: Yes, just the -- even the -- even the 11 recovery, the outcome, everything. 12 Q: Hmm hmm. 13 A: Just the sooner the better. 14 Q: All right. And did you provide any 15 primary care to Mr. Cecil Bernard George? 16 A: No. 17 Q: Okay. Now after the head-to-toe 18 assessment, was he provided with any immediate medical 19 treatment to your knowledge? 20 A: I -- I don't think I was even back 21 there after that. 22 Q: All right. 23 A: As -- as the charge nurse, I would be 24 circulating. I wouldn't be directly involved with the 25 patient care unless it was needed --

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1 Q: Hmm hmm. 2 A: -- and at the same token, I would 3 have to make sure that the rest of the department, like 4 the phones needed to be answered. If -- like -- so 5 basically, I would be in and out, and about, having an 6 eye on everything and just keeping things going smoothly. 7 Q: All right. Do you recollect where 8 Nicholus Cotrelle was when -- in terms of physically, 9 where he was located when Mr. Cecil Bernard George came 10 into the Trauma Room? 11 A: He was in the Trauma Room. 12 Q: And did you have any concern that he 13 was in the Trauma Room, at this time, given his state of 14 awareness? The fact that he was obviously lucid and 15 conscious. 16 A: I was concerned. I was concerned 17 that if he -- if he was well enough not to be in there, 18 then he really didn't need to be in there, for both his 19 sake and for the sake of my staff. 20 Mainly because, as a lay person, this 21 young man may not understand anything that we were doing 22 and sometimes, like even, it can look like we're -- we're 23 hurting someone and we're not. So just for the fact that 24 you don't want him to have to be exposed to unfamiliar 25 situation, to looking -- looking at someone that's hurt

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1 that he possibly knows. 2 Just for that patient's sake and for the 3 nurses as in -- is in, I'm sure, any type of a job factor 4 there's a local jargon and we have a local jargon too. 5 And, in that way, I felt that my nurses needed to be 6 protected. 7 If something was not going well and we're 8 -- like if we were up to -- and this did not happen but 9 I'm using this for an example, where we're apt to be 10 saying, you know, hand me that quick, I'm going to lose 11 him, I've got to get this -- and you talk like that. 12 Because you both understand it's high stress, you know 13 you need help now and so on. 14 But you certainly wouldn't want a patient, 15 you know, listening to you talk like that because it can 16 be so misconstrued. 17 Q: All right. And did you do anything 18 then, as a result of this concern, concerning Nicholus 19 Cotrelle? 20 A: Yes. Because -- because he was -- he 21 wasn't like a huge trauma, he was stable, I decided that 22 he should move across the hall into what we call the side 23 rooms. These are cubicles where people with -- with 24 minor concerns, minor injuries await to see a doctor. 25 And they're -- they're basically treatment rooms.

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1 Q: Would he be able to see the goings on 2 of the trauma room from that vantage point? 3 A: No. Not all of it. I would say that 4 probably no was the more sure answer than -- more sure 5 answer than not. He -- and I can't remember if he was in 6 the first cubicle, the first cubicle is -- is directly 7 across from the trauma room, and the cubicle next to it I 8 would feel fairly safe in saying no, not at all. 9 Q: All right. 10 A: The first he may be able to see a 11 little bit, kind of in around the corner, but that would 12 be it. 13 Q: Would he be able to hear in a general 14 way what was going on in the trauma room from that 15 vantage point? 16 A: I -- I really can't say for sure. I 17 suppose it depends on how loud you were talking or -- but 18 I -- I don't -- I don't really know. 19 Q: Do you recall, relative to -- to the 20 arrival of the second and the third patient we haven't 21 spoken of yet, when you made the decision -- or when 22 Nicholus Cotrelle was transferred out of the OR? 23 A: It seems to me he was transferred out 24 either at the same time, or just as the third patient was 25 arriving. There wasn't -- there wasn't much of a time

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1 frame difference. 2 Q: All right. And do you recall now the 3 approximate time that the third patient arrived, relative 4 to Cecil Bernard George's arrival? 5 A: Practical on his heels. They were 6 very -- I would say within a minute or two (2). 7 Q: All right. Now I wonder is you would 8 go to Tab 3. I should ask you, do you know now the name 9 of that third patient who arrived? 10 A: Right here, Anthony George? 11 Q: Yes. 12 A: Mr. Anthony George. Yeah he was 13 referred to as Dudley. I never knew his name was Anthony 14 for quite a while. 15 Q: And this is Inquiry Document Number 16 5000243, Front Number 5002938 -- 17 A: 8 eight (8)-- 18 Q: -- six (6), I think it was. 19 A: I think it's eight (8). 20 Q: Eight (8), thank you. And I see 21 there's an admission time. This is an Emergency and 22 Outpatients -- 23 A: Hmm hmm. 24 Q: -- Record for Anthony George and the 25 admission time is approximately 00:08 hours.

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1 A: Right. 2 Q: Does that sound about right to you? 3 A: I would say yes. I mean, they were 4 basically one (1) right after the other. 5 Q: I'd like to make this the next 6 exhibit, please. 7 THE REGISTRAR: That is P-388, your 8 Honour. 9 COMMISSIONER SIDNEY LINDEN: P-388. 10 11 --- EXHIBIT NO. P-388: Document Number 5000243, 12 Emergency and Outpatient 13 Record of Mr. Anthony George, 14 September 07/95 15 16 CONTINUED BY MS. SUSAN VELLA: 17 Q: Now, when were you alerted -- first 18 alerted, to the presence of a third casualty that night? 19 A: When the -- the ambulance attendant 20 came in to get me, that they needed help outside the 21 Emergency, on the ramp. 22 Q: All right. And what did you do when 23 you heard the request for assistance from the ambulance 24 attendant? 25 A: I went running out with him.

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1 Q: All right. Can you tell me 2 approximately how many yards there are between the 3 entrance of the Emergency Department, or the Trauma Room 4 if you will, and the -- and the entrance to the hospital 5 at the department -- Emergency Department entrance? 6 A: From the ramp to the actual doors of 7 the hospital, it's ten (10) feet maybe. 8 Q: All right, and then from the doors of 9 the hospital to the OR? 10 A: Probably a hundred (100) -- a hundred 11 (100) yards. 12 Q: Okay. 13 A: Maybe at the most. 14 Q: When you went out to -- did you go 15 out to the parking lot? 16 A: Went out to the ramp. 17 Q: Out the ramp, all right. And did you 18 observe anything when you got to the ramp? 19 A: Yes. 20 Q: What did you see? 21 A: There was a car pulled up on the 22 ramp. The back -- the back passenger door was open and 23 there was a -- a man lying across the back seat, on the 24 back seat, with his feet toward the open door. 25 Q: All right. And was this passenger

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1 side or driver's side of the car that his feet were at? 2 A: It was the passenger. 3 Q: Do you recall what position he was 4 in, in the back seat? 5 A: Just laying -- lying right on the 6 back seat. 7 Q: And was he on his back, stomach, or 8 side? 9 A: Back. 10 Q: All right. Can you describe, as 11 carefully as you can, any observations you made of this 12 individual while he was in the back seat? 13 A: Yes, and his feet were actually 14 toward the hospital door -- 15 Q: Okay. 16 A: Like, they were pulled up on the ramp 17 so that -- that as soon as I came out the door, it was 18 the feet and the body. 19 And right away, I could see that he -- 20 there was certainly movement of his chest, there was no 21 breathing. The next thing that I looked at, of course, 22 was his skin colouring and right away I could see that he 23 was mottled around the jowls, and in the neck area. 24 There was absolutely no movement from him 25 at all.

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1 Q: Now when you say the skin was 2 mottled, can you please firstly describe the appearance 3 of mottled skin and, secondly, your understanding of its 4 cause? 5 A: Mottled skin is -- it's almost like a 6 patchy blue -- blue grey hue to the skin and what happens 7 as to how this occurs, de-oxygenated blood tends to 8 become, or look to become this colour, on the skin's 9 surface. 10 It's the oxygen in the haemoglobin that 11 gives us that nice, pink glow to our skin. So if, for 12 some reason, this person isn't breathing, or the heart 13 isn't pumping, or both, of course you're not going to 14 have any oxygenated blood. 15 After this blood isn't circulating any 16 more, then it begins to pool, and this blood will pool 17 into the dependant areas, gravity -- 18 Q: All right. 19 A: -- type of thing. 20 Q: Did you observe any such evidence of 21 pooling of blood in such areas? 22 A: Well, I say like around the -- around 23 the jowl area, around the neck area -- 24 Q: All right. 25 A: -- there certainly was.

