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 April 19th, 2005 25


1 Appearances 2 Derry Millar ) (np) Commission Counsel 3 Susan Vella ) 4 Donald Worme, Q. C ) 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 ) (np) Student-at-Law 12 13 Peter Rosenthal ) Aazhoodena and George 14 Jackie Esmonde ) Family Group 15 16 Anthony Ross ) (np) Residents of 17 Kevin Scullion ) Aazhoodena (Army Camp) 18 William Henderson ) (np) Kettle Point & Stony 19 Jonathon George ) Point First Nation 20 Colleen Johnson ) (np) 21 22 Kim Twohig ) (np) Government of Ontario 23 Walter Myrka ) 24 Susan Freeborn ) (np) 25


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 ) (np) 15 16 Mark Sandler ) (np) Ontario Provincial 17 Andrea Tuck-Jackson ) Ontario Provincial Police 18 Leslie Kaufman ) (np) 19 20 Ian Roland ) Ontario Provincial 21 Karen Jones ) (np) Police Association & 22 Debra Newell ) K. Deane 23 Ian McGilp ) (np) 24 Annie Leeks ) (np) 25


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 Erin Tully ) 19 20 David Roebuck ) (np) Debbie Hutton 21 Anna Perschy ) (np) 22 Melissa Panjer ) (np) 23 Danya Cohen-Nehemia ) (np) 24 25


1 TABLE OF CONTENTS 2 Page 3 Exhibits 6 4 5 WALTER PETER HOLMES HARDING, Resumed 6 Cross-Examination by Mr. Andrew Orkin 7 7 Cross-Examination by Mr. Peter Rosenthal 25 8 Cross-Examination by Mr. Kevin Scullion 69 9 Cross-Examination by Mr. Ian Roland 118 10 Cross-Examination by Mr. Al O'Marra 120 11 12 GLEN ALAN MORGAN, Sworn 13 Examination-In-Chief by Ms. Katherine Hensel 132 14 Cross-Examination by Ms. Jackie Esmonde 202 15 Cross-Examination by Mr. Kevin Scullion 227 16 Cross-Examination by Mr. Jonathan George 243 17 Cross-Examination by Mr. Ian Roland 249 18 Cross-Examination by Mr. Al O'Marra 255 19 20 KAREN BAKKER-STEPHENS, Sworn 21 Examination-in-Chief by Ms. Susan Vella 267 22 23 Certificate of Transcript 354 24 25


1 EXHIBITS 2 No. Description Page 3 P-341 Document Number 2001400 St. John's 4 Ambulance, London-Middlesex Corps 5 Missing Items - Not Returned 6 November 1995; Interim Report and 7 Attendants Report Re: Ipperwash 8 Provincial Park, September 06/95. 282 9 P-342 Document Number 1002921 St. John's 10 Ambulance Patient Report of Cecil 11 Bernard George by Witness Ms. Karen 12 Bakker-Stephens, September 06/95 311 13 P-343 Document Number 1005723 September 07/95 14 Will State of Karen Bakker 337 15 16 17 18 19 20 21 22 23 24


1 --- Upon commencing at 9:01 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 COMMISSIONER SIDNEY LINDEN: Good 7 morning. Good morning. I guess we'll start right off 8 with cross-examination with Mr. Orkin, yes. 9 MR. ANDREW ORKIN: Good morning, Mr. 10 Commissioner. 11 COMMISSIONER SIDNEY LINDEN: Good 12 morning. 13 14 WALTER PETER HOLMES HARDING, Resumed 15 16 CROSS-EXAMINATION BY MR. ANDREW ORKIN: 17 Q: Good morning, Mr. Harding. My name's 18 Andrew Orkin, I'm Co-Counsel to the Dudley George Estate 19 and the Sam George Family Group and as you saw the lineup 20 on what the timing is today, I'm only going to be asking 21 you very few questions. 22 I understand that the St. John Ambulance 23 organization is the world's oldest, or perhaps one (1) of


1 the oldest humanitarian charitable organizations; is -- 2 is that your understanding? 3 A: Yes, it derives its history from -- 4 from the Benedictine Order and goes back to the ten (10) 5 hundreds, officially. And other than the church 6 organizations, I suppose the only oldest one would be in 7 the Masonic Lodge as Knights Templar -- 8 Q: Right. 9 A: -- where the knights were given 10 responsibilities of various responsibilities and ours was 11 hospitallers. We were looking after the pilgrims 12 travelling the Holy Lands, both defending them and -- and 13 looking after their needs. 14 Q: And if I understand the use of the 15 word, 'humanitarian' as it's used in the -- in the St. 16 John Ambulance context, does that have any specific 17 meanings other than caring for human beings in your 18 understanding? 19 A: For the service of mankind. 20 Q: For the service of mankind. The 21 emblem of the St. John Ambulance, which I see you have on 22 your -- your shoulder there and is -- is prominently 23 displayed on all of the vehicles in the pictures we saw


1 yesterday, is there anything you can tell us about the 2 history of that, and perhaps, in particular -- 3 A: A lot of people refer to -- 4 Q: -- the -- the Amalfi Cross. 5 A: I'm sorry, a lot of people refer to 6 it as the Maltese Cross, but it's not, it's the badge of 7 Amalfi. 8 Q: Yes. 9 A: It's -- which is a republic on the 10 south coast of Italy. It was adopted by the Benedictines 11 at the time when the property was bought back from the 12 Turks, around the Holy Sepulchre where the hospital is 13 today, in Jerusalem. And the -- this badge was used as a 14 sign of help to -- in their way- stations. 15 It was on a field of black, same as today, 16 field of black. If you -- the Johanniter is a field of 17 red -- 18 Q: Hmm hmm. 19 A: -- and the same badge of Amalfi is 20 used. A lot of people refer to it as the Maltese Cross 21 because our headquarters was in Malta for three hundred 22 (300) years. And Malta adopted the eight (8) pointed 23 cross also, but half red and half white, half -- the red


1 for the republic, the white for the Knights of Malta who 2 worked -- who lived and defended the -- the Valette. 3 Q: All right. I understand there is 4 perhaps a relationship between the -- the emblem of the 5 Amalfi Cross and that of the Red Cross via the -- the 6 Swiss connection and that the -- do you know anything 7 about that connection in this? 8 A: Well, I can tell you that the Geneva 9 Cross which is -- 10 Q: Right -- 11 A: -- the Red Cross. The Geneva cross 12 is a specific -- it came into being after the -- after 13 St. John, after the White Cross. It was designed for a 14 time of conflict. It was designed specifically for the 15 use of the Red Cross. 16 Q: Hmm hmm. 17 A: if anything happens and there is a 18 conflict, and specifically referring to war, our cross 19 changes to the red cross. We become adaptable and we use 20 the red cross as a sign of -- of our work. 21 Q: So, leading on -- on the discussion, 22 the brief discussion we've just had, there's a tremendous 23 importance, then, is there, in addition to a history,


1 there's a tremendous importance to the existence and use 2 of these emblems and people's general understanding that 3 they represent and mean help? 4 A: There is a specific use for the red 5 cross, under the Geneva Convention. There is not for the 6 Maltese cross which is a sign of just direct help for 7 anyone. 8 Q: Right. So, beyond the -- the 9 trademark interest that the St. John Ambulance might have 10 in its --in its cross and in this emblem of universal 11 help, as you just put it, what reasons might there be to 12 prohibit the misuse of an emblem, of a distinctive 13 emblem, like the St. John Ambulance cross? 14 A: Well, there's specific guidelines 15 laid down for the Red Cross -- 16 Q: Hmm hmm. 17 A: -- in which it says not to be used 18 for specific purposes. We do not have that agreement 19 with the -- with -- under Geneva. 20 When we go into a -- a conflict situation 21 whereby in -- during war, that's why we come under the 22 jurisdiction of the Red Cross and the Red Cross is used 23 in that regard --


1 Q: Right. 2 A: -- such as with the military and with 3 other various situations like that. 4 Q: So, you -- it's fair to say that you 5 are aware of the, at least in the Red Cross contexts, the 6 importance of the avoidance of the misuse of emblems that 7 signify help -- 8 A: Oh, most definitely, yes. 9 Q: Right. What -- and you've mentioned 10 the Geneva Convention, which I presume is the fourth 11 convention and others of the immediate postwar -- post 12 World War II era. 13 Are there any Canadian arrangements that 14 you're aware of in law or policy with respect to emblems 15 like the Red Cross emblem? 16 A: The red -- the Canadian Red Cross 17 adopted the same -- the same policies with the Geneva 18 Convention and they follow the same regulations, yes. 19 Q: Now, with the prominent display of 20 this emblem on your vehicles, as we saw yesterday and in 21 particular, such vehicles as the -- the medic vehicle and 22 the command post vehicles that we saw yesterday in those 23 -- in those photographs, could you perhaps tell us what


1 the impulse is in displaying that emblem as prominently 2 on your vehicles as you do? 3 Why -- why is it that those -- that the 4 St. John Ambulance name and that very famous and ancient 5 cross -- 6 A: Well, it's -- 7 Q: -- is so prominently displayed on -- 8 on your vehicles? 9 A: Well, it's -- we -- we -- if you're 10 looking at our perspective, is that 1, the four (4) arms 11 symbolise the Christian virtues; prudence, temperance, 12 justice and fortitude, and the eight (8) points represent 13 the eight (8) beatitudes which spring from the practise 14 of those virtues. 15 Q: Yeah. 16 A: That is why we display it. It is our 17 -- it is our symbol of people coming to us and asking for 18 assistance when it is required. And that was flown for 19 years and centuries as on the field of black. 20 Q: Hmm hmm. 21 A: And it was for those to be recognized 22 to come to us for assistance. That's specifically what 23 the reason was.


1 Q: So, it's not just an accident that 2 one might hope that people gathered in any situation or 3 passing by, when they see one (1) of those vehicles could 4 have a sense of confidence that that is a place or an 5 instrument in which assistance and -- and all of the 6 other virtues as represented in the eight (8) points of 7 that cross in your credo -- 8 A: That's correct. 9 Q: -- is manifested in that place? 10 A: Yes. That's fair -- that's fair to 11 understand, I think. 12 Q: You mentioned yesterday that in 13 providing the vehicle that you did or vehicle -- it was 14 one (1) vehicle -- 15 A: Yes. 16 Q: -- is that correct? 17 A: No, there was two (2) vehicles. 18 Q: There was two (2) vehicles. And 19 provided -- 20 A: And a third vehicle was a -- was a 21 transport-type of unit. 22 Q: Right. 23 A: Actually, about four (4) vehicles


1 were involved, all total. 2 Q: In responding -- in -- in providing 3 those vehicles, you were responding to official requests, 4 were you not? 5 A: We -- yes, requests for assistance 6 from the Ontario Provincial Police, yes. 7 Q: And in -- in receiving those 8 requests, you saw it as appropriate in the event that 9 persons or groups required assistance, that it was 10 appropriate for the St. John Ambulance to be providing 11 equipment and material that -- that might provide aid? 12 A: I forget the first part. We -- I 13 just -- I'm sorry, would you -- 14 Q: In providing those vehicles in 15 response to the official request -- 16 A: Yes? 17 Q: -- your hope in -- in doing so was 18 the equipment and material would be available in the 19 event that individuals or groups needed the assistance of 20 that -- of that equipment and of your... 21 A: It was pretty -- it was narrower -- 22 we agreed to provide the equipment for a specific 23 purpose.


1 Q: Hmm hmm. 2 A: And a specific type of spec -- 3 equipment was used, provided for that purpose and it was 4 provided for communications, yes. 5 Q: For communications. Who was your 6 understanding -- in your understanding, who was it that 7 would be using that equipment for communications? 8 A: It was be -- to be used by the 9 Ontario Provincial Police for communications; that's my 10 understanding at the time of discussions. 11 Q: Now, you mentioned yesterday that the 12 -- one (1) of the outcomes of the situation as you now 13 see it testifying with the -- with the benefit of 14 hindsight, is that there had been a perception of 15 equating of St. John's Ambulance with the police 16 operation; is that correct? 17 You used the phrase, "Equating with the 18 police operation," yesterday. 19 A: I believe we're probably equated with 20 the police operation in very many situations, with our 21 canteen service, with our communications units, with our 22 heavy light generators. Yes, it would be equated with 23 the police operation, yes.


1 Q: But you also said that there was no 2 intent on the part of St. John Ambulance to confuse. 3 Would you like to expand a little on confuse who and 4 confuse who with what? 5 A: Well, I think there's been some 6 speculation around that -- that we -- we had -- were -- 7 that we had misidentified ourselves by helping the 8 Ontario Provincial Police and -- and that was not a fact 9 at all. Our vehicle had -- our vehicles had been in 10 various responsible areas for doing these jobs for quite 11 some time and as we develop these jobs we were doing, 12 such as our various -- our canteen service, our 13 rehabilitation units -- 14 Q: Hmm hmm. 15 A: -- our heavy light generators and 16 that, we started to identify them and we were in the 17 process of identifying these units all the way along. 18 This was -- we were talking ten (10) years 19 ago, I guess, pretty well, and then before that -- so the 20 last fifteen (15) years or so, we've been sort of 21 developing these -- these various responsibilities 22 because really, this area is really the only one that 23 does that St. John-wise.


1 Q: Right. 2 A: And we've been learning. It was a 3 pilot project; we started off with one (1) and we sort of 4 went along. And as we started to develop that, we 5 started to develop the specific vehicles for those 6 purposes and then we started to identify those vehicles 7 like that. 8 Q: Right. As far as you know at the 9 time, did the OPP not have any of its own command post 10 units or command post facilities? 11 A: At that time? 12 Q: Communications facilities? 13 A: At that time? 14 Q: Yes. 15 A: No, they didn't. In fact today they 16 designed a unit much the same as ours. A fifth wheel 17 unit that they use today and they use it very effectively 18 in -- in a lot of different situations that they have. 19 At that time, no, they had much as -- like 20 the railway, they had a very large 18 wheel vehicle that 21 they bring from the Toronto area, the metropolitan areas. 22 And, no, they didn't have any advanced equipment at that 23 time. Lighter equipment -- and they didn't have a great


1 flexibility in that -- that area for communications 2 outside their one (1) command post. 3 Q: When was it that you would have 4 received that request? 5 How -- how much -- and with what kind of 6 lead time might you have received a request for that 7 vehicle? 8 A: I -- I specifically hadn't looked 9 through the -- the -- I believe if I remember correctly, 10 I spoke to Superintendent Carson about a week to a week 11 and a half prior to the vehicle being called. I -- I 12 believe it was around that timeframe. 13 Q: And that vehicle was stored where? 14 A: In London at 741 King Street. 15 Q: Okay. So, it would have taken a 16 matter of an hour or a couple of hours to drive down and 17 bring it to the area? 18 A: To us -- no, it would bring about the 19 same time as we drive now, it drives about the same speed 20 as a normal car. I would say forty-five (45) minutes. 21 To -- well to -- to fifty (50) minutes to an hour, yes. 22 Q: So, this would perhaps have been a 23 matter of the -- of -- of increased convenience in your -


1 - in your view for the -- the Ontario Provincial Police 2 to be requesting to use your equipment rather than to 3 bring a larger vehicle in from Toronto or...? 4 A: No. They brought their unit in from 5 Toronto also. 6 Q: They brought the big unit in from 7 Toronto; the 18 wheel? 8 A: This was -- I think when we talked 9 about it and as we stress with our -- our work with the 10 OPP, is safety. It's all safety and what we try to do, 11 our communication unit was designed to be able to afford 12 at major instances specific for fire what it was, better 13 safety precautions. 14 In other words if you knew what was 15 happening and we had good communications, then it was 16 much safer for everyone. In all aspects of -- of their 17 work and usually the work we were involved in was heavy - 18 - heavy type of work such as very large accidents or 19 derailments and that type of thing. 20 Q: All right. No, I -- thank you. 21 Would you agree going back to the issue of the -- of the 22 emblem and the very distinctive character of your vehicle 23 written with St. John Ambulance written on the side of it


1 and the -- the emblem, the helping emblem on the vehicle, 2 that it might be possible for others -- other 3 organizations, other entities to seek -- to misuse or 4 confuse by having one of your vehicles in a situation 5 where that -- that cover would be provided? 6 A: I -- no, I wouldn't say that. I -- I 7 believe the OPP have got enough moral fibre to say to us 8 if they want to use it that way and make us -- let us 9 have the decision of -- of saying no. We wouldn't 10 provide it for that reason. 11 They were very upfront and they -- they 12 had a concern that they needed communications and that's 13 what we supplied and that was afforded to. There was -- 14 we would not have done that if -- and I think they would 15 have told us. They have in the past if there's been some 16 concern about something, they've always been upfront with 17 us and I think that's the only way you can run a 18 relationship like that really. 19 Q: So, in the event that you were to 20 receive the request and you say you would have had the -- 21 St. John Ambulance would have had the moral capacity to 22 refuse -- 23 A: Well -- I'm sorry.


1 Q: No, go ahead. 2 A: Yes, I think -- for instance they 3 came to us, between their team and the London City Police 4 team, they had a -- a grow-op type of thing, there was 5 special chemicals and that, that we had the acid to 6 respond to but they put up front what the problem could 7 have been for us when we went there and what we would -- 8 and that was -- I mean, they would tell us something if 9 they wanted to and that was not the case. 10 Q: Now, with the benefit of hindsight of 11 the last ten (10) years and the way that particular 12 operation turned out and we'll be hearing evidence, much 13 more evidence about what was involved when we get to 14 police witnesses, but with the benefit of -- of your 15 experience in the following years, have you thought -- 16 have -- has St. John's Ambulance thought about putting 17 policies in place in which specific questions are asked 18 of police and other organizations about the nature of the 19 potential use of your emblem and your vehicles to ensure 20 that they're not inserted into contexts into which things 21 can go awry? 22 A: I think we're getting very -- quite - 23 - as we work with the various entities, we're getting


1 much better at that to -- to put these things -- see this 2 was a very a -- very pilot, this was a very focussed type 3 of operation within the structure here, and we are 4 becoming very, I said familiar with, what things that -- 5 that might come up, and -- such as our SAR unit with 6 letters of understanding, that type of thing. 7 So, as we progress along, yes, we are 8 asking for more clarification on the various things and I 9 think, also, people are -- know where we stand a little 10 closer, too. 11 Q: Hmm hmm. Do you feel at all that the 12 event, as it turned out at Ipperwash Park in September of 13 1995, has in someway resulted in a -- in a black mark on 14 St. John's Ambulance reputation? 15 A: Do I think so? 16 Q: Yes. 17 A: No, I don't think it has. I think 18 that -- that there was a misconception around at the 19 time that we were involved. 20 Now, I picked it up through the various 21 Court cases and that, that I've had to attend to, and 22 listen to talk and that, but generally I don't think it 23 has. But, I think, as I said, I have -- my family was


1 around from around this area and that we travelled this 2 area and we had noticed that, in someone's mind, there 3 was still some concern, yes. 4 Q: Have you been receiving requests for 5 provision of vehicles to aboriginal pow-wows or to 6 aboriginal gatherings of any kind? 7 Are those requests -- have those continued 8 to come in, if they did before, or -- 9 A: Yes -- 10 Q: -- they have? 11 A: -- yes, they have, yes. Very much 12 so, yes. 13 Q: Good. 14 A: In fact, more than we had before. 15 Q: Good. 16 A: I -- 17 Q: Thank you for that. 18 A: Thank you. 19 Q: Thank you, Mr. Commissioner. 20 COMMISSIONER SIDNEY LINDEN: Thank you. 21 Yes, Mr. Rosenthal...? 22 23 (BRIEF PAUSE)


1 MR. PETER ROSENTHAL: Thank you, Mr. 2 Commissioner. Good morning. 3 COMMISSIONER SIDNEY LINDEN: Good 4 morning. 5 6 CROSS-EXAMINATION BY MR. PETER ROSENTHAL: 7 Q: In the process of coming to the 8 podium my computer crashed, but I think it will come up 9 in a moment. Excuse me. 10 11 (BRIEF PAUSE) 12 13 Q: It's did. Okay. Good morning, sir. 14 A: Morning. 15 Q: My name is Peter Rosenthal. I'm one 16 of the Counsel representing a group of people from Stoney 17 Point, under the name Aazhoodena and George Family Group. 18 Now, before I get into some more general 19 areas, I wanted to begin with a narrow, discrete topic if 20 I could. 21 The issue of Karen Bakker, your ambulance 22 driver and her monitoring of Cecil Bernard George -- 23 A: Yes, yes.


1 Q: -- on the way to hospital. Now, I 2 gather you spoke to her about that situation prior to her 3 filling out her ambulance call report; is that correct? 4 A: No, I -- well, we have what we call 5 debriefing -- 6 Q: Yes. 7 A: And during the debriefing, one of the 8 concerns that any senior officer has, is how it affects 9 people at a specific, given time -- 10 Q: Yes. 11 A: -- and we have to -- we try to 12 monitor what is. And specifically with a younger person, 13 at the time, and a person just starting into, and a 14 person that was placed into a position that we hadn't 15 thought they would be in, I took specific -- myself, to 16 speak with her to -- to find out how she -- she was 17 feeling with the situation and she was a little nervous 18 and she was a little upset. 19 Q: Okay. And -- 20 A: Because she was just starting into 21 her career, and that was a major thing for her. 22 Q: Yes. And at that debriefing you 23 suggested to her something like, anybody could have


1 missed the vital signs given the noise as one travels in 2 an ambulance like that. 3 A: No, I wouldn't do that. I wouldn't 4 say I suggested to her. And she had brought -- mentioned 5 to me, and she had mentioned the fact that the medics on 6 scene had said the person had been stable. Once they 7 started travelling, that point in time in travelling, she 8 lost -- she could not obtain the vital signs, 9 specifically when she was doing the blood pressure and 10 that. 11 And she said then all of a sudden it was 12 back again, and I'm not sure what the wording was in 13 between that -- 14 Q: Yeah. 15 A: -- but then the person was stable and 16 was back again, and she said, How could that happen? 17 Well, she sort of indicated, How could that happen? 18 And I said, That it most certainly can in 19 -- in professionally -- even professionally. It is very 20 difficult. It takes a little bit of -- of -- of training 21 to distinguish the road noise coming up through the 22 system as you're travelling and that, and it is -- it is 23 difficult if you're -- and especially if you're nervous


1 yourself and your own adrenalin's pumping. 2 Q: Yeah. And this conversation took 3 place, though, before she filled out her ambulance call 4 report; is that correct? 5 A: I'm -- I'm not sure. I -- she -- 6 yes, she -- in fact, I think she had -- they fill it out 7 immediately after -- immediately after the call. 8 Q: Yes. 9 A: And I think she -- she had it with 10 her. I'm not sure if she had it with her or it was 11 handed in to the box as it usually is. 12 Q: And what had she told you she had 13 done in order to try to check Mr. Cecil Bernard George's 14 vital signs? 15 She had felt manually for a pulse I take 16 it; is that correct? 17 A: Well, she did a -- a -- from what I 18 understood and what she laid out, she had done a -- a 19 precursory examination. I think she found something at 20 the back of the head when she went around the head. She 21 followed through an examination of -- of the patient -- 22 Q: Yes. 23 A: -- after she was in -- the patient


1 was in the unit. 2 Q: But -- but specifically, with respect 3 to the vital signs, she would have done a manual check 4 for pulse, would she, by reaching at his wrist or his 5 throat? 6 A: I would say, yes. 7 Q: And, also, did she tell you that she 8 applied a blood pressure cuff at any time? 9 A: Yes. 10 Q: And the blood pressure read zero? 11 The blood pressure cuff read zero? 12 A: Well, I -- I'm not sure, I -- I 13 didn't -- I can't -- it's been ten (10) years is why. We 14 sort of had a view and I didn't write down notes on it -- 15 Q: Yeah. 16 A: -- and I'm sorry. I -- if -- I'd be 17 -- I'd be guessing at it to tell you right now, like, 18 from word-to-word exactly what she said, how she put it-- 19 Q: Yes. 20 A: -- at that time. 21 Q: You would agree, sir, that it happens 22 from time-to-time that a person's heart stops and then 23 spontaneously starts again ten (10) seconds later, twenty


1 (20) seconds later or a minute later; isn't that correct? 2 A: I can't -- I can't dispute that. I'm 3 -- I'm not a medical person to be able to say. I have 4 heard it happening, but I can't tell you what 5 circumstances at all. I wouldn't even try and guess it. 6 Q: Okay. I'm moving to another area, 7 then. 8 Now, sir, you've had a lot of experience 9 with the Fire Department over the years, you've told us, 10 and with ambulance services. 11 In Toronto it seems, I don't know about 12 other parts, that when there's an emergency and a 9-1-1 13 call, the Fire Department almost invariable gets there 14 before ambulance service does. Is that -- 15 A: Sometimes. 16 Q: Sorry? 17 A: Sometimes. 18 Q: Now, is that your understanding as to 19 what generally happens in this area, for example? 20 A: In this area, yes, it would be -- 21 well, no, just a minute. Depends on -- on the state of 22 whatever -- whatever the -- the emergency facilities 23 would be.


1 In other words, if your car is -- I 2 believe they run two (2) cars out of Forest or this area, 3 and at the time that we're talking about, and if they -- 4 one (1) car was in London and one (1) car was in Sarnia 5 or vice versa, then it could be the Fire Department would 6 be there and deal with it a lot longer, maybe they would 7 have first response maybe here, yes. 8 Q: Yes. 9 A: I don't know. 10 Q: Generally, when there's a 9-1-1 call 11 indicating a first aid emergency of some kind, both fire 12 and ambulance respond to that call; is that correct? 13 A: In larger centres, yes. 14 Q: Yes. And you don't know what the 15 practise is in this centre, then, sir? 16 A: I'm not sure if they have a first -- 17 first call response system or not here. 18 Q: I see. Thank you. And, you don't 19 have any understanding as to -- it appears that the Fire 20 Department never responded to the Ipperwash situation? 21 A: Not -- 22 Q: In this case, you don't have any 23 understanding as to what would occur?


1 A: No, I do not have any understanding 2 of that. 3 Q: Thank you. Now, sir, getting into 4 the area that Mr. Orkin, the previous Counsel, asked you 5 about a bit, first off, the St. John's Ambulance Service 6 is particularly respected I would to suggest to you in 7 general, because people know not only is it a medical 8 service that gives first aid, but also it's staffed by 9 volunteers and people particularly respect that. 10 Is that your understanding, sir? 11 A: Yes, we're all volunteer. All the 12 people in uniform. 13 Q: But, it gains particular respect, it 14 appears, because of that additional factor as well? 15 A: I -- yes, I believe so. 16 Q: Now, on the other hand, except for 17 that factor, in general, members of the public don't have 18 a clear understanding as to the difference between the 19 St. John's ambulance and other ambulance services; isn't 20 that fair to say? 21 A: No. That's -- fair to -- well, they 22 do not realize, a lot of people do not realize it's not 23 subsidized by the Government. In other words they feel


1 it's a Government service. 2 Q: Yes. And they don't realize that 3 there are any particular operational differences between 4 them even though they are in fact are? 5 A: They're not -- no, they're not 6 educated to that fact, no. 7 Q: I'm sorry? 8 A: There's no -- there's no education to 9 that fact. Yeah. 10 Q: Yes. So -- so people think they're 11 pretty much the same operation. 12 A: They're part of the system. 13 Q: Yes. Now -- 14 A: And -- and I might just qualify that 15 and say one (1) -- one (1) point. And they are part of 16 the system and is accepted by the Ministry that at the 17 time, that they were on the call order. 18 Q: Yes. Yes. They are part of the 19 system in a certain sense -- 20 A: Yes. 21 Q: -- but the general public doesn't 22 realize the limitations of that -- 23 A: Yes, yes.


1 Q: -- is that fair to summarize it? 2 A: That's fair to say, yes. 3 Q: Now, you told us that the purpose of 4 the communication trailer was for safety; is that 5 correct, sir? 6 A: That's correct, yes. 7 Q: Now we've of course had much evidence 8 at this Inquiry and you may have heard of some of it and 9 you undoubtedly learned some from the press over the 10 years, that the operation that it was involved in, in 11 fact, was a policing operation at Ipperwash Park at which 12 it was used for, apparently to further the police 13 operation and the police operation ended up with the 14 killing of Dudley George. 15 You understand that; is that correct, sir? 16 A: I understand that, yes. 17 Q: Now, an additional fact that we've 18 learned at this Inquiry is that after Mr. George was 19 shot, there was no ambulance that came to transport him 20 to a hospital. He was transported by his brother Pierre 21 in a harrowing drive and, unfortunately, by the time he 22 arrived at hospital, he was unable to be saved. 23 You understood that too, did you, sir?


1 A: The particulars, I understand he 2 arrived at the hospital by car. I'm not sure what in 3 between with the exception that you stated to me, all 4 that I know there were three (3) amb -- there were two 5 (2) ambulances besides ourselves located with the OPP. 6 Q: Yes, in any event, sir, I just wanted 7 to suggest that to you is background. You told us that 8 you understand why people might have been frustrated, to 9 some extent, as to what happened and with respect to your 10 vehicle and so on. 11 And I thought it might be useful to you to 12 put some of the testimony of one (1) person explaining 13 that relation as he did. David George was one of the 14 witnesses who testified at this Inquiry. He was one of 15 the First Nations people who were in the Park that night. 16 And he testified on October 21st at page 17 82 for those who want to check that I'm reading 18 accurately. 19 "Question: Yeah, you told us that the 20 next day you went to the MNR parking 21 lot with the St. John's Ambulance 22 vehicles? 23 Answer: Yes.


1 Question: And then you beat the van? 2 Answer: Yeah, I gave it a couple of 3 kicks. 4 Question: Why did you do that? 5 Answer: I was just venting my 6 frustration and anger. 7 Question: What -- was it the fact 8 that it was labelled St. John's 9 Ambulance? Did that have any 10 particular affect on you? 11 Answer: Well yeah. Because St. 12 John's Ambulance, they wouldn't help. 13 They wouldn't come to help Dudley or 14 anybody else that night. It was their 15 God damn ambulance. They wouldn't let 16 us use it. And it wasn't -- that one 17 that was there wasn't even an 18 ambulance. There was no lifesaving 19 equipment in there." 20 Now, that's one person's expression of the 21 reason that he felt angry when he saw your vehicles in 22 the parking lot that had been used as command 23 headquarters for the operation that killed Dudley George.


1 A: And he did not realize that that 2 later that time, we were asked to help and we did the 3 relation of -- one of the George's at that time. 4 And we -- and we were caught off guard 5 with that, but because of the nature of the request, we 6 -- we then responded and that was not -- we were not 7 planning on doing that. 8 Q: But, sir, I gather that in the ten 9 (10) years since that event, there hasn't been any high 10 level discussion within St. Johns as to how to guard 11 against something like that happening in future; am I 12 correct? 13 A: Oh I think there has been. We -- 14 we've discussed this a number of times, of protocols; 15 trying to make sure that all our protocols are clear. Oh 16 yes, we -- we've discussed it with the emergency service 17 officer in both levels, national and provincial. 18 Q: Now, sir, if Inspector Carson came to 19 you tomorrow then, with the same request, would you allow 20 him to use the vehicle in the same way as you did ten 21 (10) years ago? 22 A: If he came to me and asked me for the 23 vehicle for communications, I would certainly agree to


1 loan him the vehicle, yes. 2 Q: In spite of what we've learned about 3 the affect it had on people when they saw that a vehicle 4 that they thought of as an ambulance vehicle that should 5 help people was, in their view, implicated in killing, 6 without any justification, Dudley George? 7 A: That would be the same way of 8 refusing the OPP assistance with the rehab -- 9 rehabilitation unit at Ingersoll during the protest. 10 It's there to help -- it's there to help people. It's 11 there to -- to do the best they can for people. 12 That would be like saying the same thing 13 to the Fire Department; We will not respond to a fourth 14 alarm fire because our unit is on the street, and -- and 15 three (3) people die in the fire. 16 I mean, I'm just trying to relate that. I 17 -- I don't know -- I don't know how to answer that. 18 Q: Well, may I -- may I give you 19 suggestion and find out if this has been considered, sir? 20 Has it at least been considered within St. 21 John's that in a situation where the police are 22 requesting use of one (1) of your vehicles for their own 23 operational purposes and where it's going to be under


1 their command as you indicated it was in this instance, 2 that at least the labelling on the outside, 'St. John's 3 Ambulance' and so on, be covered over so that it does not 4 appear to people to be an ambulance vehicle when it's 5 really being used as a police support vehicle? 6 A: We -- we talked about that and -- and 7 what we thought would be a better thing is what we have 8 been trying to do is label the units very clearly again 9 with very defined cresting, in other words, such as a 10 city cresting, such as communications. 11 And that's what we've been trying now, is 12 to increase that so it's not mistaken for another type of 13 vehicle. You're -- yes. 14 Q: Well, sir, isn't it the case that the 15 mobile trailer as now labelled -- 16 A: Yes. 17 Q: -- would still be taken by virtually 18 everyone as being a medical unit when they look at it in 19 spite of the fact that it says, 'Communications Unit' on 20 it? 21 A: I -- I really don't -- besides 22 saying, 'Communications Unit' on it, with all the 23 antennas, I would -- I'd be hard pressed to try to make a


1 judgment. I don't know. I -- I would not, but of 2 course, I'd read it -- I -- but, on the other hand, it 3 maybe could be, I -- I couldn't tell you that. 4 Q: Now, sir, I would suggest to you that 5 virtually everyone except for those in the know like you 6 who know what the numbers mean and so on, would assume 7 that such a vehicle is a communications vehicle if they 8 were able to read that smaller print -- 9 A: Well, it's supposed to be -- 10 Q: -- that was used -- excuse me, sir -- 11 A: Sorry. 12 Q: -- that even if they read that, a 13 communications vehicle to be used for medical assistance 14 purposes rather than for an OPP operation against the 15 First Nations people occupying a park? 16 A: Well, the only thing I can say to you 17 in this regard is, not only is -- St. John's is not only 18 medical, it's safety -- it's safety. We -- we train in 19 first aid to prevent accidents. 20 We provide equipment to prevent accidents, 21 prevent things happening, to make it easier so that we 22 don't run into these specific problems and that's -- it's 23 not just medical; it's safety. It's safety all around in


1 all aspects and that's what we try to teach and that's 2 what we try to provide. 3 Q: And it's your understanding, sir, 4 that in this instance your vehicle contributed to safety? 5 A: I hope so. 6 Q: And in what way was it your 7 understanding it committed -- it contributed to safety 8 rather than lack of safety to the Native people? 9 A: I provided -- oh, I'm sorry, go 10 ahead. 11 Q: What was your understanding as to how 12 it contributed to safety in this instance, sir, where we 13 have the evidence that Dudley George was killed, Cecil 14 Bernard George was very badly beaten -- 15 COMMISSIONER SIDNEY LINDEN: You don't -- 16 you don't need to do -- 17 MR. PETER ROSENTHAL: I don't need to 18 reiterate all that. 19 COMMISSIONER SIDNEY LINDEN: Your 20 question was fine: How did it contribute to safety? 21 MR. PETER ROSENTHAL: Thank you, sir. 22 THE WITNESS: Well, by providing a -- a 23 communicating system to -- virtually in that -- in that


1 unit was directly to -- to ambulance communications; they 2 could have used it. They could have used -- there's a 3 number of systems in that, but it provided a good source 4 of work out of location that they could process the work 5 that they were doing and do it fairly clearly, instead of 6 maybe on pads of paper in -- in cars and that. 7 It provided -- so in that way, it was a 8 much safer way to work. Now, I can't comment what 9 happened during that, but it -- it was a -- good 10 communications is safer in any -- any type of business. 11 12 CONTINUED BY MR. PETER ROSENTHAL: 13 Q: Sir, as you may know, one of the 14 purposes of this Inquiry, in addition to finding out as 15 much as we can about what happened in the events 16 surrounding the death of Dudley George, is the 17 possibility of making recommendations to avoid violence 18 in future. 19 Now, sir, if this Commission were to make 20 a recommendation to the effect that any vehicles that are 21 used in a police operation as part of the police 22 operation as opposed to medical use, should not be 23 labelled medically, should not give people the impression


1 that they're medical vehicles, would St. John's Ambulance 2 take such a recommendation seriously and -- and consider 3 that policy, sir? 4 A: Oh, certainly we would. We would 5 certainly take any recommendation that the Commission 6 would offer and act accordingly and try to do the best to 7 -- to follow through with it. 8 But, I -- to -- to suggest that we not 9 involve ourself with the police in any aspect is, I 10 think, a disservice to the community and to the public, 11 because it is public equipment that we try to be use to 12 the best -- to the best of everyone. 13 Q: Now, you told us, I believe, that -- 14 and in any event, I understand that one of them will tell 15 us, that -- that the two (2) persons from St. John's who 16 went to accompany the trailer, were to act under the 17 direction of the Ontario Provincial Police; is that 18 correct? 19 A: They -- to provide -- they were -- 20 when they went, they -- we were to provide fuel for the 21 unit, to check the -- the generators and that and to 22 refuel the tanks when as required. And that was done on 23 the request of the OPP when the fuel was running low.


1 Q: And were there any restrictions, sir, 2 that you gave them, as you set them on this duty? 3 Did you -- did you caution them they 4 shouldn't think of themselves as police officers, they 5 should just do the specific job, they shouldn't get 6 involved as police officers; anything like that? 7 A: Oh, yeah, yes, very much so. They -- 8 and they were quite aware that they weren't around the 9 actual vehicle, they were back away from the vehicle, so 10 they were set aside from the actual operation. 11 Q: Now, you told us that Inspector 12 Carson attended London about a week before the vehicle 13 was sent in order to make a request that you provide the 14 vehicles -- 15 A: Yeah -- 16 Q: -- and that he inspect them; is that 17 correct? 18 A: A week, a week and a half. 19 Q: Week, week and a half, yes. 20 A: Yes. 21 Q: I'm not worried about the precise 22 date, but I am interested in what he told you they were 23 required for, more specifically.


1 Did he -- he told you that there was going 2 to be some operation involving First Nations people in 3 this area; is that correct? 4 A: What -- no, he said they were 5 expecting to have to provide facility that they could 6 work in, do their paperwork, provide communications and 7 what would we have available. 8 He looked at two (2) different units; 9 actually three (3) different units of -- we got a smaller 10 type of van that has a desk in it and so on and so forth. 11 So, it was more or less a location that 12 they could put out into the field and be able to work out 13 of, to do their paperwork and to provide communication; 14 that type of thing. 15 Q: Yes. 16 A: That's what he sort of looked at and 17 that's what he was looking at -- 18 Q: But, he explained it was with respect 19 to some First Nations people, did he not? 20 A: I don't know if he said first Nations 21 people. He said, I believe he did say Ipperwash -- 22 Q: Ipperwash -- 23 A: -- or the --


1 Q: Yes. So he gave you the 2 understanding in whatever words he might have used, and I 3 realize it's ten (10) years later and you wouldn't recall 4 the words probably, but he gave you the understanding 5 that it was some operation to do with Ipperwash Park and 6 some policing operation with respect to that -- 7 A: Yes. 8 Q: -- is that correct? 9 A: Yes, yes, yes. 10 Q: That he anticipated, I believe you 11 told us yesterday, he anticipated such an operation being 12 required sometime but he wasn't sure when and where? 13 A: He wasn't even sure it was going to 14 come to fruition. 15 Q: Okay. 16 A: He just said if -- if this something 17 materialized would we be able to assist him with the 18 facility to be able to provide this office type space. 19 Q: And did you understand that it was 20 with respect to anticipated occupation of Ipperwash Park 21 or no? 22 A: No, I don't -- I can't say that, no. 23 Q: You can't recall if --


1 A: No, I can't say, no. 2 Q: You recall Ipperwash Park, but you 3 don't recall -- 4 A: No. 5 Q: -- more detail? 6 A: Yes. Well, Forest area. The 7 Ipperwash Forest area, he said. 8 Q: Now, when you were answering 9 questions for Mr. Worme yesterday, you indicated 10 something like, you were always cautioned not to speak 11 about such matters when you were involved in such 12 discussions with police officers. 13 You recall that evidence, sir? 14 A: No, I said it's always -- no matter 15 where we go -- 16 Q: Yeah -- 17 A: -- we're always cautioned, both CN, 18 fire, anywhere, that there's only one (1) speaking voice 19 and not to -- not -- if anyone is to ask, it's always to 20 be directed through the public relations person for that 21 specific entity. 22 Q: Yes, but then the -- 23 A: And he -- and Carson had spoken to


1 me, he said that I was to deal with him and any was to be 2 referred to him if there was any questions. 3 Q: Yes. But then, more specifically, 4 Inspector Carson told you something to the effect of, we 5 should keep this information to ourselves -- 6 A: Well, I think the -- the point -- 7 yes, he said that it should not be -- it should not be -- 8 it should not make -- spoken around or that if there's 9 any questions about us, it should be directed to him. 10 That's -- it's as simple as that. It's 11 not like he was saying that I wasn't -- he just -- it 12 wasn't supposed to be, you know, just bandied about, hey. 13 And that's common practice; that's a 14 caution that they always say. The police always say, you 15 know, You talk to us, you do not talk to anybody else 16 about any type of their work. 17 And that's not only police, but that's 18 pretty well anyone we deal with. You can't -- you can't 19 do that. It's got to go through one (1) person. One (1) 20 person's the boss, eh, when you get involved? 21 Q: Yes, one (1) person's boss and one 22 (1) person is spokesperson, but, sir, I would suggest to 23 you in this case, you were told specifically by Inspector


1 Carson, let's keep this to ourselves and you understood 2 that this had some particular secrecy about it, did you 3 not, sir, at the time? 4 A: No, I don't think -- sorry, no I 5 don't think so; the secrecy isn't that much. I think he 6 wanted to make sure that if anyone was questioning 7 anything that he had -- he was able to deal with it. 8 I -- I don't think there was any secrecy 9 on it. He just didn't want us to -- to direct it to any 10 other Detachment, because he was from Region (phonetic), 11 I believe. 12 And there -- there was, I think, another 13 Detachment on Exeter Road, I believe. So, there was a 14 couple of different places, so I think what he was trying 15 to tell me was to -- to direct everything to him, not to 16 -- to go through any other locations. 17 18 (BRIEF PAUSE) 19 20 Q: Sir, would you please turn to your 21 Tab 11, which is a document entitled, Anticipated 22 Evidence of Peter Harding, and it's the SIU interview 23 with you, sir, that took place on 27 September, 1995.


1 A: Page...? 2 Q: Do we -- 3 A: I'm sorry, page? 4 Q: It's your Tab 11. 5 A: My eleven (11), but page? 6 Q: Yes, I'll refer to the page in a 7 moment, sir -- 8 A: Oh -- 9 Q: -- but I wanted to ask you first. Do 10 you recall being interviewed by the SIU, an officer named 11 -- or an SIU person named Muir (phonetic), apparently? 12 A: It's getting a little murky, but I -- 13 I -- I must have been interviewed at least four (4) or 14 five (5) times -- 15 Q: Yes. 16 A: -- by various entities. 17 Q: Yes. And this one at the -- at first 18 page, it says today is Wednesday 27 September, 1995. So, 19 you would -- 20 A: I won't dispute that, no. 21 Q: You probably were interviewed by this 22 person on that day, sir? 23 A: Yes, I probably -- yes, I would think


1 so, yes. 2 Q: So, this would have been several 3 weeks after the event? 4 A: All right. Yes. 5 Q: As opposed to ten (10) years and you 6 been -- 7 A: Yes, oh yeah. 8 Q: -- would have been much better, 9 obviously. 10 Now, sir, on Page 3 then, virtually right 11 in the middle of the page, you're asked by Officer Muir: 12 "Okay. And what happened after that 13 time?" 14 And you answer as follows, according to 15 the transcript: 16 ˘Inspector Carson asked me if I would 17 keep this visit completely within our 18 own -- ourselves, as they were 19 expecting an operation at Ipperwash. 20 They didn't know when or where, or if 21 it would materialize, but they were 22 planning in case something did happen." 23 A: "Ourselves"; I -- in that context, it


1 means our region rather than the other policing units 2 there. And there was a London detachment on Exeter Road 3 and the regional detachment was out somewhere else, so I 4 think that not -- that's where I -- what I had meant to 5 tell the SIU, when they were talking is that what you 6 want to do is not to -- if I had to deal with them, was 7 not to these other detachments. 8 It was to the regional unit within 9 ourselves, within the unit to -- to deal with him rather 10 than units there, because there is a number of -- of -- 11 and now, today, it's even more confusing than ever with 12 the various detachments around. 13 Q: Now, you understood at the time you 14 were speaking with Inspector Carson that there was a 15 potential for violence at this incident that he was going 16 to use your vehicle for; is that correct? 17 A: I -- I wouldn't say that, no. In 18 fact, no, I thought they were, as most cases be, that 19 they were going to arbitrate and there would be -- there 20 would be nothing come of it. No one would ever have 21 guessed that that would have happened really, I don't 22 think, not -- especially the police. 23 Q: Well, sir, you were concerned about


1 the security of the people that you were sending, right? 2 A: Security of them? 3 Q: Security of your persons? 4 A: I was -- I was concerned that, like 5 in every case that we -- we put them in, that they do not 6 bother the -- the entity with -- they're serving with and 7 that they keep themselves separately from it. I'm not 8 sure with the safety of them. 9 Q: Well, sir, if you could turn, please, 10 to page 8 of the same document that you have in front of 11 you? 12 A: Page -- page 3? 13 Q: Page 8, sir. 14 A: Oh, eight (8), I'm sorry. 15 Q: Towards the -- the bottom, the last 16 entry under the name, 'Harding' on that page says: 17 "He -- I had some specific questions of 18 him [and 'him' is obviously Inspector 19 Carson from the context] and I 20 questioned him as to the security of -- 21 of our people on such an operation. Of 22 course, we always do that and we had 23 agreed that our people would not be


1 part of the overall operation with 2 exception of what it took to maintain 3 any specific unit we had there and it 4 would be a very secondary role." 5 So, evidently, sir, you did express 6 concern about security of your people? 7 A: Well, that not only means them being 8 hurt an any way. We're always concerned about heavy 9 equipment and that, no matter where we put our unit. 10 Security is -- does not mean one (1) 11 specific thing, but that they're -- they're out of the 12 way, that they have -- they're not in the way of anyone 13 specifically. Security is sort of a broad term, too. 14 Q: Now, sir, I would refer to the next 15 page of that document, the SIU interview, as well. Your 16 name appears again right in the middle of the page and 17 the answer attributed to you is: 18 "Yes, and he explained at that time it 19 was like a two-fold. The reason why we 20 had to keep the request confidential 21 and one (1) was, they weren't sure that 22 there was going to be anything -- 23 anything happen at all was one (1)


1 thing. And the other situation was 2 that if something did happen, or if 3 they did not want to give, you know, 4 second-guessing from anyone or any 5 agency. 6 So, they -- the people they wanted 7 involved, they wanted them -- indicated 8 to them directly themselves, so in the 9 applying stages that they weren't sure 10 what was going to happen so they wanted 11 it to be kept fairly quietly." 12 Now, sir, I would ask you several things 13 about your answer there. 14 It does suggest, does it not, that there 15 was a particular request about confidentiality in this 16 case as opposed to the general notion that there's only 17 one (1) spokesperson? 18 A: They wanted -- well, still it's -- I 19 refer back -- it's going back to the region. They wanted 20 to deal with the regional unit, rather than getting 21 involved with any other of the constables or any other of 22 the -- of the -- the staff, as it were, within our whole 23 area and they wanted to keep it within the regional


1 because it's their -- it was their responsibility and it 2 was their assignments. 3 Q: Now, what did this mean about 4 Inspector Carson not wanting any second-guessing from 5 anyone or any agency? 6 What did you understand that to mean, sir? 7 A: That -- they didn't want us to -- 8 they wanted -- if there was any question that we had, we 9 were not to ask any other person on the department 10 because they would not know exactly what was happening. 11 I was to go directly to him. Now, if 12 anyone else was involved with our units, our units -- our 13 search and rescue or whatever the case may be, not search 14 and rescue, but our emergency services support team, they 15 were to go directly to him. 16 In other words, if I assigned a senior 17 officer to it, he was to -- to directly deal with Mr. 18 Cars -- or Superintendent Carson. 19 Q: Sir, do you assert that that's a 20 common request also that the police or other agencies 21 requesting assistance from you say words to the affect 22 of, We don't want any second-guessing from anyone or any 23 agency?


1 A: That could've been my term. I don't 2 remember John Carson saying that. That could have been 3 my interpretation of what he told me, because I think I 4 said, a second-guessing. 5 Q: Well, sir, did you -- you do agree 6 that you would have said these words on September 27, 7 1995? 8 A: Yes I -- if they're written down, I 9 would agree that I said them, yes. 10 Q: And would you agree that what you 11 said at that time was that he explained to you, among 12 other things, that he didn't want any second-guessing 13 from anyone or any agency? 14 And that's what you said at that time; is 15 that not true, sir? 16 A: That's what I said at that time -- I 17 must have. I -- I can't remember exactly, no. 18 Q: Yes. 19 A: But, if you're asking me now to 20 interpret what I suggest at that time, I'm -- I'm asking 21 -- just saying to you that that meant that we were not -- 22 we're to go directly to him. We weren't to try to send a 23 unit out without having it cleared with him.


1 If we changed a unit breakdown it had to 2 be cleared with him, if we replaced a unit; I believe 3 that's what we're trying to get across. 4 Q: But, you don't recall now, ten (10) 5 years later, what you meant at that time, right? 6 A: What I meant at that time? 7 Q: When you explained to SIU that John 8 Carson told you he didn't want anyone second-guessing. 9 A: Well, I think that's quite right. He 10 didn't want -- he wanted to be -- look after the complete 11 operation and he didn't want anyone suggesting to him to 12 change what we had agreed upon. 13 Q: Now, sir, you told us something 14 cryptically yesterday that I'm not sure if I understood 15 in answering questions to Mr. Worme. You were asked by 16 Mr. Worme on page 153 towards the end of the page, and 17 then it continues on page 154, if anyone wants to check 18 that I'm reading it accurately. 19 "Question: Outside of London you 20 provided these services? 21 Answer: Yes, we do. We do on the 22 request. It has clear our Province and 23 if it goes outside of our Province it


1 has to clear on National Headquarters." 2 Now, I wanted to ask you, sir, the first 3 part of that: 4 "We do on the request. It has to clear 5 our Province." 6 What is the process for clearing our 7 Province? 8 A: I, if -- if it goes anywhere outside 9 our Province, anywhere outside my area -- 10 Q: Outside the London area that you're 11 faced with. 12 A: London to Middlesex. 13 Q: Yes. 14 A: With the exception of the corridor 15 between Windsor and Toronto, I have agreements to work in 16 that corridor because of the equipment we have. It's not 17 handled anywhere else than St. John, in the province. 18 If outside that -- the norm of our 19 operations by going to the Province I cleared -- I mean I 20 have to call the emergency service officer for the 21 Province of Ontario and tell him that our equipment has 22 been requested and that it is now being used. 23 In other words, he can't rely on it for


1 another situation might come up. 2 Q: I see. And that's an emergency 3 service officer of the St. John's Ambulance unit? 4 A: That's correct, yes. 5 Q: And so in this case when this request 6 was made, was that sufficiently out of -- was that out of 7 your area and therefore requiring such -- 8 A: No. That's -- this request was in 9 the -- within our jurisdiction between Windsor and 10 Toronto in southwestern Ontario. And that was -- we 11 responded on 12 that -- 13 Q: So, you did not have to seek anyone 14 else's permission or notify anyone else in order to 15 dispatch this vehicle? 16 A: No, but we did. 17 Q: But you did? 18 A: Yes. 19 Q: I see. And who -- who did you re -- 20 A: We notified our emergency service 21 officer that our equipment was being used. 22 Q: I see. 23 A: When it was dispatched. Not -- not


1 prior to it -- 2 Q: Yes. 3 A: -- but when the equipment went out 4 the door and we said now it's -- it's being used and it's 5 not available to anyone else. 6 Q: And after the events that transpired 7 -- did transpire with respect to this, was there any 8 discussion at higher levels of how your vehicle had been 9 used on that occasion, within St. John's Ambulance 10 Service? 11 A: Yes, there was. 12 Q: And can you tell us about that, sir? 13 A: Well, of course I had to -- to submit 14 a report on the whole operation and, of course, that's -- 15 report was regarding the damage and there was a number of 16 meetings in reference to it. 17 Q: And was there any conclusion about 18 whether it was appropriate to deploy the vehicle in these 19 circumstances, whether there should be any cautions in 20 future or anything like that? 21 A: They ask or they rely on every 22 officer within the -- within the structure to be able to 23 -- be able to make a judgment to when to respond units,


1 and there is very little time that we wouldn't respond a 2 vehicle. 3 I mean, I can -- when we sent these five 4 (5) units to Nyann (phonetic) in Quebec for five (5) 5 weeks, that was a very dangerous situation and, you know, 6 if I was looking at -- you know, I wouldn't have gone if 7 I -- if I was concerned about danger or not -- of losing 8 some equipment. 9 It could happen any time and in any 10 situation, but I'm not -- I don't know what you're 11 driving at in regard to... 12 Q: Now, you told us yesterday and, to a 13 naive person like me and, I would assume, to other naive 14 people, it seems odd that you were concerned about the 15 possibility of your vehicles being used for ambulance 16 services, because there are restrictions on that, and you 17 weren't concerned about them being used for non-ambulance 18 services. 19 But, getting to the restriction on 20 ambulance services, you -- you understood, you told us, 21 that there were no other ambulances available, is why the 22 St. John's ambulance was pressed into service with 23 respect to Cecil Bernard George; is that correct?


1 A: Well, I -- you have to -- you have to 2 question the people onsite. On the report that I 3 received and on the brief -- debriefing, I understood 4 that at the time that our unit has -- was asked to 5 request to be of help to Mr. George, was when they had 6 been standing by. 7 One (1) vehicle left, a second vehicle 8 left, because they had two (2) Ministry ambulance units 9 standing by there; obviously they had been sent out on 10 call somewhere. And then we were then asked to assist 11 when Mr. George came up. 12 Q: Yes. And it was your understanding 13 that there were no other Ministry ambulance vehicles 14 available, and that's why you were called upon to assist; 15 is that correct? 16 A: All I can say, there was none there. 17 There was none right, physically -- 18 Q: Yes. 19 A: -- at this location. 20 Q: And if there had been Ministry 21 ambulances available nearby, then they should have been 22 utilised rather than your ambulance; is that correct? 23 A: If they had have been there, they


1 would have been probably used, yes. Well not probably, 2 they would have been used. 3 Q: And should have been? 4 A: Yes. 5 6 (BRIEF PAUSE) 7 8 Q: Now, you spoke to Inspector Carson, 9 also, after the incident at Ipperwash Park on September 10 6th; is that correct? 11 A: That's correct. 12 Q: And what explanation did he give you, 13 sir, for having left your equipment in the Ministry of 14 Natural Resources parking lot? 15 A: He explained to me that the officers 16 had to leave. And I'm trying to figure out his way -- 17 how he put it; I didn't -- I didn't review that. 18 He had a -- they had to leave and they had 19 to also leave some of their equipment at the same time, 20 and they had to leave in a -- in a hurry, type of thing. 21 I'm just -- can't remember the word he 22 used, but they left in a hurry. 23 Q: I see. And did he -- did he indicate


1 at what time that was, in relation to the killing of 2 Dudley George? 3 A: No. 4 Q: Was it right after, did he say, or 5 some other point? 6 A: No, he didn't -- he didn't emphasize 7 any time specifically, just that it had happened. And, 8 see, prior to that he called me and asked me to come up 9 to see him. I was in London and he asked me to come to 10 Forest to see him and I came to Forest and that's when he 11 explained to me what happened. 12 And then he just went on to explain of -- 13 that the equipment was still not returned and that they 14 would keep us informed of what was happening. 15 Q: At the time you had this 16 conversation, you knew and it was evident to you that 17 Inspector Carson knew, that Dudley George had been 18 killed; is that correct? 19 A: I'm trying to think back. I -- I'm 20 assuming I knew with that -- that -- I probably didn't 21 know that. 22 Q: Yes. 23 A: I --


1 Q: Well -- and you also certainly knew 2 that Cecil Bernard George had been badly beaten because 3 you had had the debriefing with Ms. Bakker? 4 A: I knew -- I knew that, yes. 5 Q: And you -- had you, perhaps, heard 6 that some other people had been injured as well or no? 7 A: No. No. 8 Q: Okay. So, in your discussion with 9 Inspector Carson after the event, did he give you any 10 information about what had happened with respect to 11 Dudley George -- 12 A: No. 13 Q: -- and your -- Mr. Cecil Bernard 14 George? 15 A: No. 16 Q: No? 17 A: No. 18 Q: That wasn't discussed? 19 A: No. 20 Q: Did he explain to you why the Ontario 21 Provincial Police had marched on the Park at night time? 22 A: No. 23 Q: Did he indicate to you in any way


1 that there was political pressure surrounding the OPP 2 activities on that occasion? 3 A: No, he didn't at all. 4 Q: Were you aware of such allegations 5 from any source, sir? 6 A: Not until quite a while after, I -- 7 only reading the papers and that I was able to see there 8 was some concern. 9 Q: Now, you told us, I believe 10 yesterday, that Inspector Carson was very concerned about 11 how the damage to your vehicle would affect the whole 12 community; is that correct? 13 A: Well, as -- as far as being of 14 service to, if it was needed again for something else, he 15 was concerned. He was concerned about the damage to the 16 equipment and not being available if -- if anything 17 happened and they would try to alleviate that as soon as 18 possible. 19 And, he didn't know anything about the 20 damage at the time, I don't think, when I was talking to 21 him because we hadn't even gotten it back yet. I don't - 22 - I mean, I'm not sure, because I'm not sure if he said 23 anything about the damage, he just said the equipment was


1 -- was at the Park and they did not have it back. He 2 never really emphasized much damage on the equipment at 3 that time. 4 Q: I see. Did he express to you any 5 concern about how the killing of Dudley George might 6 affect the community? 7 A: No. No, he -- he never -- he never 8 mentioned anything to me about anybody at all other than 9 our part. 10 Q: Did he, in any way, suggest to you 11 any regret about the way the OPP operation had taken 12 place? 13 A: I'm not so much sure he said it, I 14 think he was -- I think he was disappointed that -- that 15 it all unfolded the way it did. 16 I think he was surprised it unfolded the 17 way it did to a certain degree. You could almost see it 18 -- the way when he was sort of halfway apologizing that 19 we didn't have the equipment and that, that he was -- he 20 was surprised and I think he was taken aback and I think 21 he was concerned. I don't know how to put other than 22 that. He wasn't -- he wasn't his cheerful self, anyway, 23 I'll tell you that right now.


1 MR. PETER ROSENTHAL: Your indulgence, 2 Mr. Commissioner. Thank you, Mr. Commissioner. Thank 3 you, sir. 4 COMMISSIONER SIDNEY LINDEN: Thank you 5 very much, Mr. Rosenthal. 6 Mr. Scullion...? 7 8 (BRIEF PAUSE) 9 10 MR. KEVIN SCULLION: I can say, Mr. 11 Commissioner, I have a new found appreciation for my 12 fellow Counsel over the past eight (8) months, as I 13 follow along the cross-examinations and made a couple of 14 checkmarks on my notes, but I'll try to keep close to my 15 time estimate, although it may be a little disjointed. 16 17 CROSS-EXAMINATION BY MR. KEVIN SCULLION: 18 Q: Superintendent Harding, as I've 19 listened to your evidence, it's clear to me that you're 20 quite proud of the St. John Ambulance organization. 21 You've been there with -- for thirty-two 22 (32) years; is that fair to say? 23 A: Thirty-five (35) getting close to,


1 now. 2 Q: Thirty-five (35) now. Okay. Back in 3 '95, you'd been around twenty-five (25) years, then, with 4 the St. John? 5 A: Yes. 6 Q: Okay. And you had significant 7 experience from your days as Chief of the London Fire 8 Service? 9 A: Experience in what? 10 Q: I guess in all kinds of life saving 11 techniques and -- and situations? 12 A: Community response and overall EMS, 13 yes. 14 Q: Okay. 15 A: Yes, I think so. 16 Q: You'd agree with me that this was a 17 fairly extraordinary situation or it turned into an 18 extraordinary situation? 19 A: It did, to say the least. 20 Q: Okay. I've -- I've been proceeding 21 on the assumption that you are ultimately responsible for 22 the St. John Ambulance vehicles being in this parking lot 23 and assisting the OPP; is that -- is that fair or did you


1 report to somebody else? 2 A: No, I was ultimately responsible. 3 They -- I have a certain amount of leeway and 4 flexibility in -- in -- in issuing the units and that, 5 yes. 6 Q: Okay. 7 A: I was totally responsible. 8 Q: But, the decisions were ultimately 9 made by you after you received phone calls from, I guess, 10 initially it was somebody from the OPP and then you 11 consulted with Superintendent Carson? 12 A: I was contacted once. I believe it 13 was one of the corporals I believe, and I didn't mark the 14 name down, and he said that Inspector Carson, we can 15 contact in the -- in that -- there wasn't any other 16 discussion. They just if you want to talk, where could 17 he get a hold of me that was all. 18 Q: Right. It was just a contact person. 19 They set up a meeting with you and Superintendent Carson. 20 And that was about a week, week and a half beforehand 21 from what I've heard? 22 A: Yeah I -- 23 Q: I'm not looking for the exact.


1 A: -- between a week and a week and a 2 half, yes, roughly. 3 Q: Okay. Is it fair to say that when 4 you met with Superintendent Carson, he indicated to you 5 that they expected something to happen the week of 6 September 4th in the Ipperwash area? 7 A: He -- he indicated to me that 8 something happened. He -- I'm not sure if he said that 9 there was going to be something happening. He wasn't 10 sure if they were going to be involved in a response to 11 that area and how -- the size of the response would be; 12 if that's a way to put it. 13 He wasn't sure of yes or no, if it was 14 going to happen, it wasn't going to happen, but there was 15 something afoot. That's all I can say. 16 Q: Okay. Just to be clear. You had a 17 discussion with Superintendent Carson when he came to 18 visit and take a look at your equipment, the trailers -- 19 A: Yes. 20 Q: -- and you had a discussion with 21 Superintendent Carson after the incidents of September 22 6th? 23 A: That's correct.


1 Q: Did you speak with him between those 2 two (2) time periods? 3 A: Only on telephone. He called me and 4 -- and said -- asked me to -- to attend in Forest; that 5 was after the incident happened. 6 Q: Okay. 7 A: And he explained that he had some 8 equipment problems. 9 Q: Okay. I'm -- I'm just trying to 10 clarify. So, before the vehicle -- or before you 11 received a call to move the vehicles September 4th, you 12 met with Superintendent Carson? 13 A: At our station, yes. 14 Q: -- right. You walked him through 15 your equipment, he picked the one that he preferred -- 16 A: Yes. 17 Q: -- which is what we've now seen as 18 four four four (444)? 19 A: Right. 20 Q: After that point in time you didn't 21 speak with Superintendent Carson, specifically, up until 22 after the September 6th incident? 23 A: That's correct.


1 Q: All right. You received a call from 2 somebody on September 4th saying that what they had 3 expected to occur was now occurring and they needed your 4 assistance? 5 A: They asked us to attend. And I said 6 Forest yesterday and I'm mistaken. 7 We were sent to a checkpoint. It was out 8 of Forest, the checkpoint was supervised out of Forest, 9 and to meet an officer; I believe it was an NCO. And the 10 NCO would take the vehicle into that location, but they 11 had to go to a checkpoint first. 12 Q: Okay. But, that wasn't 13 Superintendent Carson who called you at that point. 14 A: No. No. 15 Q: It struck me as curious, you 16 mentioned today in response to one of the questions, I 17 believe it was from Mr. Rosenthal, that you thought they 18 were going to arbitrate. And that's what I noted from 19 your evidence this morning that they were going to 20 arbitrate. 21 I suggest to you that when you spoke with 22 Superintendent Carson, when you walked him through the 23 vehicles, he indicated to you that he expected there to


1 be a peaceful protest of the Ipperwash Provincial Park 2 and he thought it might happen after September 4th. 3 A: Yeah. That's what he suggested. I 4 mean he asked -- that's sort of the an inference. And he 5 wanted the equipment for good communications and that 6 they wanted sort of an office advance type of office 7 where the -- where the protest was happening. 8 And now we use "protest," he didn't use 9 the word "protest." I think he -- he used demonstration 10 or something like that or -- but I can't tell you, 11 exactly, the wording. 12 Q: No I understand. A protest, 13 occupation, demonstration. But, he used something along 14 those lines and said it's going to be a peaceful 15 occupation of the Park and that they -- they needed your 16 assistance and he picked out 444 Trailer? 17 A: Yes. And then he wanted a place they 18 could work out of, like office and communication space. 19 Q: Sure. And if I understand you 20 correctly, you understood this to be your -- your trailer 21 would be used as their advance location and that they 22 would have a far more sophisticated or larger trailer or 23 operation that would be located presumably in Forest or


1 back from where your advance position would be? 2 A: Well he didn't go -- he said that 3 they had -- he didn't have any plan at this -- this -- it 4 was going to be an advance situation to them and that if 5 it unfolded, there would be -- we didn't know and I 6 didn't know that they did have a command -- a large 7 command unit. 8 And he indicated to me when we were 9 talking that there was a -- if anything unfolded that 10 this would be used also and I don't think he mentioned 11 where it was going to be or anything like that. I know 12 where it eventually ended up was in Forest. 13 Q: Right. On September 4th they 14 indicated where they needed yours to go. 15 A: Yeah. Well they -- they said they 16 would direct it to where they wanted it to do. 17 Q: Somebody would take you but you 18 understood it would be in the general vicinity of the 19 Park? 20 A: Well, we weren't sure that -- before. 21 Prior to that, no, they said in the Forest/Ipperwash 22 area. 23 Q: Okay, just generally?


1 A: Yes. 2 Q: All right. He didn't 3 specifically you were going to be an advance unit close 4 to the Park or in the Park? 5 A: No, no, no. 6 Q: All right. Is it fair to say that 7 when he was discussing this with you, you understood it 8 would be simply a communications situation; you were just 9 providing support for their communications? 10 A: Communications and office space 11 availability to conduct business type of things, yes. 12 Q: Right, to add on to what they already 13 had? 14 A: Yes. Correct, yes. 15 Q: And if I understood you correctly, 16 you now say that they have a fifth wheel of their own 17 now, kind of mimics what you had back in '95? 18 A: I think they may have a couple of 19 them, but yes, almost the same type of unit. 20 Q: Okay. Your understanding was they 21 didn't have that back in '95 and they needed to borrow 22 yours for this purpose? 23 A: No, they didn't have. No, they


1 didn't it have because it just came out after -- 2 Q: Okay. There was some question this 3 morning about security of your people and I understood 4 your evidence to be that simply your general 5 understanding or generally you like to look out to see 6 what they're doing, how they're doing it, and -- and 7 what's going to happen as opposed to making sure they're 8 not going to be shot or part of an incident? 9 A: Well, it's not only that, but 10 depending on wherever we go, for instance, if we're with 11 the Railway, we sure don't want them on track line with 12 the heavy equipment unless they're, you know, they're 13 protected, too, to make sure that -- we don't want to put 14 them in harm's way in any way, shape or form. That's 15 all. 16 Q: Okay. And that's how you were using 17 the term "security" at the time? 18 A: Yes. 19 Q: All right. Yesterday there was a 20 booklet made in Exhibit P-339 that seemed to set out a 21 protocol. 22 A: Yes. 23 Q: Do you need to take a look at that or


1 do you know it fairly well? 2 A: No, I think I -- I think I know. 3 It's changed now. The protocol's changed a little bit, 4 but I -- I think I can remember back. 5 Q: Well, I noticed that you wrote it, so 6 I assume that you knew it pretty well. 7 A: Yeah, well, I can remember -- I think 8 I remember the changes. 9 Q: Okay. My impression from that 10 protocol was, it has to do with situations where you're 11 called in for medical assistance or other kind of 12 assistance as opposed to simply providing this 13 communication system? 14 A: Yes. The -- they can ask for 15 whatever they wish. If -- you noticed in the protocol 16 there's a list of -- of seven (7) -- five (5) different 17 areas -- areas of -- rehabilitation, canteen, heavy light 18 generators, communications; there are various areas of 19 responsibility. 20 Q: Right. 21 A: And the protocol follows any one of 22 those responsibilities, say. So, in other words, if 23 anyone wanted -- see, that book is usually at all of the


1 communication centres within our area. 2 And what happens there with that book is 3 that they are able to look through it and find what 4 service or what they may require. They look at the 5 equipment that they may want and then they'll go through 6 the procedure in notifying us. 7 Q: Okay. And the protocol is the 8 general process that you look to your personnel to follow 9 so you can keep track of their requests, what the 10 response is, what the result is and any debriefings 11 afterwards? 12 A: That's correct, yes. 13 Q: All right. And my comment was that I 14 didn't see anything specific to the provision of the 15 communications unit. I'm assuming that's done on a 16 little more of an ad hoc basis. 17 There isn't as much paperwork that goes 18 with that type of request? 19 A: There is now. The communications 20 unit -- you mean it's not listed in there? 21 Q: It's not. 22 A: Well, it is now. 23 Q: All right. So, it's changed?


1 A: In the new -- the new -- that was -- 2 Mr. Worme asked me for the original units, you notice the 3 cresting is not on the vehicles or anything else, either, 4 in that. And that was the original protocol book we had. 5 The one now has got the communications 6 listed and -- and, I believe, one (1) more 7 responsibility. SARS is also listed now, too, which 8 wasn't in that book. 9 Q: Okay. All right. So, that's changed 10 since 1995? 11 A: That's correct, yes. 12 Q: We -- we were focussed in 1995. 13 A: Okay. 14 Q: That's why all these requests have 15 been made for the '95 period. We're trying to see what 16 was in place at that point in time. 17 A: All right. 18 Q: So, is it fair to say that there was 19 no note or no log book in effect back in 1995 where you 20 would make a note say, I was called by so-and-so for the 21 following purpose for the communications vehicle? 22 A: Yes. Well -- no, when I was called 23 originally, you mean for the first interview?


1 Q: Yes. 2 A: No. 3 Q: Okay. 4 A: I didn't log that. The only -- the 5 log would start for that vehicle when the second call 6 came for the unit to respond. 7 Q: Right. 8 A: Then the time would be marked down 9 and who called and then it would follow on from that 10 point. 11 Q: All right. So, you didn't log the 12 first call, you didn't log the visit by Superintendent 13 Carson, only when you got called on the 4th and the 14 vehicle was arranged to travel? 15 A: That's correct, because it was not 16 even -- at the time, we didn't even know it was going to 17 be a fact. 18 Q: Okay. 19 A: It was just suspecting the incident. 20 Q: Fair enough. On the 4th, when you 21 were called, you still thought this was a simple, 22 straightforward request for a communications system that 23 would be assisting the OPP in whatever they were doing in


1 the Ipperwash area? 2 A: That's correct, yes. 3 Q: And your vehicle responded, it had a 4 police escort and they took it where it needed to go? 5 A: Once it reached the checkpoint, yes, 6 then they escorted it to where it had to go. 7 Q: Okay. Were you involved at all in 8 this particular operation after, or from September 4th up 9 until the call after the September 6th incident? 10 And I'll be more -- 11 A: I was not involved. Once that unit 12 left London, I was not -- I had a senior officer involved 13 from that point on to -- when the equipment was lost. 14 The next time I became involved was when I received a 15 phone call to attend at Forest, and then I became 16 involved with seeing Inspector Carson and listening to 17 what happened and -- 18 Q: I'll -- 19 A: -- then receiving -- 20 Q: -- I'll get to that in a -- 21 A: Okay. 22 Q: -- in a little bit. 23 A: Okay, sorry.


1 Q: So, you didn't receive any phone 2 calls, I understand, on the 4th, 5th or the 6th up until 3 the one we're now speaking of -- 4 A: No. 5 Q: -- and who was the senior officer 6 that was in charge of the area for you? 7 A: Paul -- Paul Harding. 8 Q: That's your son? 9 A: Yes. 10 Q: All right. Would he be in constant 11 contact with the people that were manning the service of 12 this communications centre? 13 A: Yes, he had been there since its 14 placement. The unit was placed in position and he left 15 the location because it was very quiet and it was -- they 16 were expecting no problems whatsoever. 17 He went back and changed shifts for the 18 next day and went -- came back to London for some rest. 19 Q: Okay. Let's go through that in 20 pieces. You say that he left the area; I'm assuming 21 that's on September the 6th? 22 A: No, he took the unit in, I'm just -- 23 I haven't got the dates here, he took the unit in and I


1 think by the time they got it placed, it was being close 2 to midnight, it was 11:00 -- 11:00 at night, it was very 3 late in the night. 4 Q: Yeah. Let me help you with the 5 dates. Your evidence and notes that we have indicate 6 it's around midnight, 12:30 the morning of September the 7 5th, the Tuesday. 8 That's when it arrives -- 9 A: Arrived at site -- 10 Q: -- and was put in place. 11 A: Yes. 12 Q: All right. So Paul Harding is in 13 charge of that -- 14 A: The unit -- 15 Q: -- operational unit -- 16 A: -- at that time. 17 Q: -- and he sits-- 18 A: He was there all day, pretty well. 19 Q: All right. 20 A: And he would be there for some time 21 and then he made arrangements for a replacement of crews. 22 Q: Okay. 23 A: He returned, as it was all quiet.