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1 Q: All right. Did you make any attempt 2 to take his pulse at this time? 3 A: No. 4 Q: Why not? 5 A: My priority, at that time, would be 6 to get him in to the department where we can actually try 7 to do something. He was -- he was a big man and to -- 8 like, I'm not going to try to climb in there with him to 9 see if he's got a pulse. The best possible, fastest 10 treatment, would be to get him in where we can treat him 11 properly. 12 Q: All right. And what preliminary 13 conclusions, if any, did you draw, relative to his 14 condition as a result of your observations? 15 A: Well, in the back of my mind I was 16 just sort of saying, oh my God, he's dead; like, in -- in 17 my mind. 18 Q: Yes. 19 A: But, you know, you -- you don't act 20 on that, you act on getting him to where you can try to 21 do a resuscitation. 22 Q: All right. Now, do you recall 23 whether he was wearing any clothing in the back seat? 24 A: Yes. 25 Q: And, if so, what -- what he was

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1 wearing? 2 A: I don't know what he was wearing, but 3 I remember he was wearing some clothes. 4 Q: Did he have anything on his top part 5 of his body? 6 A: Yes, he -- he had a shirt on. 7 Q: And did you -- did you see any 8 visible blood? 9 A: If I did, it didn't even register. I 10 don't really remember seeing it. 11 Q: Did -- you've given a very careful 12 description of the physical appearance of Mr. George in 13 the back of the car, can you tell me what the lighting 14 conditions were? 15 A: There's -- the -- the ramp has an 16 over roof because, of course, for winter travel and it's 17 well lit with -- with fluorescent lighting. It's well 18 lit. 19 Q: All right. Did you give any 20 instructions, or directions, to the ambulance attendants 21 as a result of your conclusions and observations? 22 A: Just that I wanted him out of the 23 back and I wanted him onto the stretcher as quickly as 24 possible. At that -- the fastest way to get him out, I 25 concluded, was to put the stretcher parallel with the

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1 back -- with the back door that was open. 2 Q: Parallel with the back door, so 3 perpendicular -- 4 A: No, I meant with the -- like, with 5 the vehicle, I guess. 6 Q: Parallel with the vehicle? 7 A: Yes. 8 Q: So, he's perpendicular, then, to the 9 vehicle, Mr. George? 10 A: Who? The patient? 11 Q: Mr. George. He would be -- 12 A: Oh, to the stretcher, you're saying? 13 Q: Yes, to the stretcher. 14 A: Yes. 15 Q: Okay. 16 A: Yes. 17 Q: And did you observe whether or not 18 the ambulance attendants had any difficulty transferring 19 Mr. George's body from the car to the stretcher? 20 A: Just -- just in the heaviness. 21 Q: All right. 22 A: Just in -- it's -- like, it's just 23 harder to hold onto someone that is unresponsive; they're 24 heavier, there's no tone to their muscle to help you with 25 this. So, it's just a lot more, sort of, lifting and...

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1 Q: And did you observe the lack of 2 muscle tension when the transfer was occurring? 3 A: Yes, completely. Yeah, completely 4 flaccid. 5 Q: Approximately how long, in your 6 estimation, did it take the ambulance attendants to 7 transfer Dudley George from the car, onto the stretcher, 8 and then wheel him into the Trauma Room? 9 A: I would say -- I would say three (3) 10 to five (5) minutes. I mean, just getting -- the 11 transfer wasn't that -- or the, you know, getting into 12 the department wasn't that long, but getting -- getting 13 him out and into the department, a fair estimate would be 14 three (3) to five (5) minutes. 15 Q: All right. And again, is this a 16 specific recollection you have or this based on your 17 general knowledge as to how long it must have taken? 18 A: I believe that's how long it must 19 have taken. Nobody was looking at their watches right 20 then. But I -- I would say that's a very fair 21 estimation. 22 Q: And we've heard evidence from Robert 23 Scott who was one (1) of the ambulance attendants that he 24 thought that period of time took two (2) to three (3) 25 minutes tops. Is that a feasible estimate?

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1 A: I -- I can understand where he would 2 think that, because in a situation like this time is 3 flying. Your adrenalin is pumping, and you're moving 4 just as fast as you can, but in reality, he was a big 5 man. He was completely dead weight and I would -- I 6 would say three (3) to five (5) minutes would be more 7 realistic. 8 Q: All right. And when you say -- use 9 the term, "dead weight," you're referring to the lack of 10 muscle tension -- 11 A: I am. 12 Q: -- which then makes it -- makes the 13 body more difficult to carry -- 14 A: Right. 15 Q: -- than if there was such tension? 16 A: That's right. 17 Q: All right. Now again, did you 18 receive any advance notice from the ambulance attendants 19 en route as to the condition and -- sorry, from anyone en 20 route with respect to the condition of this patient? 21 A: No. 22 Q: And are you aware -- sorry, was a -- 23 was a code assigned to this patient? 24 A: Yes. 25 Q: What code?

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1 A: Code blue. 2 Q: And is that -- is that also known 3 some -- as code 6? 4 A: Yes. 5 Q: All right. 6 A: It's code blue now, sorry. 7 Q: Who assigned that code? 8 A: I believe that Dr. Marr and I both 9 agreed that it should be a full code 10 Q: And can you tell what -- what a code 11 blue or code 6 connotes? What kind of conditions is that 12 assigned to? 13 A: This type of a code refers to a 14 complete resuscitation; again the basic airway, 15 breathing, circulation. That's what keeps you alive. 16 And so a full code means that we are going to try to 17 resuscitate or bring back the functioning of these areas. 18 Q: All right. And can you tell me first 19 of all were you part of the resuscitation attempts? 20 A: Yes. 21 Q: Can you tell me, then, the order of 22 steps and what steps were taken in the resuscitation 23 efforts of Mr. Dudley George? 24 A: A resuscitation, especially if you 25 have a team present or several nurses, it -- it's not

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1 just done step by step. You're working together and 2 you're working for those three (3) causes. 3 So this patient was intubated which means 4 essentially taking care of that airway, opening up his 5 airway, putting a tube down into the tracheas. 6 Q: All right. 7 A: He had two (2) intravenous' which is 8 going to give -- give you your circulation, try to get 9 you your volume to circulate. Then you're going to do 10 your -- your oxygen and your chest compressions. 11 In other words you're going to try to 12 artificially provide life -- life support for this 13 person. 14 Q: Is that also known as CPR? 15 A: CPR is the actual act of 16 cardiopulmonary resuscitation, yes. 17 Q: And did that happen here? 18 A: The chest -- yes, it did. 19 Q: And was there any -- any monitoring 20 of the heart beat? 21 A: Yes. Yes. That -- that is -- we put 22 the monitor leads onto the chest in such a position that 23 the machine itself will pick up any type of electrical 24 activity in the conduction system of the heart at all 25 causing it to -- to actually compress.

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1 Q: And do you recall how many minutes 2 were consumed before all of these steps that you've 3 listed were actually underway? 4 A: How minutes -- before? 5 Q: Yeah. I -- I'm gathering that these 6 are commenced all at the same time, are they? 7 A: Sure. 8 Q: All right. 9 A: Yeah. You just -- as soon as this 10 patient would be in the trauma room that's what would 11 happen. 12 Q: And so how many nurses and doctors 13 were attending at Dudley George during the resuscitation 14 effort. 15 A: There was -- Dr. Saettler was there 16 then, as well, and I don't recall exactly when, I -- it 17 may have even been while I was helping to bring the 18 patient in. 19 There was Dr. Saettler and Dr. Marr, 20 myself, Marlene, and Glenna. So there was at least -- at 21 least five (5) of us plus the ambulance fellow that came 22 in with us. 23 Q: And did you -- what part did -- or 24 what role did you play in this treatment process or 25 resuscitation process?

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1 A: I believe I did the intravenous. 2 Q: All right. I wonder if you would go 3 to Tab 4 of the nurses' -- sorry, the hospital records. 4 It's Exhibit P-384, Inquiry Document Number 5000245. And 5 it's the cardiopulmonary resuscitation record -- 6 A: Yes. 7 Q: -- for Anthony George. 8 A: I see it. 9 Q: And do you recognize this document? 10 A: Yes. 11 Q: It indicates -- well perhaps you can 12 interpret the document for us starting with item 1? 13 A: Yeah, that's pretty self-explanatory. 14 events leading to the code blue, gunshot wound to the 15 upper left chest. 16 Q: Yes. 17 A: So already there you know that you're 18 looking at either -- what's in your -- what's in your 19 upper left chest? Either your heart, your lung -- at the 20 -- they are the major -- they would be your major 21 concerns. 22 Q: All right. 23 A: Number 2 is just the date and the 24 location, that it was in te emergency department. 25 Physicians present, Dr. Marr, Dr. Saettler.

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1 Q: And I just back you up. I note the 2 time recorded is 00:08 -- 3 A: Hmm hmm. 4 Q: All right, who would have recorded 5 that? 6 A: Who was the recording nurse here? It 7 was Glenna Ladell. 8 Q: All right, thank you. 9 A: And that -- you know, that wouldn't 10 be a -- that's a big bugaboo. I think in all hospitals, 11 it -- you'll see it just like the big clock on the wall 12 there. We have one (1) in each room, too, and it 13 wouldn't -- it would not be unusual for these clocks to 14 be maybe a minute or two (2) from one another -- 15 Q: All right. 16 A: Or maybe her watch, depends what she 17 was looking at, at the time. 18 Q: All right, and then item 3, what does 19 that tell you? 20 A: It means that he -- well -- he was 21 being supplied oxygen by a -- a -- an Ambu bag, which is 22 basically the football shaped hollow bag that has a stem 23 attached to it, whereby you attach the tubing to the 24 oxygen in the wall -- 25 Q: Hmm hmm.

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1 A: So then the bag is attached to the 2 mask, which is approximated as to size per patient, so 3 that it fits snugly around the nose and around the mouth 4 area and into the chin, so that you're not going to have 5 a big leak. 6 And then basically what the person doing 7 the resuscitation will do is to squeeze this oxygenated 8 bag. 9 Q: Hmm hmm. 10 A: The endotrachial intubation, tube 11 size seven point five (7.5). That's just giving the -- 12 giving the diameter -- 13 Q: Hmm hmm. 14 A: -- that's a recording of the diameter 15 size of the endotrachial tube. And the endotrachial tube 16 means that it is going into the trachea. 17 So, this oxygen that you're now delivering 18 with the bag is going directly into the trachea, so then 19 it'll go right into that bronchial tree and right into 20 the lungs -- 21 Q: Okay -- 22 A: So, you're hopefully getting a 100 23 percent oxygen at this point in time. 24 Q: And this was inserted by Dr. Marr, 25 was it?

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1 A: Yes. 2 Q: And it says at 00:11, so -- 3 A: Hmm hmm. 4 Q: -- that's when -- when it was 5 inserted and this procedure started, is that right? 6 A: That would be when the insertion took 7 place. 8 Q: Okay. And then number 4, what -- 9 what does that tell was done to this patient? 10 A: Yes, that's the -- that's the chest 11 compressions. 12 Q: Hmm hmm. 13 A: Closed chest massage, that means 14 that's over top of the sternum -- 15 Q: Hmm hmm. 16 A: It is -- it is done as an up and down 17 action, trying to give an artificial pumping action to 18 the heart. And it take -- to be effective, it takes a 19 compression of approximately one and a half (1 1/2) 20 inches on the sternal area. 21 Q: Okay, number 5 -- 22 A: So that shows that that was being 23 done, and the monitor, 24 "Please attach strips on the other 25 side," so...

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1 Q: And perhaps you would just look at 2 Tab 8 for a moment, and we'll come back to this document. 3 And this is Inquiry Document Number 5000250. 4 A: Okay. 5 Q: It comes from the hospital chart of 6 Anthony George. Is this a true representation of the -- 7 the heart monitor -- 8 A: Yes, I would say -- 9 Q: -- results? 10 A: -- yes, it is. 11 Q: All right. I'd like to make this the 12 next exhibit, please. 13 THE REGISTRAR: P-389, Your Honour. 14 COMMISSIONER SIDNEY LINDEN: Thank you. 15 MS. KATHERINE HENSEL: Thank you. 16 17 --- EXHIBIT NO. P-389: Document Number 5000250, 18 Pages 2924 to 2930, ECG strip 19 of Mr. Anthony George. 20 21 CONTINUED BY MS. SUSAN VELLA: 22 Q: And let's go back to Tab 4, where you 23 were. And can you -- from -- based on your recollection, 24 what was the result of the -- or what information did you 25 gather from the heart monitor?

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1 A: That it is in what -- what is 2 referred to as asystole or there is not effective 3 electrical conduction taking place to cause a contraction 4 of the heart muscle. 5 Q: All right. And so that means the 6 heart wasn't pumping at any level? 7 A: No. 8 Q: Okay. And number 6 is the 9 intravenous therapy? 10 A: Yes. The "RL" stands for ringers 11 lactate. That is a type of solution that is referred to 12 as a plasma expander, the part -- the viscous part of the 13 blood; not the red blood cells, but the other part, this 14 helps to bulk it up, to give it some volume which is what 15 you need to -- to supply if they're suspected of having 16 lost blood. 17 Q: And that's so that there is some 18 heart in the -- in the -- blood in the heart so that it 19 will then start to pump? Is that the way it works? 20 A: No, it's -- 21 Q: No? 22 A: -- it's the circulatory system that 23 you're now trying to replenish. 24 Q: Okay. And number 7 is -- is 25 defibrillation?

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1 A: Yes. 2 Q: I see that that's not filled in? 3 A: No. 4 Q: So, that wasn't attempted here? 5 A: In order to defibrillate a person 6 you, as we would say, need to have something to work 7 with. So, you need to have some type of electrical 8 activity. 9 Because when you defibrillate, basically, 10 that's what you are doing is you are trying to stimulate 11 or heighten or you're trying to get any type of 12 electrical activity to occur in the heart that may help 13 it to once again resume its pumping. 14 Q: Okay. 15 A: Contracting. 16 Q: Thank you. 17 A: That was not done. His -- because he 18 was basically without any electrical activity there would 19 be no point in doing it, at this point in time. 20 Q: Similarly, no medication, obviously, 21 was administered? 22 A: No. 23 Q: And I see that there's a notation 24 under additional medication or procedure -- notation 25 saying:

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1 "00:19, pupils fixed and dilated. No 2 CPR done during transport here." 3 A: Right. 4 Q: Did you observe, in fact, that the 5 pupils were fixed and dilated? 6 A: Someone did. 7 Q: All right. And what -- what 8 typically does that mean? 9 A: That -- that's quite common when 10 there's -- again when the person has deceased. That's 11 what happens; those muscles relax, and the pupils dilate. 12 Q: Meaning that they get bigger? 13 A: Yes. 14 Q: All right. And number 9, the vital 15 signs, it appears that the vital signs were taken at 16 three (3) different times -- intervals? 17 A: Yes. 18 Q: 00:08 hundred hours, 00:11 hundred 19 hours and 00:20 hundred hours on September the 7th and 20 there is a score of zero, meaning that this is absent 21 vital signs all the way through? 22 A: Right, right. 23 Q: All right. And eleven (11), the 24 outcome, is obviously deceased at 00:20 hours? 25 A: Yes.

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1 Q: And were you present when -- when 2 this -- 3 A: Physician? 4 Q: -- yes. 5 A: The physician pronounced. 6 Q: In your presence? 7 A: Yes. 8 Q: Thank you. 9 10 (BRIEF PAUSE) 11 12 Q: Now, it would appear that -- did the 13 -- was the CPR commenced at 12:08 a.m.? 14 A: The CPR was commenced as part of the 15 resuscitation. 16 Q: And do you know how quickly that 17 would -- would that have been at 12:11 or -- I'm trying 18 to think when that would have started. 19 A: As soon as we brought him into the 20 Trauma Room and put him into position, meaning, you know, 21 a position where the doctor could do the intubation; we 22 could get the monitor on; that would -- that -- the CPR 23 would be commenced then. Or if we had had to slow down 24 at the doorway in order to manipulate the stretcher the 25 ambulance attendant would start doing it at the time.

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1 Whenever you feel -- whenever we felt that we could have 2 done effective. 3 Q: All right. In here it says, "No CPR 4 done during the transport" and was there any done on -- 5 when -- when Mr. George was being wheeled into the Trauma 6 Room? 7 A: No. 8 Q: All right. So, it would have been 9 sometime after 12:08 that that was commenced? 10 A: Yes. 11 Q: And probably by 12:11 a.m.? 12 A: I would say that would be -- yeah. 13 Q: That time frame? 14 A: That would be a good, yeah. 15 Q: And it stopped at 12:20, then, a.m.? 16 A: Right. 17 Q: So, approximately eight (8) -- eight 18 (8) -- to eleven (11) minutes? 19 A: That's right. 20 Q: Or eight (8) to twelve (12) minutes, 21 I should say. 22 A: Hmm hmm. 23 Q: All right. Now, to your knowledge, 24 would it normally be expected that someone would provide 25 the Emergency staff with the circumstances giving rise to

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1 this kind of an injury, the kind that Mr. George 2 suffered? 3 A: Who did you say was to give it to us? 4 Q: Would it normally be expected that 5 someone would provide the Emergency staff with an 6 indication as to the circumstances of the injury? 7 A: They would -- when we get told by the 8 central dispatch as to who we're getting in the Emerg. -- 9 Q: Yes. 10 A: -- we're usually -- we're usually 11 told approximately their age, what their signs and 12 symptoms are. If they know a mechanism of injury they 13 will tell us. And they usually try to give us a time of 14 arrival. 15 And if they have done a treatment along 16 the way, they will often tell us that as well. 17 Q: And did you get any of this 18 information from London central dispatch, aside from the 19 fact it was a gunshot wound? 20 A: No. 21 Q: Did you receive any such information 22 from any -- any OPP officers at the hospital? 23 A: Just the gunshot wound, that's all we 24 were told. And when -- and then we actually thought that 25 perhaps if there was a patient coming by car, that's what

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1 we refer to as walking wounded usually. 2 Usually the one that comes by car is the - 3 - is a very minor type of injury because they're able to 4 come by car. They're not in emanate danger or needing 5 help along the way. So, really, we had no idea. 6 Q: All right. To your knowledge was any 7 nurse sent out of the trauma room or the OR to try to 8 locate any persons who might have knowledge of the 9 circumstances giving rise to this injury and the other 10 relevant information that you just addressed? 11 A: I -- I don't really know unless one 12 (1) of the supervisors did that. They -- they may have. 13 Q: Would you expect a nurse to have gone 14 in search of the people who brought in this patient? 15 A: It wouldn't be unusual for a family 16 to be able to provide some pertinent information. 17 Q: But would you expect the nurse -- 18 Emergency nurse to have gone in search of the people who 19 brought in this type of a patient to get more 20 information? 21 A: I believe that one (1) of the 22 supervisors would, yes. 23 Q: All right. But you have no knowledge 24 as to whether it happened? 25 A: I don't know.

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1 Q: And normally in a situation where 2 police are involved, would you expect the police to 3 advise of any such information they may have to assist in 4 the patient assessment and treatment? 5 A: I don't think with the actual 6 treatment, no, no. 7 Q: Okay. 8 A: They'll often -- if they do come in, 9 they'll say where they were, what happened. But it 10 wouldn't be an expectation at all. 11 Q: Going back to the initial scene on 12 the ramp then, when you first approached the car with 13 Dudley George in it, did you observe any OPP officers in 14 the vicinity? 15 A: No. 16 Q: Did you observe any First Nation 17 persons outside? 18 A: There were some people, as to whether 19 they were First Nations I don't really know. I was just 20 zeroed in on that patient. 21 Q: And do you recall whether there were 22 any OPP officers in the trauma room while treating any of 23 these three (3) patients that evening? 24 A: Not that I recall. 25 MS. SUSAN VELLA: Commissioner, I'm just

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1 noticing that we've -- it's quarter to 3:00, shall -- 2 perhaps it might be the time to take the afternoon break? 3 COMMISSIONER SIDNEY LINDEN: Do you have 4 much longer with this witness? 5 MS. SUSAN VELLA: Probably about fifteen 6 (15) twenty (20) minutes. 7 COMMISSIONER SIDNEY LINDEN: That's fine. 8 Let's take a break now. 9 MS. SUSAN VELLA: Thank you. 10 THE REGISTRAR: This Inquiry will recess 11 for fifteen (15) minutes. 12 13 --- Upon recessing at 2:45 p.m. 14 --- Upon resuming at 3:06 p.m. 15 16 THE REGISTRAR: This Inquiry is now 17 resumed. Please be seated. 18 19 CONTINUED BY MS. SUSAN VELLA: 20 Q: Thank you. Ms. Derbyshire, what 21 happened after Mr. George was pronounced dead by -- by 22 Dr. Marr? 23 A: Afterward we moved him to another 24 room. We moved him up near the front of the department 25 to a room numbered -- room number 9. And the reason that

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1 -- that we did this, is because that room has a door on 2 it. 3 Whenever there's a death in the Emergency 4 department, we try to provide as best we can, some 5 privacy for the family and in this case, this was also 6 going to be a coroner's case. 7 So that was another reason that we wanted 8 to have him in a room where we could -- where we could 9 have the family be with him and where we could also 10 provide a place for him to stay until the Coroner 11 arrived. 12 Q: So once it becomes a coroner's case, 13 is there is an obligation on the hospital to, if you 14 will, maintain the integrity of the bodily remains until 15 the -- 16 A: Absolutely. We're not allowed to -- 17 to touch or disturb anything. 18 Q: Now were there any family members 19 present by this time? 20 A: I believe there was. 21 Q: Did you have any contact with them? 22 A: I didn't have any directly. 23 Q: All right. To the best -- 24 A: I -- 25 Q: I'm sorry?