1 They were expecting -- it was pretty normal and there was 2 no problem. He came back to London for a rest and the 3 crew -- other crew went up and changed places. 4 Q: Okay. So, that takes us into 5 September the 6th. When does the next crew change place, 6 or change positions? 7 A: I'd have to -- I haven't got that 8 right here, but I believe that that would be when Bakker 9 and -- and -- Bakker came on duty and the other chap, the 10 driver. 11 Q: Okay. And do you recall when that 12 shift change would have occurred -- 13 A: No. 14 Q: -- when Bakker -- 15 A: Not right here, no. 16 Q: Would you have a log book that would 17 indicate when that change occurred? 18 A: Yes, there should be -- the SIU had - 19 - had the log books and that. 20 Q: Okay. 21 A: It should be in their report 22 somewhere. I'm pretty sure that they -- because I wasn't 23 there, so I don't know exactly when -- when it happened.


1 Q: No, I understand. I'm just trying to 2 get your information from what was reported back to you. 3 So, Paul Harding didn't attend on the 6th 4 in the area, September 6th? 5 A: No. 6 Q: All right, so Bakker and I believe it 7 was Morgan -- 8 A: Chris -- yes, Morgan. 9 Q: Morgan the driver, come on shift, but 10 you don't know at what point in time that is in the 11 evening of the 6th? 12 A: I believe they reported to one (1) 13 location and they were held for a few minutes and then 14 they went to the other location. They had to check in at 15 a checkpoint or in Forest; I'm not too sure which one 16 that was now. 17 Q: Okay. 18 A: I can't recall that. 19 Q: I'm just looking -- 20 A: I'm sure I was told, but I can't 21 recall now. I can't tell you for sure. 22 Q: I'd like to look at the process. 23 They checked in with the OPP, then they went to the


1 location -- 2 A: Yes. 3 Q: -- where the vehicle was? 4 A: Anytime -- anytime the crews were 5 coming or going, they always had to go through a 6 checkpoint and check with the OPP. 7 Q: All right. And they were there for 8 simple support? 9 A: They were there, they had -- they 10 took up a second medic unit, that's what they were 11 travelling in. But, they parked the medic unit to take 12 over the -- the tender unit that was there with the gas 13 and diesel and all that equipment in it. 14 Q: Okay. So, when they arrived there 15 was three (3) St. John Ambulance vehicles there -- 16 A: Yes. 17 Q: One (1) was the main trailer that was 18 being used by the OPP? 19 A: Trailer and tractor, yes. 20 Q: Trailer and tractor, the truck part 21 had been parked off to the side. 22 A: Yes. 23 Q: Then there's the tender unit which --


1 A: The tender unit, yes. 2 Q: -- that carries the gas and the 3 replacement parts -- 4 A: That's right. 5 Q: -- anything that they need to fix 6 what's happening with the trailer? 7 A: Yes. 8 Q: And then you've got the medic unit 9 that they drove there in? 10 A: That's correct. 11 Q: And if I understand your evidence 12 yesterday, you said that: 13 ˘We didn't go near the trailer unless 14 we were called upon by the police.÷? 15 A: That's correct. Once -- once they 16 started their work, no matter what is, we -- I mean 17 people want to be able to conduct their business and -- 18 and we don't get involved in that unless we are asked to 19 look at something specific. 20 Q: Okay. 21 A: And that's gas and that type of 22 thing. In fact, they set up a routine, I believe, where 23 -- how they were to be contacted with the person in


1 charge of the vehicle -- 2 Q: All right. And -- 3 A: -- when the gas came down and that 4 type of thing. 5 Q: That routine was recorded in a log 6 for the individuals being -- 7 A: No, it's recorded on -- if you saw 8 the photos from the SIU or the involved in 9 investigations, it was recorded on a white board on the 10 vehicle -- in the vehicle. 11 Q: On or in the vehicle? 12 A: In the vehicle. 13 Q: All right. 14 A: The information was recorded there 15 for -- there's various types of information; one was 16 where to get a hold of us, how to get a hold of us, what 17 time the gas and oil were changed last, et cetera, et 18 cetera. 19 So, they kept a log on -- on this white 20 board within the vehicle. Then they had other numbers 21 for other business that they had. 22 Q: All right. The OPP kept track of 23 what needed to be done according to their log board and


1 your individuals remained outside in the tender vehicle? 2 A: Yes. And they were set over in an 3 area, you'd have to get exact area from them, but 4 apparently there was two (2) ministry ambulance units and 5 some other equipment stationed in the same location, away 6 from the trailer park itself -- or away from the command 7 and communications unit, itself. 8 Q: Okay. And this trailer was powered 9 by one (1) main 7,000 Watt generator; is that correct? 10 A: That's correct. There is a gas 11 generator on the vehicle. There's a second vehicle, but 12 it's not a backup. It doesn't start automatically, you 13 have to start it. But you also have to have gas in the 14 main tank to be able to start the second generator. 15 Q: And the main tank, from what I 16 understand, ran both of these generators? 17 A: Yes. 18 Q: So, if you ran out of gas, not only 19 did the main generator go, but so did its backup. 20 A: Well, you couldn't start the backup 21 generator. The backup generator is only if the main 22 generator goes down for some mechanical reasons. 23 Q: Okay.


1 A: The gas -- it's a fairly big tank. 2 It's a very big -- fairly big tank on the unit. 3 Q: How long would that tank last for 4 that unit, on average? 5 A: A good six (6) hours or more. No, it 6 would be a good eight (8) hours. 7 Q: So six (6) to eight (8) hours this 8 gas tank would -- 9 A: Depending on how -- depends on what 10 they're using it, too, ow much power they're using, 11 because it -- it begins to fluctuate; the generator goes 12 into heavier working mode. 13 Q: All right. But, minimum six (6) 14 hours and up to eight (8) hours -- 15 A: At least, yes. Between six (6) and 16 eight (8) hours. 17 Q: All right. And when this power went 18 out on the main generator, would all the lights go out, 19 all the communications go out in the trailer? 20 Is that the effect of losing -- 21 A: If the power -- 22 Q: -- power? 23 A: -- if the power from the generators -


1 - if the generators stopped for any reason, then all the 2 power in the -- the trailer would go out, unless they had 3 a shoreline. 4 Q: Unless they had a shoreline? And 5 from your knowledge of this situation, they didn't have a 6 shoreline? 7 A: No, not that I -- 8 Q: You weren't aware of one? 9 A: No. 10 Q: So, it would be pretty obvious at 11 10:00/ 10:30 at night when this power went out, because 12 the lights would all go out? 13 A: Yes. 14 Q: All right. 15 A: The lights -- everything would go 16 out, yes. 17 Q: And somebody would come out the door 18 and say, We need more gas? 19 A: Well someone said -- would say, yes, 20 I forgot the call. 21 Q: All right, I saw from your booklet 22 there was a listing of what was available with this 23 trailer.


1 And it's P-339 for the record, Mr. 2 Commissioner. 3 There's only one (1) point I wanted to 4 raise with you and it's said that there's a Bell phone 5 line connection. 6 A: Yes. 7 Q: And that there's nine (9) ports. 8 A: No, there's five (5) ports. 9 Q: So, this, it lists in your -- 10 A: Well -- 11 Q: -- equipment list -- 12 A: -- nine (9) ports, but there are only 13 five (5) operational. 14 Q: All right. So, four (4) don't work-- 15 A: They can hook up -- they can hook up 16 at the five (5) places, but the only five (5) would -- 17 nine (9) places, but only five (5) would be -- would be 18 operational. 19 Q: All right. That's what I wanted to 20 clarify, because you did mention five (5) yesterday but 21 so there were nine (9), five (5) worked, one (1) was 22 dedicated to a fax -- 23 A: Yeah, what -- it's a block. The Bell


1 telephone hooks into a block. It's like a block with 2 screws in it and when they bring their lines they sort of 3 hook onto those screws. 4 There's nine (9) position screws and 5 there's five (5) actual locations; one (1) is a fax 6 line, could be used for a fax, one (1) is a modem line 7 for the computer and three (3) of them are regular Bell 8 lines -- 9 Q: All right. 10 A: -- which you never hooked up. 11 Q: So, it's capable of doing a computer, 12 a fax and three (3) phone lines. 13 A: That's correct. 14 Q: Three (3) hard phone lines. 15 A: Yes. 16 Q: Plus any cell phones that were in 17 there had a charging device as well? 18 A: They had -- they could work off 12 19 volt. Same as you would, you'd plug into your car. They 20 could work on -- they had another antenna on the actual 21 roof it. So, there was about three (3) or four (4) cell 22 antennas on it. 23 Q: And those are booster antennas for


1 the cell? 2 A: It gives you a little more height 3 than the -- yeah. 4 Q: Right. So, your cell phone works 5 better with that? 6 A: A little better, yeah. It could be - 7 - well, depends on where you are. 8 Q: Do you know how many of those lines 9 were hooked up by Bell -- 10 A: There was none. 11 Q: -- in this situation? 12 A: None. There were no lines hooked up 13 by Bell. 14 Q: There were no lines hooked up into 15 this trailer? 16 A: Not that I -- not that I'm aware. 17 Q: All right. So, you don't know that 18 there were no lines, you just don't know if there were 19 lines or there weren't? 20 A: There was no indication in any of the 21 paperwork that I got that any lines were hooked up be 22 Bell. My understanding, only from the paperwork, not 23 from anyone saying, is that everything was done by radio.


1 Q: Right. But you can't say that there 2 were or there weren't? 3 A: No. I'm sorry, I can't. 4 Q: It's simply what you've seen. You 5 haven't seen any indication of a hookup. 6 A: No. There was nothing on the reports 7 that Bell hooked in. Although they could have. They 8 could have very well and I not know about it, because 9 that could have been handled by the police department. 10 Q: Well, the capability was there to 11 hook up? 12 A: Yes. 13 Q: They could have hooked up if they 14 wanted to? 15 A: Yes. 16 Q: You just don't know if they were 17 hooked up or not? 18 A: That's correct. 19 Q: Fair enough. I'm about to move in 20 another fairly discreet category. Can I -- would it be a 21 good time for a break? 22 COMMISSIONER SIDNEY LINDEN: Would this 23 be a good time for a break?


1 MR. KEVIN SCULLION: Yeah. And I'll 2 probably be about ten (10) more minutes. 3 COMMISSIONER SIDNEY LINDEN: Thank you 4 very much, Mr. Scullion. We'll take a break now. 5 THE REGISTRAR: This Inquiry will recess 6 for fifteen (15) minutes. 7 8 9 --- Upon recessing at 10:31 a.m. 10 --- Upon resuming at 10:47 a.m. 11 12 THE REGISTRAR: This Inquiry is now 13 resumed. Please be seated. 14 15 CONTINUED BY MR. KEVIN SCULLION: 16 Q: I thought I was going to move onto 17 another topic, but I had one more question for you. If 18 you could just turn to Tab 11 of your book, page 10 of 19 what appears to be a transcript from the SIU 20 investigation. 21 Do you have that before you? 22 A: Page 10, yes. 23 Q: Page 10. Well, if you start at the


1 bottom of page 9, there's a comment regarding the 2 delivery of your vehicle, a St. John Ambulance vehicle, 3 on the morning of September the 5th and your comment is: 4 "Now I believe we also received 5 instructions when we arrived there from 6 the TRU officers on how one of -- the 7 TRU officers then explained to him how 8 to -- how he wanted it setup or where 9 he wanted it placed or parked." 10 A: That's -- 11 Q: Just give me one moment. 12 A: Okay. 13 Q: I noticed that you had specif 14 reference to a TRU officer. First, you know what a true 15 officer is with the OPP? 16 A: I remember back I believe it's 17 tactical unit. 18 Q: The tactical response unit? 19 A: Yes. 20 Q: And they can be heavily armed? Were 21 you aware of that back in your meeting with the SIU? 22 A: All I know, they referred to it as 23 tactical unit. That's all I --


1 Q: Okay. It refers to your reference to 2 TRU officers; is that a correct reference or did you want 3 to qualify that? 4 A: Well first of all, yes, I would 5 qualify it to the extent that I wasn't there. This was 6 just reported back to me. 7 Q: By Paul Harding. 8 A: By Paul. I wouldn't -- 9 Q: Okay. 10 A: -- when -- what he went through and 11 that was -- I was not there, I can't -- I can't tell you 12 for cert -- as far as directly. 13 Q: All I wanted to know from you, is 14 when he reported back to you as to the setup of the 15 vehicle, did he mention or do you recall him mentioning 16 the word or the words 'TRU officers' and if he did, did 17 that increase your concern regarding this operation or 18 did it affect your concern at all? 19 A: No. I -- through my working with the 20 -- involved with the OPP, given what situation is they 21 will bring officers from all various walks of life or 22 their physical being sometimes on the stopping of cars 23 and that, they'll use officers in different uniforms and


1 that. 2 So, it's -- I've seen them use officers 3 and various things and it doesn't mean that that's a 4 dangerous place. It's just that they're using that 5 officer and that and if he has to respond somewhere else, 6 he wears a -- he has a specific type of clothing to wear. 7 Q: All right. So -- 8 A: I mean I -- no, I can't relate that 9 to any -- 10 Q: The quick answer is if he did refer 11 to TRU officers it didn't matter to you? 12 A: No. It didn't, no. 13 Q: All right. And it still the same 14 operation you thought it was going to be which is simply 15 providing communications assistance on September 4th? 16 A: That's correct. 17 Q: And on September 6th as far as you 18 knew, you were doing the exact same thing as you had been 19 originally requested to do by Superintendent Carson? 20 A: Yes. Yes. 21 Q: All right. Were you in any radio 22 contact with your personnel at any point on the 6th? 23 A: No.


1 Q: All right. So, anything that you can 2 tell us today is as a result of the discussions 3 afterwards, the debriefing that occurred afterwards with 4 your personnel? 5 A: I -- 6 Q: Immediately after and I'd like to be 7 specific, with regards to the travel from the Park to the 8 Strathroy Hospital that two (2) of your personnel 9 involved in? 10 A: No. No, we were -- I was never 11 involved in any discussions at that time or the time of 12 travel or anything like that, no. 13 Q: Okay. I heard evidence from you and 14 I just wanted to -- to take it a bit -- a bit further 15 regarding the travel by your personnel and their 16 transport of Cecil Bernard George to the Strathroy 17 Hospital. 18 A: Yes. 19 Q: And if I understood you correctly, 20 you had a discussion after the fact with one of your 21 personnel regarding her being upset about the incident? 22 A: I'm not sure if she was referred to 23 as --that would be Karen, she wasn't upset but she was


1 concerned that the she -- the patient that reported had 2 been reported as a stable patient. 3 And that at a certain time during the 4 transport, she had noticed a couple of things and that 5 she was having difficulty getting a -- the vital signs. 6 And I just tried to alleviate her concern 7 on that regard because it is very difficult even for a 8 professional, a long standing professional, sometimes 9 because of the road noise coming up through the system to 10 hear your stethoscope to -- and it takes a little bit of 11 -- of practice in being in those situations to be able to 12 do that. 13 And I just wanted to relieve her mind 14 because she was a student nurse and -- and it meant a lot 15 to her and that she was to -- she was able to carry on 16 with her profession without being any doubts in it. 17 Q: All right. I appreciate it's been 18 almost ten (10) years and that it may be difficult to 19 remember all the details, but I'm going to suggest to you 20 that there were a couple more concerns that she raised 21 with you in that discussion, that it wasn't simply 22 limited to not being able to find vital signs. 23 And if I could take you --


1 A: Yes I think she somebody about the 2 back of the head that wasn't -- it was mentioned before. 3 Q: Let me take you to Tab 1 of the 4 documents in front of you there. 5 A: Tab 1? 6 Q: Tab 1. In fact it would be Tab 1 and 7 Tab 2. Do you recognize those two (2) documents? 8 A: At Tab 1 is a patient report form 9 that you're referring to, yes. 10 Q: That's the first tab; the Ambulance 11 Unit Patient Report Form which was filled out. Well, it 12 doesn't say the exact time that that was filled out 13 Do you know when that would have been 14 filled out by Ms. Bakker? 15 A: Well, the occurrence time was what, 16 23:45? 17 Q: So, that's -- 18 A: Clear time was 00:45. 19 Q: I see those two (2) times but does 20 that assist us in determining when this was filled out? 21 A: Oh, at what point after? Well what 22 would happen probably, if you would have to check with 23 the driver or Ms. Bakker and find out -- they usually


1 have a duty book and they'll mark the times down in a 2 duty book or on a piece of paper and then fill this out 3 after and transfer the times over onto this form. 4 Q: Okay. Well, Ms. Bakker's going to be 5 testifying, we'll ask her those questions as well. 6 A: Okay, yeah, sure. 7 Q: But in her notes on this patient 8 report there's a number of references to injuries that 9 she found on secondary examination. And from what I can 10 make out from her writing it would appear that on her 11 secondary exam, while she's inside the transport vehicle, 12 she determines: 13 "There's a deep [it says, 2 centimetres 14 above it] laceration to the upper lip, 15 wound edges not at all approximated and 16 bleeding profusely." 17 That's number 1. 18 "There's a laceration to the back of 19 the head." 20 Number 2. 21 Number 3. "There's blunt trauma to the 22 left forehead." 23 Number 4. "There's abdominal pain to the


1 whole region." 2 And Number 5. "There's pain and swelling 3 to the right arm above and below the 4 elbow." 5 She then goes on to say, that: 6 "During transport the patient lost..." 7 I'm assuming LOC means loss of 8 consciousness; is that correct? 9 A: Yes. 10 Q: She was unable to locate, at that 11 time, vital signs and she has a little not that says: 12 "Due to noise." 13 But he did come around. 14 She then gets into what she did by way of 15 stabilizing the arm and the pressure. She notes that 16 she: 17 "Kept the patient awake as best as 18 possible, re: head trauma, and the 19 pupils were not [perhaps you can help 20 me with that word] responding..."? 21 A: Yes, dilating back and forth. 22 Q: All right. 23 "...when unable to assess vital signs."


1 Then, if I take you to Tab 2, at the top 2 of the last paragraph, she says and I quote: 3 "The patient was not C-collared or 4 boarded before transport as OPP 5 paramedic made it sound it like his 6 condition was not as serious." 7 And I'd suggest from those passages that 8 I've just read to you, all those combined caused her some 9 concern because she received a patient that she thought 10 wasn't that seriously injured. 11 And on secondary examination in the 12 vehicle, she found a number of problems and was concerned 13 enough to ask the drive to turn the lights on and 14 expedite delivery to the Strathroy Hospital. 15 A: And I'm -- 16 Q: Does that help your memory at all? 17 A: No, that's just getting less on that. 18 Those were all identified as problems. Now, that -- that 19 was -- she was not concerned about that, she identified 20 those very well and she was not concerned about those and 21 that was great that she was able to find and identify all 22 that. 23 The only thing that I tried to help her


1 with, she seemed to be concerned of something -- not able 2 to get the vital signs and all of a sudden being able to 3 get them again and the only thing I could suggest to her, 4 there was a noise in the vehicle; only in that one (1) 5 thing. 6 The other points, the fact that she was 7 able to identify all that, that was great. And that was 8 right forth -- forthright and she mentioned that which is 9 in the report. 10 I've -- I've no question on that at all. 11 That was -- but I'm not questioning the seriousness of 12 the patient. All I'm saying I was trying to answer in 13 her mind, why she may not have been able to get the vital 14 signs through the stethoscope because of the road noise 15 and even to palpitate the wrist also is sometimes 16 difficult when the vehicle's moving, when there's noise. 17 That's all, just relating to one (1) 18 thing, not -- it was good that she found all those other 19 things and she came right up front and said that. 20 Q: Well, sure, and we've heard from Mr. 21 Cecil Bernard George regarding his injuries and regarding 22 his treatment he received at the hospital. They were 23 serious injuries that he had.


1 A: Yeah. 2 Q: My comment to you was that Ms. Bakker 3 raised those as concerns in her discussion with you and I 4 understand from you that that is correct. 5 A: Yes, that's correct. 6 Q: Did that cause you any concern that 7 this patient was transferred from an OPP medic, as 8 described, to your personnel with the line: 9 "His condition was..." 10 Or she thought the condition was not as 11 serious. 12 Did that cause you any concern that your 13 personnel were put in that kind of situation? 14 A: Your always concerned about a 15 patient, no matter what you get, but for us to be able to 16 identify that, that -- that was -- to my mind, that was 17 advantageous to us to be able to -- and for the patient - 18 - to have those things identified right away once they 19 got on the transport area. 20 And now I -- I can't comment on the -- 21 because the senior person that transport or that turned 22 that patient over to our people was a -- was a paramedic 23 or was actually the EMT and that's a senior position to


1 ours, so I -- I couldn't comment on his -- what he had or 2 what he didn't find. 3 I am just pleased with our personnel that 4 were not of that experience to be able to identify a 5 number of things happening and where -- and I think did 6 fairly well in the transport they did. 7 All that I was saying to you and in my 8 statement was, trying to say why a certain thing didn't 9 happen is that, you know, it's the only reason that was - 10 - and that's about the return of pulse and that. 11 Q: I appreciate that. But, what I'm 12 looking for is whether or not it caused you concern that 13 your personnel, as St. John's Ambulance personnel as 14 opposed to the Ministry of Health ambulances that are 15 normally in the situation, were put in such a situation 16 when you originally thought you were simply there for 17 communications assistance? 18 A: Was I concerned about that? 19 Q: Yes. 20 A: I'm glad we were there to be able to 21 help the patient. If we hadn't been there, it would have 22 been some time again for that patient to wait quite 23 possibly. I mean, I don't know where the other vehicles


1 were. 2 But, I was there -- I was concerned enough 3 to be there -- to take in consideration that the crew 4 said yes, they would respond. They didn't have to. 5 They could've said no. And I -- it would 6 have been very unfortunate that the patient had been left 7 there on the ground until the unit came from wherever to 8 transport him. 9 I was very pleased to that. I was 10 concerned enough that they did that. So, to be concerned 11 about transporting him, no, I wasn't concerned about 12 transporting him. I think they reacted and we reacted 13 the way we should have. 14 Q: I think they reacted the way they 15 should have. My question is more to your concerns that 16 your St. John ambulance personnel were put in a position 17 that was significantly different from what you originally 18 agreed to do with the OPP, which was communications 19 assistance. 20 Would you agree with me that at that point 21 in time, your role as part of this operation moved from 22 simple communication assistance to offering medical 23 assistance in a situation of a police --


1 A: Our role did move. 2 Q: -- move -- 3 A: Our role -- I -- I agree with you, 4 our role did move. Was I concerned about that? It was 5 done. How could I be concerned about it? 6 Q: Are you concerned that you received 7 no notice that your role was going to change at this 8 incident and, in particular, move from communication 9 assistance which you agreed to, to the role of a medical 10 assistance. 11 A: Well, it wasn't -- I don't think it 12 was the police -- the police did not intend that. And I 13 don't think anyone intended that to happen. I think if 14 all had of played out the way it -- that the emergency 15 would have, the other units would have been sitting there 16 when the police officers needed them. 17 And I can't answer anymore than that. I 18 don't think any of this was planned. I think it happened 19 and everyone reacted upon the happening. And that's all 20 I could say. I -- I'm not trying to -- 21 Q: No question. We're here to figure 22 out how it happened. We know that it did happen and I'm 23 looking into how it happened.


1 And my point is, you never received a call 2 from the OPP saying we're going to need your assistance 3 in this regard; is that accurate? 4 A: Not -- not originally we didn't 5 receive any call. But, we -- the OPP did ask us when we 6 were there. 7 Q: They asked your two (2) junior, 8 inexperienced people who were manning the gasoline 9 replacement for the trailer, to help in a medical 10 assistance? 11 A: That's correct. 12 Q: All right. They didn't call you who 13 was the superior at St. John Ambulance and ask you if 14 it's okay to change your role in the operation? 15 A: And I think -- and I doubt -- I think 16 time was a concern. I don't think that contact -- it 17 would have been a matter of some time to do that. And I 18 don't think that -- I think they responded the way they 19 should have. 20 Q: I appreciate that. Your evidence was 21 that you were upset and you wanted to address that at the 22 Hearing, the actions of St. John Ambulance were equated with 23 that of the OPP.


1 And you wanted to be perfectly clear, if I 2 understood your evidence yesterday correctly, that you 3 weren't equated with the OPP, you were simply providing 4 communications assistance as requested. 5 A: And I suggest to you yesterday that I was 6 concerned that some -- felt, I was concerned that some felt 7 that were trying to deceive or our equipment was used to try 8 to deceive. That's all I was -- and it was not the fact. We 9 -- we were doing the very thing we had agreed to do. 10 Q: Right. Well, we've certainly had a 11 lot of testimony here today. Much of it from my clients 12 that they were deceived and they thought that you were 13 part of that operation. So, I appreciate that that's 14 what you were addressing with that comment. 15 My question for you is: Knowing what you 16 know now, which is there was a movement on the Park by at 17 least forty (40) officers, there was a police shooting, 18 there's been what's referred to a police beating and 19 there was a requirement for ambulance services to go to 20 the Strathroy Hospital on an emergency basis at 11:00 21 p.m. at night, would St. John Ambulance have provided 22 their assistance to the OPP? 23 A: If ever I knew that in advance?


1 Q: Yes. 2 A: No, I think they would have had five 3 (5) ambulances sitting there if they -- if they knew 4 something like that was going to happen. It would only 5 be -- yeah, they would have much more equipment there if 6 they knew something like would happen. 7 Q: I appreciate the OPP may have done 8 things different and had more ambulances available. 9 If the request had been made to St. John 10 Ambulance, would you have made your people available for 11 that type of operation? 12 A: Yes, we would have and we would have 13 put senior people on. We put a -- possibly an EMT or, at 14 that time there were no paramedics, they were all EMTs, 15 and that would have been the same qualification as a 16 Ministry unit. 17 If we had have known that, we would have 18 assigned other crews to that, to be able to do that. 19 Q: So, what you -- 20 A: It was unfortunate that -- and that's 21 all we thought, and -- I mean, that's second-guessing, 22 I'm sorry. 23 Q: But, St. John Ambulance would have


1 still been there, simply with different vehicles and 2 different people manning them? 3 A: If we're asked to do a medical 4 standby. If we're asked to do a medical standby, and we 5 do that sometimes. The Ministry's only got so many 6 resources, to put in a place to stand by. 7 And we do also derailments, CN 8 derailments. We do medical standby for CN derailments, 9 because a lot of the smaller places do not have vehicles; 10 they only have one (1) or two (2) assigned to a specific 11 location. And we will put proper crew -- more 12 experienced crews now in those -- in those locations to 13 do that job. 14 And if it's planned, but this was not 15 planned. 16 Q: I'd suggest to you that a CN 17 derailment is very different from a backup medical 18 assistance to a police operation; would you agree with 19 that? 20 A: No, I can -- if you've seen a CN 21 derailment and the equipment they're using, a fellow can 22 lose his arm just as quick as a blink of an eye. No, 23 it's very dangerous, both are very dangerous.


1 If you're talking about -- no matter what 2 it is. 3 Q: Okay. Those all my questions, Mr. 4 Commissioner. 5 COMMISSIONER SIDNEY LINDEN: Thank you, 6 Mr. Scullion. 7 Mr. Eyolfson, do you still have some 8 questions? 9 MR. BRIAN EYOLFSON: I do not have any 10 questions. 11 COMMISSIONER SIDNEY LINDEN: Thank you. 12 Ms. Tuck-Jackson...? 13 MS. ANDREA TUCK-JACKSON: I no longer 14 have any questions for this Witness. 15 COMMISSIONER SIDNEY LINDEN: Thank you. 16 Mr. Roland...? You estimated five (5) 17 minutes, Mr. Roland. Is that still an accurate 18 assessment? 19 MR. IAN ROLAND: No, it's not. 20 COMMISSIONER SIDNEY LINDEN: How long do 21 you estimate? 22 MR. IAN ROLAND: Maybe two (2). 23 COMMISSIONER SIDNEY LINDEN: Oh, good.


1 CROSS-EXAMINATION BY MR. IAN ROLAND: 2 Q: Sir, you were taken to Tab 1, which 3 is the patient report. There were some reference in 4 earlier cross-examination about -- about taking blood 5 pressure, and I note at the very bottom near the right 6 hand side, under the heading 'blood pressure', it says: 7 ˘Not applicable due to lack of cuff.÷ 8 Do you see those words? 9 A: Yes. 10 Q: Which I take it means there wasn't a 11 blood pressure cuff on board the ambulance -- 12 A: Yes. 13 Q: -- unit? 14 A: Right. 15 Q: And for that reason, there was no 16 blood pressure taken -- readings taken? 17 A: I'm assuming that was the case, yes. 18 Q: And if we look at the pulse, under 19 pulse and respiration, apart from the second notation 20 where there's none indicated, the others appear to be in 21 normal range, do they not? 22 The pulse is in -- within normal range? 23 A: Yes, it seems to be.


1 Q: And the respiration appears to be in 2 normal range? 3 A: Yes. 4 Q: Right. And if -- if a patient is 5 without -- is actually without pulse or respiration, that 6 calls for CPR to be administered immediately, if it's -- 7 if that's actually the case? 8 A: That's usually procedure, yes. 9 Q: Yes -- 10 A: If there's no -- breath -- not 11 breathing -- not -- 12 Q: Sorry? 13 A: -- the cessation of breathing, yes. 14 Q: Yes. A cessation -- cessation of 15 pulse and cessation of breathing, you're going to have to 16 administer CPR immediately, aren't you? 17 A: You should, yes. 18 Q: Yes. Thank you. 19 COMMISSIONER SIDNEY LINDEN: Thank you 20 very much. I think that leaves us with Mr. O'Marra. 21 22 (BRIEF PAUSE) 23


1 MR. AL O'MARRA: Thank you, Mr. 2 Commissioner. 3 COMMISSIONER SIDNEY LINDEN: Thank you. 4 5 CROSS-EXAMINATION BY MR. AL O'MARRA: 6 Q: Superintendent, my name is Al O'Marra 7 and I appear on behalf of the Chief Coroner and we are 8 participating in the Inquiry to -- to assist. 9 And I just have a few questions around 10 your -- your operation with the emergency equipment that 11 you provide and the kinds of events that you -- that you 12 attend to; that's the first area. 13 And the second is your involvement in the 14 de-briefing of Karen Bakker and her involvement in the 15 transport of Cecil Bernard George. 16 Okay. Now, with respect to the first 17 area, I noticed in the literature that you provided and 18 your evidence yesterday you -- you make reference to a 19 number of different kind of disasters that -- that you 20 provided equipment to, natural disasters, rail disasters, 21 fire and -- and other kinds of catastrophes. 22 In 1995, you attended to -- you provided 23 equipment to the -- the situation that occurred at -- at


1 Ipperwash. Up to that point, had you ever provided 2 equipment or support in that kind of situation where 3 there's a potential confrontation between interests? 4 A: Confrontation between -- no, not -- 5 not -- not, no, not -- 6 Q: Where we had one (1) group and 7 another group and they came into contact and there was 8 physical conflict? 9 A: No. No -- oh, yes, there was. I 10 believe there was a -- a labour -- a labour situation in 11 the London area that we took part in to -- to help. 12 Q: And, did you provide the same kind of 13 equipment by way of communication or was it more the 14 canteen type of service to assist those that were 15 policing the -- the dispute line? 16 A: Two (2) the canteen and one (1) 17 medical unit. 18 Q: Okay. And, did you have any -- 19 A: First aid unit. We'll put it that 20 way. 21 Q: First aid unit. Did you have any 22 difficulty with the use of your equipment in -- in that - 23 - in that event?


1 A: No. 2 Q: Okay. And, since September of 1995, 3 have you used your equipment in that kind of scenario 4 where there's a potential consequence or conflict between 5 two (2) interests or two (2) groups? 6 A: Two (2) months ago we were at the 7 tractor protest. There was no conflict, as such, but I 8 mean it was a protest and we supplied the canteen 9 rehabilitation unit for that protest. And that was when 10 they blocked the four-o-one (401). 11 Q: Okay. Now, since 1995, you made some 12 -- some changes to the markings of your equipment? 13 A: That's correct. 14 Q: Have you made any changes to the 15 availability or use of your equipment depending on the 16 request? 17 A: Open to -- to request to everyone? 18 No, there's no changes to that. 19 We, as a precautionary step, said everyone 20 lives and learns and we would certainly make sure that 21 things would not happen again the way they had the first 22 time. And that was only referring to -- we may have been 23 a little naive maybe, I would say, in thinking that


1 something couldn't happen. If it's going to happen, I 2 think Murphy's law steps in. 3 Q: So, being naive and -- and having 4 learned from experience, do you have a process in place 5 where you -- you ask questions to -- to attempt to 6 ascertain -- 7 A: Not only that, we have a letter of 8 intent now exactly what -- what covers. For instance 9 last -- two (2) weeks ago when we were on the search with 10 the OPP, there's a letter of intent through OSARVA on how 11 to operate. Yes, we have -- we have taken steps to 12 correct all the, sort of the areas in which we have to be 13 more clear. 14 Q: Okay. I'm sorry, you said the letter 15 of intent and something through OSARVA. I don't -- what 16 is that? 17 A: That's -- that's the provincial body 18 for search and rescue. 19 Q: Okay. 20 A: And that's the -- the body which the 21 Ontario Province subscribes to and then we work under 22 that jurisdiction 23 Q: Okay. And do you require the use of


1 this letter of intent for all requests and -- and 2 provision of your equipment? 3 A: We're doing now with every police 4 department we get involved with, yes; the letter of 5 intent. And then we try -- we're trying to build that as 6 we go. 7 Q: Okay. Now, I'd like to, then, turn 8 to the transport of -- of Cecil Bernard George. You 9 spoke to Ms. Bakker afterwards because she -- she was, 10 based on the level of experience of -- of your volunteers 11 at the lower end, just -- she was just starting, wasn't 12 she? 13 A: She -- she was a -- a new -- she 14 hadn't had a lot of exposure to any of -- any of the 15 transport areas and that. Yes, she was just starting and 16 she was starting out in -- in life, too. She was just in 17 a nursing program and so, yeah, it -- we were concerned. 18 Q: Okay. And can you tell us, have you 19 ever been in that situation yourself as -- as an 20 attendant in the back of a medic unit assessing vital 21 signs? 22 A: Have I ever been in that position? 23 Q: Yes, sir.


1 A: Yes. 2 Q: Okay. And even for someone 3 experienced, it's -- it's a difficult thing to obtain a 4 pulse, even to palpitate a wrist pulse? 5 A: Well, esp -- especially if you've 6 been lifting and especially if you've running, especially 7 if you've, you know, the adrenaline's been pumping, you 8 can almost sometimes hear your -- your heart in your 9 ears, your own pulse in your ears type of thing. 10 And yes, it's difficult to -- to settle 11 down and -- and take the proper... 12 Q: Okay. And even on the smoothest of 13 roads, even standing still it's difficult to palpitate a 14 wrist pulse. 15 A: It is. It is, yes. 16 Q: And did you have any understanding as 17 to how Ms. Bakker attempted to -- 18 A: Specifically if it thready. If the 19 pulse is thready and all weak or anything like that, yes. 20 Q: And thready means just so -- what? 21 A: A weaker -- 22 Q: A weak pulse? 23 A: -- not as -- not as detectible.


1 Q: Okay. But because you don't find a 2 pulse doesn't mean there isn't a pulse? 3 A: No, no. 4 Q: Okay. And to suggest that because a 5 -- a pulse couldn't be found doesn't translate to the 6 person's heart having stopped does it? 7 A: No it doesn't. That's what I was 8 trying to -- to mention that it's -- there's usually -- 9 there's other things come up too. 10 Q: And in fact you -- you clarified that 11 with -- with Ms. Bakker afterwards, didn't you? 12 A: Well, she -- yes, in the debriefing 13 we -- we talked about it and she was -- seemed to be 14 concerned or -- the question was that how can this sort 15 of happen; I got something now -- now I haven't got it 16 type of thing. 17 And she seemed to be a little concerned 18 about it. And we -- we talked about it, that's all, and 19 just sort of to relieve her mind. 20 Q: And based on everything that she told 21 you, there is no objective evidence that she provided to 22 you that the patient's heart stopped. 23 A: I'm sorry, jus --


1 Q: Based on everything she told you -- 2 A: Yes. 3 Q: -- in your debriefing there is no 4 objective evidence that suggested to you that this 5 patient's heart stopped? 6 A: That's true. And on the contrary 7 when I read the -- the report that was submitted that it 8 seems to carry through with the pulse rates and that and 9 this was -- the PMT had suggested. 10 Q: And while no one questions that the 11 patient may have had serious injuries as a result of 12 trauma, there is nothing to suggest that his heart 13 stopped as a result of that based on your discussions 14 with Ms. Bakker? 15 A: That is quite correct. And -- and 16 what we've done -- what she had done to upgrade the 17 situation, if she wasn't sure that she should not take 18 any chances. 19 Q: And in addition to not being able to 20 find a pulse to check vital signs, you'd want to find out 21 whether the person was still breathing, right? 22 A: Yes. 23 Q: A person's heart stopped, the


1 breathing will stop won't it? 2 A: Yes. 3 Q: Okay. And if you have that in 4 combination, what's the -- what's your medic response to 5 that? 6 A: Cessation of breathing? 7 Q: Yes. 8 A: CPR. 9 Q: Okay. 10 A: And -- we usually apply oxygen or it 11 depends on unit you got, you use a bag, your bag method 12 with oxygen attached and CPR. 13 Q: And none of that happened, did it? 14 A: No. 15 Q: And if somebody is still breathing 16 and then you started CPR, what would happen? 17 A: Well you make it more difficult for 18 them in respects to that, first of all they're breathing, 19 then you're pressing down on their Zyphoid process and 20 they can't breathe as well; one (1) thing. 21 And then if they are having any problem at 22 all, it could be a heart problem, cause a problem with 23 the heart.