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1 A: I -- I didn't have any directly with 2 them at the time that we transferred the patient up to 3 the other room. 4 Q: Did you receive any or did you have 5 any direct contact with his family members afterwards? 6 A: Afterward, they did make a request to 7 perform what they called a sweet grass ceremony. 8 Q: All right. Was this request made to 9 you? 10 A: Yes. 11 Q: And what was your response? 12 A: I was very sorry that it couldn't be 13 done at the time; number 1, due to health and safety 14 issues. We have oxygen piped throughout that department 15 and there would be no lighting of any flame in there. 16 And, of course, the second being that we 17 were expecting the Coroner to come, and everything is 18 just to stay as it is until he gets there. 19 Q: All right. Do you recall which 20 members of the family you did speak with? 21 A: I don't remember their names. 22 Q: All right. Do you recall what 23 relations they were -- what relationship they were to Mr. 24 George? 25 A: I can't be certain.

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1 Q: Was there any OPP presence at this 2 time in and around Mr. Dudley George? 3 A: Yes, there was a policeman in the 4 department by that room. 5 Q: And was -- did he appear to you to be 6 stationed at the door -- 7 A: Yes. 8 Q: -- of room 9? All right, and do you 9 recall who that was? 10 A: No. 11 Q: All right. Do you know -- have any 12 understanding as to why a police officer was stationed 13 outside of room 9? 14 A: I wasn't told directly as to why he 15 was stationed there, but this would probably be 16 considered an unusual occurrence and it wouldn't be 17 uncommon for a police to be present at -- at an uncommon 18 occurrence. 19 Q: All right, and I take it from -- from 20 your past -- from your testimony earlier this afternoon 21 that the OPP did not provide any -- any -- or present any 22 barrier to your ability to treat or assess these 23 patients? 24 A: Oh, no, not at all. 25 Q: All right. And you -- we've heard

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1 testimony from Dr. Marr and Dr. Saettler that assuming 2 Mr. George could have been resuscitated, he would have 3 required cardio-vascular surgery. 4 And you've indicated earlier that your 5 department, the Emergency Department was not capable of 6 carrying out this procedure? 7 A: That's right, we would not. 8 Q: And you indicated some issues with 9 respect to the equipment deficiencies, but would there 10 have been any staffing issues or problems concerning the 11 ability to carry out this kind of invasive surgery? 12 A: Yes, we're -- we're not equipped to 13 do any type of -- any type of resuscitive thoracic 14 surgery, meaning chest -- opening up a chest, or clamping 15 off large vessel. And this, remember, is not an 16 operating room. 17 Plus, we would not have an anaesthetist, 18 you know, who has to be present to do any type of surgery 19 as well. 20 Q: All right and -- 21 A: We just wouldn't be able to do 22 something of that magnitude at our hospital. 23 Q: All right. Now was there an 24 anaesthetist on staff at the hospital? 25 A: There is an anaesthetist on staff,

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1 but they -- they're on call. 2 Q: So, they'd have to be brought in -- 3 A: Yeah. 4 Q: -- after receiving -- 5 A: Yeah, and depending on where they 6 live, I don't recall where they lived in particular at 7 that time, but we have had anaesthetists that would have 8 to come from London or come from Grand Bend. It 9 would take them longer to get to our hospital than it 10 would actually for us to transfer into London. 11 Q: All right. What was the closest 12 facility at that time capable of carrying on 13 cardiovascular thoracic surgery? 14 A: It would be London, probably -- I -- 15 I'll just have to guess -- University, but it would 16 definitely be one (1) of the London centres, not us. 17 Q: All right. And we have heard 18 evidence that Strathroy Hospital was selected for the 19 transport of these patients over Sarnia General, because 20 it was closer to Ipperwash Provincial Park. 21 Does the Strathroy Hospital generally 22 receive Emergency patients from the Ipperwash area? 23 A: I can't comment on generally, because 24 I don't know how many go elsewhere, but we -- it's a very 25 grey area. It's just on the border, as a matter of fact,

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1 as to whether they go to Sarnia or whether they come to 2 Strathroy or sometimes even to Exeter. 3 A lot of it depends on exactly which one 4 is closer, and the other is often patient preference; 5 where their doctor is or where they're used to going. 6 So, there's not a specific -- you know, there's not a 7 specific place where they have to go. 8 Q: Now, based on your prior experience 9 at -- at Sarnia General Hospital, would that Emergency 10 Department facility, if you can comment, would that 11 department have had any better capability to -- to treat 12 three (3) trauma patients in short order than your 13 facility? 14 A: I honestly -- that was too long ago; 15 I'm too old. 16 Q: Okay. 17 A: No, that was years ago that I was 18 there and I'm sure that they've updated and whatever. I 19 don't know what they have available. 20 Q: Can you think of any other reason to 21 have transported these patients to Strathroy rather than 22 Sarnia, aside from distance considerations? 23 A: I don't know unless that's where the 24 -- the patient's family or whoever was with him wanted 25 them to come.

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1 Q: In the event that Mr. Dudley George, 2 for example, could have been resuscitated and stabilized, 3 would it make any sense to have come to your hospital 4 over Sarnia for that resuscitation and stabilization 5 process? 6 A: Resuscitation procedure is 7 standardized. As far as an emergency resuscitation 8 procedure goes, it's very standard. Beyond that, and the 9 needs beyond that, various facilities provide various 10 needs. I don't think that they have -- that they have 11 had thoracic surgeons in their area either. But that's 12 speculation on my part, I don't know it for a fact. 13 Q: All right. Is it fair to say that 14 assuming that the -- the closest facility to have 15 undertaken this type of invasive procedure would have 16 been London, that it would make sense to send patients 17 first to Strathroy to be stabilized and on to London, 18 rather than going to Sarnia first and then on to London? 19 A: That would make sense. 20 Q: In terms of pure distance? 21 A: Yes. 22 Q: Thank you. 23 A: If you're looking at the, you know, 24 sort of the means to the end, yes, Strathroy would be the 25 way to go and they -- and they would need to stop at our

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1 place to be stabilized. And by that, I mean they need to 2 have -- they need to have this resuscitation done and get 3 a volume of circulation going, be oxygenated and so on 4 that we talked about earlier. 5 Q: All right. And once the patient is 6 stabilized, then on to London for the more invasive 7 surgery? 8 A: Right. 9 Q: All right. Do you know what became 10 of Nick Cotrelle after he was removed from the Emergency 11 Department? 12 A: He went to one (1) of the floors. 13 Q: All right. 14 A: He was admitted into the hospital. 15 Q: And so, he was admitted as an 16 inpatient as opposed -- 17 A: I believe so. 18 Q: -- as opposed to an outpatient? 19 A: I believe so, but to tell you the 20 honest truth, I -- I didn't have much direct contact with 21 the patient after just -- after I knew they were in the 22 care of some other nurses. 23 Q: All right. 24 A: But I -- I thought they were all 25 admitted, at least overnight.

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1 Q: And perhaps you would turn to Tab 1 2 of the Hospital Records binder. This is Exhibit P-356, 3 Inquiry Document Number 1000043 and it is the Summary 4 Sheet for Strathroy Middlesex General Hospital for 5 Nicholus Cotrelle. 6 A: What -- what tab was that again? 7 Q: Tab 1 and the first page. 8 A: Okay, yes. 9 Q: And I note here -- first of all can 10 you identify this record? 11 A: Nicholus Cotrelle? 12 Q: Yes. 13 A: Yes, I see it? 14 Q: Is this -- is this a standard record? 15 A: Yes, it is. 16 Q: And I see that there's an admission 17 date of September the 7th, 1995 and an admission time of 18 2:05 a.m. 19 A: Okay. 20 Q: What, if anything, does that tell you 21 about his -- 22 A: That tells that he became an 23 inpatient, what we refer to an inpatient. In other 24 words, admitted to a floor from the Emergency Department. 25 Q: All right. And I note that the

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1 discharge time and date at the middle of the page on the 2 right-hand side is listed at September 7th, 1995 at 3 16:35. 4 So would that tell us then that he was 5 discharged at about 4:35 p.m. on the 7th? 6 A: That's right. 7 Q: Thank you. And did you have any 8 involvement at all in the patient care of Mr. Cotrelle 9 after he was transferred from the Emergency Department? 10 A: No. 11 Q: And you said earlier that you had no 12 involvement in his primary care while he was in the 13 Emergency Department; is that right? 14 A: That I didn't. 15 Q: All right. Similarly, after Dudley 16 George was pronounced deceased, did you return at all to 17 Cecil Bernard George? 18 A: I don't recall doing so. 19 Q: All right. To your knowledge, did 20 his condition improve while he was in the Emergency 21 Department? 22 A: Not to my knowledge. 23 Q: Do you know what became of Mr. George 24 -- Cecil Bernard George after he was removed from the 25 Emergency Department?

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1 A: He was admitted, as well. 2 Q: And perhaps you would go to Tab 2 of 3 the Hospital Records binder, Exhibit P-387, first page. 4 This is a Summary Sheet as well -- 5 A: Hmm hmm. 6 Q: -- for Cecil Bernard George and it 7 indicates an admission date of September the 7th, 1995 8 and an admission time of 2:27 a.m. 9 And does that mean that he was admitted as 10 an inpatient at that time? 11 A: That's what that means. 12 Q: And in the right-hand side, middle of 13 the page indicates that he was discharged on September 14 the 8th at 16:30; is that right? 15 A: Yes. 16 Q: Thank you. And again, did you have 17 any involvement with him once he became an inpatient? 18 A: No. 19 Q: And you indicated that you had no 20 further involvement or no involvement at least with his 21 patient care in any Emergency Department either? 22 A: Yes. Not -- no direct care. 23 Q: Now one (1) of the tasks assigned to 24 this Commission is to make recommendations to avoid these 25 types of situations in -- in the future and that can

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1 include common thing on the emergency services response 2 and treatment. 3 On reflection, could anything have been 4 done which may have improved the chances of resuscitating 5 Dudley George from your perspective? 6 A: From my -- in my opinion? 7 Q: Yes, as a nurse? 8 A: I feel that if -- if anything could 9 have been done that just coming by ambulance with the 10 support of care that he could have had on board that 11 ambulance, would have been best. 12 And I say that because it's well known 13 that anyone, particularly the heart or the brain, that is 14 without oxygen from three (3) to five (5) minutes, 15 there's damage and after five (5) minutes it's -- there - 16 - that cannot be resuscitated in any way. 17 I don't know if -- if having had, you know 18 100 percent oxygen all the way to our hospital would have 19 made a difference. But that is something that could have 20 been available. They also have -- I don't think they did 21 at that time, so it's not pertinent. They now have 22 monitored defibrilators. I don't believe they did then. 23 Q: All right. 24 A: But I think the oxygen factor, there 25 could have been some CPR done at the -- the chest

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1 compressions and at least you would be trying to 2 circulate oxygenated blood and if there was any chance of 3 anything staying viable, it would have stayed viable. 4 Q: Thank you. And further, on 5 reflection, are there things which could have been done 6 in order to improve the delivery and efficiency of the 7 emergency patient care and treatment services that night 8 for -- for these three (3) patients? 9 10 (BRIEF PAUSE) 11 12 A: In the capacity of our hospital, I -- 13 I don't believe that there was anything more that we 14 could have done. 15 Q: Fair enough, but would there have 16 been any -- any -- any things that could have been to 17 improve the efficiency of your assessment and treatment 18 of these patients? 19 Not necessarily by you, but by others and 20 for -- 21 A: I really can't -- I can't think of 22 anything. If there's -- you know, there is a standard 23 treatment in place and those -- those standards of our -- 24 are of high quality and they're expected. And I honestly 25 I -- with the exception of maybe having a modern scanner

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1 as part of the equipment, but as far as nursing 2 perspective, I honestly -- I don't think so. 3 Q: Now, you indicated earlier in your 4 testimony that you didn't receive any information from -- 5 about these patients while they were en route concerning 6 certain circumstances such as their age, or the nature 7 and severity of their injuries -- 8 A: Hmm hmm. 9 Q: -- would that kind of communication 10 have been prudent or might it have improved the delivery 11 of your treatment services that night? 12 A: No. Their condition is more so -- 13 all that -- when -- when we're told the age of a patient, 14 then we can, in our own mind sort of go through what 15 predisposing factors may be present with an ageing 16 process or that type of thing and, you know, older people 17 tend to have, you know, maybe a little bit of heart 18 trouble or arteriosclerosis. 19 Q: Hmm hmm. 20 A: That type of thing, and it tells us, 21 sort of, just a general health standpoint. The younger 22 the person, usually, you know, the stronger the heart. 23 You know, just in your mind as you sort of are trying to 24 picture what's going on, you know you -- you -- you sort 25 of sift through these things and -- but as far as being

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1 pertinent to what you're going to actually do, unless 2 they were to give very specific -- a broken femur or this 3 or that and you get -- 4 Q: Hmm hmm. 5 A: -- specific splints ready. A 6 resuscitation is a resuscitation and we will always 7 prepare for the worst, if we don't know what exactly what 8 we're getting. 9 Q: All right. Thank you very much, that 10 concludes my exam -- 11 COMMISSIONER SIDNEY LINDEN: Just before 12 you leave, you asked this witness, Ms. Derbyshire, to 13 make estimate of the dimensions of the trauma room or the 14 OR and she did in terms of from here to there? 15 MS. SUSAN VELLA: Yes, she did. 16 COMMISSIONER SIDNEY LINDEN: It might be 17 useful if you try to put some estimate for the record on 18 the actual size. From here to there -- 19 MS. SUSAN VELLA: Well, I tell you my -- 20 my estimate would probably be about as good as nurse 21 Derbyshire's estimate. 22 THE WITNESS: How would you do, like 23 square feet or would you actually do -- 24 COMMISSIONER SIDNEY LINDEN: Some 25 small --

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1 THE WITNESS: -- length of the walls? 2 COMMISSIONER SIDNEY LINDEN: Somebody 3 must be able to estimate the area in here, just for the 4 record. Twenty (20) feet by thirty (30) feet? 5 MS. SUSAN VELLA: I was going to suggest 6 that might be accurate, approximately. Does that sound 7 about right to you? 8 THE WITNESS: That sound about right? 9 COMMISSIONER SIDNEY LINDEN: I don't 10 know, does somebody here have a better way of -- 11 MS. SUSAN VELLA: In any event, I would-- 12 COMMISSIONER SIDNEY LINDEN: Just 13 something that we can have on the record. 14 THE WITNESS: Yeah. 15 COMMISSIONER SIDNEY LINDEN: Give us -- 16 THE WITNESS: I would -- I would say that 17 probably is -- is pretty accurate. 18 COMMISSIONER SIDNEY LINDEN: No one's 19 objecting, so it's close enough. 20 21 (BRIEF PAUSE) 22 23 MS. SUSAN VELLA: Yeah, we're just 24 looking at the -- the roof tiles, actually, and if 25 they're about two (2) feet across, then two (2) ...

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1 It's about thirty (30) feet across and 2 perhaps twenty (20) feet wide if you -- 3 THE WITNESS: I think that that's about 4 right, then. 5 MS. SUSAN VELLA: And -- 6 COMMISSIONER SIDNEY LINDEN: Thank you 7 very much. 8 MS. SUSAN VELLA: Thank you very much. 9 Those conclude my questions -- 10 COMMISSIONER SIDNEY LINDEN: Thank you. 11 MS. SUSAN VELLA: We now may have some 12 questions from the other parties and we'll just canvass 13 that at this time. 14 THE WITNESS: Okay. 15 COMMISSIONER SIDNEY LINDEN: Does anybody 16 have any questions for this witness? 17 Yes, Mr. Orkin and Mr. Rosenthal and Ms. 18 Jones and Mr. O'Marra. Let's do a quick estimate of 19 time. 20 MR. ANDREW ORKIN: Five (5) minutes or 21 less, Commissioner. 22 COMMISSIONER SIDNEY LINDEN: Five (5) 23 minutes or less? 24 MR. PETER ROSENTHAL: About five (5) 25 minutes as well.

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1 COMMISSIONER SIDNEY LINDEN: Five (5) 2 minutes or less. 3 MS. KAREN JONES: Fifteen (15) minutes at 4 most. 5 COMMISSIONER SIDNEY LINDEN: Fifteen (15) 6 minutes at most, and Mr. O'Marra...? 7 MR. AL O'MARRA: Two (2) minutes. 8 COMMISSIONER SIDNEY LINDEN: Two (2) 9 minutes. Let's -- let's go. And we'll start with -- it 10 gives you an idea of how long you might be -- 11 THE WITNESS: That's fine. 12 COMMISSIONER SIDNEY LINDEN: -- being 13 questioned. 14 Mr. Orkin...? 15 16 (BRIEF PAUSE) 17 18 CROSS-EXAMINATION BY MR. ANDREW ORKIN: 19 Q: Good morning, Ms. Derbyshire. My 20 name's Andrew Orkin, I'm Co-Counsel to the Estate of the 21 Late Dudley George and to the Sam George Group of Family 22 Members. I don't have many questions for you as I 23 indicated a moment ago, but one (1) particular area 24 interested me which I'd like to question you a little bit 25 about.

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1 You indicated that at the start of the 2 series of three (3) patient encounters, that you had 3 given instructions to some of the other hospital -- 4 hospital personnel who you had drawn into the emergency 5 environment; is that correct? 6 A: That's true. 7 Q: And you indicated in particular, 8 firstly that you had asked them to chart -- to chart 9 meticulously? 10 A: Yes. 11 Q: Now, I would assume first that 12 charting meticulously is a standard procedure in any 13 hospital environment, could you elaborate a little as to 14 -- a little more as to why you emphasized or felt the 15 need to emphasize that on that particular evening? 16 A: I felt that it should be emphasized 17 because first of all, sometimes the -- the girls that 18 came down -- the RN's that came into the Emergency 19 Department, are not used to working there. Secondly, 20 they -- they may feel a little bit on edge because of the 21 situation. 22 So, what I wanted them to do was I wanted 23 -- and -- and on the floors when they chart, sometimes 24 they chart by exception. In other words, if everything's 25 well, we just won't put anything down.

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1 Given -- given the fact that there had 2 been an incident and you have to assume that this may be 3 a -- a legal matter, then in this case, I do want them to 4 chart more than they would normally would and I want them 5 to chart legibly, very -- which, you know, sometimes, 6 finishing off a shift or this and that, you just tend to, 7 Let's get it down and let's get going. 8 And I just wanted them to really be aware 9 of the fact that everything that you say and do may 10 become part of a legal record, which they're not used to 11 and that's why I emphasized it. 12 Q: That's fair. To go onto something 13 else you said, you indicated that you had asked or 14 instructed the personnel to whom you were giving these 15 instructions not to ask the patient or patients what, in 16 particular, had happened to them, but simply to limit 17 their questioning, I think if you put it -- if I -- if 18 I'm putting this correctly, to the clinical details of 19 what they were experiencing; is that correct? 20 A: And -- and their injuries. 21 Q: And their injuries? 22 A: Yes. 23 Q: Now, with respect to what you were 24 asking them not to ask the patients, if I can go 25 hypothetical for a moment.