1 Q: Now, when I asked you before as to 2 whether there is anything objective as to whether his 3 heart had stopped, do your vehicles carry ECG units? 4 A: We carry -- no, we don't carry ECG 5 units. We now -- at that time, no, they didn't. Now, 6 they carry defibrillators and all that, and they can read 7 -- some of the defibrillators have -- there's a physio- 8 type that reads a -- ECG reads across the board and if 9 you're in the area of be able to read it then you can use 10 it. But if you're not, if it's just an automatic 11 defibrillator, then you take it to that degree at which 12 you are trained to. 13 Q: Okay. Thank you very much. Those 14 are my questions. 15 COMMISSIONER SIDNEY LINDEN: Thank you 16 very much. Mr. Worme, anybody, re-examination? 17 MR. DONALD WORME: I don't have any re- 18 exam, Mr. Commissioner, but I do wish to thank 19 Superintendent Harding for his attendance and his 20 testimony here. 21 COMMISSIONER SIDNEY LINDEN: Thank you 22 very much, Superintendent Harding. 23 THE WITNESS: Mr. Commissioner, I just


1 would -- could I make a statement to you? 2 COMMISSIONER SIDNEY LINDEN: It depends 3 on how long it is. 4 THE WITNESS: Well, no, I just want to 5 apologize if there was any misunderstanding for the -- 6 the work of St. John in and at this area and at this -- 7 and I would suggest that -- that if there's anything we 8 can do to resolve that, we would certainly do it. 9 And even to the extent that we do attend a 10 lot of the communities -- native communities, and 11 possibly they would want a St. John unit division right 12 on the community, within the community. And we're 13 certainly willing to even look at that, if that could 14 come to be. 15 But, if there was any misjudgment on our 16 part, we apologize, and there was never any intention 17 that that would happen at all and I don't think on 18 anyone's part. 19 COMMISSIONER SIDNEY LINDEN: Well, we 20 certainly welcome your input in any recommendations that 21 I will be making at the end of this Inquiry. 22 So, we'll probably look to you at that 23 time.


1 THE WITNESS: Thanks. 2 COMMISSIONER SIDNEY LINDEN: Thank you. 3 4 (WITNESS STANDS DOWN) 5 6 MR. DONALD WORME: Thank you for that, 7 sir. Thank you, Commissioner. 8 COMMISSIONER SIDNEY LINDEN: Thank you. 9 MR. DONALD WORME: Ms. Hensel will be 10 leading the next witness. 11 12 (BRIEF PAUSE) 13 14 MS. KATHERINE HENSEL: The Commission 15 calls, as its next witness, Mr. Glen Morgan. 16 17 (BRIEF PAUSE) 18 19 THE REGISTRAR: Good morning, Mr. Morgan. 20 MR. GLEN MORGAN: Good morning. 21 THE REGISTRAR: Would you prefer to swear 22 on the bible, sir, or affirm? 23 MR. GLEN MORGAN: The Bible.


1 THE REGISTRAR: The bible is right there 2 to your right. Just take it in your right hand please 3 and would you give us your name in full. 4 MR. GLEN MORGAN: Glen Alan Morgan. 5 THE REGISTRAR: Thank you. 6 7 GLEN ALAN MORGAN, Sworn 8 9 EXAMINATION-IN-CHIEF BY MS. KATHERINE HENSEL: 10 Q: Good morning, Mr. Morgan. 11 A: Good morning. 12 Q: Could you state for the record your 13 full name? 14 A: Glen Alan Morgan. 15 Q: Thank you. And your date of birth? 16 A: July the 10th, 1970. 17 Q: Okay. Now, I understand, Mr. Morgan, 18 that you volunteered with St. John Ambulance in the 19 London area from 1993 to 1998? 20 A: Approximately, yes. 21 Q: Yes. Can you describe, for the 22 Commission, your -- your role with St. John during that 23 period and the duties that you would have undertaken?


1 A: Over that period of time, I had 2 numerous duties for St. John Ambulance. It did change 3 over time. 4 When I initially began to volunteer for 5 St. John Ambulance it was for basically computer and 6 administrative support. 7 I maintained the organization's database, 8 record of vehicle usage -- 9 Q: Hmm hmm. 10 A: -- record of members' hours, the 11 types of duties they performed, how long they were at 12 each duty. 13 And then over the time with my 14 involvement, I took part in the First Aid and medical 15 training that they provided to me, and then became an 16 active member on various duties. 17 Most of them would probably be best 18 described as public events or providing First Aid and 19 medical coverage things, like the Western Fair, hockey 20 tournaments, baseball, softball tournaments, that kind of 21 thing. 22 As my time with the organization 23 progressed, I also took part in a few patient transfers,


1 say between a nursing home and a hospital, you know the 2 low -- low risk where the casualty is very stable. 3 I also took part in -- we would have a 4 relationship with a sister volunteer squad, in Dayton, 5 Ohio. I went down and helped out with their air show a 6 couple of times. So, a wide range of duties, actually. 7 Q: Okay. And at any time during the 8 entire period that you served with St. John, did you 9 engage in any policy making for the organization? 10 A: Not really; maybe on a very minor 11 level. There was one -- one year where, at the Western 12 Fair, it was our division, the division that I was a 13 member of that was responsible for coordinating the 14 coverage of the Western Fair. 15 And, I mean, that was mainly just minor 16 logistics like where we would have one of our trailers 17 parked; where we -- 18 Q: Hmm hmm. 19 A: -- we would have our golf carts, 20 which was a minor medical response unit; where that would 21 be located; where we would do foot patrols. 22 So, minor details like that would be the-- 23 Q: Hmm hmm.


1 A: -- the highest level of policy making 2 I would ever make. 3 Q: Okay. And did you directly take 4 requests from other organizations or entities about where 5 St. John units would be deployed? 6 A: Probably on a -- on a minor level. 7 There were a couple of times during my role as the 8 Administrative Support where I would cover the phones at 9 our brigade office. 10 Q: Hmm hmm. 11 A: And if a phone call came in to say, 12 You know we need medical coverage for a -- for a softball 13 tournament, I'd put that down in our log book, you know, 14 make sure that there were no conflicts and, you know, 15 pass that up the chain of the command to say, you know, 16 we've got this request, can we do it; make sure that 17 everything was approved. Those would be the type of 18 requests that I would take. 19 Q: Okay. And if you received any 20 request from a police organization, for example, 21 would you handle that request yourself? 22 A: No. Any -- any professional request 23 of that nature, I would definitely forward it up to a


1 higher ranking officer, either a Divisional 2 Superintendent or the Corps Superintendent, Mr. Harding. 3 Although there are some circumstances as, 4 I believe Mr. Harding stated in his testimony, where we 5 have kind of a standing response to, like, fires or where 6 we send out a canteen unit. 7 Q: Hmm hmm. 8 A: If a call comes in for that, it comes 9 over the pager, you just sort of act on those. But 10 telephone requests from a professional organization like 11 police, that would definitely be moved up to a higher 12 officer. 13 Q: Okay. So, if you receive, for 14 example, a request for your organization to provide 15 operational support to police, would you -- would you 16 handle that request yourself or would you send it up? 17 A: No, I wouldn't be authorized to do 18 that on my own. 19 Q: Okay. Okay. So, in 1995, can you 20 describe the level of first aid training you would have 21 received? 22 A: At that time, the system used by St. 23 John Ambulance for brigade members was called the Brigade


1 Training Systems, BTS, and I was a BTS level 1 qualified 2 provider. To compare that to a comparable level today, 3 St. John Ambulance provides training, a course called, 4 "An Advanced First Aid Course." 5 It's essentially a First Responder. 6 Medical First Responder. People like firefighters or 7 people who potentially want to be firefighters often take 8 that course to have a higher level of training. It 9 essentially puts you at a greater level than somebody who 10 has standard first aid, a public course. 11 It's still essentially first aid, but 12 you're also trained on using more advanced equipment such 13 as splints, spine boards, administering oxygen, so that 14 was the level that I had at the time. 15 Q: All right. And, in terms of that 16 training, what level of seriousness of injury would you 17 be prepared to treat on your own without attempting to 18 transport the -- the patient to more advanced medical 19 care? 20 A: Usually, the moment we determine -- 21 for St. John Ambulance, usually what our mandate is, the 22 moment we do encounter a casualty who has severe or 23 considerable injuries, if we feel that they do need


1 immediate transport to a hospital, usually the events 2 that we cover we're able to call in a Ministry of Health 3 Unit and arrange for transport immediately. 4 In many cases, we just treat casualties in 5 what we call a treat and release basis where their 6 injuries are relatively minor. We help them and 7 essentially send them on their way. 8 It would be hard to say specifically what 9 type of injury -- where I would draw that line. I mean, 10 I can splint fractures and keep them stabilized and, you 11 know, if it's minor like a wrist or an ankle, they can 12 generally be driven to the hospital on their own by a 13 relative or a friend, but again, to actually draw a fine 14 line, it's hard to say. 15 We -- any injury we come across, we treat 16 to the best of our ability and call in the help when we 17 need it. 18 Q: Thank you. And, since 1995, what 19 further first aid training have you undertaken? 20 A: At around -- around 1997 I obtained 21 my instructor certification with St. John Ambulance. I 22 believe Mr. Harding dealt with that yesterday with -- 23 that's the -- the people who work for St. John Ambulance


1 on an honorarium basis to teach public first aid courses. 2 And that was simply the standard first aid courses. My 3 medical knowledge was actually beyond that, but I was 4 teaching basic first aid and CPR to the public. 5 Around the year 2000, I increased my 6 qualifications to the advanced first aid teaching 7 qualifications, essentially the Medical First Responder 8 and I've been -- I still teach that to this day. 9 Q: And, I understand that you're 10 currently a student? 11 A: That is correct. 12 Q: And where are you a student? 13 A: King's University College at the 14 University of Western Ontario. 15 Q: And, what program are you enrolled 16 in? 17 A: It's a Bachelor of Arts, essentially 18 in Theology. The specific program is Catholic Studies. 19 Q: So, beyond what you've described, do 20 you have any other professional volunteer or educational 21 experience in the first aid or medical fields? 22 A: Other than the volunteer work I did 23 and the advanced first aid instruction that I still do,


1 no more than that. 2 Q: Thank you. Moving now to September 3 of 1995, prior to your being called to duty during that 4 period, were you aware that there was a situation 5 developing at Ipperwash Provincial Park? 6 A: Before I went up there, really all I 7 knew was what I'd heard a little bit on the news reports 8 that there was, essentially, a situation between the 9 First Nations people who were remaining at Ipperwash and 10 the Ontario Provincial Police that had responded to that 11 area. 12 Severity or details, I really didn't know 13 before I went up there. 14 Q: All right. And can you describe for 15 us how you came to be on duty on September 6th, 1995? 16 A: Essentially, we had -- I -- I can't 17 remember exactly which day our -- 18 Q: Hmm hmm. 19 A: -- vehicles had initially gone up 20 before. I know it was probably twenty (20) -- between 21 twenty-four (24) and forty-eight (48) hours before I went 22 up there myself. 23 Q: Just to interrupt, sorry. I am sorry


1 to interrupt, but were you aware what -- that those 2 vehicles had been sent up when they were sent up, or that 3 vehicle had been sent up? 4 A: Yeah, I knew that we had already sent 5 vehicles up there. 6 Q: Hmm hmm. 7 A: I can't pinpoint the date through my 8 own recollection now. 9 Q: Okay, and how did you learn that? 10 A: Just being around the station. 11 Q: Hmm hmm. 12 A: I -- our facilities, I just knew that 13 other people had already taken vehicles up there. 14 Q: Okay. 15 A: And because -- because of the nature 16 of our Communications Unit 444, running on generators, 17 there's the understanding that as long as the situation 18 is going on, various members would have to go up there, 19 tender the unit, replace gas, oil -- 20 Q: Hmm hmm. 21 A: -- in the generators as required. 22 So, even before I went up there, I believe a couple of 23 other teams had gone up to --


1 Q: Hmm hmm. 2 A: -- perform that duty before I was 3 sent. 4 Q: Okay. And just to clarify, Unit 444 5 is the -- 6 A: The Communications Unit. 7 Q: Yeah, okay. So, on September 6th, 8 1995, how did you -- did you receive a phone call? 9 A: I think I was actually at the station 10 that day and my divisional superintendent, Paul Harding, 11 asked if I would be able to go up there for that evening 12 to -- to tender the communications unit. 13 Q: Okay. And so what did you do? Do 14 you recall, first of all, what time of day he would have 15 made that request of you? 16 A: Mid to late afternoon, and I was 17 supposed to go up early that evening, after dinner, mid- 18 evening kind of thing. 19 Q: Okay. And so what did you do as a 20 result of that request? 21 A: I -- I was under the impression that 22 I would probably be there overnight and that I would come 23 back the following morning when another crew --


1 Q: Hmm hmm. 2 A: -- would go up. I think I actually 3 went home for a little bit. I grabbed myself a novel -- 4 Q: Hmm hmm. 5 A: -- because I thought, initially, that 6 I'd probably just be sitting in our -- 7 Q: Hmm hmm. 8 A: -- utility vehicle, reading a book 9 and/or sleeping for most of the evening. 10 Q: Hmm hmm. 11 A: Reported back to the station early 12 evening and prepared a vehicle to go up to Forest. I was 13 told to report to the Ontario Provincial Police 14 Detachment. 15 Q: Okay. And just to go back, when Mr. 16 Harding raised the possibility of you going up, or -- or 17 instructed you to go up, did he -- did he tell you that 18 you would be providing any First Aid or medical services 19 onsite there? 20 A: Not -- not specifically. It -- it's 21 kind of a general understanding for St. John Ambulance 22 that if anyone comes to us -- 23 Q: Hmm hmm.


1 A: -- or one of our units and says, you 2 know, I've injured myself, I've hurt myself, can you help 3 me out, we'll do so. That's -- it's -- 4 Q: Hmm hmm. 5 A: -- kind of a blanket understanding 6 that we'll provide First Aid if there's -- 7 Q: Hmm hmm. 8 A: -- somebody who needs First Aid. But 9 was that a specific order that, you know, you're up there 10 to do medical coverage? No. 11 Q: Okay. And was it your belief, prior 12 to going up, that you would be providing medical coverage 13 or First Aid coverage of any kind? 14 A: Unless an accident happened, I -- 15 Q: Hmm hmm. 16 A: -- wouldn't have anticipated any 17 other medical coverage being provided. 18 Q: Okay. You said that you returned to 19 the base to prepare a vehicle. Which unit did you take 20 custody of to do that? 21 A: The one that I drove to Ipperwash 22 was, I believe, Unit 406 which was our utility vehicle. 23 Q: Okay. And what was the main function


1 of that vehicle? 2 A: It's a utility vehicle. 3 Q: Hmm hmm. 4 A: It carries extra generators, extra 5 lighting, jerry cans with gasolene -- 6 Q: Hmm hmm. 7 A: -- oil. It's essentially a vehicle 8 designed to maintain our other vehicle -- other vehicles 9 and other equipment. 10 Q: Okay. And did you take an inventory 11 of that vehicle prior to leaving the base? 12 A: A standard one, I believe, a 13 checklist -- 14 Q: Hmm hmm. 15 A: -- for the vehicle report that's just 16 -- if everything's present. 17 Q: Okay. And do you know what became of 18 that checklist? 19 A: I believe it remained in the vehicle 20 that -- 21 Q: Hmm hmm. 22 A: -- evening and I don't believe it was 23 there when the vehicle was returned to us.


1 Q: All right. Thank you. Okay. Do you 2 recall what time you left London for Forest? 3 A: Probably between 8:00 and 9:00 p.m. 4 on that evening. 5 Q: Okay. And, if I could take you to 6 Tab 2 of the binder of documents in front of you. And 7 for the record, that's Inquiry Document Number 1002424. 8 A: Yes. 9 Q: Now, that is an ambulance -- it's 10 titled, Ambulance Unit Ambulance Duty Report, and it 11 bears your signature and it's for Unit Number 100. 12 A: That is correct. 13 Q: Okay. Now, you've noted that you 14 left in Unit 406? 15 A: Correct. 16 Q: Can you explain why your signature 17 would have appeared on that form? 18 A: My partner for that evening, Ms. 19 Karen Bakker, drove up a second unit, the Medic Unit 100, 20 in question. The reason for that, we had discussed 21 having two (2) people up there that evening and if memory 22 serves me correctly, she had to return earlier that 23 evening or there was essentially a logistic reason why


1 the two (2) of us couldn't go up or return at the same 2 time, and I can't remember exactly. So, she brought up 3 the second unit. 4 The reason my name is on the 100 Vehicle 5 Report Form is, because I was the driver the evening that 6 we transported Cecil George to Strathroy General 7 Hospital. So, since I did use that vehicle to transport 8 a casualty to the hospital, my name should appear as the 9 signature on that vehicle report. 10 Q: Okay. And, it notes under, Time Out 11 20:00 hours, which would have been 8:00 p.m. 12 A: Yes, she actually probably started 13 the vehicle report, I simply signed it at the completion 14 and listed myself as the driver because I was the last 15 person to drive the vehicle. 16 Q: Okay. And when would you have 17 completed this report or signed it? 18 A: With the time in, when -- actually we 19 returned to St. John Ambulance that next morning at about 20 -- it does state there 08:00 hours is when we eventually 21 did return the vehicle to St. John Ambulance in London. 22 Q: Okay. Okay. So, you travelled in -- 23 in your vehicle, Unit Number 406, to Forest; can you


1 recall the route that you took? 2 A: At this point, no. 3 Q: Okay. And, along the way did you 4 notice any unusual -- did you see any police units on the 5 way prior to arriving in Forest? 6 A: I don't think I saw a police unit 7 until actually arriving at the police station. 8 Q: Okay. And where did -- where did you 9 go in Forest when you first arrived? 10 A: Directly to the OPP station and 11 parked in the parking lot. 12 Q: And, what did you see when you -- 13 when you arrived at the police station? 14 A: A number of police vehicles, a number 15 of police officers. The main thing that I was concerned 16 about at that point was just reporting to somebody to 17 receive further instruction. 18 Q: Okay. And, had Ms. -- Ms. Bakker 19 arrived prior to your -- prior to your arriving? 20 A: I -- again, it's hard to remember. 21 Q: Hmm hmm. 22 A: I think she arrived shortly after I 23 did, but I can't be 100 percent sure, ma'am.


1 Q: Okay. And, just to go back for a 2 second. I apologize, but, to clarify Ms. -- the unit 3 that Ms. Bakker drove up was a medical unit? 4 A: Yeah, I believe at -- back in 1995, 5 the words that would have appeared on -- I mean they 6 would -- they're stated -- St. John Ambulance is written 7 on the side, but I believe on the front doors at that 8 time, it was called, Mobile First Aid Post. So, it -- it 9 was our basis medic unit at that time. 10 Q: Okay. And, the only reason for her 11 taking up that vehicle instead of riding with you in unit 12 406, the tender vehicle, would have been to allow you 13 some independence, each of you in terms of your coming 14 and going -- 15 A: Correct. 16 Q: -- the next day? 17 All right. Okay. When you arrived in 18 Forest at the OPP detachment, how many officers did you 19 see -- can you recall seeing in the -- in the parking 20 lot? 21 A: With memory, I -- I -- probably at 22 any given time, I know I probably would have seen maybe 23 half a dozen that I know I actually saw. Any specific


1 numbers -- it would be hard to say. 2 I know I went to one (1) room where there 3 seemed to be a number of officers, like, where I was told 4 to report to somebody in charge, and there were 5 probably six (6) to ten (10) officers actually in there. 6 Outside, I can't really remember. 7 Q: Okay. And, so you proceeded into the 8 OPP detachment and eventually reported to an officer? 9 A: Correct. 10 Q: Do you recall who that officer was? 11 A: No, I can't recall the name at this 12 time. 13 Q: And was Ms. Bakker accompanying you 14 by that point? 15 A: I don't believe she was with me and I 16 can't remember whether you had actually arrived at that 17 point. She may have been and I may have said I'll go and 18 check-in for us, but I can't remember clearly. 19 Q: And can you describe the conversation 20 that you had with the officer that you did report to? 21 A: I -- I simply said Hi, I'm Glen 22 Morgan, I'm with St. John Ambulance. I'm here for this 23 evening. We're this shift crew.


1 The general response that I got or the 2 impression was and I think it wound up in my report was, 3 you know, the officer indicated that he was glad that we 4 were here. He said, We may need your assistance this 5 evening, can you standby? 6 And I just -- I -- I didn't really know 7 how to take it at that time but I just assumed that okay, 8 I'll receive further instruction. 9 Q: Okay. And when -- when he told you 10 that the OPP may need your assistance, did you take that 11 to mean assistance over and above servicing the 12 communication centre? 13 A: Hindsight makes me think that way. 14 But, at the time I don't think that really completely 15 into my mind. 16 Q: Okay. If I could actually -- just to 17 refresh your memory, take you to -- just one (1) moment, 18 Commissioner -- to Tab 8 of the Book of Documents in 19 front of you which, for the record, is 1004978. 20 At page 177 of that document, that is your 21 testimony at the trial of Cecil Bernard George in July of 22 1996. 23 A: I have it.


1 Q: Okay. Okay. You testified there 2 that an OPP inspector at the Forest Detachment told you 3 there was a situation that may be arising that evening 4 and that we may be required to perform medical services 5 for them. Does that -- does that refresh your memory at 6 all? 7 A: Yeah. Thank you. Yeah, again, I 8 can't remember the exact words but yeah, it we were 9 requested to do medical standby the nature of that I 10 wouldn't have known at the time. But again, it's one of 11 our understandings that if we're requested to help out in 12 a medical way, we can -- we will do so if requested. 13 Q: Okay. And can you remember anything 14 else of significance about your conversation with that 15 officer on that evening? 16 A: I think after that point it -- it was 17 fairly brief. I just was told to wait for their 18 instruction and we would be guided up to Ipperwash 19 Provincial Park and I believe we followed a police unit 20 that guided us up there. 21 Q: Okay. All right. And do you call 22 the -- the route that you would have taken to the Park? 23 A: No.


1 Q: Or to the -- to the -- 2 A: With the evening I wouldn't have 3 really seen any road markings or... 4 Q: Okay. And just to -- I'm going to 5 ask you a few questions about the communication centre 6 itself. Can you describe what your duties would be in 7 relation to the servicing of that centre? 8 A: For the communications unit itself, 9 essentially whatever was on the inside, we really weren't 10 instructed to do anything about that. The Ontario 11 Provincial Police were utilizing the facilities inside, 12 whether it was the computer, office space, communications 13 equipment. 14 Our essential orders were simply to make 15 sure that the generators were working; filled with gas; 16 oil level was proper to keep power running. And most of 17 those -- I think actually all of those can be accessed 18 from outside the vehicle. 19 Q: And you'd received training on how to 20 service the communication centre? 21 A: Yes. They are very similar to the 22 generators on any of our other units. 23 Q: All right. And had you worked with


1 this particular unit before in -- in the servicing 2 capacity? 3 A: No. I think it was one of the first 4 instances that the unit was used. The ones that I had 5 actually worked with generators on -- prior to that were 6 our canteen unit predominantly. 7 Q: Okay. So, you drove to the Ministry 8 of Natural Resources' parking lot near Ipperwash 9 Provincial Park, do you recall what you observed when you 10 first arrived there? 11 A: There were a number of police cars 12 parked. Again to get an accurate number, I wouldn't be 13 able to say for sure. There were also -- I believe they 14 were there before so I believe the two (2) Ministry of 15 Health Unit ambulances were already present and were 16 parked fairly close to the entrance of the parking lot. 17 There was a parking area with the road 18 leading back out to the main road -- 19 Q: Hmm hmm. 20 A: They were parked kind of nose to 21 end -- 22 Q: Hmm hmm. 23 A: -- and we parked our unit behind


1 those two (2) vehicles. 2 Q: Okay. And you -- do you recall what 3 time in the evening that you arrived there? 4 A: Again, hard to remember for sure. 5 Maybe between 10:00 and 11:00 p.m. 6 Q: Okay. And it was dark, by -- 7 A: Yes. 8 Q: -- the time you arrived? Was it dark 9 by the time you arrived at the Forest OPP Detachment? 10 A: Relatively, yes, yes. 11 Q: Relative? Getting dark? 12 A: Probably -- since I probably didn't 13 get there until about 9:00 or 9:30, I would -- 14 Q: Hmm hmm. 15 A: -- say at least, anyway, and being 16 September I would think that it was fairly dark at that 17 point, too. 18 Q: Okay. Okay. So, what did you do 19 when you arrived at the parking lot? 20 A: We parked the vehicle where we were 21 requested to. Actually, there -- we did bring both 22 vehicles to the parking lot -- 23 Q: Hmm hmm.


1 A: -- and I can't remember who was 2 driving which one at the time. Our utility vehicle, 3 406 -- 4 Q: Hmm hmm. 5 A: -- we still brought that up, and I 6 was anticipating that we would still be serving the 7 command unit, the communications unit; that was parked 8 off to the side. 9 The medic unit was parked with the 10 Ministry of Health units and we simply awaited further 11 instruction which was provided to us by an OPP officer 12 who identified himself as an OPP medic, and -- 13 Q: Hmm hmm. 14 A: -- again, I'm sorry, I can't remember 15 the name. 16 Q: Okay. If I -- if I suggested to you 17 that his name was John Edward Slomer, would that -- or 18 Officer Slomer, would that -- 19 A: I trust you. 20 Q: Okay. Okay, and can you describe the 21 conversation that you had with Officer Slomer? 22 A: The details, again -- 23 Q: Hmm hmm.


1 A: -- are -- are not 100 percent clear. 2 He -- he simply requested Karen and myself, my partner 3 and myself, Ms. Bakker, to standby at our unit. 4 Q: Hmm hmm. 5 A: The same instruction was given to the 6 Ministry of Health paramedics who were manning their unit 7 to simply remain with our vehicles, to standby and we 8 would receive further instructions if necessary. 9 Q: Okay. And just to clarify. When he 10 instructed you to stay with your unit, he was referring 11 to Unit 100, the medical -- 12 A: That is correct. 13 Q: -- or the First Aid unit? 14 A: That's correct. 15 Q: Okay. And did you, in fact, at any 16 point that evening have the opportunity to service Unit 17 444, the communications centre? 18 A: No. 19 Q: And why was that? 20 A: Prior to any opportunity the 21 incidents in question that this Inquiry -- 22 Q: Hmm hmm. 23 A: -- is for, wound up taking place and


1 my partner, Ms. Bakker, and myself -- 2 Q: Hmm hmm. 3 A: -- were asked to -- to care for an -- 4 Q: Hmm hmm. 5 A: -- individual, a casualty, Cecil 6 George -- 7 Q: Hmm hmm. 8 A: -- and transport him to Strathroy 9 Hospital. 10 Q: Okay. And we will come to that. On 11 your arrival, however, you didn't immediately approach 12 the -- the communications centre to -- to check its fuel 13 levels or -- 14 A: No, we were simply directed to remain 15 with our unit -- 16 Q: Hmm hmm. 17 A: -- and we'd receive further 18 instruction. Essentially at that point, I -- I deferred 19 to all instruction from the police officers as they were 20 in charge of that scene. 21 Q: All right. And throughout the 22 evening, once you arrived at the Forest Detachment, you 23 were taking instructions exclusively from OPP officers?


1 A: That's correct, they -- 2 Q: All right. 3 A: -- essentially, with this type of 4 duty, they were the ones to request our presence, they're 5 in charge of the scene, and in the emergency response 6 system for the province of Ontario -- 7 Q: Hmm hmm. 8 A: -- police, fire and ambulance do 9 supercede St. John Ambulance. We will defer to their 10 instruction. 11 Q: Okay. And so did you take any 12 instructions at any point from any ambulance personnel? 13 A: No, there was really nothing that the 14 paramedics asked or requested us to do. 15 Q: Okay. Okay. And in terms again of 16 servicing the communications centre of your own 17 initiative, would you have approached the communications 18 centre? 19 A: No, to leave my unit would have been 20 to disregard -- 21 Q: Hmm hmm. 22 A: -- an order of the police officers. 23 Q: Okay. And once you arrived in the


1 MNR parking lot, at any time did you communicate with 2 your direct superiors at St. John Ambulance? 3 A: No, at -- considering ten (10) years 4 ago, cell phone technology isn't even great up there 5 now -- 6 Q: Hmm hmm. 7 A: We didn't have one, so there was no 8 real way for us to call back to London and our radios 9 would not transmit that far as well, either. 10 Q: All right. So, you wouldn't have had 11 the opportunity to check back in. 12 A: No. 13 Q: Or to, perhaps, update your superiors 14 at St. John Ambulance, that the nature of your -- your 15 duties appeared to have changed? 16 A: No, at that time I really didn't have 17 the ability to update them. 18 Q: Okay. While you were waiting on 19 standby in the parking lot, what did you observe going 20 on? 21 A: It was fairly difficult to observe 22 anything. We were requested, as I said, to stay with our 23 units. And I believe our units were some distance from


1 where the confrontation actually did take place. 2 Again, it was relatively dark. We -- we 3 were really only able to make out things by moonlight. 4 So, seeing -- I really actually didn't see a lot of what 5 took place. 6 Q: So, there was no artificial lighting 7 in the area that you recall? 8 A: No, not that I could tell, no. 9 Q: All right. Did you see any large 10 groups or groups of police officers? 11 A: I can't remember seeing a large 12 group. I -- I know there were a number of police cars 13 there and I -- I remember seeing a number of officers in 14 and around the area at different times, but I don't ever 15 remember actually seeing a large single group. 16 Q: And did you observe, while you were 17 on standby, did -- did anything else of not or 18 significance happen that you observed? 19 A: Prior to -- 20 Q: Prior to being approached and asked 21 for assistance with Mr. George. 22 A: About the only thing and I -- I 23 remember being interviewed about this by both the SIU and


1 other organizations, and I almost -- I regret to say it 2 in this way but I did hear banging noises. I'm not 3 trained to recognize specifically the sound of gunfire or 4 different types of gunfire, but there were banging noises 5 a distance from us. 6 Couldn't really make out voices or 7 anything like that but that was the one (1) -- the one 8 (1) memory that I do have that's relatively distinct. 9 Q: And can you -- can you recall the 10 number of banging noises you would have heard? 11 A: No. 12 Q: And whether they were in quick 13 succession or...? 14 A: No. It -- it was really hard to 15 tell. I can't -- I can't remember if they were very 16 rapid or anything. But, I just remember hearing like 17 repeated noises but how -- what the distance in spacing 18 was of them, it would be hard to remember. 19 Q: And at the time did you believe that 20 you were hearing gunfire? 21 A: Probably in my own mind I was 22 thinking that, a little worried about it and believing 23 that there were police present, that there was a


1 conflict. I was hoping it wasn't. 2 You know, sometimes, you know, 3 firecrackers could be set off to freak people out or to 4 scare people. I couldn't be sure what it was but I mean, 5 yeah, that was one of the options that crossed my mind. 6 Q: And did you have any discussions when 7 you heard that -- those noises? Did you confer with any 8 officers or any of the other emergency medical personnel 9 in the parking lot about what you had heard? 10 A: There wasn't a -- there was not an 11 officer near us at the time and I think maybe just being 12 a little bit surprised about what we were hearing, we 13 just kind of stood there. 14 Q: Okay. And at any point did you note 15 the police officers or police vehicles entering the 16 parking lot, you know, while you were on standby, like, 17 returning to the parking lot? 18 A: Specific police vehicles entering I 19 can't remember. The only vehicle movement that I 20 remember after hearing the noise that I did was the two 21 (2) Ministry of Health units left. I can't remember if 22 it was simultaneously or if there was some time period 23 between the two (2) of them leaving.


1 And then shortly after that point, there 2 was one (1) or two (2) dark coloured vans that seemed to 3 park a short distance from us, maybe thirty (30) or forty 4 (40) feet. 5 Q: Okay. And just to take you back to 6 the Ministry of Health vehicles. So, you can't recall 7 what time they would have left precisely? 8 A: I didn't -- I didn't know to note 9 that, no. 10 Q: All right. And did you know which 11 direction they left? 12 A: They left the parking lot back up to 13 the main road. 14 Q: Okay. 15 A: And which way they went after that, I 16 have no clue. 17 Q: Okay. And did you communicate with 18 any of the personnel on those units about where they were 19 going or...? 20 A: No, I think they simply went into 21 their vehicles and proceeded. 22 Q: Was it a cause for concern for you at 23 that point that there were no other -- there were no


1 Ministry of Health ambulances in the parking lot at that 2 time? 3 This is prior to anyone approaching you 4 for assistance. 5 A: Being not a full paramedic at the 6 time, I would have liked to have still had a Ministry of 7 Health unit with me. So, possibly a little bit of 8 concern. But just the fact that, you know, we're -- 9 we're now the next line of medical response here. 10 Q: Okay. And did you communicate with 11 anyone in the parking lot prior to being asked for 12 assistance about the fact that there were no Ministry of 13 Health vehicles there? 14 A: Again, nobody was with us from the 15 police at that time until we were asked to respond. 16 Q: Hmm hmm. 17 A: Prior -- when we were first directed 18 to our location by the police medic, one (1) of the 19 things that we did make very clear to him, both my 20 partner and myself, was that we were not a full Ministry 21 equipped unit, that we were a basic life support unit, 22 that we just had the basic type of equipment, not -- not 23 any advanced equipment that would be found on a Ministry


1 ambulance. So, I said, you know, if we do need to help 2 anybody, please take that into account. 3 Q: Okay. And, just to take you back to 4 that conversation, did you discuss with the medic any -- 5 about the possibility of you transporting patients? 6 Was that -- was that raised at all? 7 A: I think it was in general terms. 8 There was an initial conversation between the other 9 Ministry crews, the OPP medic, and Ms. Bakker and myself, 10 just if transport was required, where would we go. It 11 was -- we were just trying to determine whether it would 12 be Sarnia or Strathroy. And it was determined that it 13 would be Strathroy, simply because it was closer. 14 Q: Okay. And, who determined that? 15 A: It seemed to actually be kind of a 16 consensus decision. 17 Q: Okay. 18 A: But the OPP medic agreed with that 19 assessment and said that's where the transport will go 20 to. 21 Q: Okay. And, you mentioned that 22 eventually you saw some police vehicles return to -- you 23 described as cargo vans or vans?