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1 In a hospital situation where you have a 2 patient presenting in an emergency context in which the 3 patient may have been a victim of a circumstance in which 4 a crime had been committed, and in which the crime was 5 part of the injuries that the patient was reporting; 6 would it not be part of a clinical record -- clinical 7 presentation interviewing process to get enough 8 information about the context in which the injuries may 9 have occurred? 10 A: We would be mostly interested in the 11 mechanism of injury. 12 Q: Right. 13 A: And unless it was pertinent as to 14 distance, as to mass, as to strength, like anything that 15 was pertinent to the injury alone, but as far as whose 16 house it was at or whose car or who was with them, we -- 17 we really don't need to know that. 18 Q: Now, let's go to a situation, 19 perhaps, involving abuse of a -- of a child or an elderly 20 person? 21 A: Yes? 22 Q: That presented with -- with injuries? 23 A: Yes. 24 Q: Would it be of interest to the 25 Commission in that circumstance, to ask the question, how

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1 did these injuries happen to you? 2 A: What would happen is, the nurse would 3 not be responsible in that area. What she would do, is 4 she would tell what the patient had portrayed, she would 5 pass onto the doctor, and it would probably go into like 6 a social system, or the doctor would take care of the 7 actual outcome of what they had said. 8 Yes, the nurse may quote directly, in her 9 notes, and make it as a quotation as to what the patient 10 has actually said to her. But we're not going to fish 11 for that information. 12 Q: So it was not unusual in -- in a 13 circumstance where an individual's -- individual was 14 presenting with gunshot wounds, it was not unusual that 15 you would be giving the instruction to your -- to your 16 staff, not to ask questions as to how that patient got 17 shot? 18 A: I just wanted them to concentrate on 19 doing a total assessment and -- and as to a mechanism of 20 injury, that type of thing. But not as to -- not as to 21 the situation in which it occurred. 22 Q: That's very helpful. Thank you for 23 this. 24 Thank you, Commissioner. 25 COMMISSIONER SIDNEY LINDEN: Thank you

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1 very much. 2 Mr. Rosenthal...? 3 4 (BRIEF PAUSE) 5 6 MR. PETER ROSENTHAL: Good afternoon, Mr. 7 Commissioner. 8 9 CROSS-EXAMINATION BY MR. PETER ROSENTHAL: 10 Q: Good afternoon, Ms. Derbyshire. My 11 name is Peter Rosenthal. I'm one (1) of the lawyers 12 representing a group of Stoney Point people under the 13 name Aazhoodena and George Family Group, as my sign will 14 tell you, if you wish to look at it. 15 I want to just clarify a couple of things, 16 if I could. I didn't quite understand your answer to a 17 question that Ms. Vella asked you, towards the end of 18 your testimony, about people bringing a patient in 19 providing information. 20 In general the more information you know 21 about how the injury might have occurred, the better off 22 you are as an emergency room person, is that fair? 23 A: Yes. I do accept that. That's true. 24 Q: And -- and for example, you were 25 answering Mr. Orkin, just now, that what you want to know

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1 from the patient is the mechanism of injury, if possible. 2 You don't care who did it but you want to know, he was 3 hit over here, or he was hit there, and so on, right? 4 A: Yes. Yes. 5 Q: And that's very helpful. But if a 6 patient is so injured that he or she cannot provide that 7 information, it's very useful if you can get that 8 information from someone who brings the patient in, isn't 9 that fair? 10 A: Not in the initial -- not in the 11 initial treatment. 12 Q: Well, I mean wouldn't it be useful to 13 know if somebody had been hit in the head or not, for 14 example; in general? 15 A: It -- it may be. But it's not going 16 to be necessary for the treatment that you're going to do 17 right away. 18 Q: Well, with respect to Mr. Cecil 19 Bernard George, for example. You said that you would 20 have conjectured, seeing him, that one (1) of the 21 possibilities might have been that he'd been in the head? 22 A: Yes, for sure. 23 Q: Now if someone told you that he was 24 hit in the head by a baseball bat, that would have been 25 useful to you, right? You would have explored that.

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1 A: It would be -- it would be useful, 2 yeah. 3 Q: So, in that sense, knowing the 4 mechanism of injury can be very useful in directing your 5 efforts more specifically right at the beginning? 6 A: Not the immediate. Not -- not -- not 7 in the immediate treatment and assessment of that 8 patient. 9 Q: Okay. Well, I don't understand but-- 10 A: Well, I believe -- 11 Q: -- what did you know about? 12 A: -- I believe that perhaps may -- one 13 (1) of -- did one (1) of the supervisors go and speak 14 with the family afterward? Or I know the family came in 15 afterward anyway. 16 But my -- the point that I'm trying to 17 make is -- is that while we're actually in the process of 18 doing an initial assessment, and doing what we have to do 19 maintain that physical integrity, we're going to do 20 whatever we have to do, no matter what the mechanism of 21 injury. 22 So eventually we will find out what 23 happened, but at -- in the Emergency Department, we are 24 doing what has to be done immediately. And that happens 25 like patients that come in that have even had a heart

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1 attack and -- but right away, we'll look after the 2 patient. 3 After the patient is stabilized or has had 4 all the initial treatment done, then we will go and look 5 for a family. 6 Q: So, for example, whether someone was 7 shot or not, you wouldn't want to know that when you 8 begin to assess the patient? 9 A: Well, I think that the doctors do the 10 assessment, and they knew that, and we had been told that 11 that what's we were getting. 12 But was it going to make a difference to 13 how we were treating them initially? No. 14 Q: Well, in any event I'll move on, if I 15 may. Now, talking about the need to be stabilized, you 16 recall your answer to Ms. Vella, that if a patient were 17 to end up in the Trauma Unit at London, for example, the 18 patient would be stabilized first, and Strathroy would be 19 a way to do. 20 Would you agree, that if there were 21 advanced paramedics available, who had procedures that 22 they could use to try to stabilize the patient, then 23 another possibility would be for those advance paramedics 24 to stabilize the patient at the scene, and then go 25 directly to a Trauma Centre where the injuries could be

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1 actually dealt with. 2 Is that fair? 3 A: Yeah, I -- it's not -- certainly not 4 up to me to sort of say, but if the patient could be 5 resuscitated by whatever means, either en route or at the 6 scene, or whatever, sure, the sooner the better. 7 Q: Yeah. 8 A: But as far as saying -- as far as 9 saying that the ambulance fellows should be doing that, I 10 -- I really don't know what -- what they have available 11 to them. 12 Q: Yes. Now you told us that it took, 13 in your estimate, three (3) to five (5) minutes to get 14 Dudley George from the back of the car, in which he'd 15 been brought, into the Emergency room -- 16 A: Right. 17 Q: -- and you indicated that was because 18 of the difficulty of getting him out of the back seat? 19 A: Yes. 20 Q: Would you agree that if he had 21 brought by ambulance, then he would have been gotten in 22 much more quickly, because the ambulance has a -- 23 A: Physically -- 24 Q: -- an arrangement where you get him 25 right, directly --

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1 A: That -- 2 Q: -- from the ambulance? 3 A: That's right, yes. The ambulance has 4 a -- like, they can just slide the stretcher right out of 5 the back door and drop the wheels down and they're there. 6 Q: Yes. Thank you very much, those are 7 my questions. 8 COMMISSIONER SIDNEY LINDEN: Thank you, 9 Mr. Rosenthal. 10 Ms. Jones...? 11 12 (BRIEF PAUSE) 13 14 CROSS-EXAMINATION BY MS. KAREN JONES: 15 Q: Good afternoon, Ms. Derbyshire. 16 Excuse me, my name's Karen Jones and I'm one (1) of the 17 lawyers for the Ontario Provincial Police Association, 18 and I just have a few questions for you. 19 One (1) of the things, as you know, in 20 front of you there's some binders that contain some 21 material, one (1) of which is medical records and one (1) 22 of which is other things like interviews and Ms. Vella 23 had taken you to an interview earlier in your evidence. 24 There's a document that you may want to 25 refer to, and if you look not in the medical brief, but

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1 in the other brief, and I believe it's at Tab 6. 2 A: And what was it, where was it? 3 Q: I think it's at Tab 6 if you -- 4 A: Okay. 5 Q: -- just check. 6 7 (BRIEF PAUSE) 8 9 A: Yes. 10 Q: Okay. And I think that should be a 11 document entitled "Anticipated Evidence of Jackaline 12 Derbyshire." 13 A: Right. 14 Q: Do you see that? 15 A: Yes. 16 Q: And this was a interview you had with 17 the SIU, I believe, on September 16th, 1995. 18 A: Okay. 19 Q: Okay. Do you remember being 20 interviewed by the SIU, Ms. Derbyshire? 21 A: I remember -- yes, I do remember. 22 Q: Okay. And the -- I'm going to ask 23 you some questions, and I may refer you to some specific 24 pages of this interview to see if it helps you remember 25 something, and it may and it may not, it --

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1 A: Yes. 2 Q: -- doesn't matter to me one (1) way 3 or the other, but this is ten (10) years after the fact-- 4 A: I know. 5 Q: -- which is very hard. 6 A: Yeah, that's right. 7 Q: And this interview was done close to 8 the time, so it may assist you, and it may not and -- and 9 as I say I'll take you there. 10 Now, have you had a chance to look at this 11 interview, or any of the other interviews? 12 A: I did. 13 Q: You did? Okay, good. I just wanted 14 to start out, you had talked about, earlier in your 15 evidence, that you had received a phone call from the 16 London OPP prior to any of the patients coming in on the 17 night of September the 6th? 18 A: Yes. 19 Q: And there had been some discussion or 20 some asking back and forth, I think, about who was in the 21 department, and if there were people there, could be -- 22 could they be moved out? 23 A: Yes. 24 Q: And did you, in fact, have anyone in 25 the department at the time?