1 A: Yeah, they were dark coloured and 2 they looked like cargo-style vans. 3 Q: And there were two (2)? 4 A: I can't remember if it was one (1) or 5 two (2). I -- I distinctly remember seeing one (1); 6 there may have been a second, but I distinctly remember 7 one. 8 Q: All right. Okay. And, what did you 9 observe -- how far -- first of all, how far away did that 10 vehicle or vehicles park from you? 11 A: It probably wasn't much more than 12 thirty (30) feet. Again, it was still fairly difficult 13 to see what was going on, excuse me, but what I could 14 make out was a little bit activity around the back of one 15 (1) of them. 16 Q: Hmm hmm. 17 A: Probably three (3) or four (4) people 18 standing outside and there seemed to be a person seated 19 in the rear. 20 Q: In the rear. Okay. And, the three 21 (3) or four (4) people standing outside, could you tell 22 if they were police officers or...? 23 A: From that distance it was hard to


1 say. 2 Q: Okay. And, where was the person 3 seated in the vehicle? 4 You said in the rear, was he sitting on 5 the edge of the van or inside the van? 6 A: Probably just inside it. I can't 7 remember for sure, and again, hard to see whether his 8 legs were dangling to the outside, but it did appear that 9 somebody was actually seated just in the area where the 10 doors on the rear of that type of van would open. 11 Q: Okay. And, how long was it before -- 12 before anyone approached you concerning that -- that 13 individual? 14 A: Probably not long, maybe five (5) 15 minutes. If it was ten (10), that would be long, but 16 again, hard to judge time at that -- at that point, but I 17 would probably estimate around five (5) minutes. 18 Q: Okay. Okay. And, can you describe 19 what happened? First of all, who approached you? 20 A: I believe it was the same police 21 medic who had been giving us the instruction previously. 22 Q: Okay. And, what did he say to you? 23 A: He said, We have a casualty, that we


1 need you to help. Can you come over and essentially take 2 over? 3 Q: Hmm hmm. 4 A: And we proceed, Ms. Bakker and 5 myself, over to the van. 6 Q: Okay. And, when he -- when he first 7 approached you, did he say anything about the -- the 8 medical condition or the -- the state of the -- the 9 patient? 10 A: I can't remember if it was at that 11 point or when we actually arrived at the van, but yeah. 12 Q: Okay. And, so either at that point 13 or when you arrived at the van, what did he tell you 14 about the state of the patient? 15 A: It was a fairly general rundown, it 16 was just, you know, we -- that it was a First Nations 17 casualty, that had sustained injuries. He had a fat lip, 18 I believe was the term he used, and laceration to the 19 back of the head. 20 And if we could, you know, take him back 21 to our vehicle and -- and I think at that point, I asked 22 him whether they wanted us to simply treat his injuries 23 and return him, Cecil George, back to his care. I didn't


1 know the name at the time -- at that time. 2 Q: Hmm hmm. 3 A: Simply treat the casualty and return 4 him back to the care of the police or to transport and we 5 were directed to transport him to the hospital. 6 Q: Okay. And, just during this 7 conversation or when you first approached the van, did 8 you directly observe Mr. George yourself? 9 A: Yeah, just saw the individual who 10 now, I realize, was the individual who was seated in the 11 back of the van that I'd seen earlier. 12 Q: Okay. And, what can you tell us 13 about what you observed in terms of his condition? 14 A: He was seated, probably slouched over 15 slightly, didn't seem to be very coherent at the time 16 and -- 17 Q: Why -- why do you say that? 18 A: Again, he was just -- his head was 19 down, he didn't seem to be talking or interacting with 20 anybody around him, so he just -- he didn't seem to be 21 fully alert. 22 Q: Okay. And, if I could just take you 23 to Tab 5 of your -- the documents in front of you.


1 I'm referring the Witness to Inquiry 2 Document Number 1002918. That is a memo from you, Mr. 3 Morgan, to P. Harding, Corps Superintendent. 4 And P. Harding, would that have been Paul 5 or Peter Harding? 6 A: Peter Harding. 7 Q: Peter Harding. Okay. And that's 8 dated September 8th, 1995? 9 A: Correct. 10 Q: Okay. First of all, when would you 11 have drafted this -- the date is September 8th, but when 12 would you have actually drafted this memo? 13 A: I believe I actually did write it on 14 that day. 15 Q: Okay, on September 8th? 16 A: Yes. 17 Q: Okay. And, would you have been 18 relying on your notes to do so or...? 19 A: Between notes, memory and -- well, 20 the notes would have been included on our patient 21 reports, our vehicle reports and from the memory of the 22 events. 23 Q: Okay. All right. And, if I could


1 take you to, I think it's the fourth paragraph there or 2 the third paragraph, you state that: 3 "At approximately 23:40 to 23:45 an OPP 4 officer who had earlier identified 5 himself as a medic approached us and 6 requested assistance at the vans. When 7 we arrived, the medic reported to us 8 the following: 9 Native Canadian approximately twenty- 10 five (25) years old, the first name, 11 Cecil, stated that the patient claimed 12 no alcohol use and that he, medic, 13 could not smell any on the breath of 14 the patient. 15 Injuries were a laceration to the 16 occipital region of the head and a fat 17 lip. The medic confirmed that he 18 wished -- wished us to transport the 19 patient to hospital. Strathroy General 20 was selected at the destination -- as 21 the destination." 22 So, did the medic give you any information 23 about or mention that Mr. George had a possible head


1 injury? 2 A: Other than when it mentions the 3 laceration to the occipital region of the head -- 4 Q: Hmm hmm. 5 A: -- that's -- using layman's terms, 6 that's a cut to the back of the head. That would have 7 been the only indication of any type of head injury at 8 that time. 9 Q: Did he indicate whether he had 10 assessed the patient for a possible concussion? 11 A: No, he didn't mention concussion. 12 Q: Okay. And, did he comment at all on 13 Mr. George's level of consciousness? 14 A: I don't believe so. I think it was 15 just as we observed. 16 Q: And, had he, at that time, reported 17 to you that Mr. George had a possible head injury beyond 18 the laceration, or a decreased level -- level of 19 consciousness, would that have raised a concern for you 20 in terms of your transporting that patient? 21 A: Potentially, just because of the 22 situation, type of injuries, decreased level of 23 consciousness, a lot of those things will indicate shock,


1 which can be a fairly significant -- 2 Q: Hmm hmm. 3 A: -- medical circumstance, but with the 4 initial observation, he hadn't fully lost consciousness, 5 he was still seated upright. 6 Q: Hmm hmm. 7 A: So, my level of concern at that point 8 wasn't to the same extent as was -- as arose during the 9 transport itself. 10 Q: Okay. And, you've described your 11 first aid training and experience for us, as -- in the 12 normal course of performing a first aid assessment, would 13 you expect the assessor to note the absence of the smell 14 of alcohol? 15 A: Generally not. Usually you're -- 16 you're stating what is present. When you -- the primary 17 assessment on the casualty is what's called the ABC's; 18 airway, breathing, circulation. 19 When you're assessing breathing, you're -- 20 and opening up the airway, generally you'll make note of 21 any unusual odours, whether it be alcohol and another 22 odour that we often describe is kind of an acetone smell, 23 which is related to things like diabetic emergencies.


1 The fact that he mentioned it, though, in 2 that type of situation was, perhaps, merely to reassure 3 Ms. Bakker and myself that, you know, the casualty you 4 have is, you know, has not -- is not under the influence, 5 will not be a violent casualty that you'd have to deal 6 with. 7 So, in that situation it might be more 8 normal to mention it, but again, I think, it changes from 9 situation to situation. But quite often, it's only the 10 unusual smell that you note. 11 Q: Thank you. And at that -- at any 12 time while you were in the parking lot, did any of the 13 officers present tell you how Mr. George had received his 14 injuries? 15 A: Nobody mentioned this, no. Nobody 16 mentioned what we call the mechanism of injury, no. 17 Q: And did you ask them how he'd been 18 injured? 19 A: No, actually I really -- really just 20 not thinking -- 21 Q: Hmm hmm. 22 A: -- at the time. It was more what the 23 injuries were --


1 Q: Hmm hmm. 2 A: -- and what were we to do with the 3 casualty,, I think, is what my focus was at the time. I 4 didn't really think to question them on -- on the 5 details. 6 Q: Okay. And did you note whether Mr. 7 George was under any restraints? 8 A: If I do remember correctly, I believe 9 the police have, on occasion, used almost like a type of 10 zip tie -- 11 Q: Hmm hmm. 12 A: -- to restrain an individual and I 13 believe there was one of those zip ties around Mr. 14 George's wrists. 15 Q: Okay. And were they in front or in 16 back. 17 A: I believe it was in front of him. 18 Q: Okay. All right. Mr. Commissioner, 19 I'm going to be moving on to a, sort of, separate area. 20 Would this be a good time to break for lunch? 21 COMMISSIONER SIDNEY LINDEN: Do you want 22 to break for lunch now? I was going to go a little 23 longer, but this is as good a time as any.


1 MS. KATHERINE HENSEL: Yeah, I've got a - 2 - I've got a fair ways to go and it's all fairly 3 continuous, so... 4 COMMISSIONER SIDNEY LINDEN: We'll break 5 for lunch. Thank you very much. 6 MS. KATHERINE HENSEL: Thank you. 7 THE REGISTRAR: This Inquiry stands 8 adjourned until 1:15. 9 10 --- Upon recessing at 12:06 p.m. 11 --- Upon resuming at 1:15 p.m. 12 13 THE REGISTRAR: This Inquiry is now 14 resumed. Please be seated. 15 MS. KATHERINE HENSEL: Good afternoon, 16 Commissioner. Good afternoon, Mr. Morgan. 17 COMMISSIONER SIDNEY LINDEN: Good 18 afternoon. 19 THE WITNESS: Good afternoon. 20 21 CONTINUED BY MS. KATHERINE HENSEL: 22 Q: Just prior to the lunch break, we 23 were -- I had asked you some questions about how you 24 first came to know that Mr. Cecil Bernard George was in


1 the parking lot. And you had described how an OPP medic 2 had -- had brought you over to a van and that you saw Mr. 3 George there. 4 I understand that you then -- you placed 5 him -- you assisted on placing him on a stretcher? 6 A: That's correct. 7 Q: Okay. And did you personally perform 8 any further medical assessment of Mr. George? 9 A: Personally, no. I was -- excuse me, 10 I was simply responsible to help assist Mr. George onto 11 the stretcher. We wheeled him back to our medic unit, 12 placed him in the rear of the unit. I was the driver 13 that evening, so any further assessment and care was the 14 responsibility of my partner, Ms. Bakker. 15 Q: Okay, and who -- who assist -- or who 16 worked with you to move Mr. George back to your unit? 17 A: Myself, Ms. Bakker and there may have 18 been an officer assisting as well, but I know officers 19 assisted us to place him on the stretcher but it may have 20 just been Ms. Bakker and myself that moved the stretcher 21 itself back to the unit. 22 Q: Okay. And can you recall any further 23 conversation amongst your -- either between you and Ms. 24 Bakker or you and any of the other people present about 25 his condition at that point?


1 A: No, we had simply determined where we 2 were transporting Mr. George and at that point it was 3 just to proceed to place him inside our medic unit and 4 begin transport. 5 Q: Okay. So he was placed inside your 6 unit and -- 7 A: That is correct. 8 Q: -- and this point, can you recall 9 once he was placed on the stretcher, was he still wearing 10 restraints? 11 A: I believe at one (1) point they were 12 removed and I can't remember whether that was prior to 13 him being placed on the stretcher, right after he was 14 placed on it. I -- I'm not clear exactly the precise 15 moment. 16 Q: Okay. And do you recall who would 17 have removed those restraints? 18 A: It would have been a police officer. 19 I don't think we were capable of doing so. 20 Q: Okay. Okay, so Mr. George is in the 21 back of your unit, you then left the MNR parking lot? 22 A: That's correct. 23 Q: Okay, and you were headed towards 24 Strathroy -- 25 A: That's correct.


1 Q: -- Hospital? Do you recall the route 2 that you took? 3 A: No. I have to be honest on this one. 4 I'm not very comfortable with the roads and the routes of 5 this area. There was another police officer accompanying 6 me -- 7 Q: Hmm hmm. 8 A: -- in the -- in our medic unit. 9 Q: Hmm hmm. 10 A: I informed him that we were going to 11 Strathroy and that I would appreciate him being the 12 navigator, so to speak. 13 Q: Okay. And how did he end up in your 14 vehicle? Did you request that he come or did... 15 A: He -- he simply said that I'm 16 accompanying you to the hospital and I took that as kind 17 of a standard procedure. 18 19 (BRIEF PAUSE) 20 21 Q: Why would you -- why would you assume 22 it was a standard procedure? 23 A: Mainly -- mainly because of the -- 24 the situation with St. John Ambulance. We're not a 25 regular Ministry of Health paramedic provider.


1 The police were, as I've stated earlier, 2 they were in charge of this situation. We were acting 3 under their direction at all times, so it simply -- I 4 guess it seemed natural to me that a police officer would 5 be accompanying us -- 6 Q: Hmm hmm. 7 A: -- simply because we are under their 8 direction at that time. 9 Q: Okay, and so that officer provided 10 you with directions at every stage to get -- to get to 11 the hospital? 12 A: Yes. 13 Q: Okay. At any point -- do you 14 remember the names of any of the roads that you would 15 have travelled on? 16 A: I believe upon leaving the parking 17 lot, I believe for a short period of time we were on 18 Highway 21 -- 19 Q: Hmm hmm. 20 A: I know there were at least one (1) or 21 two (2) other roads that we used between being on Highway 22 21 and I know the last major road that we were on was 23 Highway 81, leading into Strathroy -- 24 Q: Hmm hmm. 25 A: As the actual names of them, I


1 couldn't be sure of the other. 2 Q: Did you stay to paved routes the 3 entire way? 4 A: Yes, the entire trip was on paved 5 road. 6 Q: And were you on any major highways, 7 like four (4) lane highways at any time? 8 A: Like the 402 or something? No, not 9 at all. 10 Q: Okay, and as you -- as you drove away 11 from the MNR parking lot, was Ms. Bakker communicating to 12 you about the patient -- the patient's condition? 13 A: Probably not immediately upon leaving 14 the parking lot. But throughout the -- throughout the 15 trip was when she would occasionally report from the back 16 as to findings or conditions that she was noting. 17 Q: Okay. And what was her first -- do 18 you recall when she first started to communicate or the 19 nature of her first communication with you, about his 20 condition? 21 A: Precisely when, I couldn't be sure of 22 the timing. It was probably within five (5) or ten (10) 23 minutes of leaving the parking lot. 24 Q: And what did she tell you? 25 A: I -- I can't remember exact words


1 that she was using. I know she was saying something 2 like, you know, he's bleeding from -- from the cut to his 3 lip, which she noted in the patient report. She said it 4 looked like his arm might be injured. I remember her 5 mentioning that. 6 And then the next major mention was when 7 she did state to me that she was having problems reading 8 a pulse. 9 Q: Okay. Did she tell you anything else 10 at that time? 11 A: Specifically I can't remember 12 clearly. 13 Q: Okay. So she said that she was 14 having a hard time getting a pulse. What did you do as a 15 result? 16 A: My initial reaction when she was 17 saying that she was having a hard time reading a pulse, I 18 think I may have been a little more concerned about the 19 condition of our casualty. 20 So I -- I simply indicated to the police 21 officer who was beside me at the time it's like, you 22 know, If -- if he's getting worse we got to get there 23 faster and he said, Use whatever, you know, whatever you 24 need to do to get there as -- as you need to do. 25 So I increased the warning levels that we


1 were using on our unit. Usually in general terms we call 2 that, you know, going up to a Code 4. So I turned on all 3 of the unit's lights, warning lights, the main red 4 flashers and I was using the siren as necessary at 5 intersections. 6 Q: Okay. Prior to -- to your making -- 7 changing to a Code 4, how fast would you estimate you'd 8 been travelling? 9 A: Probably close to the speed limit in 10 most areas around the 80 kilometre an hour range that 11 most of those roads allow. 12 Q: And -- and you would have been 13 stopping at stop signs or? 14 A: In that type of situation, you slow 15 at a stop sign, making sure that the way is clear. You 16 may not actually windup coming to a complete stop, 3 17 second, check everything, but if the way is clear, you 18 slow and then proceed through safely. 19 Q: Okay. And how fast would you have 20 been going once you'd switched to a Code 4? 21 A: Maybe one ten (110), one fifteen 22 (115) a lot of the time. 23 Q: Okay. And do you recall how far into 24 your trip you were when you made this switch? 25 A: Maybe fifteen (15) minutes into the


1 transport. 2 Q: Okay. And in its entirety, how long 3 -- how long was the trip from the parking lot? How long 4 did that trip take you? 5 A: Judging -- again I -- I don't think I 6 took really careful recorded times on it. But it seemed 7 to be between thirty (30) to forty (40) minutes total 8 time approximately. 9 Q: So you would have been roughly half 10 way when you switched to a Code 4? 11 A: Yes. 12 Q: And did Ms. Bakker communicate with 13 you any further about the patient's level of 14 consciousness while you were on the road or her ability 15 to -- to get vital signs from him? 16 A: After that one (1) instance where she 17 did say that -- that she was having a hard time reading 18 his vital signs, she did say okay, I've got a pulse again 19 which I wasn't sure it was to mean, you know, she got a 20 pulse again or she was just able to read it again. 21 I wasn't -- again, with the noise of the 22 vehicle it was hard to communicate really clearly. 23 Q: How -- how long was it before she 24 said that? 25 A: Oh, after the initial one? Probably


1 within three (3) or four (4) minutes after that first. 2 Q: And did you continue at a Code 4? 3 A: Yeah, we continued on that way just 4 simply because, you know, if he's had -- if she's having 5 a hard time getting a pulse on him, it might mean that 6 the pulse is weak, it might mean that he is in a state of 7 shock which indicates to us that, you know, he does need 8 to be seen by medical professionals as quickly as 9 possible. So we maintained the speed and warning levels. 10 Q: Okay. And as you left the MNR 11 parking lot, at that point if you'd had serious concerns 12 about his level consciousness or in the possibility of a 13 head injury or the patient being in shock, would you have 14 proceeded at how you initially described, under the speed 15 limit or at the speed limit? 16 A: I think if we had been really 17 concerned of his condition immediately, it would have 18 started out as a -- as we mentioned a Code 4 run it would 19 have been a rapid transport right from the outset. 20 Q: I understand you were also 21 accompanied by a police cruiser? 22 A: I really couldn't see it well myself. 23 But I was -- from speaking with the officer beside me -- 24 Q: Hmm hmm. 25 A: -- I was given the indication that


1 his partner was following us in a police car. 2 Q: Okay. And were you -- did you have 3 any access to radio communication along the trip? 4 A: We do have a radio in that -- in the 5 unit that was being used, Unit 100. Unfortunately, the - 6 - the most commonly used frequency on that is St. John 7 Ambulance's own frequency to be used -- 8 Q: Hmm hmm. 9 A: -- to communicate with our vehicles 10 in our home base which, in that situation, would not have 11 provided us any use at all. 12 Q: Hmm hmm. 13 A: The radios are also supposed to be 14 able to contact, I believe the terminology is CAC, or 15 central ambulance communication. 16 I did attempt to switch the frequency and 17 contact that -- that dispatch, but I wasn't able to. 18 Q: Okay. Okay, so you continued on to 19 the hospital at a Code 4 status? 20 A: Correct. 21 Q: Can you describe what happened when 22 you arrived at the hospital? 23 A: Actually, sorry, I should back up one 24 (1) thing with the radio communication. 25 Q: Hmm hmm.


1 A: Because I wasn't able to -- to raise 2 the dispatch, I actually asked the officer beside me if 3 he was capable to communicate with his partner following 4 us, and if he would be able to contact them. 5 So, I don't know whether they were able to 6 do so, but I did make that request. Upon arriving at the 7 hospital, we simply parked the unit within the parking 8 area, just outside of their emergency department, 9 proceeded to remove Mr. George from the back of the unit 10 on the stretcher and take him into the hospital as 11 quickly as possible. 12 Q: Okay. And did you note the presence 13 of any police cruisers in the hospital parking lot? 14 A: I believe there were -- there was at 15 least two (2) that I remember seeing for sure. Whether 16 there were more than that, I can't be -- I can't remember 17 clearly. 18 Q: Okay, were there any other ambulances 19 in the parking lot at that time? 20 A: I think there may have been at least 21 one (1). 22 Q: Hmm hmm. 23 A: But again, that's not unusual to come 24 across an ambulance parked outside of an emergency 25 department.


1 Q: And do you have any recollection of 2 the time that you would have arrived at the hospital 3 there? 4 A: Shortly after midnight I believe it 5 was. 6 Q: Okay. Okay, and so you actually 7 accompanied Mr. George into the -- into the hospital? 8 A: Pretty much as far as the actual 9 emergency room -- 10 Q: Hmm hmm. 11 A: -- at which point he was turned over 12 to the care of the nursing and doc -- the nursing staff 13 and the doctors at Strathroy General. 14 Q: And can you describe his condition, 15 once you'd taken him out of your -- your unit, on the 16 stretcher? 17 A: I -- I can't remember for sure 18 whether he was unconscious or semi-conscious at that 19 state. He would not have been what you would classify as 20 alert -- 21 Q: Hmm hmm. 22 A: He may have been semi-conscious, 23 though, at that point. 24 Q: Okay. Did he speak to you? 25 A: No, no he did not.


1 Q: And did you speak to him? 2 A: No, actually I don't believe I ever 3 spoke to him during the entire incident. 4 Q: Okay. And so what did you do after 5 you had delivered Mr. George to -- to the emergency room? 6 A: After I -- after I'd turned him over 7 to the care of the hospital staff, my partner Ms. Bakker 8 actually remained with him for some time. I believe once 9 they had found out that she had -- was just completing 10 her nursing qualifications, I believe they asked her to 11 remain and assist. 12 I left the general area, he remained on 13 the stretcher so one (1) of our pieces of equipment was 14 still with Mr. George. I believe at that point I 15 proceeded outside the hospital and tried to collect my 16 thoughts, to be quite honest. 17 Q: Hmm hmm. Yeah, I -- we could 18 understand if you were in a state. It was some what 19 surprising to have provided the services that -- that you 20 provided that evening -- 21 A: Correct. 22 Q: -- and experience what you 23 experienced. Okay, did you return to your vehicle? 24 A: Within a fairly short period of time. 25 Any time that we do transport -- well, transporting is


1 not all that common, but any time we actually treat a 2 casualty in one (1) of our units, one (1) of the 3 responsibilities is to clean a unit. 4 So one (1) of the things I did was 5 eventually go back to the unit and start to clean up the 6 rear of the unit from the treatment that had taken place. 7 Q: Okay. And did you make any notes or 8 complete any paperwork at that point? 9 A: I don't think that we actually 10 completed any paperwork until Ms. Bakker was released 11 from assisting in the ER, at which point we completed the 12 patient report. 13 I assisted her with that -- 14 Q: Hmm hmm. 15 A: -- although she was the one who did 16 perform the treatment, so most of that was her 17 responsibility, made some note -- notations on our 18 vehicle report as far as where we had got that we did 19 transport a casualty to Strathroy. I made some notations 20 on that, and I believe there was also as statement that 21 we were requested to make to the OPP about our actions. 22 Q: Okay. And, at that point you -- you 23 made that statement? 24 A: I believe so. I -- I think it's one 25 (1) of the...


1 (BRIEF PAUSE) 2 3 A: I believe Tab 3, the -- 4 Q: Tab 3? 5 A: September 7th, 1995, Document 6 1000365, the OPP statement of Glen Morgan. 7 Q: So, that would have been -- that 8 would have been completed while you were still at the 9 hospital? 10 A: With the -- yeah -- date, it says on 11 the first page, date of interview 7th of September 1995, 12 place of interview was Strathroy Hospital. 13 Q: Okay. Okay. While you were at -- at 14 the hospital, did you ever notice the arrival or presence 15 of a white car in the parking lot? 16 A: No, I didn't. I -- I do remember 17 seeing it when we finally did leave to return to Forest, 18 but I didn't actually witness it coming into the parking 19 lot. 20 Q: Okay. And, did you see any other -- 21 did you observe any other patients in the -- while you 22 were in the hospital undergoing treatment? 23 A: When I had helped wheel Mr. George in 24 on the stretcher, there was another individual either on 25 a treatment gurney or another stretcher within the


1 emergency room. I had no idea of who that was at the 2 time, though. 3 Q: Okay. And, did anybody speak to you 4 about who he was or... 5 A: No. 6 Q: How -- approximately how long was it 7 before Ms. Bakker was able to join you outside of the 8 emergency room? 9 A: Again, hard to place on time. It may 10 have been as short as fifteen (15) minutes; it may have 11 been up to half an hour. She may have a better 12 recollection of how long she was in the treatment room, 13 but I can't remember clearly. 14 Q: All right. And, I understand you 15 also had to wait for some time to retrieve your 16 stretcher? 17 A: A little bit of time. It may have 18 been a total of between half an hour to an hour. Again, 19 I'm not a 100 percent clear on the times, but it was 20 probably some time before they had transferred Mr. George 21 to one (1) of their own beds or one (1) of their gurneys, 22 at which point we were able to retrieve our stretcher. 23 Q: Okay. And, at any point while you 24 were in the hospital, did anyone -- did you hear any 25 discussion of Mr. George being HIV positive, possibly?


1 A: I do remember that comment coming 2 about. Precisely when that comment was first made, I -- 3 I can't remember if that was actually at the hospital or 4 when we took care of the casualty at the parking lot, but 5 it was mentioned at some point, but I'm having a hard 6 time remembering exactly when. 7 Q: Okay. And, did that have any 8 influence on your actions throughout the course of the 9 evening? 10 A: No. Anytime you're dealing with a 11 casualty, regardless of their background, regardless of 12 who they are, if a casualty is bleeding, if a casualty 13 has any bodily fluids coming out of them, you take all 14 standard precautions, that's using gloves, taking very -- 15 taking great care in dealing with them. 16 One (1) of our -- one (1) of our rules is 17 assume everyone has something and that's just standard 18 procedure. 19 Q: Okay. And, on leaving the hospital, 20 do you recall first of all, what time you did leave the 21 hospital? 22 A: The exact time was probably somewhere 23 between -- probably if I was estimating the time, maybe 24 about an hour after initially arriving, it may have been 25 a little bit longer, though.


1 Q: Okay. And, what did you on leaving 2 the hospital? 3 A: While at the hospital I'd actually -- 4 because of now having access to a phone, I did call back 5 to St. John Ambulance headquarters in London -- 6 Q: Hmm hmm. 7 A: -- informed them that we had 8 transported a casualty to Strathroy General Hospital, 9 that unit 406 and the communications unit were still 10 present at Ipperwash Provincial Park and we informed them 11 that we would be returning there to hopefully get our 12 units. 13 And we left Strathroy and returned to -- 14 actually, we returned to the police station, the OPP 15 station here at Forest. 16 Q: In Forest? 17 A: Yes. 18 Q: And what did you do when you arrived 19 there? 20 A: Reported that we were back and parked 21 our unit and waited for further instructions. 22 Q: Okay. Did you ask whether you should 23 go back to the MNR parking lot? 24 A: No, we just asked, you know, what 25 should we do and I think they just mainly told us just to


1 stay where we are and we'll let you know what to do, so 2 we just waited until we received further instructions. 3 Q: Okay. And, at any point were you 4 joined by other St. John Ambulance personnel? 5 A: Yes, another unit came up with a 6 couple of members to -- they brought up another unit in 7 case we were going to be bringing the rest of them back 8 so that we would have enough drivers to bring everything 9 back to London. 10 Q: Okay. And were you able, at any 11 point, that -- on September 7th that in the night or into 12 the morning, able to retrieve any of your equipment or 13 vehicles? 14 A: No. The only two (2) vehicles were 15 able to bring back to London that day was Unit 100 which 16 we'd used to transport Mr. George and the other unit that 17 was driven up by the members who came up from London. 18 Q: Okay. And did you have any 19 conversations with the OPP about whether you could 20 retrieve your equipment? 21 A: Honestly, I can't remember that much. 22 One (1) of the -- I believe one (1) of the people who 23 actually came up that evening was a person who held a 24 higher rank than myself and who had been with St. John 25 Ambulance for a number of years longer than myself.


1 And at which -- he may have actually been 2 the one to discuss with the police. But we were 3 basically given the impression earlier that morning, 7:00 4 or 8:00 a.m. that we wouldn't be able to go back to the 5 site and that we should just head back and they would be 6 in contact with our headquarters. 7 Q: Okay. And who was that that 8 accompanied you or that joined you there? 9 A: I believe it -- I'm trying to 10 remember whether it was Paul Harding who is my divisional 11 superintendent or Chris Mumberson, my divisional training 12 officer. 13 And in all honesty I can't remember who it 14 was at this time. 15 Q: Okay. And can you recall who else 16 may have joined you there? 17 A: There was another member, name of 18 Shelley Burchell and I think that would have been the 19 extent of the members to join us. 20 Q: Okay. And did you -- 21 A: Sorry. There may have been one other 22 but again, it's remembering everybody who was there at 23 the time is difficult. 24 Q: Okay. So when did you eventually end 25 up leaving the Forest OPP Detachment?


1 A: Probably between 7:00 a.m and 8:00 2 a.m., the morning of the 7th. 3 Q: Okay. And until then were you just 4 on standby waiting? Did you -- did you do anything else? 5 A: We pretty much just sat in our medic 6 units just outside the police headquarters here in Forest 7 and just waited. 8 Q: All right. And did you do any 9 debriefing or what you would -- what you would regard as 10 debriefing at that time? 11 A: No. The main debriefing for the 12 incident was carried out by Corp Superintendent Peter 13 Harding the next day in London. We did talk, you know, 14 to the other members who did come up about what had 15 happened but not in an official debriefing manner. 16 Q: Okay. And the next day, do you mean 17 September 8th or September 7th? Would it have been the 18 same -- you said that you returned at 7:00 or 8:00 the 19 morning of September 7th? Would it have been that day? 20 A: Yeah. I'm just trying to -- so yeah, 21 later that -- later that day with -- probably later the 22 day on September 7th is when I actually was talking with 23 Corp Superintendent Harding, I believe. 24 Q: And so what happened with the 25 vehicles, to the best of your knowledge, what happened


1 with the vehicles? In particular the vehicle that -- 2 that you had driven to the area of Ipperwash? 3 A: At that time I had no knowledge of 4 what happened to it until it subsequently was returned to 5 us in the condition that it came back. 6 Q: Okay. And do you recall when that 7 was -- when they were returned to you? 8 A: I can't remember which day it was 9 actually. 10 Q: And were you at the Base -- or did 11 you go to recover that vehicle yourself? 12 A: No, it was brought back. I don't 13 think it was in a driveable condition. I think it was 14 either towed back or brought back in some other manner. 15 Q: But you did see it when it was 16 brought back? 17 A: Yeah. It was returned to our parking 18 lot at the headquarters in London. 19 Q: Okay. And when you signed that unit 20 out, was there any noticeable or did you not any damage 21 to the vehicle, that was the previous day. 22 A: Nothing -- nothing noticeable damage. 23 I mean it was an older vehicle. I was one of our -- 24 probably one (1) of the older ones that we had in our 25 fleet. I mean there was some rust points on it, there


1 may have been the odd scratch and ding that kind of 2 thing. But it wasn't anything that anybody would 3 classify as significant damage. 4 Q: And when you next saw the vehicle can 5 you describe the condition it was in? 6 A: Significantly damaged. I believe the 7 steering column had been removed, most of the equipment 8 was missing out of it. I believe some windows had been 9 broken. There were some dents, fairly significant and 10 large dents to the vehicle. So it was in worse shape 11 than when I took it up there. 12 Q: Okay. And did you engage in any 13 other efforts or activities with St. John to -- to 14 recover any of the equipment that was -- 15 A: No. I think most of that because of 16 the nature of what had happened and I believe in Corp 17 Superintendent Harding's testimony was that he was 18 working with the Ontario Provincial Police who were 19 working with the -- 20 Q: Hmm hmm. 21 A: -- First Nations people to deal with 22 how to get that equipment back to us. So, at that point, 23 I would have had no further responsibility in that 24 regard. 25 Q: And you weren't involved in any of


1 the efforts that he would have described? 2 A: No. 3 Q: All right, Mr. Morgan, I -- I have no 4 further questions for you, so possibly if we could 5 canvass the parties for -- or Counsel for the other 6 parties as to whether they would like to cross-examine? 7 COMMISSIONER SIDNEY LINDEN: Does anybody 8 have any questions for Mr. Morgan? 9 10 (BRIEF PAUSE) 11 12 COMMISSIONER SIDNEY LINDEN: Okay. Yes, 13 Ms. Esmonde...? 14 MS. JACKIE ESMONDE: Twenty (20) minutes 15 to half an hour. 16 COMMISSIONER SIDNEY LINDEN: Twenty (20) 17 minutes to half hour. 18 MR. KEVIN SCULLION: Maybe the same, 19 depending. 20 COMMISSIONER SIDNEY LINDEN: I'm sorry, I 21 can't hear. 22 MR. KEVIN SCULLION: Maybe the same, 23 depending -- 24 COMMISSIONER SIDNEY LINDEN: Maybe the 25 same?


1 MR. KEVIN SCULLION: -- if I have some 2 overlap. 3 COMMISSIONER SIDNEY LINDEN: And Mr. 4 George? 5 MR. JONATHON GEORGE: Depending on what 6 goes before me, maybe ten (10) minutes. 7 COMMISSIONER SIDNEY LINDEN: Mr. 8 Roland...? 9 MR. IAN ROLAND: Five (5) minutes, your 10 Honour. 11 COMMISSIONER SIDNEY LINDEN: And Mr. 12 O'Marra...? 13 MR. AL O'MARRA: About the same, five (5) 14 minutes. 15 COMMISSIONER SIDNEY LINDEN: Okay, let's 16 get on. 17 18 (BRIEF PAUSE) 19 20 CROSS-EXAMINATION BY MS. JACKIE ESMONDE: 21 Q: Good afternoon, Mr. Morgan. My name 22 is Jackie Esmonde, I'm one (1) of the lawyers 23 representing some of the people from Stoney Point under 24 the name Aazhoodena and George Family Group. 25 A: Okay.


1 Q: Now, first of all you told us earlier 2 that it was the general policy of St. John Ambulance to 3 provide first aid if you were approached, and that -- 4 A: That's correct. 5 Q: -- requested to provide such? 6 A: That's correct. 7 Q: And I take it that's happened to you 8 when you've been out in the community in a St. John 9 Ambulance vehicle? 10 A: Yeah, I can actually -- one (1) of 11 the earliest memories I have of joining St. John 12 Ambulance was returning to our station one (1) evening, 13 in one (1) of our medic units, and getting ready to park 14 in, in our parking lot, and somebody running up the 15 street from one (1) of the houses short -- just a short 16 distance from our station, saying, Help, help, I need 17 some help. My sister or my cousin is ill. 18 Q: Hmm hmm. 19 A: So immediately, with my training and 20 with the mandate of St. John, I did what I could to help, 21 so if we're asked to help, we'll help. 22 Q: And one (1) way in which people know 23 they can approach you, is when they see the name St. John 24 Ambulance on your insignia? 25 A: I believe so, yes.


1 Q: Now, you've told us as well, that 2 when you -- when you left for Forest on the evening of 3 September 6th, it was your understanding that you would - 4 - your role would be to service the St. John 5 communication unit? 6 A: yes, primarily. 7 Q: And we heard from Superintendent 8 Harding this morning that there was -- there was a white 9 board in the communications trailer, that would have had 10 a log of when servicing was required and so on. 11 What do you know about what would have 12 been on that white board? 13 A: Probably the last time that the 14 generators had been filled with gas, the last time -- you 15 know, the -- the readings that were on it. 16 The evening in question, I never actually 17 got to the vehicles, so never saw the white board and 18 what was on it. 19 Q: Okay. Do you know how frequently the 20 unit needed to be serviced? 21 A: Unfortunately that can vary depending 22 on how much the equipment's being used. If all of the 23 computers have been being used, and all the lights have 24 been on continuously, it would be a significantly shortly 25 time than if very little of the equipment is being used.


1 So, we -- unfortunately, we really have to 2 go by who's using it and -- 3 Q: Hmm hmm. 4 A: -- wait for them to request us to 5 come in and check. 6 Q: Okay. So, I take it from your answer 7 that you -- you couldn't predict what time you might be 8 expected to service the vehicle? 9 A: No, I couldn't have. 10 Q: And I take it was -- you were 11 supposed to replenish the gas before it ran out? Was 12 that the idea? 13 A: Yeah, generally you try and do that. 14 And if they'd been using it fairly heavily, one (10 of 15 the things that I could have done, had things proceeded 16 normally that evening, was simply, actually, approached 17 one of the police officers and asked, would you like me 18 to check it now and if it had been a good time, we 19 probably would have been allowed in. 20 So that's -- I would have just informed 21 them, I'm here if you want me to check it out right now. 22 If not, just give me a call when you're ready. 23 Q: I see. And I take it, I mean the 24 circumstances you were faced when you went there, you had 25 to stay with your --


1 A: Yeah. 2 Q: -- medic unit and you couldn't do 3 that? 4 A: Yeah, there was never an opportunity. 5 Q: Okay. Now, you told us as well, the 6 first place you went was the Forest Detachment and you 7 spoke with an OPP inspector? 8 A: I couldn't tell you his rank. All I 9 know is I looked for -- I asked, who should I report to 10 that we're here, and they directed me to an individual. 11 Q: And it was at that point that you -- 12 you realized that your role had changed or would change? 13 A: To a certain extent. With -- with 14 the comment that I made earlier today about we might be 15 required to provide medical -- 16 Q: Hmm hmm. 17 A: -- assistance, that was a slight 18 change to the role. As I said, with St. John Ambulance, 19 we're always prepared to provide medical help when 20 required. 21 I hadn't anticipated it that evening other 22 than perhaps somebody injured themselves in an accident. 23 When they simply said that, You know, we may need medical 24 help at that point, I knew the role had changed slightly. 25 Q: Okay. And, were you provided any


1 explanation as to why they may need you... 2 A: No. 3 Q: ...to provide medical services? 4 A: No. 5 Q: Did you ask? 6 A: They didn't actually go into details, 7 they just said they might need us to help out. 8 Q: And you -- and you didn't ask? 9 A: At that point, I -- I really didn't 10 ask, I said, Okay, I'll be by the unit. Let us -- let us 11 know what we need to do. We'll stand by. 12 Q: And, did you have any discussion with 13 that officer about the limitations on what kind of 14 medical services you could provide? 15 A: Not with that officer. I did clarify 16 that, however, with the OPP medic who I encountered at 17 the parking lot. 18 Q: I see. And, you've told us that you 19 were -- you were at that Forest detachment between 9:00 20 and 9:30, as far as you can recall? 21 A: As close as I can remember. 22 Q: And, so then you proceed to what 23 we've learned is the MNR parking lot? 24 A: Correct. 25 Q: And you had your discussions with the


1 medic? 2 A: Correct. 3 Q: And, you've told us that you had no 4 capacity to contact St. John Ambulance at that point? 5 A: No, no. We had no way of 6 communicating directly with our headquarters. 7 Q: And, if you had had such an 8 opportunity, was that the kind of situation in which you 9 normally would call back to St. John Ambulance to make 10 sure that you were doing -- that it was okay for you to 11 change your role? 12 A: Generally. I don't know whether it 13 would have been so much of an asking permission, but I 14 probably would have contacted them and stated, Look, the 15 police have asked us be to standby to help to medically. 16 Q: Hmm hmm. 17 A: And, what the call would have been 18 from headquarters on an answer to that, I can't begin to 19 speculate. 20 Q: So, you stayed with the medical unit? 21 A: Correct. 22 Q: The medic unit. And -- and how much 23 time passed, then, before Cecil Bernard George was -- was 24 brought to your unit? 25 A: Again, it's hard to estimate. I know


1 we had to wait at the Forest detachment for a period of 2 time before we went up to the parking lot and then there 3 was another period of time waiting at the parking lot 4 before we had -- we were given the care of Mr. George, so 5 to place the two together, it's kind of hard to really 6 give an accurate time. 7 Q: Okay. Now, in your discussions with 8 the OPP medic, upon your arrival at the MNR parking lot, 9 that was when you -- you were again told that they wanted 10 you -- you were told they wanted you on standby in case 11 there was a medical emergency? 12 A: Correct. 13 Q: And, at that time, were you -- was 14 there any explanation as to why you may be needed in that 15 capacity? 16 A: No, they just simply said to standby 17 and to assist with anybody who was injured if required. 18 Q: Were you told that the OPP was -- was 19 conducting an operation that evening? 20 A: Nothing specifically in that 21 terminology, no. 22 Q: Were you given any indication about 23 what kind of injuries to expect? 24 A: No. 25 Q: In particular --


1 A: No, sorry, one (1) thing I should 2 clarify, since -- sine there was nothing specific 3 requested of us, that was the point where I did instruct 4 the OPP medic of the limitations of our vehicle and 5 simply stated considering the type of injuries and what 6 we're capable of treating, ensure that we don't get a 7 casualty beyond our level of treatment. 8 Q: I see. I take it, then, there was no 9 discussion of the possibility of gunshot injuries? 10 A: That term never came up. 11 Q: Okay. So, moving ahead, then, to 12 when Cecil Bernard George was brought to your unit and 13 you were asked to transport him. 14 A: Okay. 15 Q: Now, at that point, did you ask if it 16 was possible to get a Ministry of Health ambulance to do 17 the transport? 18 A: No, I didn't ask at that point. I 19 had -- I had assumed on my own, with the fact that we had 20 had two (2) other units there and they had left, it was 21 my understanding that we were the last available unit to 22 assist and to request another one. 23 I wouldn't have been sure how long it 24 would have taken to get another one and in situations 25 like that, and the indication we were given about his


1 condition, we thought, okay, he'll get faster treatment 2 if we transport him ourselves. 3 Q: And, the information you had about 4 his condition was what you received from the OPP medic? 5 A: Correct. 6 Q: That he had a fat lip and a 7 laceration to the back of his head? 8 A: Correct. 9 Q: And, as you told us, you later 10 learned that he actually had -- he had more serious 11 injuries than that? 12 A: That's correct. From -- from the 13 report that I heard from my partner who was doing the 14 secondary assessment. 15 Q: Now, had you known that at the time, 16 would you have suggested contacting the Ministry of 17 Health ambulance? 18 A: Potentially. At which point -- or 19 had even tried to drive to a meeting location to try and 20 get him there faster and treated him as best as we could 21 until we can turn him over. 22 Again, those types of injuries are really 23 hard to determine the severity until they actually get 24 fully examined at a hospital. But, it would have -- it 25 would have probably made us more aware of, okay, he's


1 hurt a little bit more than we had anticipated. 2 Q: Hmm hmm. And had you known the 3 extent of his injuries would you have carried out -- used 4 different procedures to move him from the van to your 5 ambulance? 6 A: Quite possibly. I know I've been 7 questioned in the past about not using a C-collar or a 8 spine board and that's usually standard procedure for 9 head injuries. 10 With -- with the report that we had from 11 the police medic and as well as the condition of Mr. 12 George when we saw him, the fact that he was seated and 13 at least semi-conscious really didn't bring into our mind 14 the need for a C-collar or a spine board immediately 15 Knowing the injuries he had now, it 16 probably would have been done as a precaution. I know 17 that ultimately it was not required, but it probably 18 still would have been done as a precaution. 19 Q: And had you known the extent of his 20 injuries, I take it you would have used a Code 4 from the 21 beginning, from the moment that you left? 22 A: Potentially. Just -- the injuries 23 itself may not have warranted a Code 4 initially. It was 24 mainly the -- the report of the vitals and the potential 25 for shock that increased -- increased it.


1 Somebody could have had injuries similar 2 to the ones that he sustained and been relatively stable 3 for most of the trip. But, it was -- it was mainly the 4 vitals which made me want to increase to a Code 4. 5 Q: Now, you've told us there was a 6 consensus decision to go the Strathroy Hospital? 7 A: Correct. 8 Q: And that consensus was reached 9 between yourself, Ms. Bakker, Stevens and the other 10 Ministry of Health ambulance attendants; is that right? 11 A: And the OPP medic as well. 12 Q: And the OPP medic. 13 A: Correct. Mainly due to distance. 14 Q: Okay. So, that was the -- that was 15 the major factor, and your decision was that Strathroy 16 Hospital was the closest. 17 A: Yeah. I actually -- I believe it was 18 -- the question was posed to the Ministry of Health 19 paramedics, which one is faster to get to from where we 20 are; Sarnia or Strathroy. They indicated that you could 21 get to Strathroy faster and that's pretty much what -- 22 what made the decision. 23 Q: Now, it's my understanding that 24 Strathroy Hospital is a primary care hospital? 25 A: I'm not clear on the terminology.


1 Q: You don't use that terminology? 2 A: Well, I'm just not clear on what 3 level Strathroy General actually is from my own personal 4 knowledge. 5 Q: Oh, I see. 6 A: I -- I did have a general awareness 7 that evening that Sarnia's facilities would be superior 8 to Strathroy. But, as far as determining which one was 9 primary or that type of degree, I don't think I was 10 totally aware of it at that time. 11 Q: And that wasn't a factor you were 12 taking into consideration when you were determining which 13 hospital to go to? 14 A: They -- actually that was mentioned 15 that evening. It was because somebody did say, you know, 16 Sarnia would have better facilities. However, they said, 17 you know, in the case of an injury -- I guess there's a 18 term in first aid or in medical terminology called the 19 'golden hour'. 20 When somebody has suffered a trauma or an 21 injury. Getting them to professional help in that first 22 hour is the most critical time. Therefore they said, you 23 know, Sar -- or sorry, Strathroy would have had 24 facilities. They did have an emergency department and 25 we'd be able to get them there guaranteed under the hour.


1 So, all of that kind of went together to 2 lead the decision to go to Strathroy. 3 Q: Okay. Now, I wanted to ask you some 4 questions about Mr. George's condition enroute. And 5 specifically I would like to refer to the statement that 6 you provided to the OPP at the Strathroy Hospital. 7 A: Okay. 8 Q: And that is at Tab 3. I see you 9 already have it open. For My Friends, that's Document 10 Number 1000365. 11 A: Okay. 12 Q: Just past the halfway mark in -- in 13 the typed version it states: 14 "At approximately 24:00 hours, I was 15 informed by my attendant that the 16 casualty coded (no calls, no response) 17 I immediately went from running a low 18 priority Code 3 to full Code 4 using 19 sirens as necessary." 20 Now, this was the statement that you 21 provided very shortly after -- 22 A: Right. 23 Q: -- arriving at the hospital; that's 24 right? 25 A: Yes, correct.


1 Q: And you state here that the attendant 2 told you that the casualty had coded? 3 A: Yeah, that was probably the term that 4 I put into the report and I was probably trying to put in 5 terminology sounding more professional. 6 I believe as -- as close as I can 7 remember, the term that she actually used in the -- in 8 our medic unit itself was, I can't get a pulse, and, you 9 know, which I did put in brackets, no pulse and she had 10 indicated that he had lost consciousness so no response. 11 So, probably using the term, 'coded' in 12 that first -- in the first report that I gave was 13 probably not the best term I could have used. 14 Q: Is it not the case, though, that Ms. 15 Bakker did actually call a Code 4 at that time? 16 A: She didn't call -- I don't believe -- 17 I can't remember if she actually called me to go to Code 18 4, she simply said, I can't get a pulse, he's not 19 responsive; at which point that's -- if you hear from 20 your partner that somebody's -- it's kind of a standard 21 procedure you go to a higher -- a higher warning level. 22 Q: Perhaps it would be of assistance to 23 refresh your memory if you looked at the statement that 24 Ms. Bakker provided -- 25 A: Okay.


1 Q: -- to the OPP at the hospital. I 2 believe that's at Tab 16 of your book and that is Volume 3 IV, Document 1005723. 4 A: Okay. 5 Q: And, again, I'm about halfway through 6 the typed version. It states: 7 "Approximately 24:00 patient had no 8 pulse and no response. At this time I 9 called a Code 4. My attendant 10 responded accordingly. Patient's 11 consciousness returned before CPR was 12 begun." 13 Now, it seems that she -- we will ask her, 14 of course, when she takes the stand after you, but it 15 seems from this statement that she did call a Code 4. 16 A: Yeah. I guess that's probably in the 17 discussion we had, the precise words that we could use. 18 It's like, if she had actually said to me, You know, I 19 can't get a pulse, he's not responsive. Go to Code 4. 20 It's like, Okay, I'm going to Code 4. 21 It's -- it would just have been, you know, a discussion 22 going between the two (2) of us, just clarifying that 23 we're increasing the warning level and that she was 24 concerned about his condition and we needed to proceed. 25 Q: Right. Now, I'm -- I'm not a medical


1 professional, so I -- perhaps you could explain what is 2 meant when you say, There was no -- he was not 3 responsive? 4 A: Even -- even when we train people in 5 first aid, one (1) of the very first things that you look 6 for is a casualty's ABC's; Airway, Breathing, 7 Circulation. And even before that, you assess whether 8 your casualty is responsive. 9 First aid CPR training you could go up to 10 somebody and, you know, gently move their shoulders, you 11 know, look at them and say, Hey, can you hear me? Can 12 you wake up? 13 If they don't respond to you in any way, 14 we say the casualty's unresponsive. 15 Q: Hmm hmm. 16 A: So, unresponsive can simply mean 17 unconscious or in a very, very decreased state of semi- 18 consciousness. 19 Q: So, that's what you took her to mean 20 when she said there was no -- he was unresponsive or 21 there was no response? 22 A: When she said, You know, I can't get 23 a pulse, he's unresponsive, because I wasn't actually 24 physically examining I wasn't sure how severe it was. 25 All I knew was, the situation was worse than where we had


1 actually initially received him. 2 Q: Right. And, you believed there was a 3 serious medical emergency? 4 A: Yeah. Actually, one (1) of the 5 things that we train in first aid courses, is the moment 6 a casualty is unresponsive, it is considered a serious 7 medical condition. When a person goes unconscious they 8 need medical help, so you get them to help accordingly. 9 Q: Okay. Now, you gave -- you've given 10 a number of statements about -- about this evening over 11 the years. I'd like to turn you to the document at Tab 5 12 of your book, which is Document Number 1002918. 13 Now, this was a statement that, according 14 to the subheading, was given on Friday, September 8th, 15 1995 at 2:00 p.m.? 16 A: Yes. 17 Q: And this was to the Corps 18 Superintendent, Mr. Harding? 19 A: Correct. 20 Q: And if you could turn to page 2, I 21 believe it's, I guess, the third paragraph: 22 "Although my attendant did not state 23 the pulse or respiration rate, she 24 stated to me at approximately 24:00 25 that both were hard to read. At this


1 time, for safety considerations, I 2 turned on the top red flashers of the 3 unit and the headlight flashers." 4 A: Correct. 5 Q: Now, would you agree with me that 6 that's a somewhat different description than what you 7 provided to the OPP at the Strathroy Hospital? 8 A: Slightly different in terms of -- in 9 terminology. As I mentioned in the previous statement, 10 the word, 'coded' was probably not the best term that I 11 could have used. 12 However, it's still, so that you know, at 13 approximately twenty-four (24) both were hard to read or 14 that she couldn't read them. Again, trying to even 15 remember exactly what was said, even the night before, 16 was difficult, even exact wording. 17 The second statement: 18 "At this time, for safety 19 considerations, I turned on the top red 20 flashers of the unit and the headlight 21 flashers." 22 That is essentially going to a Code 4. 23 Q: Hmm hmm. 24 A: At that time of night you only use 25 the siren when you're going through an intersection.


1 Q: Right, there's no mention here, 2 though, of the fact that he was non-responsive and you 3 felt there was a serious medical emergency. 4 A: With -- the fact that with vitals and 5 respiration both being hard to read and for safety 6 considerations, increase in the warning system, for 7 medical procedure both of those together do indicate that 8 the medical condition has worsened. 9 You're taking more increased 10 considerations to transport the casualty faster. 11 Q: Now, I believe in other statements 12 you've also suggested that the reason that a pulse 13 couldn't be obtained by Ms. Bakker was because of the 14 noise in the vehicle. 15 Now, this statement that we're looking at 16 right now, this was written after you'd had a debriefing 17 with Superintendent Harding; is that correct? 18 A: Yeah, we discussed what had 19 transpired the day before. 20 Q: And it was during that discussion 21 that the issue of the noise in the ambulance was -- was 22 discussed? 23 A: Correct. 24 Q: And it was Superintendent Harding 25 that had raised that as an explanation?


1 A: I -- yeah, I believe he suggested 2 that due to his experience of actually being a -- an 3 attendant in vehicles in the past. Something that 4 neither Ms. Bakker, myself, had a lot of significant 5 experience with. 6 Q: And you accepted that as a reasonable 7 explanation that he had provided to you? 8 A: Yeah, actually it makes a lot of 9 sense. Even some of the other events that I've covered 10 in the past such as an air show, or even the fair, 11 occasionally makes it hard to get a really good pulse 12 reading even just with surrounding noise from people or 13 rides or an air show event. 14 So, actually being in a vehicle with the 15 engine running and the road vibration would be at least 16 as hard, if not more difficult. 17 Q: Okay. Can you explain how the noise 18 in the vehicle would have, if it would have impaired her 19 ability to determine if he was responsive or not? 20 A: Potentially, again I wasn't in the 21 back of the unit, so I wasn't able to see what level of 22 response he actually had. 23 But, with somebody, if their eyes are 24 closed and they're not really responding to you or 25 talking to you, that would -- that would be where you


1 would go to determine what their level of responsiveness 2 was. 3 Q: Right. And -- and that would not be 4 affected -- her ability to see those signs would not be 5 affected by noise in the vehicle? 6 A: At that -- the ability of him to 7 respond, no. 8 Q: Okay. And I just have one (1) other 9 question for you. It's with respect to the -- the police 10 officer accompanying you in the ambulance -- 11 A: Correct. 12 Q: And you had explained earlier that 13 you just assumed this was a standard procedure? 14 A: Yes. 15 Q: Okay. Now, you were asked about that 16 when you testified at the trial for Mr. Cecil Bernard 17 George? 18 A: Okay. 19 Q: And the transcript of your testimony 20 is found at Tab 8. 21 A: Okay. 22 23 (BRIEF PAUSE) 24 25 Q: And for My Friends, that's Volume


1 III, Document 1004978. 2 If you could just turn to page 179, and 3 commencing at about line 23. 4 A: Okay. 5 Q: Quest -- sorry, I'll start at line 6 20. 7 ˘Question: And you had Karen Bakker 8 with you, the casualty and anyone 9 else?÷ 10 A: Okay. 11 Q: ˘Answer: There was an OPP officer 12 riding in the front of the unit with me 13 who was assigned.÷ 14 A: Correct. 15 Q: ˘Question: Do you know what he was 16 doing there? 17 Answer: No, as I had not heard 18 anything in regards to that, but I 19 believe they said it was just standard, 20 since we were transporting a native 21 casualty that we would have a police 22 officer accompanying us.÷ 23 I was just wondering if you could explain 24 what you would have meant by that answer that it was 25 standard when transporting a native casualty?


1 A: I -- probably, at that time, or in my 2 own view, I -- considering that it was an indication of a 3 conflict between the First Nations people at the site and 4 the Ontario Provincial Police, that in transporting one 5 of the casualties from the First Nations people that it 6 would have been standard procedure to have a police 7 officer with me, plus the fact that they were instructing 8 me where to go. 9 I -- I just thought it was -- it was 10 standard to have the officer with me, I just -- I didn't 11 even question it at the time. 12 Q: Okay. It just -- your answer at the 13 trial suggests that somebody actually said to you; it 14 says: 15 "They said it was just standard since 16 you are transporting a native 17 casualty." 18 Do you remember today that you spoke with 19 an OPP officer who gave you that explanation? 20 A: I -- I don't remember who would have 21 given me the explanation at that time, and I don't know 22 whether it just made sense because it was a conflict 23 situation between the two (2) groups, that him mentioning 24 that just made it seem like that would have been the 25 normal procedure at the time.


1 I didn't really think -- think of it in 2 the terminology that it was being used in that regard. 3 It was simply, we're transporting -- we're working under 4 the direction of the Ontario Provincial Police, we're 5 transporting an individual who was, for lack of a better 6 term, on the opposing side of a situation, and therefore 7 the police are required to accompany us. I just took 8 that as would have been normal procedure. 9 Q: Okay. And somebody did say something 10 to -- these words to -- something to this effect to you 11 at that time? 12 A: Yeah, I -- 13 Q: You just can't recall who? 14 A: -- I don't know how exactly how it 15 was said, but, you know, you're taking one of the First 16 Nations' casualties, we should have somebody accompanying 17 you. I don't know how the terms were used, but it was 18 just, you know, we're going to have an officer with you, 19 and I was like, okay. 20 Q: Thank you very much, sir. Those are 21 all my questions. 22 A: Thanks. 23 COMMISSIONER SIDNEY LINDEN: Thank you 24 very much. 25 Mr. Scullion...?


1 CROSS-EXAMINATION BY MR. KEVIN SCULLION: 2 Q: Good afternoon, Mr. Morgan. 3 A: Good afternoon. 4 Q: My name is Kevin Scullion. I'm also 5 one of the Counsel representing residents at Aazhoodena. 6 Pardon my voice, I lost it; it's hopefully coming back to 7 me. 8 I take it nobody, and I mean nobody, one 9 of the police officers that evening, told you that Mr. 10 Cecil Bernard George was under arrest? 11 A: I had never heard those terms used -- 12 Q: Okay. 13 A: -- directed towards me. 14 Q: Do you know why the police car, your 15 escort, was behind your vehicle when you were driving to 16 the hospital? 17 A: I think during the conversation that 18 I had with the officer beside me, it was indicated that 19 it was his partner, so I thought it would just be, his 20 partner was going along with him, so that when he left 21 the hospital or he'd have -- he'd have a vehicle himself. 22 Q: Right. No -- you don't know why he 23 was behind as opposed to in front? 24 A: No, I just knew it was a partner. 25 Q: Okay.


1 A: Yeah. 2 Q: When this situation seemed to ramp up 3 a little bit when you're -- was -- Ms. Bakker in the back 4 indicated that she couldn't find vital signs and you 5 flipped on the lights did you notice whether or not the 6 officer with you was surprised by that? 7 It's just what your recollection is, what 8 you noticed. 9 A: I -- I don't really remember, I just 10 said, look, we got -- I think when Ms. Bakker or myself 11 used the terminology, look, we should go to Code 4, we're 12 going to Code 4, I said we should be getting him there 13 faster, and I think is -- the only words to me was like, 14 Do what you need to do. 15 Q: Sure. You relayed it to the officer 16 and he said do what you need to do. 17 A: Well, he would have over -- sorry, 18 excuse me, he would have overheard the conversation 19 between us and I just said, you know, we got to get him 20 there and he's -- he just responded, Do what you need to 21 do. 22 Q: Okay. Did the car behind you, the 23 police car behind you, move in front of you with his 24 lights on? 25 A: No, we were always in the lead.


1 Q: So, the car behind you stayed behind 2 you the whole way to the hospital? 3 A: As far as I can remember, I believe 4 it arrived at the same time we did. So, I believe he 5 kept up with us. 6 Q: All right. Now, maybe it's just me, 7 but I was trying to follow, when you're shift started 8 that evening, as a volunteer, was it eight o'clock that 9 evening? 10 Do you recall? 11 A: The shift -- arriving at the 12 Headquarters in London and the start of the shift in 13 Forest, there would be -- there would be a time 14 differential in there. I -- 15 Q: Let me help you out a little bit. If 16 you turn to Tab 2, of the book in front of you, you've 17 got an Ambulance Duty Report there for the Ambulance Unit 18 Number 100. 19 A: Correct. 20 Q: And that's your signature at the 21 bottom? 22 A: Correct. 23 Q: There seems to be on the top right, 24 four (4) boxes down, a time out of approximately 8:00 25 p.m. --


1 A: Correct. 2 Q: -- and a time in of approximately 3 8:00 a.m. 4 A: Correct. 5 Q: Is that -- would that help your 6 memory as to an 8:00 to 8:00 shift? 7 A: Yeah. Yeah. As far as the shift 8 goes, we -- the vehicle itself left London at 9 approximately 8:00 p.m. but at the time -- but there 10 would be a different between the time that we actually 11 arrived at the site. 12 Q: Sure. And it would take you, I think 13 I've heard, approximately fifty (50) minutes or so to get 14 to Forest with that vehicle? 15 A: Approximately. 16 Q: All right. And it -- I've seen in 17 documents from it's -- you've been referred earlier, 18 you've made a number of statements regarding this over 19 the years, but it seems from a statement that you made to 20 the SIU, which is Tab 7 in the document in front of you, 21 page 2 at the top; have you had a chance to take a look 22 at that? 23 A: Okay. 24 Q: It seems that the reason you had two 25 (2) different vehicles there was simply that you left at


1 different times? 2 A: Correct. 3 Q: And it was fortuitous that you took 4 with you, a medic vehicle, which a detective then saw you 5 at Forest and said, We could use you tonight. 6 Is that fairly accurate? 7 A: Very close, yes. I believe so. 8 Q: All right. You thought when you left 9 London that you were simply going to be tendering a 10 communications centre? 11 A: That's correct. 12 Q: You were simply going to provide 13 support and fill up the gas tank as and when needed and 14 deal with any difficulties that might arise? 15 A: Yes. 16 Q: And, if I heard you earlier, you were 17 bringing a book, because that wasn't the most exciting of 18 jobs? 19 A: I -- yeah, I actually -- I can't 20 remember the name of the novel, but I know I had thrown 21 one in the truck with me. 22 Q: All right. It was there for a 23 reason? 24 A: Yeah, I was either going to sleep or 25 read.


1 Q: Okay. But when you got to Forest, 2 that obviously changed? 3 A: Correct. 4 Q: And you were told by the OPP that 5 this was going to be different? 6 A: That it was going to be different? 7 Q: Could be different? 8 A: I didn't know to the degree, though. 9 Q: It could be different? 10 A: Correct. 11 Q: We'll -- we'll get to that in a 12 second. 13 A: Okay. 14 Q: Were you replacing two (2) volunteers 15 that were already at the site? 16 A: No, because one (1) of the 17 vehicles that were being used, like the -- the 406 Unit, 18 which tenders the communications unit which has all the 19 supplies had come back to London, so it was now back in 20 London; we were taking that one back up, so there were no 21 St. John Ambulance personnel there for probably a few 22 hours or a couple of hours. I don't know how long, 23 though. 24 Q: Well, it seems that if there's only 25 one (1) vehicle that does this tendering and that was the


1 one that you took at eight o'clock, it had to be at least 2 since seven o'clock that no St. John's ambulance vehicle 3 had been in that area of the communications centre. 4 A: That would be a good estimate. 5 Q: Okay. In fact, it could have been 6 more if they came back a little bit earlier with that 7 truck? 8 A: Potentially, yes. 9 Q: Okay. Do you know who those two (2) 10 people were that had the shift before you? 11 A: I don't know who was up there ahead 12 of time, no. 13 Q: Okay. And, had you done a shift at 14 that site by the communications centre before? 15 A: No, I was -- that would have been -- 16 it was my first and only time to -- 17 Q: All right. 18 A: -- to do that -- that duty. 19 Q: Quite a time to be there? 20 A: Yes. 21 Q: All right. So, you arrived about 22 9:30 -- ten o'clock? 23 A: In that range, yes. 24 Q: In that range at the communications 25 centre? Before that you were up in Forest and I'm not


1 sure I made an accurate note, but how many police 2 officers and vehicles did you see at the Forest Police 3 Station at that time? 4 A: Again, trying to go back by memory 5 about ten (10) years ago, because I didn't make notes on 6 it, it would be hard to actually state an exact number. 7 I know there were a number of police cars there and I 8 mean there were a number, probably half a dozen police 9 officers I saw walking around the building. 10 The room that I went to, to initially make 11 contact with the person in charge, there probably would 12 have been anywhere from half a dozen to ten (10) officers 13 in that room itself. 14 So, probably before going to the parking 15 lot, I may have seen a total of twelve (12) to eighteen 16 (18) officers. 17 Q: Okay. And that's back at the Forest 18 detachment? 19 A: Yes. 20 Q: Then you drive your car and it takes 21 -- or the truck, it takes about fifteen (15) minutes down 22 to where you're supposed to go to at the communications 23 centre? 24 A: Yes, we were -- we were directed the 25 direction to go.


1 Q: All right. And you're travelling 2 with a police escort? 3 A: I believe we did have an escort. 4 Q: Okay. And, when you get there, how 5 many officers do you see at that location when you arrive 6 between 9:30 and 10:00? 7 A: Officers actually at the site itself, 8 I don't think I saw as many as I saw at Forest. I saw a 9 number of police cars again, and mainly it was a small 10 number of officers. And I mainly only had contact with 11 that one (1) medic who directed us to wait with our unit. 12 I don't know where the other officers were at that time. 13 Q: All right. And you met that -- you 14 call a 'medic'; it's a paramedic with the OPP? 15 A: I don't know what his full 16 qualifications were. 'Paramedic' is a very legal and 17 strict terminology as far as medical training goes, but 18 he introduced himself as, I believe, an OPP medic, which 19 led me to believe that that was his capacity with the 20 Ontario Provincial Police. 21 Q: Fair enough. That's what he 22 introduced himself as? 23 A: Yes. 24 Q: And, did he tell you what was going 25 to be happening that night?


1 A: Not in any detail. It was simply, 2 We're just having you standby for medical support if 3 anything -- if anything happens and we need your 4 assistance. 5 But as far as any procedures, plans, 6 actions, he gave no details. 7 Q: All right. Did he tell you it was a 8 stand-off? 9 A: I don't know what term he used, 10 whether it was -- I don't know whether he said there may 11 be a confrontation or stand-off. 12 Again, trying to remember exact 13 terminology, I -- I think maybe the best word that I can 14 remember that he used is, you know, we want you here in 15 case any medical -- any medical emergencies arise from 16 the situation. 17 Q: Sure, it's difficult to remember 18 exact wording, but let me help you out again. In Tab 2, 19 if you go back to your ambulance duty report that we 20 looked at before -- 21 A: Correct. 22 Q: -- at the top, it seems to say, if my 23 reading is correct: ˘Ipperwash stand-off÷. 24 Did you fill that in? 25 A: Yeah, and I think we were just using


1 that terminology because that's what had been -- it had 2 been reported as in the media. 3 Just going by, you know, that was the term 4 that was being reported on the news reports over the 5 previous couple of days leading up the time that I was 6 there. 7 Q: So, that's your understanding of what 8 was going on down there? 9 A: Yeah, just the two (2) groups were in 10 that location and trying to resolve it. 11 Q: While you were there waiting for 12 something to happen and for you to be required to provide 13 possible medical assistance, you didn't tender the 14 communications at all? 15 A: No, I was not able to get -- 16 Q: You -- well -- 17 A: -- to the vehicle. 18 Q: You weren't able to, but you weren't 19 called upon by the police to come over and look at 20 anything? 21 A: No, they didn't ask me to deal with 22 our Communications Unit at all. 23 Q: Okay, you didn't provide gas or 24 refill the gas tank? 25 A: No.


1 Q: And you weren't asked to do any 2 technical work if you were able to do any? 3 A: No, not that evening. No. 4 Q: All right. Nobody but the medic 5 spoke to you that evening before you were called upon for 6 medical assistance? 7 A: I don't believe so. I think that was 8 the only officer that we dealt with directly, from the 9 point of arriving at the Park. 10 Q: All right. From the point that you 11 arrived at the Park, to the point where you left the area 12 to go provide or to take Cecil Bernard George to 13 Strathroy Hospital, did you notice at any point in time 14 the communications centre having no lights or having 15 nobody in the communications centre or coming out to seek 16 some assistance? 17 A: I don't even think I really clearly 18 saw the communications vehicle. From where we were 19 parked on standby with our units, from what I understand, 20 the communications unit was some distance from us and 21 with the fact of it being dark, I really didn't even see 22 it clearly. 23 So, I wouldn't have even known whether the 24 lights were off or if they had shut them off or what the 25 state of the unit was.


1 Q: Back in 1995 how large was this 2 parking lot that you were in, waiting for something to 3 happen? 4 A: I've actually never seen the parking 5 lot in daylight, so I can only go by what I saw that 6 evening. 7 Q: All right. And you're far enough 8 away from the communications centre that you couldn't see 9 anybody signalling you for assistance anyway? 10 A: No. 11 Q: So, you were directed -- is it by the 12 medic at the time? 13 You were directed by the medic off to the 14 side to wait; is that correct? 15 A: That's correct. 16 Q: And you were put off to the side 17 beside two (2) other Ministry vehicles? 18 A: Correct. 19 Q: And at some point in the hour or so 20 that you were there, the two (2) Ministry ambulances 21 leave? 22 A: Yes. 23 Q: And you weren't told why they left, 24 they just left? 25 A: Yes. The paramedic crews for those


1 vehicles got into their vehicles and drove away without 2 talking to Ms. Bakker or myself. 3 Q: They didn't let you know you're the 4 last one in the parking lot? 5 A: Well, I believe there was a bit of 6 time space between the two (2) of them leaving. So, one 7 (1) left and then the other two (2) got in that one (1) 8 and the second one left, so there -- I -- they never 9 actually reported to us. 10 Q: All right. You mentioned something 11 that you referred to as banging noises? 12 A: Right. 13 Q: Did the two (2) Ministry ambulances 14 leave before, after or did they straddle those banging 15 noises that you heard? 16 A: I think it was after. To the best of 17 my ability, I believe it was after, but I couldn't state 18 that with certainty now. 19 Q: All right. I've seen in statements 20 that you had earlier that it was about a ten (10) or 21 fifteen (15) minute wait between when you heard those 22 noises and when you were called upon to assist Mr. 23 George. 24 A: It's about the best estimate I could 25 make, yes.


1 Q: Is that fairly accurate? 2 Was there a lot of activity by police and 3 by cars -- police cars, in that parking lot in that time 4 that you were waiting? 5 A: I don't recall. Again, my partner 6 and I were pretty much just going by what we were told to 7 do. It was like, you know, stand by your unit until we 8 come and talk to you and that's what we did. 9 Q: Right, well, you used the term you 10 deferred to the OPP officers? 11 A: Yes. 12 Q: And that wouldn't be something new, 13 that's something that you would always do? 14 A: Yes, that's correct. 15 Q: All right. In fact, if you're there 16 to assist with the communications centre, you're, again, 17 deferring to the OPP officers? 18 A: That's correct. 19 Q: All right. When you received your 20 instructions from one (1) of the OPP officers at Forest 21 Detachment, did you think of calling back to St. John in 22 London to let them know things might be changing? 23 A: When they did ask us to do medical 24 standby it was -- it was a thought that may have briefly 25 crossed my mind, but again, I didn't know to the level of


1 what medical help that we were being asked to do. I 2 wasn't -- I wasn't thinking of, you know, how severe it 3 could get or how bad it could get. 4 And, unfortunately, just with my equipment 5 at the time, I had no way of directly contacting the 6 headquarters in London. 7 Q: Right. Is it fair to say that you 8 assumed at the time that if it was going to be a change 9 in what you had to do, if it was something serious, the 10 OPP would have already contacted St. John? 11 A: Potentially, or part of it was -- I 12 guess part of it was my thinking, you know, we're St. 13 John Ambulance, we're a volunteer organization. I guess 14 my own thought was, I couldn't imagine them asking us to 15 do something if it was going to get really bad. I just - 16 - I didn't think it was, you know, going to get bad. I - 17 - I don't think that really occurred to me until it 18 happened. 19 Q: And I think you mentioned that you 20 hoped that it wasn't a police conflict. 21 A: Pardon? 22 Q: You hoped that it wasn't a police 23 conflict or wasn't turning into a police conflict? 24 A: Yeah, I -- I mean, even when we're 25 asked to provide, you know, medical standby and if there


1 was going to be a confrontation, I -- I guess, again, my 2 thought was, they asked us to help, we're a volunteer 3 organization. 4 I didn't think it was going to be severe 5 or drastic as it did become, so, yeah, in my own mind, 6 probably while I was there, I'm like, I -- I hope it 7 doesn't get bad. 8 Q: Okay. Those are all my question, 9 Commissioner. 10 COMMISSIONER SIDNEY LINDEN: Thank you, 11 Mr. Scullion. Mr. George...? 12 MR. JONATHAN GEORGE: I'll be very brief, 13 Commissioner, thank you. 14 15 CROSS-EXAMINATION BY MR. JONATHAN GEORGE: 16 Q: Good afternoon, Mr. Morgan. 17 A: Good afternoon. 18 Q: My name's Jonathan George and I 19 represent the Kettle and Stoney Point First Nation and 20 I'll be very brief, sir. 21 I understand from your testimony that 22 initially, from you leaving the Ipperwash Provincial Park 23 with Mr. George in the back of your unit, that you were 24 initially travelling approximately 80 kilometres an hour 25 or at or near the speed limit, was that --


1 A: Very close. 2 Q: Okay. And, it wasn't until, just so 3 I understand the chronology, it wasn't until Ms. Bakker 4 reported the issue with respect to his vital signs that 5 you upped the code, so to speak, and began to travel at a 6 higher rate of speed? 7 A: Correct. 8 Q: At or around a 110/115 kilometres an 9 hour? 10 A: Yeah, best estimate. 11 Q: Okay. And, I think you've been very 12 clear in your testimony that you did, contrasting it with 13 your initial assessment of Mr. Cecil Bernard George, you 14 did later become aware, based on your travels from 15 Ipperwash Provincial Park to the hospital and based on 16 your partner, Ms. Bakker's secondary assessment, that the 17 injuries Mr. George sustained were much more serious than 18 what you initially believed; is that fair to say? 19 A: Correct, correct. 20 Q: Okay. And I know you've already told 21 Ms. Esmonde earlier that were you to have known that 22 initially, you may or may not have increased the code 23 initially and travelled at that higher rate of speed, 24 initially? 25 A: Correct.