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1 A: I think we had one (1). 2 Q: Okay. 3 A: And they were allowed to -- they were 4 treated and released. 5 Q: Okay. And I -- and did you 6 understand, from the OPP, that they were asking you about 7 that, so that the Emergency Department would be cleared 8 by the time the people showed up? 9 A: That's what I took from it. 10 Q: Yeah, so it would be safer and more 11 contained -- 12 A: Yes. 13 Q: -- to deal with? 14 A: Yeah. 15 Q: Yeah, and then you were asked some 16 questions about when did the police come to the Emergency 17 Department, and I think your answer to Ms. Vella was you 18 couldn't really recall. 19 You could remember setting up 20 communications, but couldn't really recall the time, and 21 this is one (1) of those areas where it may be helpful if 22 you go to your -- 23 A: Okay. 24 Q: -- document, and if you look at page 25 4. And, I'm sorry, for the assistance of Counsel, it's

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1 Inquiry Document Number 1002249. And if you look at the 2 very top of the page, about the third line down -- 3 A: Hmm hmm. 4 Q: -- it talks about the -- 5 A: Oh, they arrived -- 6 Q: "-- OPP arrives first and that 7 occurred around midnight and the OPP 8 officers arrived first. There were, 9 you know, at least three (3) or four 10 (4); they did introduce themselves." 11 A: Okay. 12 Q: Yeah. Does that -- does that help 13 you at all? 14 A: It doesn't help me with the time 15 frame any more than it did and -- 16 Q: Okay. 17 A: -- I -- I'm sure that that -- you 18 know, it's just not a priority. 19 Q: Oh -- 20 A: I mean in my method of thinking, I 21 just... 22 Q: I -- I understand. 23 A: Yeah, because twenty (20) -- about -- 24 you know that half hour to three-quarters (3/4) of an 25 hour in there was just happening pretty quickly.

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1 Q: Okay. And do you remember any 2 discussion with the OPP officers when they came in about 3 they were there for security and they were there to 4 ensure the safety? 5 A: Yes, I do remember that. 6 Q: Yeah. 7 A: And that they were going to set up a 8 -- a communications in the Outpatient Department, which 9 is -- which is the patient registration area. 10 Q: Yeah. And I take it as the nurse in 11 charge, one (1) of the things you would have been very 12 concerned about was the safety and security of patients 13 in the department and your staff? 14 A: Yes. Yes, I was, and also anyone 15 that may come -- want to come to the hospital -- 16 Q: Yeah. 17 A: -- like, and wonder, like, what is 18 going on in there? So, yeah it was a concern. 19 Q: Yeah. And, I take it, then, it would 20 have been a bit of a relief when the OPP showed up, and 21 they were there and available if you needed them? 22 A: Well, I didn't -- I didn't really 23 have to think about that. 24 Q: Yeah. That was -- 25 A: But I don't -- I don't consciously

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1 remember thinking, Oh, what a relief. To tell you the 2 truth, I do remember thinking, Oh, thank God, I won't 3 have to answer that phone again. The phone was ringing 4 off the wall, but yeah, it -- yeah, I'm sure that it was 5 probably good to have them there at that time. 6 Q: Sure. Sure. And then you were asked 7 some questions, and you talked a little bit about after 8 the first two (2) patients came in. 9 A: Hmm hmm. 10 Q: You had talked about the 11 circumstances under which you went outside and saw the 12 car and saw the person in the back of the car. And I 13 just wanted to see if we could break that down a little 14 bit, or what you actually recalled about what happened. 15 Because there are -- there are a few 16 differences between what you said now and what you said 17 in that interview with the SIU. 18 A: Okay. 19 Q: And it -- it -- it may assist you to 20 go back with what you said at the time and it may not and 21 again -- 22 A: Okay. 23 Q: -- I can just see if that can help a 24 bit. First of all, when you first heard about there 25 being someone out in the car, and help was needed, do you

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1 remember were you in the OR at the time, or were you out 2 in the reception area, or -- 3 A: I may have just been sort of coming - 4 - I think I was -- I was still fairly near the back, if I 5 wasn't in the back. 6 Q: Okay. 7 A: And the -- the -- the man came in and 8 yelled, you know, that he needed some help. 9 Q: Okay. Okay. And, were -- from -- 10 from what you can recall, were most or all of the staff, 11 that is, the nurses and the doctors, at that time in the 12 OR attending to patients, and standing by there? 13 A: Yes. 14 Q: Okay. 15 A: Yeah, there wasn't anyone up -- we 16 had no reason to even be near the front. 17 Q: That's right. 18 A: Patients that we had were at the 19 back, and we were expecting someone else there, so that's 20 where they were. 21 Q: Okay. And then you talked about 22 someone, and you said it was an ambulance attendant, 23 saying that they needed a stretcher and needed some help. 24 And do you specifically -- was it a person in uniform 25 first of all, that came in and said that?

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1 A: Yes. 2 Q: Okay. And could you tell was it -- 3 what kind of uniform it was or was it just a person in 4 uniform? 5 A: Oh, I'm -- I -- I'm sure that it was 6 the ambulance fellow because I think he brought the 7 stretcher as far as the entranceway with him, and then 8 left it, and ran on in and we both ran out with it. 9 Q: He had a stretcher outside? 10 A: Outside, yeah. 11 Q: And he brought -- he was bringing it 12 in? 13 A: I thought that he was bringing it in, 14 but maybe they were just moving it around there. But 15 I'm -- 16 Q: Right. 17 A: -- sure that it was the ambulance guy 18 that came in. I -- I'm sure it wasn't the police that 19 came in. 20 Q: Okay. And then when you went out -- 21 A: Yes. 22 Q: -- did you take anything out with 23 you? 24 A: No, not that I recall. 25 Q: Okay. And -- and again, when I look

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1 at your interview -- 2 A: Hmm hmm. 3 Q: -- with the SIU, and if you look 4 again on page 4 -- 5 A: Hmm hmm. 6 Q: -- about -- at the bottom third of 7 the page, I don't know if you want to just take a minute 8 to look at that, and see if that helps? 9 10 (BRIEF PAUSE) 11 12 A: There -- there weren't any ambulance 13 attendants in our department, is that what you're asking 14 me? 15 Q: Well, I want to ask you about two (2) 16 things. One (1) was, according to your notes and what 17 you said when the ambulance attendant came in, he said 18 that they needed help, they needed a stretcher, right? 19 And that doesn't make a whole lot of sense 20 if he already had a stretcher right there. 21 A: Yeah, well, maybe they -- yeah, maybe 22 they had the stretcher. It was something about the 23 stretcher. Maybe he said we need help with the stretcher 24 or whatever. 25 Q: Something about a stretcher.

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1 A: Something about the stretcher, yes. 2 Q: Okay. And also, when I looked at 3 your statement, you -- you talk about the ambulance 4 attendant coming in, yelling something about they need a 5 stretcher fast, at least in your statement, and then you 6 talk about going out to the ramp and you say: 7 "Two (2) ambulance attendants came to 8 assist that were out there somewhere. 9 I don't know where they came from." 10 A: Right. 11 Q: And when I looked at that, it looked 12 to me like there would have been three (3) -- at least 13 three (3) other people, besides you, there with the 14 stretcher by the car. 15 A: And there may have been. 16 Q: Okay. 17 A: I -- I think that probably what -- 18 I'm assuming that what happened is that the other ones 19 from bringing in the first two (2) fellows, hadn't left 20 yet. That would account for them being out there, but I 21 know they came and helped. 22 Q: So there -- there -- there could have 23 been a number of people -- 24 A: Oh, sure. 25 Q: -- that were -- Sure --

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1 A: Sure there was. 2 Q: Yes. 3 A: I remember there were a number -- 4 Q: Yeah. 5 A: -- of people, I just don't remember 6 who they were, and I don't remember talking to any of 7 them. 8 Q: Sure. 9 A: Just sort of -- 10 Q: Because you were focussed on -- 11 A: Yeah. 12 Q: -- the person -- 13 A: Yeah. 14 Q: -- that was in the car? 15 A: For sure. 16 Q: Okay. 17 18 (BRIEF PAUSE) 19 20 Q: And there were just two (2) other 21 things that I wanted to ask you about, and again they're 22 in your statement. If we turn to page 5 of your 23 statement, you had -- you mentioned in the statement and 24 you talked a little bit today as well about seeing some 25 people outside on the ramp area --

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1 A: Hmm hmm. 2 Q: -- and it sounded like, from what you 3 said today, you really couldn't recall who was out there 4 or what they were doing or anything. 5 A: Right. 6 Q: Is that right? 7 A: Yes. 8 Q: And again, that's because you were 9 focussed on -- 10 A: Yes. 11 Q: -- the person in the car? 12 A: Sure. 13 Q: So there could have been a number of 14 people around? 15 A: There could have been 16 Q: Yeah, okay. And then you go down a 17 little bit in the statement, and you talk about the fact 18 that both doctors are in the Trauma Room and you say: 19 "We pushed the ambulance stretcher up 20 into a third space." 21 A: Okay. 22 Q: And I take it that because there were 23 -- there had already been two (2) patients come in that 24 the two (2) beds that you had or the bed and the 25 stretcher in the OR were already in use?

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1 A: We may have pushed it up into the 2 third space just because that's where we had everything 3 set up -- 4 Q: Sure -- 5 A: -- to do a resuscitation. 6 Q: Yeah. 7 A: The operating room table is not very 8 wide, so it wouldn't be used at all. 9 Q: Right. 10 A: And we may have already used the 11 spare stretcher for -- for one of them, although I don't 12 -- I don't really recall any of them being off the -- I 13 don't recall Cecil being off the ambulance stretcher 14 immediately. And I don't think the other boy was off the 15 stretcher until he was in a side room. 16 Q: Okay, because you talk then about -- 17 you say they were -- we pushed the ambulance stretcher up 18 into a third space -- 19 A: Up -- up alongside -- up -- actually, 20 up along the table. 21 Q: Yeah. 22 A: Yeah, on the right hand side of it. 23 Q: Okay, and -- and I took it from that, 24 that you just would have wheeled him in, put him in a 25 position and started working on him?