1 Q: Okay. And, I'm not going to re-ask 2 that question, I'm just sort of setting the background 3 here, because when I listened to your evidence with 4 respect to that initial introduction to Cecil Bernard 5 George and when you initially observed him at the van, I 6 get the sense from your testimony that the OPP officer, 7 and I believe it was the OPP medic who made that 8 introduction? 9 A: Yes. 10 Q: Okay. Correct me if I'm wrong, sir, 11 but I -- I get the impression from your testimony that 12 this individual did that -- made that introduction and 13 described his injuries in a very casual way. 14 For instance, you described it as him 15 giving you the rundown and described him as having a fat 16 lip and laceration and that was it? 17 A: Correct. 18 Q: Do you agree with my 19 characterization? 20 A: It -- it was a fairly brief -- 21 Q: Okay. 22 A: -- brief description of the injuries, 23 probably in relatively layman's terms. 24 Q: Okay. 25 A: I don't know if he was doing that


1 because he knew that we weren't a full Ministry paramedic 2 unit or what -- I don't know what his reasoning was for 3 giving the description the way he did. 4 Q: Okay. But you agree that he did do 5 it in a very casual way? 6 A: Yeah -- 7 Q: Or -- or maybe I can put it a 8 different way. Certainly, forgetting about your initial 9 assessment, certainly nothing he told you caused you to 10 consider upping the code to a Code 4? 11 A: Yeah, his -- his initial statement of 12 his findings wouldn't -- didn't raise an alarm. 13 Q: Okay, nothing he said gave you an 14 elevated concern? 15 A: Not at that point, no. 16 Q: Okay. And regardless of code, sir, 17 is it fair to say that if you were initially told by this 18 officer that Mr. Bernard George had suffered some blunt 19 force strikes to his head or had been involved in an 20 altercation with several police officers, where he 21 suffered several blows, is it fair to say that would you 22 have expedited the trip somewhat, at least initially? 23 A: If -- depending on the situation, if 24 -- if it was ourselves that we're still going to have to 25 do the transport if there was no Ministry unit available


1 at that point, like if the injuries warrant, we 2 absolutely prefer t have a Ministry unit do the 3 transport. 4 Q: Right, sure. 5 A: But in that situation, if I had been 6 aware of more severe injuries, yes, the trip would have 7 been done at a higher code starting with, because we 8 would have been more concerned about shock, as well as 9 the method that we had placed him on the unit would have 10 been different, i.e., the collar and the spine board. 11 Q: And I take it, looking back, sir, 12 you're fairly concerned over the fact that you didn't 13 have that full information, given the situation you were 14 put in? 15 A: I -- I would have much preferred to 16 have had a clear indication of -- of the injuries -- 17 Q: Okay. 18 A: It -- it helps us. It helps us in 19 the long run to have a clear indication of a person's 20 injuries. 21 Q: Okay. 22 A: But by the same token, even I know 23 with -- with practices ourselves, we can't rely on what a 24 person tells us. We also have to do our own assessment. 25 Q: Sure.


1 A: So I mean, that's still standard as 2 well, and many times, once you start doing your own 3 assessment, we do find more things. 4 I -- my guess is right now that Mr. 5 George's initial assessment was done in a van -- 6 Q: Right -- 7 A: -- in the dark whereas Ms. Bakker was 8 able to fully assess him in the light of the unit which 9 could have made things easier. 10 So, I don't want to blame the OPP medic 11 for giving a less than full patient report, but I would 12 have liked to have had a better indication of the 13 injuries. 14 Q: Thank you. And both yourself, Mr. 15 Morgan, and Mr. Harding actually spoke to us somewhat 16 about the difficulties Ms. Bakker may have encountered 17 and -- in finding the pulse or vital signs. 18 A: Correct. 19 Q: Okay. And I just want to confirm 20 this briefly, sir, surely you don't offer that 21 explanation as a way to minimize the injuries suffered by 22 Mr. Bernard George? 23 A: No, no. The thing is, even if -- if 24 somebody is really, really healthy, you know, they have a 25 normal pulse, they have normal respirations and they're


1 fully conscious, even a vehicle that's moving and noisy, 2 you're still going to have an easier time finding a 3 person with a strong pulse and strong respirations than 4 you're going to have finding a person whose pulse and 5 respirations may not be as good, based on the injuries. 6 So, the fact that it was hard for her to 7 find it in that vehicle at that time, still does indicate 8 that his injuries made it harder to read. 9 Q: Okay, thank you very much, sir. 10 Thank you, Commissioner. 11 COMMISSIONER SIDNEY LINDEN: Thank you 12 very much. 13 Mr. Roland...? 14 15 (BRIEF PAUSE) 16 17 CROSS-EXAMINATION BY MR. IAN ROLAND: 18 Q: Good afternoon, Mr. Morgan. My 19 name's Ian Roland. I act for the Ontario Provincial 20 Police Association. 21 Picking up on the last line of questions 22 that were asked of you concerning the OPP medic, we know 23 in these proceedings that the person who was acting as 24 the OPP medic that evening was an individual by the name 25 of John Edward Sloman, S-L-O- -- Slomer, S-L-O-M-E-R.


1 And we have, in Document Number 2003877, a 2 statement from him, from an interview of him, at page 3 3 of that, that he indicates -- I'm just going to read this 4 -- that he indicates that he briefed the attendants, this 5 is presumably you, the St. John's attendants, and he 6 writes: 7 ˘I briefed the attendants as to my 8 findings, stating that the bottom line 9 was he -- ˘ 10 Referring to Cecil Bernard George -- 11 MS. KATHERINE HENSEL: Excuse me, Mr. 12 Roland. Thank you. If we could have the opportunity to 13 at least put this up on the screen so the Commissioner 14 could follow along. 15 MR. IAN ROLAND: Well, it's only one (1) 16 line, I'm just reading it. I'd be happy to do it but, -- 17 COMMISSIONER SIDNEY LINDEN: Okay. I -- 18 MR. IAN ROLAND: -- it's very brief. 19 COMMISSIONER SIDNEY LINDEN: That's fine. 20 Yeah, go ahead. 21 22 CONTINUED BY MR. IAN ROLAND: 23 Q: -- "stated that the bottom line was 24 that he [Cecil Bernard George] had a 25 decreased level of consciousness and


1 should be taken for hospital for 2 evaluation." 3 Now, does that refresh your memory at all 4 with respect to what the -- the medic said to you? 5 A: I can't remember actually whether he 6 did state that the level of consciousness was decreased. 7 Q: Yes. 8 A: I -- I simply remember him mentioning 9 the injuries as presented to us. 10 Q: I see. But it's -- what you're 11 saying is you don't remember one (1) way or the other, 12 it's possible he did tell you that? 13 A: As well as the decreased level of 14 consciousness, it may be possible, I mean, it was one of 15 the things that I've even indicated in my testimony, that 16 we did see that he was slumped over in -- in the van and 17 just didn't look completely alert. 18 Q: And do you recall that the discussion 19 around whether or not he'd consumed alcohol, was in the 20 context of this decreased level of consciousness, that it 21 wasn't explained by any consumption of alcohol, as far as 22 the medic was concerned? 23 A: I do remember the comment regarding 24 alcohol but I don't -- I didn't make the immediate 25 connection between his state of consciousness and alcohol


1 consumption. 2 Q: All right. 3 A: Or lack thereof. 4 Q: All right. Now, in your -- in Tab 3 5 of your book of documents, you indicate that the -- near 6 the beginning of that, about four (4) lines down: 7 "OPP had been examining casualty, 8 Cecil, for approximately ten (10) to 9 fifteen (15) minutes before we were 10 called in." 11 I take it you're referring to the medic 12 again, you observed the medic examining Mr. George? 13 A: I -- I have to admit that's probably 14 somewhat of an extrapolation. I do remember as I -- as I 15 mentioned, the vehicle that we went to take Mr. George 16 from onto the stretcher was, by the looks of it, a cargo 17 van. And for a period of time, probably around that ten- 18 (10) minute time before we were called over, it appeared 19 that there was an individual sitting in that van and 20 people were working around that individual. 21 Whether that was for a medical 22 examination, I can't specifically say, because I wasn't 23 right beside them. But, I assume that that was what was 24 being done. 25 Q: You assumed that it was a medical


1 examination? 2 A: More than likely. 3 Q: And you calculated it at 4 approximately ten (10) to fifteen (15) minutes, in there? 5 A: Probably. As I've said, timing is 6 difficult, I think, maybe in my testimony earlier I said 7 five (5) to ten (10), so, ten (10) minutes might be a 8 good average. 9 Q: All right. And I take it you 10 recognized, Mr. Morgan, that an examination of ten (10) 11 minutes is -- is an examination of some length, that you 12 can -- you can determine a good -- good amount of the 13 injuries of an individual in a ten (10) minute 14 examination? 15 A: Usually. When I teach the advance 16 First Aid Course, the final exam is a practical scenario 17 that we run our students through, and the general timing 18 given to them is fifteen (15) minutes to do a full 19 primary and secondary. 20 Q: Yes. All right. Let me ask you 21 about, then, the trip to the hospital: We have it from 22 the patient record that the occurrence is recorded at 23 11:45, and is that the departure time when you left the 24 Park area with Mr. George? 25 A: That's probably close to my estimate.


1 I know from some of the other documents in there that the 2 police officer accompanying me had a slightly different 3 time, having us leaving at 11:35 or 11:40, but it's 4 fairly close to that departure time. 5 Q: And how did you come to that? Did 6 you --were you wearing at watch? Did you look at your 7 watch? 8 A: I -- I almost always wear a watch, 9 but I think I don't -- I probably, once I started 10 driving, I just went and didn't look at it and was just 11 trying to go from, -- 12 Q: Right. 13 A: -- arrival time and working back. 14 Q: And then you have in your notes, 15 arrival at the hospital at 00:30 hours, that is at thirty 16 (30) minutes after midnight. 17 A: Right. 18 Q: That's in your Tab 3 notes. We note 19 on the -- on the Stratford Hospital Record for Cecil 20 Bernard George, and this is -- I'm not going to pull it 21 up, but this is Number 1000047, but they indicate an 22 arrival at :08, that is eight (8) minutes after midnight. 23 A: Right. I put in -- 24 Q: But it's a discrepancy there. 25 A: -- again, probably arriving there and


1 by the time I actually sat down to start filling out the 2 things, and looking at my watch, and going, okay, now 3 it's probably a quarter to 1:00 when I'm filling this out 4 and thinking how long I'd been there. 5 I was doing my best to -- to remember the 6 times accurately. 7 Q: Okay. Okay. Fair enough. Thank 8 you, those are my questions. 9 COMMISSIONER SIDNEY LINDEN: Thank you, 10 Mr. Roland. 11 Mr. O'Marra...? 12 13 CROSS-EXAMINATION BY MR. AL O'MARRA: 14 Q: Good afternoon, Mr. Morgan. 15 A: Good afternoon. 16 Q: My name is Al O'Marra and I appear on 17 behalf of the Chief Coroner. And I just have questions 18 around the transport of the patient Cecil Bernard George. 19 We know both on the records and from the 20 evidence that during the transport there was you who was 21 driving -- 22 A: Correct. 23 Q: -- you had a police officer who was 24 accompanying you en route -- 25 A: Correct.


1 Q: -- and he was sitting in the front 2 seat with you? 3 A: The front passenger seat, correct. 4 Q: Front passenger seat, yes. And then 5 we had Mr. George and Ms. Bakker. 6 A: Correct. 7 Q: Now in terms of the information you 8 received from Ms. Bakker around Mr. George's condition. 9 You mentioned the lights were on in -- in the back of the 10 van? 11 A: Yes. Yes. 12 Q: Okay. Now, just -- I want you to re- 13 create for us if you would the scenario. As you're 14 driving along, what is the information as best you recall 15 it, Ms. Bakker conveying to you about Mr. George's 16 condition? 17 A: There were a few things that she 18 mentioned during the transport. In my previous testimony 19 with some of the other questions, I do remember her 20 mentioning that it did appear that he had an injury to 21 his arm. And I can't remember right now whether she said 22 right or left. 23 But said, You know, I think I see some 24 swelling on the arm, he's got an injury to his arm. She 25 said, you know, The lip's bleeding really, you know,


1 bleeding quite significantly, so, I mean, that indicated 2 the injury to the lip. 3 I can't remember if she verbalized and I 4 know it was in her patient report when we went over that. 5 I -- 6 Q: Well, I just want you to -- as best 7 as you recall and I appreciate, we all appreciate it's 8 ten (10) years later. Just what you recall from the 9 transport. 10 A: Very clearly the -- the blood from 11 the lip because she said it was bleeding pretty heavily. 12 The injury to the arm was another one that she did 13 mention to me. And then it was the vital signs. 14 Q: Did she use the words "vital signs," 15 through the course; "vital signs"? 16 A: I think probably it was mainly pulse, 17 you know, I can't get a pulse. 18 Q: Can't get a pulse, okay. Anything 19 else? 20 A: No, that was the main one because it 21 was at that point where considering, you know, the 22 difficulty in getting the pulse or the fact that she 23 couldn't read a pulse where she said, you know, Go to 24 Code 4 and I'm like, Yeah, you got it. We're going to 25 Code 4. Talked to the police officers, said, We've got


1 to move. He said, Go. 2 And from that point on -- I think at that 3 point because of my concern about Mr. George's condition, 4 that was when I did attempt to use the radio to contact 5 the central ambulance communications dispatch. Asked the 6 police officer if he could help me raise it. 7 So at that point I was more concerned 8 about getting -- getting in contact with somebody and 9 probably really didn't talk as much with Ms. Bakker about 10 the condition from that point on. 11 Q: She tells you at some point, he's 12 responsive? 13 A: Yeah. There was -- there was a point 14 where she did say, you know, it's okay -- you know, I've 15 got a pulse again, you know. And she didn't give me -- 16 she didn't give me rate or anything like that. But the 17 fact that she did say she could read it again was 18 reassuring. 19 Q: Okay. So basically what she's 20 indicating to you is that she -- she can't find or 21 couldn't find the pulse? 22 A: Correct. 23 Q: Okay. And that didn't mean that his 24 vital signs were absent? 25 A: It doesn't mean it. What went


1 through my head at the time may -- may not have been the 2 same thing. I mean, when you've got your attend -- your 3 attendant in the back of the unit and say, you know, I 4 can't get a pulse, likely the first thing that initially 5 went through my head was, Oh no. 6 I was very relieved to hear when she did 7 say, No, I've got it again kind of thing. But no, that 8 doesn't mean per se that the person's pulse has 9 completely stopped. 10 Q: Right. And at no time did she say 11 that his heart had stopped? 12 A: No, she just said I can't get a 13 pulse. I believe that was the word she used. 14 Q: And reference has been made earlier 15 to your statement given to the SIU investigators back on 16 -- in September of 1995 and I think you have it at Tab 11 17 in front of you there -- 18 A: Yes. 19 Q: -- at page -- I'm going to draw your 20 attention to page 5. 21 There's a -- this is Document 1004598. In 22 the first response, long response beside your name; you 23 see that? 24 A: Yes. 25 Q: Okay. And about half way through it,


1 there's a sentence that starts with: ˘Ahh÷ (phonetic) 2 A: Yes. 3 Q: Okay. ˘She said she was having 4 problems reading his vital signs. That 5 was partially due to the fact that the 6 noise and the simple rough riding of an 7 ambulance. It can be difficult at 8 times.÷ 9 So, I take it that -- that your 10 understanding of that situation was, perhaps because of 11 this -- the difficulty of just obtaining those readings? 12 A: Correct. Again, it's something that, 13 and has been brought up in previous testimony by myself, 14 initially a lot of training is done, as St. John 15 Ambulance members, in a classroom or in scenario 16 situations where, you know, we can get a BP-cuff going, 17 it's in a relatively quiet room. 18 And reading a pulse in a situation like 19 that is far different than -- than being in a moving 20 vehicle and, unfortunately, neither Ms. Bakker, myself, 21 had had a lot of experience with that. 22 But our Corps Superintendent, Mr. Harding 23 said, you know, I used to do this in an ambulance and I 24 can tell you, it's not an easy thing to do. 25 And when he explained it in that way, it's


1 like, you know, that does make a lot sense. 2 Q: I just want to go a little further in 3 the statement, Mr. Morgan. Mr. Kennedy asked you: 4 ˘Did you -- did at any time it come to 5 your attention that there was loss of - 6 - of body -- body signs?÷ 7 And your response: 8 ˘Loss of vitals?÷ 9 His response: ˘Loss of vitals.÷ 10 A: Right. 11 Q: And then there's a longer description 12 on the next page. 13 "No, the terminology we use is that or 14 that is, VSA or vital signs absent." 15 A: Correct. 16 Q: ˘She never told me that he was -- he 17 went vital signs absent. She just said 18 that she was having troubles reading 19 his vital signs. 20 Whenever somebody's in a state of shock 21 as well, like, any type of injury 22 causes shock, and in shock you'll find 23 that your pulse will increase but will 24 have become faint. 25 Okay. So, even though your heart is


1 pumping faster, it -- it's not as 2 bounding as a normal pulse would be, so 3 it does become harder to read, 4 breathing becomes more shallow, just in 5 pants. So -- and then, so -- don't 6 definitely know whether vital signs go 7 absent or remain absent. I don't 8 believe from what she told me that 9 vital signs went absent. I believe 10 from what she told me the patient was 11 in shock.÷ 12 A: Correct. 13 Q: So, clearly a serious situation. 14 A: Yes, shock is a -- 15 Q: Shock. 16 A: Yes, shock's never a good situation. 17 Q: And requires rapid transport for 18 medical assistance? 19 A: Correct. 20 Q: And you did that? 21 A: Correct. 22 Q: And increasing to a Level 4 was a 23 good thing? 24 A: Probably the best advised thing. 25 Q: Sure. Because you're trying to --


1 A: Standard procedure. 2 Q: -- get the patient to the hospital as 3 fast as -- as possible? 4 A: Correct. 5 Q: Okay. But it's not because you 6 received information that his heart stopped? 7 A: No. As I said, being the driver at 8 the time when she said, ˘I can't get a pulse÷ -- 9 Q: Okay. 10 A: -- as I mentioned, when driving at 11 that moment, my initial reaction would be, I can't get a 12 pulse, I may have been fearful at the time while driving 13 that -- 14 Q: Okay. 15 A: -- is he going vital signs absent? 16 Although she never used that terminology in the vehicle, 17 that would be something that would race through my head 18 while driving. 19 But, upon realizing that, you know, she 20 said I can read it again and knowing all the other 21 injuries that she was mentioning, the loss of blood for 22 one being a very -- very good clue, blood loss is one of 23 the most common causes of shock in a casualty, that would 24 have been my other concern knowing when he did have -- 25 once she did state that he did have a pulse, thinking at


1 that time, it's like, okay, he's not VSA but he's 2 definitely in shock, we've still got to keep moving. 3 Q: So, both during and after in your 4 debriefing and review of the documents prepared by Ms. 5 Bakker and yourself, there is nothing that you saw that 6 objectively said to you that Mr. George's heart had 7 stopped? 8 A: No, that term was never used. 9 Q: Okay. Now, as you'll appreciate, one 10 of the reasons for an Inquiry, of course, is to get to 11 the truth, but it's also to correct misapprehension or 12 misinformation, unfounded rumours and speculation. 13 You understand that, sir? 14 A: Yes, sir. 15 Q: Okay. Now, we've had newspaper 16 reports that Mr. Cecil Bernard George's heart stopped 17 temporarily after the beating. 18 Now, just so that we're clear, in terms of 19 that time in which you were involved with Mr. George, 20 from the Park to the hospital, did you have any 21 information or do you have any information that would 22 confirm that his heart stopped? 23 A: Not from anything that she 24 specifically said. No, that term was never used. 25 Q: Thank you, sir.


1 MS. KATHERINE HENSEL: Commissioner, I 2 have no further questions for this witness. 3 COMMISSIONER SIDNEY LINDEN: Thank you 4 very much. 5 MS. KATHERINE HENSEL: Thank you, Mr. 6 Morgan. 7 THE WITNESS: Thank you. 8 COMMISSIONER SIDNEY LINDEN: Thank you 9 very much, Mr. Morgan. 10 THE WITNESS: As -- the same, I know this 11 is the same as with my Corp Superintendent, Mr. Harding, 12 just as the driver that evening, I -- the main concern 13 that I have as a member of St. John Ambulance was that my 14 partner and myself were able to provide medical help to a 15 person who needed it. 16 Overall, regardless of the outcome of this 17 Inquiry, I'm very thankful that Mr. Cecil Bernard George 18 recovered, that he -- he received the treatment that he 19 needed, and that my partner and myself were able to at 20 least help in that regard. And thank you for letting me 21 be part of this Inquiry. 22 COMMISSIONER SIDNEY LINDEN: Thank you 23 very much. 24 MS. KATHERINE HENSEL: Thank you again, 25 Mr. Morgan.


1 COMMISSIONER SIDNEY LINDEN: Thank you. 2 THE WITNESS: Thank you. 3 4 (WITNESS STANDS DOWN) 5 6 COMMISSIONER SIDNEY LINDEN: We will take 7 an afternoon break now, and come back with, Ms. Bakker, I 8 understand. 9 MS. KATHERINE HENSEL: Yes, that's right. 10 THE REGISTRAR: This Inquiry will recess 11 for fifteen (15) minutes. 12 13 --- Upon recessing at 2:47 p.m. 14 --- Upon resuming at 3:03 p.m. 15 16 THE REGISTRAR: This Inquiry is now 17 resumed. Please be seated. 18 MS. SUSAN VELLA: Good afternoon, 19 Commissioner. 20 COMMISSIONER SIDNEY LINDEN: Good 21 afternoon, Ms. Vella. 22 MS. SUSAN VELLA: The Commission's next 23 witness is Karen Bakker-Stephens. 24 THE REGISTRAR: Yes, Ms. Bakker-Stephens, 25 do you prefer to swear on the Bible or affirm?


1 MS. KAREN BAKKER-STEPHENS: Sure. 2 THE REGISTRAR: Bible? Take the Bible in 3 your right hand, please, and please give us your full 4 name. 5 MS. KAREN BAKKER-STEPHENS: Karen Bakker- 6 Stephens. 7 THE REGISTRAR: Thank you. 8 9 KAREN BAKKER-STEPHENS, Sworn. 10 11 COMMISSIONER SIDNEY LINDEN: Good 12 afternoon. 13 14 EXAMINATION-IN-CHIEF BY MS. SUSAN VELLA: 15 Q. And Ms. Bakker-Stephens, just for the 16 record, your surname is spelled B-A-K-K-E-R dash S-T-E-P- 17 H-E-N-S? 18 A: That is correct. 19 Q: Thank you. And that, in 1995, were 20 you known as -- as Karen Bakker? 21 A: Yes. 22 Q: What is your date of birth? 23 A: January 20th, 1973. 24 Q: And your current residence? 25 A: Caledonia, Ontario.


1 Q: I understand that you graduated from 2 the Registered Practical Nursing Program at Fanshawe 3 College in 1996? 4 A: Yes. 5 Q: And how many years is that program? 6 A: It's -- at that time it was a one (1) 7 year program. 8 Q: In -- in September of 1995 then, you 9 had started your third year in practical nursing; is that 10 right? 11 A: No, that was in the Registered 12 Nursing Program. 13 Q: The first year, sorry. Thank you 14 very much. 15 A: I changed programs. 16 Q: And how long is that program? 17 A: It's a three (3) year program. 18 Q: And so in 1995, what year of that 19 program were you in? 20 A: Year three (3). 21 Q: Where did you take that program? 22 A: Fanshawe College, London. 23 Q: Thank you. What does practical 24 nursing qualify you to do? 25 A: Most things that a registered nurse


1 would do. I need to qualify that registered practical 2 nurses, their clients or patients, whichever you wish to 3 say, is -- there's a known outcome. You're still 4 nursing, you're still providing hands-on care and most 5 procedures done under the nursing umbrella, you do as a 6 Registered Practical Nurse with a few exceptions -- 7 Q: All right. 8 A: -- that the RN would do. 9 Q: Okay. Thank you. I understand that 10 you were also employed by a Paramed Services in London 11 from 1996 to 1997? 12 A: Yes. 13 Q: What position did you hold there? 14 A: Home Support Worker. 15 Q: Then you were employed by Paramed 16 Services out of Toronto from 1997 to 1999? 17 A: That is correct. 18 Q: And, again, what position did you 19 hold? 20 A: I was a Client Services Coordinator. 21 Q: I further understand that you are 22 currently employed by St. Elizabeth Health Care as a 23 Supportive Care Supervisor and have been since 1999? 24 A: Yes. 25 Q: And what are your main roles and


1 responsibilities in that position? 2 A: To supervise Personal Support Workers 3 or Home Support Workers or Health Care Aides, those three 4 (3) job classifications in an employment environment. 5 So, I take care of any concerns with those staff. 6 As well, I do assess clients for level of 7 care required and that would help me judge as to which 8 level of staff to put in. And I also do some nursing 9 functions with that as well. 10 Q: Thank you. I understand you were 11 also involved with the St. John's Ambulance organization? 12 A: Yes. 13 Q: Can you tell me over what period of 14 time you were involved with that organization? 15 A: I was involved with that organization 16 in Goderich, originally, from approximately 1994/'95. 17 And then after that when I moved to London to attend 18 college, I started with them, I think it was '94. May, I 19 please just double-check here? 20 Q: Certainly. What is it that you're 21 referring to? 22 A: It is the anticipated evidence. It's 23 actually listed on here. 24 Q: Okay. 25 A: Yeah, it was early '90's to '96 and


1 then I switched. Sorry. 2 Q: My -- my understanding was that you 3 were involved with the organization commencing in 1991; 4 is that correct? 5 A: Yes. 6 Q: And where -- which brigade were you 7 associated with in 1991? 8 A: Goderich. 9 Q: How long did you stay with that 10 brigade? 11 A: Until I graduated high school and 12 started college in London. 13 Q: Approximately when was that? 14 A: That was -- '92. 15 Q: When did you cease your involvement 16 with the St. John's Ambulance in London? 17 A: Early 1996. 18 Q: What position did you hold with the 19 St. John's Ambulance brigade in London in September of 20 1995? 21 A: I was a volunteer First -- First Aid 22 Responder. 23 Q: A First Aid Responder? 24 A: Hmm hmm. 25 Q: Can you explain to me what your


1 general responsibilities and duties as the First Aid 2 Responder was? 3 A: Generally, I would be assigned to a 4 crew, usually two (2) or more. We would attend events 5 like soccer games or track meets and we would go to those 6 events and just be there in case someone needed some 7 general first aid. 8 Q: All right. And when you say, 9 "general first aid," can you give me a sense as to the 10 scope of range of injuries that you would be qualified to 11 treat as a first aider? 12 A: Generally, a cut or a scratch or I 13 could apply ice for a sprain, those sorts of things; non 14 life-threatening. 15 Q: And, in this position were you paid 16 or were you a volunteer? 17 A: Volunteer. 18 Q: Did you receive any training in the 19 course of your position as a First Aid Responder at St. 20 John's? 21 A: Part of the organization's key role 22 is to do some training and that is done will all 23 volunteers. In London they were using a BCLS-type 24 training, which is Basic Lifesaver Certification similar 25 to some of the training done by the Emergency Medical


1 Assistants at the time. Not identical, of course, but 2 enough that we could do general first aid and you'd learn 3 how to use bandages and ice all that properly -- 4 Q: All right. 5 A: -- and deal with situations. 6 Q: And can you give me a sense as to the 7 -- the amount of training you received? 8 A: It was general training. It was 9 above the average St. John's Ambulance First Aid course 10 that most of us are familiar with that we've had to take 11 at some time. 12 Q: For Girl Guides? 13 A: For Girl Guides or Scouts or -- 14 Q: Right. 15 A: -- whatever the organization is. 16 It's a little bit more than that, a little -- 17 Q: Hmm hmm. 18 A: -- more in depth. In London, there 19 was -- obviously there's more units and they use the 20 ambulances more than in other brigades. 21 Goderich only had one (1) ambulance, so 22 you often went out with just a bag of bandages and there 23 you went, whereas in London you had access to other 24 equipment. So, we were trained a little bit more in 25 London on that equipment and how to use it properly.


1 Q: All right. And just to get back to 2 your training a little bit more, was there a routine of 3 seminars or training sessions that you were obliged to 4 attend? 5 A: Weekly we would meet, if I recall 6 properly, it was Monday nights, you would meet at St. 7 John House and do some training and go over things. 8 Q: All right. Were you provided with 9 any manuals? 10 A: None specific, like anything further 11 than the usual St. John Ambulance training manual that 12 most of us are familiar with from the course. 13 Q: All right. From the basic level 14 course? 15 A: Yeah. We used that -- just expanded 16 on those manuals. 17 Q: And did you obtain any type of 18 certificate or certification as a result of your training 19 as a first aid responder with St. John's? 20 A: There was a program called the BAP 21 and I can't remember exactly what it was called or what 22 the letters all stand for any more, but it was very 23 similar and we just had it in our files at St. John. I 24 don't have an actual certificate for that. 25 The only certificate I have is the first


1 aid one -- 2 Q: All right. 3 A: -- for the regular course. 4 Q: But when did you complete the 5 qualifications for the former -- for the certificate? 6 A: For the BAP? 7 Q: Yeah. Can you -- can you just tell 8 me what that stands for please? 9 A: You know, I'm having a hard time 10 remembering what it was. It was one of those -- the 11 jargon thing that sticks to you better than -- 12 Q: What are the initials? 13 A: It's B-A-P. 14 Q: Okay. 15 A: I think it's basic -- it's a basic 16 responder thing. I'm sorry, I can't tell you exactly 17 what it is, but... 18 Q: All right. 19 A: We would have had to have completed 20 it prior to going out to most events. And I can't 21 exactly tell you when that was completed, sorry. 22 Q: Fair to say you had it prior to 23 September of '95? 24 A: Yes. 25 Q: Can you explain to us the general --


1 your understanding of the general purpose and function of 2 St. John Ambulance organization as you understood it? 3 A: As I understood it, we were there 4 just to supplement and really just deal with very basic 5 first aid items -- and you're talking generally? 6 Q: Yes, generally. 7 A: We were not there as a substitute for 8 Ministry of Health or doctors or nurses or anything. We 9 were just there to be the first to respond and get people 10 off to hospital if they had to, like, tell them to go or 11 just, you know, give the bandage or give the piece of ice 12 if they needed that, that sort of thing. 13 Just basic, basic things. 14 Q: All right. And in the course of your 15 activities as a first aid responder, did you have 16 occasion to use a St. John's Ambulance vehicle? 17 A: That usually came with us to the site 18 wherever we were at. 19 Q: And why would that be? 20 A: That way we wouldn't have to carry 21 around the bags of bandages everywhere, because all that 22 was in the vehicle. There was also a private place, that 23 if someone got hurt, we could have them in the back of 24 the van and they could have some privacy while they were 25 being treated.


1 Q: Were you called into duty by the St. 2 John's Ambulance organization on September the 6th, 1995? 3 A: Yes. 4 Q: Do you recall what time of day you 5 were called to duty? 6 A: Honestly, I don't remember. Probably 7 in the afternoon. 8 Q: All right. Do you recall who called 9 you? 10 A: I don't recall who called me and 11 said, Hey, can you come help with this, sorry. 12 Q: Right, did you have to attend at the 13 St. John's Ambulance building in London? 14 A: Oh, definitely. 15 Q: Do you recall approximately what time 16 you attended at that building? 17 A: It would have to be seven o'clock in 18 the evening. 19 Q: Why would it have to be seven o'clock 20 in -- 21 A: Well -- 22 Q: -- the evening? 23 A: -- it would between 7:00 and 8:00 24 because we left around eight o'clock that night. 25 Q: All right. And you left for where at


1 around eight o'clock? 2 A: It'd be Forest. 3 Q: All right. And when you arrived at 4 the St. John's building in London at around 7:00 or 5 thereabouts, what, if anything, were you advised your 6 task would be? 7 A: I was told that we'd basically be 8 going out, refuelling the command unit and if -- just to 9 be there in case something happened. Like, if someone 10 fell, you know, help with a scrape, that kind of idea; 11 nothing too spectacular. 12 Q: Who -- do you recall who briefed you 13 at the St. John's building? 14 A: Not exactly, no. 15 Q: All right. Do you recall if anyone 16 else was in attendance with you or assigned to this task 17 with you? 18 A: Mr. Glen Morgan. 19 Q: And what did you understand your 20 specific role would be as distinct from Glen Morgan's 21 role, based on your discussions in London? 22 A: Just to drive down the ambulance 23 unit, follow him, and just be support with him that 24 night, so that he wasn't on his own. 25 Q: So, that Mr. Morgan wouldn't be on


1 his own? 2 A: Yeah. 3 Q: Okay. Was that a general policy that 4 you would go out in pairs or...? 5 A: Yes. 6 Q: Okay. Now, you -- did you go 7 directly from London to Forest? 8 A: Yes. 9 Q: And approximately what time did you 10 arrive in Forest? 11 A: I'd have to -- 12 Q: All right. Would it assist you if 13 you looked at Tab 9? 14 Tab 9 is Inquiry Document Number 2001400. 15 And perhaps, let's see... 16 A: I would say around 10:00 p.m. in the 17 evening. 18 Q: Sorry? Did you say 10:00 p.m.? 19 A: That we arrived in Forest around that 20 time. 21 Q: All right. 22 COMMISSIONER SIDNEY LINDEN: I'm not with 23 you, Ms. Vella. I think that Document is a list of 24 missing items, the Document Number that you gave us. 25 MS. SUSAN VELLA: The Document Number


1 is -- 2 COMMISSIONER SIDNEY LINDEN: On a list of 3 missing items? 4 MS. SUSAN VELLA: -- Tab -- it should be 5 at Tab 9. 6 THE WITNESS: I have a list of missing 7 items, actually in mine. 8 MS. SUSAN VELLA: Oh, I'm sorry. 9 THE WITNESS: That's okay. 10 COMMISSIONER SIDNEY LINDEN: Tab 9, 11 2001400 is a list of missing items not returned. 12 MS. SUSAN VELLA: No, that's right. But, 13 there are reports attached at the end of it. 14 COMMISSIONER SIDNEY LINDEN: There are 15 times? Okay. 16 THE WITNESS: Oh, I know which one she's 17 talking about. Okay. I know what -- 18 19 CONTINUED BY MS. SUSAN VELLA: 20 Q: I was going to take you to page 8 21 or -- 22 A: Sorry. 23 Q: -- what was the eighth page in. No, 24 no problem. And there appears to be a report there from 25 yourself to P. W. Harding, --


1 A: Hmm hmm. 2 Q: -- Corp. Superintendent. It's dated 3 Thursday, September the 7th, 1995. 4 A: Right. 5 Q: Is this -- does that bear your 6 signature on the second page? 7 A: Yes. 8 Q: Is this a report that you prepared on 9 September the 7th? 10 A: Yes. 11 Q: And does it assist you with what time 12 you likely arrived in or around Forest on September the 13 6th? 14 A: Yes. 15 Q: And what time was that? 16 A: It would be at the Detachment, 17 approximately, in around ten o'clock'ish. 18 Q: All right. When you arrived at the - 19 - and you're talking about the OPP Detachment in Forest? 20 A: Exactly, yes. 21 Q: Thank you. Perhaps we should make 22 that an exhibit. 23 COMMISSIONER SIDNEY LINDEN: What 24 exhibit? 25 THE REGISTRAR: P-341.


1 COMMISSIONER SIDNEY LINDEN: P-341. 2 3 --- EXHIBIT NO. P-341: Document Number 2001400. St. 4 John Ambulance, London- 5 Middlesex Corps missing items 6 - not returned Nov./'95; 7 Interim Report and Attendants 8 Report re: Ipperwash 9 Provincial Park, Sept. 10 06/'95. 11 12 CONTINUED BY MS. SUSAN VELLA: 13 Q: Now, when you arrived at the Forest 14 Detachment, were you briefed by anyone? 15 A: Mr. Morgan and I were briefed, very 16 briefly, by an officer there. 17 Q: Do you recall the officer's name? 18 A: No. 19 Q: Approximately how long was the 20 briefing by the officer? 21 A: Maybe ten (10), fifteen (15) minutes; 22 it was very short. 23 Q: Do you recall what you were advised 24 would be your tasks or the situation that you would be 25 facing down in Forest?


1 A: That we were to go to Ipperwash and 2 be with the Ministry of Health Units, and we would be 3 called on if needed. 4 Q: Okay. When you say that you were to 5 go to Ipperwash with the Ministry Units, what Ministry 6 Units are you referring to? 7 A: The Ministry of Health Ambulances. 8 Q: How Ministry of Health Ambulances 9 were there? 10 A: Two (2). 11 Q: And were they also at the Forest 12 Detachment when you arrived? 13 A: Not at that time. 14 Q: All right. Did anybody guide you or 15 tell you what route you should be taking down to your -- 16 your destination? 17 A: I just followed Glen; Mr. Morgan. 18 Q: All right. Now Mr. Morgan was 19 driving what? 20 A: He was driving a Utility Van, with 21 supplies for our Command Unit. 22 Q: You were driving the Ambulance Unit 23 itself? 24 A: Yes. 25 Q: Now, did anything that the police


1 officer briefed you about at the Forest Detachment, cause 2 you to -- or at least, give you the impression that you 3 were going to have a different role than what you had 4 understood to be the case in London? 5 A: Not really. I didn't -- didn't 6 expect it to change, really. 7 Q: Were you told that you would be going 8 into a situation where there might be the potential of 9 the exchange of gunfire? 10 A: No. 11 Q: Had you known this, would you have 12 agreed to accept this assignment? 13 A: Probably not. 14 Q: Why not? 15 A: I would have questioned and made a 16 few phone calls back to London to check with my superiors 17 first. 18 Q: Why? 19 A: I'm not comfortable with that 20 situation. 21 Q: In what respect, though? 22 A: It was something I wasn't trained 23 for. 24 Q: When you say you "weren't trained 25 for" trained to do what?