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1 A: That's right. 2 Q: Yeah. 3 A: Yes. 4 Q: Yeah, okay. And then the last thing, 5 I just wanted to ask you, and this again may assist you 6 and it may not, but you were asked some questions about 7 who was in the OR -- 8 A: Hmm hmm. 9 Q: -- when the person from the back of 10 the car was brought in. 11 A: Right. 12 Q: And if you turn to page 6, and I'm 13 looking at the top of the page, and if you -- again, if 14 you just want to take a minute and have a look at that, 15 please feel free to do that. 16 A: Okay. Okay. 17 Q: Okay. 18 A: That's fine. 19 Q: Sorry does -- did -- does that assist 20 you at all as -- as to when -- 21 A: I -- I can't picture it any better. 22 Q: Okay. 23 A: And -- and obviously I was seeing 24 clearer then -- 25 Q: Okay.

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1 A: -- as far as the -- the young man 2 being moved across. 3 Q: Yeah. After -- after that person had 4 been brought in and -- and -- 5 A: Sure and it very well could have 6 been. It could have been they passed in the hallway. It 7 could have been, you know -- 8 Q: Sure. 9 A: -- they -- I know things happened all 10 very, very quickly. 11 Q: Okay. 12 A: I do specifically remember though, 13 saying, you know, to move -- move that young boy out. 14 Q: And those are all my questions, thank 15 you. 16 A: Okay. 17 COMMISSIONER SIDNEY LINDEN: Thank you, 18 Ms. George -- Ms. Jones. 19 Mr. O'Marra...? 20 MR. AL O'MARRA: Yes, thank you 21 Commissioner. 22 23 CROSS-EXAMINATION BY MR. AL O'MARRA. 24 Q: Ms. Derbyshire, my name is Al O'Marra 25 and I appear on behalf of the Chief Coroner. We're

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1 assisting in the -- the process. I just have a few 2 questions around the timing of events. Who could have, I 3 believe it's Document 500245. I think it's P -- it's the 4 cardiopulmonary record P-280 -- or 384, I think that's 5 it. 6 Yes, thank you. 7 A: Is it the resuscitation record? 8 Q: Yes, that's right. 9 A: Okay. 10 Q: We have the time of 12:08 and we go 11 to the bottom part of the -- of the page as well. If you 12 could just go down a little lower, that's it. 13 Under vital signs, it has 12:08 zero and I 14 take it that that's a time when somebody did a -- an 15 assessment for vital signs and recorded zero. 16 A: Yes. 17 Q: Now we heard from Dr. Marr that she 18 conducted an assessment. And at that time she was of the 19 view that there were -- this is regarding of course 20 Dudley George, that are no signs of life, no pulse, no 21 heart sounds, no air entry, pupils were fixed and 22 dilated. 23 Now -- and that's when she first 24 encountered Mr. George. When you encountered Mr. George 25 for the first time, it was before 12:08, is that correct?

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1 A: It would be out on the ramp. 2 Q: Right. And -- and so we can get just 3 a fix in terms of that time, when you're asked about the 4 time to remove Mr. George from the vehicle -- 5 A: Hmm hmm. 6 Q: -- into the Trauma Room -- 7 A: Right. 8 Q: -- where I take it Dr. Marr was to do 9 her assessment, that three (3) to five (5) minutes 10 precedes 12:08? 11 A: Yes. 12 Q: Okay. So you're -- you're first 13 observing Mr. George sometime just after midnight? 14 A: Yes. 15 Q: And it's at that time that you 16 observe that there -- there's no chest movement, correct? 17 A: That's right. 18 Q: There's no movement at all? 19 A: That's right. 20 Q: All right. And in your own mind you 21 -- you as you declared, Oh my God, he's -- he's dead. 22 A: Yes. 23 Q: Okay. Now you also made reference to 24 a physical or an observation of a physical sign -- 25 A: Yes.

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1 Q: -- regarding Mr. George, and it was 2 the mottling of his skin. 3 A: Yes. 4 Q: And -- and you described it in the 5 jowl area of his -- of his face? 6 A: Right. In -- in back here and then 7 in the neck. 8 Q: In the back and the back of the neck? 9 A: Yes. 10 Q: Okay. And that is -- you described 11 was from, based on your knowledge, deoxygenated blood 12 pooling or settling? 13 A: Yes. 14 Q: Meaning that the heart had -- 15 A: Not circulating. 16 Q: Not circulating. 17 A: Right. 18 Q: The heart had stopped for some period 19 of time such that the blood wasn't pumping to the lungs 20 to be oxygenated, and, as well, it had settled, in fact 21 by gravity -- 22 A: Yes. 23 Q: -- to those areas. 24 A: Yes. Yes. 25 Q: Is that -- is that to your knowledge

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1 of the beginning of -- of levity? 2 A: Yes. 3 Q: Yes? Okay. All right. And we'll 4 hear more about that from Dr. McCallum. Thank you very 5 much. 6 A: Okay. 7 COMMISSIONER SIDNEY LINDEN: Thank you, 8 Mr. O'Marra. Do we have any re-examination? 9 10 (BRIEF PAUSE) 11 12 MS. SUSAN VELLA: Just very brief. 13 14 RE-DIRECT EXAMINATION BY MS. SUSAN VELLA: 15 Q: In your experience, all your years of 16 experience as an emergency nurse, if family members bring 17 a severely injured person into the Emergency Department, 18 is it your experience that they tend to follow him into 19 the hospital? 20 A: Sometimes they do and sometimes they 21 don't. I've seen pretty well everything. A child -- 22 they'll come running in with them in their arms. Some of 23 them follow the ambulance attendants into the room, 24 almost hysterical. Other ones will start out in a quiet 25 room provided and then they will come in anyway; they

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1 just can't stand it. And, depending on what's going on, 2 sometimes they're allowed to stay and sometimes they're 3 not. 4 Q: In you -- 5 A: When they're not allowed to stay it's 6 usually because we -- we need to have the space to work. 7 Q: You're talking about coming right 8 into the Trauma Room? 9 A: Yes. 10 Q: As opposed to the Emergency 11 Department? 12 A: That's right. 13 Q: All right. Is it your experience 14 that family members will at least come into the hospital 15 and -- and -- as far as they can come or -- 16 A: Oh, yes. Yes, usually there is. 17 Q: And had the family members of Dudley 18 George been outside near the ramp at the time that he was 19 being transported into the hospital; would you have 20 expected them to have at least entered into the hospital 21 after him? 22 A: Yes, yeah, but I -- I don't know if 23 they did because we were back there working. 24 Q: Fair enough. Thank you very much. 25 A: Okay.

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1 MS. SUSAN VELLA: Those complete my 2 questions on re-examination, Commissioner. I wish to 3 thank Mrs. Derbyshire very much for coming today and 4 giving your evidence today. It's been very important and 5 valuable to the Commission. 6 THE WITNESS: I hope it was helpful. 7 Thank you. 8 COMMISSIONER SIDNEY LINDEN: Thank you 9 very much, Mrs. Derbyshire. Thank you very much. 10 MS. SUSAN VELLA: Now, Mr. Commissioner, 11 before we close for the day, first of all I want to 12 advise that we will start at 9:00 in the morning with Dr. 13 Andrew McCallum. 14 And it's my understanding that Mr. Millar 15 is racing into the Hearing room as we speak, I hope, to 16 make an announcement as well, so I wonder if Counsel 17 would just be patient. And Commissioner, I'm sure he'll 18 be right -- right along. 19 THE WITNESS: Am I finished? 20 MS. SUSAN VELLA: Thank you, yes, you 21 are finished. 22 THE WITNESS: Okay, thanks very much. 23 COMMISSIONER SIDNEY LINDEN: Thank you 24 very much. 25

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1 (WITNESS STANDS DOWN) 2 3 MR. DERRY MILLAR: Thank you, 4 Commissioner. I just wanted to make a couple of 5 announcements with respect to some of the documents for 6 Deputy Commissioner John Carson. I will be referring 7 Deputy Commissioner Carson to the scribe notes that I 8 distributed electronically on the weekend. I'll also be 9 referring to Document Number 2002678, which is a document 10 dated May 28th... 11 12 (BRIEF PAUSE) 13 14 MR. DERRY MILLAR: Which is 2002678 is a 15 plan dated May 28th, 1993. That's the date it was 16 revised with respect to the Canadian Forces Base 17 Ipperwash. 18 One (1) of the things that I've been 19 trying to sort out this afternoon is the -- we provided a 20 number in our material 1002419 for the scribe notes and 21 the book that we distributed last week with respect to 22 some corrections to the scribe notes don't jive exactly. 23 And I've just been advised by Constable 24 Shawn Evans -- Detective Constable Shawn Evans -- that 25 that version is from 2000861 or two million eight six one

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1 (2,000,861). And there's a slight difference that we'll 2 have to sort out between the two (2) versions; and that 3 the -- something will appear, for example I know pages 89 4 and 90 in one (1) version it's at the top of the page 90 5 and the 2 -- 1002419 it's at the bottom of page 89, a 6 sentence. There seemed to be a sentence off and I don't 7 -- I don't know what the -- why that is. 8 Anyway those are -- I just wanted to let 9 everyone know about that. Thank you, sir. 10 COMMISSIONER SIDNEY LINDEN: We'll try to 11 sort that out tomorrow. 12 MR. DERRY MILLAR: At some point we'll 13 sort it out. 14 COMMISSIONER SIDNEY LINDEN: Okay, thank 15 you very much, Mr. Millar. 16 So we'll now adjourn until tomorrow 17 morning at nine o'clock. 18 MR. DERRY MILLAR: Nine o'clock. 19 COMMISSIONER SIDNEY LINDEN: Thank you. 20 THE REGISTRAR: This Public Inquiry is 21 adjourned until tomorrow, Tuesday, May the 10th, at 9:00 22 a.m. 23 24 --- Upon adjourning at 4:03 p.m. 25

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1 2 3 Certified Correct 4 5 6 7 8 _______________________ 9 Carol Geehan, Ms. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25