1 A: To be in that kind of situation. The 2 situations that we were generally trained for in the 3 volunteer units are -- you know the general outcome, 4 whereas this, you didn't know. 5 Q: All right. Now, was your ambulance 6 unit equipped to transport injured persons? 7 A: Yes. 8 Q: All right. Are there any 9 differences, to you knowledge, between your ambulance and 10 the Ministry of Health ambulance units? 11 A: Yes. 12 Q: Can you tell me what that the main 13 differences are as between the two (2) units? 14 A: First of all, the Ministry of Health 15 units, the attendants and drivers have a lot more 16 training than a St. John Ambulance person would and by 17 means of equipment, their equipment is more up-to-date 18 than what the St. John Ambulance units are. 19 Most St. John Ambulance units are used 20 ambulances from the Ministry of Health as they can't 21 afford to buy brand-new ones and they don't always carry 22 -- like, the equipment that St. John has, as well, is 23 often second-hand because it comes with those units. 24 I'm not saying it's not in good shape, it 25 is in good shape, but it's not the same stuff.


1 Q: It's not -- it's not state-of-the- 2 art? 3 A: No, and we certainly don't have 4 things like defibrillators or anything to that extent. 5 We weren't trained on that, either, so... 6 Q: And what's a defibrillator? 7 A: It's a box with a computer in it; 8 it's mechanical. You can hook someone up to it by 9 putting leads on their chest or patches to see if their 10 heart is working and if it's not, that unit will shock 11 them back and get the heart going again. 12 Q: All right. Now, what specific 13 equipment did you carry in your ambulance unit that 14 particular evening? 15 A: Very basic; stretcher, there was 16 bandages, there was blankets, water, ice, there may have 17 been some IV bags but they weren't to be used for 18 intravenous. We certainly didn't start intravenous and 19 those are needles in your arms or whatever. 20 Q: Sorry, you -- you had the IV bag? 21 A: The actual bags were in there -- 22 Q: But you didn't have the... 23 A: We don't do intravenous, like, we 24 don't start an intravenous in someone. 25 Q: Okay.


1 A: We just had them ready. 2 Q: Are you trained for that? 3 A: No. 4 Q: Okay. Did you have a collar for a -- 5 a neck collar? 6 A: There were C-collars, there was back 7 boards and something called a KED back board, which is a 8 half back board if we were -- had to take someone out of 9 a seat kind of idea. 10 Q: All right. Now, does a driver have 11 to be licensed to transport injured persons in 12 ambulances? 13 A: Normally, yes. 14 Q: And, what type of license does that 15 driver normally have to have? 16 A: A Class F. 17 Q: And did you have a Class F license? 18 A: No. 19 Q: To you knowledge, did Glen Morgan 20 have a Class F license? 21 A: No. 22 Q: Now, you say normally, one requires a 23 Class F license to transport injured persons; are there 24 exceptions? 25 A: Generally not, but that evening there


1 was. 2 Q: And, how did that exception come 3 about? 4 A: Because we were requested to take 5 this gentleman to hospital and there was an OPP officer 6 sitting with us. 7 Q: All right. And, so was that what you 8 assumed was your authority for transporting an injured 9 person without a license -- Class F license? 10 A: Yes. 11 Q: All right. You seemed uncertain. 12 A: Well, we probably shouldn't have, but 13 at the time -- 14 Q: All right. 15 A: -- he needed to get to hospital and 16 there was no Ministry of Health units available that we 17 knew of. 18 Q: So, we -- we will get to that 19 incident in a little bit. I'm just trying to get an 20 understanding of the general setup. 21 Now, to your knowledge, are Ministry of 22 Health ambulances regulated by -- by statute under the 23 Ministry of Health? 24 A: I don't think they're regulated 25 underneath the Health Professionals Act, but they are


1 regulated as a government, because it's the Government 2 that deals with them. 3 Q: All right. And, does the St. John's 4 ambulance -- ambulance units, are they similarly 5 regulated? 6 A: There is some regulation with -- 7 underneath the health part of the Government but we're 8 not really regulated by them, but we do assist. And I 9 don't know all the ins and outs of that. 10 Q: All right. Relative to the Ministry 11 of Health ambulance units, what is the level of -- of 12 regulation for a St. John's Ambulance units? 13 A: We are to follow the instruction of 14 the Ministry of Health units. 15 Q: All right. To your knowledge, did 16 the -- the appropriate legislation provide for following 17 the instruction of police officers rather than or in 18 place of Ministry of Health ambulance attendants? 19 A: Yes. 20 Q: Yes? 21 A: That was my understanding. 22 Q: All right. And can you tell me where 23 precisely you went after the Forest Detachment? 24 What was your destination? 25 A: The Ipperwash Park.


1 Q: Ipperwash Park? 2 A: Well, with the other Ministry of 3 Health ambulances. 4 Q: All right. Can you recall -- were 5 you actually inside the Provincial Park? 6 A: I'm not -- I have to apologize. I 7 can see the place but I don't know the Park very well so 8 I -- I -- it was like a parking lot to me so... 9 Q: A parking lot? 10 A: Yeah. 11 Q: And do you recall, was that off -- do 12 you recall what road that was off? 13 A: No. 14 Q: Okay. And was it a large parking 15 lot? 16 A: It seemed to me that night. 17 Q: What time did you arrive at the 18 parking lot approximately? 19 A: It would be between 10:30 and 11:00 20 p.m. 21 Q: Is it possible that you arrived 22 closer to 10:10 p.m. that evening? 23 A: Very possible. 24 Q: All right. When you arrived at that 25 parking lot, were there other vehicles that you could


1 see? 2 A: Two (2) Ministry of Health 3 ambulances. 4 Q: All right. And did you see any other 5 vehicles? 6 A: I think we could've seen our 7 communication centre in the distance. But, I don't 8 remember. 9 Q: All right. Did you see any police 10 vans or vehicles? 11 A: I know later in the evening there was 12 one. I can't remember exactly when we got there though. 13 Q: All right. Fair enough. Did you see 14 any police officers there? 15 A: Probably. 16 Q: I appreciate this is ten (10) years 17 ago and you're operating from memory. 18 A: Yeah. 19 Q: And what was your initial involvement 20 then at the parking lot? What did you do when you got 21 there? 22 A: We parked, said hello to the Ministry 23 of Health attendants. Really didn't talk about much with 24 them and went back to our unit and basically got out a 25 book so...


1 Q: Reading books? 2 A: Yes. 3 Q: Okay. Now, we've heard evidence that 4 in addition to the -- the vehicle that Mr. Morgan was 5 driving and the ambulance unit you had, there was also a 6 St. John's trailer. 7 A: Hmm hmm. 8 Q: Did you happen -- was that the 9 trailer you were meant to replenish? 10 A: Yes. 11 Q: And did you actually go into that 12 trailer? 13 A: No. 14 Q: Did you have opportunity to observe 15 the -- the contents of that trailer? 16 A: No. 17 Q: Do you -- do you know far it was away 18 from you? 19 A: Not exactly anymore. 20 Q: All right. Did you have a clear 21 sight of it? 22 A: I honestly don't remember. 23 Q: What was the lighting conditions in 24 the parking lot that night? 25 A: It was moonlight.


1 Q: Moonlight only? 2 A: Hmm hmm. There really wasn't much. 3 Q: Okay. Now, over the course of the 4 evening while you were there reading your books and 5 talking to your partner, did you hear any noises which 6 caught your attention? 7 A: We heard some firecrackers -- so we 8 thought. 9 Q: Okay. And do you know approximately 10 how long you were at the parking lot before you heard 11 these firecracker sounds? 12 A: No. 13 Q: Okay. Do you recall many you heard? 14 A: No. 15 Q: All right. Have you ever heard 16 gunshots before? 17 A: Hunting rifles. 18 Q: And did these sounds -- sound like 19 that? 20 A: No. 21 Q: Okay. Were the other Ministry of 22 Health ambulances and attendants there when you heard the 23 firecracker sounds? 24 A: I believe so. I can't remember 25 exactly though.


1 Q: Okay. And is it fair to say that 2 there were two (2) attendants per ambulance unit? 3 A: Yes. 4 Q: So there were six (6) of you 5 altogether? 6 A: Yes. 7 Q: At some point in time were you called 8 into action? 9 A: Yes. 10 Q: Do you recall approximately what time 11 that was? 12 A: About 11:30ish. 13 Q: And how is it that you know what time 14 it was? 15 A: That was based on my reports. 16 Q: Which report is that; the one that we 17 just looked at? 18 A: Yes. 19 Q: That's P-30 -- 341, for the record. 20 Now, did you have any communication 21 abilities or capability from the ambulance unit? 22 A: No. Wait -- can you clarify that? 23 Q: Sure. Did you have any equipment, 24 communication equipment? 25 A: Well, we had a radio in the


1 ambulance. 2 Q: All right. And where -- what 3 frequency did that leave you two (2)? 4 A: Well, in Forest it really was 5 useless, it was more for the London area. There is a 6 frequency for St. John but we were out of that area that 7 they could pick us up. 8 Q: All right. So, you had radio 9 communication normally with your London headquarters; is 10 that fair? 11 A: Middlesex County, yes. 12 Q: But at Forest you could not -- they 13 didn't work? 14 A: We're just too far away. 15 Q: All right. And so, as a result of 16 not having communication facilities, you -- were you able 17 to make contact with London when you were called into 18 action? 19 A: No. 20 Q: Okay. And therefore there would be 21 no logs with respect to that? 22 A: That is correct. 23 Q: Okay. Now, tell me what the nature 24 of your involvement was; what was the action that you 25 became involved in?


1 A: Basically, we received a client from 2 the OPP and transported him to Strathroy General. 3 Q: All right. Do you recall who 4 provided you with this client? 5 A: It would be the OPP paramedic. 6 Q: Paramedic? 7 A: There was a medic on. 8 Q: He was a medic, okay. 9 A: Yeah. 10 Q: And do you know what his 11 qualifications were other than being a medic? 12 A: We understood that's what his 13 background was, and he was an OPP officer. 14 Q: Okay. Do you recall his name? 15 A: Sorry. 16 Q: Fair enough. And had you seen this 17 individual before? 18 A: No. 19 Q: Were you given any patient history by 20 the OPP medic in relation to this client? 21 A: Very brief. 22 Q: Can you tell me what you were told? 23 A: I was told he had a bump on the head, 24 a fat lip, and that's pretty much it. 25 Q: Were you told of anything of the


1 circumstances which gave rise to this client needing your 2 assistance? 3 A: No. 4 Q: Had you seen the client prior to 5 being presented with him? 6 A: Yes. 7 Q: Where had you seen him? 8 A: In that same parking lot, at a 9 distance, there was a couple of OPP vans that had drove 10 up later, after we were there, and he was in the back. 11 Q: All right. 12 A: He was sitting up and then laid down, 13 and then was sat up again. And the only reason we knew 14 it was him was because he eventually came to us. 15 Q: Okay. Now, did these vans come 16 before or after the firecrackers? 17 A: I honestly can't remember, sorry. 18 Q: Okay. Well, let's put it this way, 19 once you received the patient, were you there very long? 20 A: No. I -- I would guess the 21 firecrackers were before the van came. 22 Q: Okay. And we -- we should say the 23 firecracker sounds perhaps. 24 A: Perhaps, yes. 25 Q: Do you have any -- do you have any


1 knowledge as to what the source of those sounds were? 2 A: After that evening and subsequently 3 what I've heard from the media and what I've read, it may 4 have been rifle fire, assault rifle fire. 5 Q: Okay. All right. Now, did the OPP 6 medic tell you how long they had had this person in -- in 7 its custody? 8 A: No. 9 Q: Did you form any preliminary 10 assessment of this patient before he went into your 11 ambulance? 12 A: I observed the injuries as stated by 13 the medic and I had seen him sitting up and moving his 14 limbs around, so I assumed he was not that bad. 15 Q: Not badly injured? 16 A: Not -- yes. 17 Q: And that is based on your personal 18 observations at the time and on what the medic told you? 19 A: That was prior to him coming into the 20 ambulance, before I could give a -- 21 Q: Yes. 22 A: -- do a good secondary assessment, 23 yes. 24 Q: Yes, I appreciate that. Is that 25 right, then?


1 A: Yes. 2 Q: Okay. Now, did the medic tell you 3 anything about -- well, firstly, did he tell you the 4 client's name? 5 A: No. 6 Q: Did he tell you the state of the 7 client's consciousness or orientation? 8 A: Not that I recall, but as I -- when I 9 was reviewing the binder, he may have. 10 When I mean the binder, what's in front of 11 me. 12 Q: All right. 13 A: That there was some level of 14 consciousness. 15 Q: And what did he tell you, that you 16 recall? 17 A: That he didn't smell any alcohol on 18 his breath and that he was also responding to pain as 19 well. 20 Q: And are you again looking at your 21 report? 22 A: That is the same report as you 23 previously identified. 24 Q: Exhibit P-341. All right. Now, is 25 it normal for you to receive advice from another medical


1 person on presenting a patient as to whether or not he 2 could smell alcohol? 3 A: That's not normally something that 4 should be discussed. 5 Q: Why not? 6 A: It could bias any further assessments 7 and what further treatment could be. 8 Q: Now, if the patient was -- was, in 9 fact, inebriated you'd want to know that? 10 A: I would, but you'd also be able to 11 smell that, too, so you'd have to make your assessment 12 when it came to that. 13 Q: All right. All right. And how was 14 this patient transported from the van to your ambulance 15 unit? 16 A: The stretcher from the back of the 17 ambulance was brought over and he was put on the 18 stretcher and brought back to our ambulance unit and then 19 put inside. 20 Q: And did police officers assist you 21 with that? 22 A: Yes. 23 Q: All right. And it was your 24 stretcher? 25 A: It was a St. John's stretcher.


1 Q: And did you perform any examination, 2 other than a visual, of this patient before he was put 3 into your ambulance? 4 A: No, just a visual. 5 Q: Why not? 6 A: It was timing and there was a lot of 7 people around, and I wanted to concentrate on the 8 secondary assessment. 9 Q: All right. Did you ask any questions 10 of the patient prior to him being placed into the 11 ambulance? 12 A: No. 13 Q: And is there any reason for that? 14 A: Again, we were just trying to get him 15 on -- into the ambulance and get moving. 16 Q: All right. Now, were there any other 17 Ministry of Health ambulance units in -- in -- at the 18 parking lot at this time? 19 A: Not when we received him -- 20 Q: All right. 21 A: -- they had already left. 22 Q: Do you recall approximately when they 23 had left in relation to receiving this patient? 24 A: I would say approximately ten (10), 25 twenty (20) minutes.


1 Q: Somewhere in that vicinity? 2 A: Roughly. 3 Q: All right. So, you were the only 4 ambulance unit left -- 5 A: Yes. 6 Q: -- that you could see? 7 A: That we could see, yes. 8 Q: All right. To your knowledge, do you 9 think that the OPP medic appreciated that you were with 10 the St. John's Ambulance and not the Ministry of Health 11 emergency services? 12 A: I don't think so. 13 Q: You don't think he knew that? 14 A: Well, I -- I'm sure he was told 15 somewhat, but I'm not sure as he really knew where our 16 boundaries were. 17 Q: What your boundaries were. All 18 right. Well, my question is -- well, your ambulance, did 19 it have markings on it? 20 A: Well, yes. It said that we were St. 21 John, sorry. 22 Q: Okay. All right. But you're not 23 aware as to whether he appreciated the limitations that 24 you had as compared to the abilities of the MOH ambulance 25 attendants?


1 A: Exactly. 2 Q: All right. Did he ask you? 3 A: No. 4 Q: All right. Did you think it -- did 5 you tell him? 6 A: No, but we probably should have. 7 Q: All right. At the time why didn't 8 you tell him? 9 A: Because we were instructed to follow 10 the instructions of the medic. 11 Q: Now, who gave you those instructions? 12 A: We'd received them from St. John. 13 Q: From St. John's? 14 A: Hmm hmm. 15 Q: What about the Detachment? 16 A: And at the Detachment as well. 17 Q: All right. Now, given the fact that 18 your ambulance unit was not a Ministry of Health unit, 19 that neither you nor Mr. Morgan were technically licenced 20 to transport an injured party, why did you agree to take 21 this patient? 22 A: Because we were asked to and he 23 didn't seem to be too much -- it was more a case of 24 taking him to hospital to get him checked out. And he 25 seemed to be pretty stable.


1 Q: Did you -- did you -- okay. And at 2 the time when you agreed to transport this person were 3 you concerned that he might be suffering from life 4 threatening injuries? 5 A: Not at the initial agreement, no. 6 Q: Had you been -- had that concern, 7 would you have agreed to transport him? 8 A: No. I would have found some way to 9 get some more help. 10 Q: All right. Why is that? 11 A: Because that's above and beyond our 12 limitations. 13 Q: Now is knowing the cause of injuries 14 generally an important part of taking a patient's history 15 in your experience? 16 A: Yes. 17 Q: Why? 18 A: It gives us an idea as what's 19 happened and what's potentially going on inside the body 20 and what -- where these injuries were and the extent. 21 Q: In other words what you were able to 22 see at that time were his visible injuries? 23 A: Hmm hmm. 24 Q: And there was the possibility that 25 there could be internal injuries that you wouldn't know


1 about? 2 A: That's right. 3 Q: Did you come to know the identity of 4 the patient? 5 A: Later. 6 Q: And what was his name? 7 A: Cecil George. 8 Q: Or Cecil Bernard George? 9 A: Yes. 10 Q: Once you got into the ambulance unit, 11 the St. John's ambulance unit, did anyone accompany you 12 to the hospital? 13 A: There was an officer who sat in the 14 front seat beside the driver. 15 Q: Do you recall his name? 16 A: No. 17 Q: You know why it was that a police 18 officer accompanied you to the hospital? 19 A: I wasn't 100 percent sure. But I 20 figured he had to be there with the gentleman in the back 21 with me. 22 Q: You made that assumption? 23 A: Pretty much. 24 Q: All right. Did you know what 25 hospital you were going to be going to?


1 A: Strathroy General. 2 Q: And how did you know that? 3 A: That was discussed during the very 4 brief briefing at Forest and also when we talked with the 5 Ministry of Health. Actually, no it wasn't even talked 6 about at Forest, sorry. But it was when we were sitting 7 there with the other ambulances. 8 Q: All right. You got direction from 9 them that any patients would be transported to Strathroy? 10 A: Yes. Glen talked to them more than I 11 did and he got more of that part. What I remember more 12 is the gentleman that I treated that night, so. 13 Q: Fair enough. Now did anyone advise 14 you that Mr. George was under arrest? 15 A: No. 16 Q: How long was the trip to Strathroy 17 from the parking lot to Strathroy, approximately. 18 A: I would say approximately forty (40) 19 minutes. 20 Q: And where were you in the ambulance? 21 A: I was in the back with Mr. George. 22 Q: And Mr. Morgan and the police officer 23 were in the front? 24 A: That is correct. 25 Q: Was there anyone else in back with


1 you? 2 A: No. 3 Q: Did you take any precautions at the 4 outset like putting a collar, a c-collar on the patient? 5 A: No. 6 Q: Why not? 7 A: Again when we saw him visually, we 8 could he had been sitting up in the van and even moving 9 his limbs and even looking around. So we initially did 10 not think spinal cord injury or a nerve trauma that way. 11 Q: Now I think you -- did you -- I think 12 you indicated that the OPP medic did -- did not tell you 13 whether or not he had lost -- Mr. George had lost 14 consciousness? 15 A: I don't recall. 16 Q: You don't recall. So it's possible 17 that he did tell you that? 18 A: It's possible and I'm saying that 19 just from what I've read in the binder you provided. 20 Q: Indeed we may hear evidence from this 21 medic that he told you that he disclosed that Mr. George 22 had in fact lapsed in and out of consciousness. 23 A: Hmm hmm. 24 Q: Now would you dispute that evidence? 25 A: No.


1 Q: All right. You don't have any 2 specific recollection today one (1) way or the other? 3 A: No, I don't. 4 Q: Having had that information -- 5 A: Hmm hmm. 6 Q: -- is there something that you 7 should've done at the outset which you didn't do? 8 A: It's hard to say. I probably should 9 have put the collar on but again, I was looking at him 10 visually and we made a quick judgment. 11 Q: All right. And was he able to -- to 12 hold his -- lift his head on his own accord when you saw 13 him? 14 A: Yes. 15 Q: All right. And so was that one of 16 the factors you considered? 17 A: Yes. 18 Q: And you said he was able to move him 19 limbs? 20 A: Hmm hmm. 21 Q: Yes? 22 A: Yes. 23 Q: All right. And that also was 24 relevant? 25 A: Yes.


1 Q: Now at the time, then, that you 2 accepted Mr. George into your ambulance unit, how did you 3 assess the severity of his injuries? 4 A: I did what was called a secondary 5 assessment or head to toe. I started at his head and 6 worked my way down and when I say that, it was through 7 touching and observing just seeing what was there. And 8 observing any responses, let's say, to pain or if I saw 9 blood or anything like that. 10 Q: All right. 11 A: Or any swelling. 12 Q: And did the secondary assessment take 13 place within the first few minutes of -- of leaving the 14 parking lot? 15 A: I did as much as I could. It was 16 actually while Glen was driving, so I have no idea how 17 long it was before we left the parking lot; I was 18 concentrating on him. 19 Q: And in the course of the secondary 20 assessment, did you discover any injuries or concerns? 21 A: I discovered quite a few concerns, 22 actually. 23 Q: Can you tell us what those were? 24 A: Mr. George winced in pain any time I 25 touched his abdominal area, his arm. And if I may, could


1 I just go Tab 1, my report, because it's all in there? 2 Q: Certainly. You're referring to -- 3 A: I don't want to miss anything, so... 4 Q: Hang on. Oh, you're going to the -- 5 the report that you filled out later on that day, -- 6 A: Hmm hmm. 7 Q: -- at Tab 1. This is Inquiry 8 Document Number 1002921. First of all, before you refer 9 to this document, is this your handwriting? 10 A: Yes. 11 Q: And on the second page, is that your 12 signature at the bottom? 13 A: Yes. 14 Q: Do you recall approximately when you 15 filled this out? 16 A: I can't give you the exact time, but 17 it was either after we finished at the hospital or early 18 the next morning. 19 Q: So on September the 7th, within hours 20 of having left Mr. George at the hospital? 21 A: Yes, it would have been within hours. 22 Q: All right. 23 A: Okay. 24 Q: And is this information -- was it 25 accurate at the time that you wrote it?


1 A: Yes. 2 Q: I'd like to make this the next 3 exhibit, Commissioner. 4 THE REGISTRAR: P-342, Your Honour. 5 COMMISSIONER SIDNEY LINDEN: P-342. 6 7 --- EXHIBIT NO. P-342: Document Number 1002921 St. 8 John Ambulance Patient Report 9 of Cecil Bernard George by 10 Witness, Ms. Karen Bakker- 11 Stephens. 12 13 CONTINUED BY MS. SUSAN VELLA: 14 Q: And I do intend to take you to this 15 document more fully later, but perhaps if you read it, 16 that may refresh your memory as to the injuries that you 17 discovered on your secondary assessment in the ambulance. 18 A: Okay. The injuries that I noted 19 were: A deep two-(2) centimetre laceration to the upper 20 lip, and the wound edges were not well approximated, 21 meaning they weren't close together, and it was -- 22 Q: Okay. 23 A: -- bleeding quite a bit; -- 24 Q: Yeah. 25 A: -- a laceration to the back of the


1 head; blunt trauma to left forehead, that would have been 2 some swelling there; abdominal pain, I couldn't find a 3 specific area, it seemed to be the whole abdomen; pain 4 with swelling to the right arm, above and below the 5 elbow. 6 And during transport he lost consciousness 7 and I was having difficulty locating vital signs, due to 8 this. 9 Q: Yes. Okay. And were those the key 10 injuries, then, that you found on -- on your secondary 11 observation? 12 A: Yes. 13 Q: And you say that you found these -- 14 these injuries, basically, by observation and touching? 15 A: Yes. 16 Q: And that was it? No equipment? 17 A: No equipment? 18 Q: All right. And you indicated that 19 the whole of his abdomen seemed to be in pain, rather 20 than a specific part of it; what, if anything, did that 21 tell you about that injury? 22 A: That told me he had suffered some 23 trauma to his abdomen and it was sore. 24 Q: Okay. And when you say "trauma," 25 what do you mean?


1 A: That he had somehow had been hit or 2 he had fallen, or -- 3 Q: Physic' -- 4 A: -- somehow he had hurt himself. 5 Q: Physical trauma? 6 A: There was physical -- yes. 7 Q: All right. Fair enough. And during 8 the course of this forty (40) minute, or so, trip to the 9 Strathroy Hospital, did you also check Mr. George's vital 10 signs from time to time? 11 A: Yes. 12 Q: And why would you do that? 13 A: It's to give me an idea of how the 14 patient is doing, and whether or not he's going into 15 shock, or he's staying stable, and it gives me also an 16 idea of his condition. 17 Q: And how -- tell me the method by 18 which you check his vitals. 19 A: Okay. For pulse, I would have 20 checked his arm here by the wrist, on the inside of the 21 wrist, or I may have checked underneath the chin. 22 Q: All right. So you can't really -- 23 A: Either or, I can't remember which on 24 I did that night. 25 Q: All right.


1 A: And respirations is just by observing 2 the chest rising and falling. 3 Q: Okay. 4 A: And as I've also specified here, 5 there was no blood-pressure cuff, so I could not check 6 that. 7 Q: Okay. Yes. And how many times did 8 you check his vital signs over the course of the 9 transport? 10 A: I would say at least four (4), in 11 accordance to this report. 12 Q: All right. And approximately how 13 frequently then, were you checking it, if you can recall? 14 A: I would say approximately every ten 15 (10) minutes. But on this report it also -- there's an 16 entry where there's zero one zero. 17 Q: Yes. 18 A: I most certainly would have checked 19 it much sooner than ten (10) minutes after getting that 20 kind of entry, because I was having trouble finding it. 21 Q: And why is that? 22 A: It could be a multitude of reasons. 23 There was road noise, the ambulances that we had were 24 quite old, there was -- I think it was a late '80's model 25 and it was rattling a lot and when a patient does start


1 to go into a bit of shock, which I believe he did, the 2 pulse gets really weak and thready, so it's hard to feel. 3 Q: Yes? 4 A: And, of course, respirations will 5 slow down, as well. It was just his body's way of 6 protecting itself. 7 Q: So, I think, as I understand it, when 8 one goes into shock -- 9 A: Hmm hmm. 10 Q: -- the blood retreats from the non- 11 vital areas and concentrates on the vital areas, which 12 can make the pulse fainter and the breathing lighter. 13 A: That is correct. 14 Q: All right. Now, according to your 15 report at P-342, it would appear that it was on the 16 second occasion -- 17 A: Hmm hmm. 18 Q: -- that you checked Mr. George's 19 vitals that you could not detect either a pulse or 20 breathing. Is that accurate? 21 A: Yes. 22 Q: All right. And, when this happened, 23 when you discovered this, what, if anything, did you do? 24 A: I attempted to remain calm and I 25 asked my driver to speed it up and get us to hospital.


1 Q: I didn't hear the first part, I'm 2 sorry. 3 A: I tried to stay calm and tried to get 4 him -- I was worried about getting him to hospital, so I 5 asked my driver to -- what we would call, Code 4, and 6 that's to do lights and sirens and drive a lot faster. 7 Q: Okay. 8 A: And then I was trying to find vital 9 signs and get him to come around again. 10 Q: All right. And, what were you doing 11 to try to get him to come around again? 12 A: Again, checking vital signs, I was 13 probably shaking him a bit, saying, Mr. George, wake up, 14 kind of idea; seeing if he would respond to pain. 15 Q: And, did you -- did you detect vital 16 signs, subsequently? 17 A: Yes. 18 Q: And, do you remember approximately 19 after what period of time you were able to detect the 20 vital signs? 21 A: It was not long. 22 Q: Okay. Now, did you perform any other 23 medical intervention in response to the apparent lack of 24 pulse or breathing? 25 A: I did not need to because he started


1 again. And when I say he started again, I was able to 2 detect a pulse; I was able to get respirations again. 3 Q: All right. In other circumstances 4 where you weren't able to quickly revive him, would it be 5 appropriate to administer CPR? 6 A: We would have had to do that, yes. 7 Q: And were you qualified to do that? 8 A: Yes. 9 Q: And -- and, was there anything that 10 would have prevented you from doing that on that evening? 11 A: We would have had to stop the 12 ambulance -- 13 Q: Yes? 14 A: -- and do it at the side of the road. 15 It's too difficult to do in a moving vehicle. 16 Q: Okay. But that's something you could 17 have done if warranted? 18 A: If we had to and if I hadn't found 19 the vital signs again, I most certainly would have. 20 Q: All right. Now, at this time when 21 you advised your driver that it's a Code 4, which I 22 anticipate -- does that mean that it was a life- 23 threatening situation now? 24 A: I considered it life-threatening, 25 yes.


1 Q: All right. Did the police officer at 2 that time who was accompanying you provide you with any 3 further details regarding the circumstances giving rise 4 to Mr. George's injuries in the first place? 5 A: No. 6 Q: Did he provide you with any 7 additional detail? 8 A: I never talked to the gentleman in 9 the front. 10 Q: All right. And, he didn't talk to 11 you? 12 A: No. 13 Q: Now, did you also have occasion 14 during the course of the transport to check Mr. George's 15 pupils? 16 A: Yes. 17 Q: And, what -- what is the purpose of 18 that exercise? 19 A: Like vital signs, it's another way of 20 seeing how well a patient is doing. And I know with him, 21 his pupils didn't respond at one (1) point and that goes 22 along with the loss of consciousness and it's another 23 indicator of what kind of trauma he may have suffered. 24 And if you've had a head injury, sometimes 25 your pupils will not react properly to light. And he had


1 a head injury, so it was one (1) of our -- the cardinal 2 signs to -- to tell the doctors and... 3 Q: To tell the doctors? 4 A: Yeah. 5 Q: Did that -- did the fact that his 6 pupils did not respond combined with his loss of 7 consciousness give you any -- any idea or indication as 8 to the relative severity or the potential severity of his 9 head injury? 10 A: Definitely. 11 Q: And what was that? 12 A: Generally, if your pupils don't 13 respond properly, that there has been a bit of swelling 14 to the brain and there has been injury to the brain and 15 that is also a life-threatening issue. 16 Q: All right. So, is it possible -- in 17 -- in layperson's terms, does that mean that there may 18 have been some internal bleeding in the brain when you 19 say, "swelling?" 20 A: Yes, swelling can be caused by that. 21 Q: All right. Now, how -- how was it 22 that you actually checked his pupils? What were they not 23 responding to? I know, very basic questions. 24 A: That's okay. Basically, we all carry 25 little flashlights and you shone a flashlight in the eye.


1 That's the fastest way to check, so if a pupil was 2 responding properly, it would go to a pinpoint or very, 3 very small -- 4 Q: Yes. 5 A: -- when the light went into its eye. 6 And that's a normal response for a person. So, if it 7 doesn't do that or it's really sluggish, that tells me 8 there's something going on. 9 Don't know what, but that tells me 10 something's happened to the brain and those nerves. 11 Q: And in this case, how many times did 12 -- were his pupils non-responsive? 13 A: You know, I can't answer that, 14 probably a couple of times. 15 Q: All right. 16 A: I didn't specify that in the report, 17 so. 18 Q: So you're working on your memory? 19 A: Just memory with that. 20 Q: Fair enough. At some point, did his 21 pupils become responsive? 22 A: When I got vital signs back, yes. 23 Q: All right, okay. So just so I 24 understand, this is all -- all -- a whole number of 25 things were --


1 A: Hmm hmm. 2 Q: -- were happening at the same time? 3 He's lost consciousness? 4 A: Yes. 5 Q: His pupils are not responding to the 6 flashlight? 7 A: Yes. 8 Q: And you are unable to detect a -- a 9 visible pulse or -- or breathing? 10 A: Yes. 11 Q: For a period of time? 12 A: Yes. 13 Q: All right, and you say that this was 14 a relatively short period of time? 15 A: A very short period of time. 16 Q: Very short, so under a minute? 17 A: Probably. 18 Q: Thank you. 19 20 (BRIEF PAUSE) 21 22 Q: Now, had you had -- let me ask you 23 this. In the course of trying to get his vital signs to 24 return -- 25 A: Hmm hmm.


1 Q: -- were there any medical procedures 2 or equipment that would have assisted you, but which you 3 didn't have in your -- in your ambulance unit? 4 A: Probably a defibrillator might have 5 helped, because some of them you can actually detect 6 pulse with -- 7 Q: Yes. What about a blood pressure 8 machine? 9 A: Machine, yes, would probably done it 10 for him. I'm just trying to think of what was available 11 back at that time, so today all that stuff's in the 12 ambulance and -- 13 Q: No, but -- 14 A: Back at that time -- 15 Q: -- I mean what would have helped you 16 at the time which you didn't have. 17 A: A cuff would have been helpful. 18 Q: Okay. 19 A: I can't remember if I had a 20 stethoscope with me. I'm pretty sure I did, but again, 21 listening to that was very difficult with all the road 22 noise around, as well. 23 Again, the defibrillator, the type where 24 you can hook up and they can -- some of them can actually 25 tell if the heart's working or not --


1 Q: Hmm hmm. 2 A: -- or a pulse oximeter. I said it 3 wrong, sorry. Well, it's a little box that you can put 4 the little clip on your finger and that could also help 5 with seeing a pulse now. 6 We may not have seen it, we may have. 7 It's hard to say. 8 Q: All right, and would these pieces of 9 equipment have been normally available with an MOH 10 ambulance unit? 11 A: I would think so. 12 Q: And had your patient not regained his 13 consciousness, regained consciousness -- 14 A: Hmm hmm. 15 Q: -- as quickly as he did, what -- what 16 options or inventions did you have at your disposal to 17 assist him? 18 A: Not much. 19 Q: All right. 20 A: Short of just giving manual CPR and 21 hoping we'd get there in time. 22 Q: And what other types of equipment 23 would have been necessary for -- to -- to assist him that 24 you didn't have? 25 A: Just what I listed.


1 Q: All right, I'm just wondering whether 2 there would have been any role for intravenous. 3 A: Well, yes, there would have, sorry. 4 Q: What would that role be? 5 A: Normally, I'm not sure if they do it 6 now, but you would start an intravenous and that would 7 give extra fluid to your blood system and that would help 8 the heart keep going and it wouldn't have to work so 9 hard, and keep -- it's basically to keep the blood volume 10 up. 11 It helps with shock. 12 Q: Okay. And based on your observations 13 of Mr. George at the time that he lost consciousness, had 14 you made any -- did you draw any conclusions concerning 15 what his medical condition was, overall? 16 A: My only conclusion was this gentleman 17 had suffered severe trauma. 18 Q: All right, thank you. 19 20 (BRIEF PAUSE) 21 22 Q: In any event, under Mr. George's own 23 muster, apparently, his vital signs did return to 24 normal -- 25 A: Hmm hmm.


1 Q: Yes? 2 A: Yes. 3 Q: And during the course of this 4 transport, did you have any communication with Mr. 5 George? 6 A: I did attempt to get from Mr. George 7 how he had been hurt and his name, and just some 8 particulars -- 9 Q: Yes. 10 A: -- that had helped me to see if he 11 was oriented to time, place and person -- 12 Q: Yes. 13 A: -- which is another little mini test. 14 The only thing he kept saying to me was, I'm not going to 15 hurt you. I was caught in the middle. 16 Q: And did he repeat those types of 17 phrases over and over again? 18 A: Over and over he kept repeating, I'm 19 not going to hurt you. 20 Q: All right. So, in other words, he 21 wasn't responding to your particular questions? 22 A: No. 23 Q: And what, if any, conclusions did you 24 draw from that type of robotic response? 25 A: I would say he was not orientated to


1 time, place, and person. 2 Q: And what does that tell you, if 3 anything? 4 A: It tells me again this gentleman's 5 got something going on and that he had suffered 6 something, and that's neurologic -- that a -- 7 Q: Neurological indicator? 8 A: It is a neurological indicator. It 9 tells me if there has been any brain damage or any 10 swelling on the brain, that sort of thing. 11 Q: All right. Now, is it fair to say 12 that during the course of this transport you were fully 13 engaged in assessing and monitoring Mr. George's 14 condition? 15 A: Yes. 16 Q: And, as I understand it, there's only 17 windows at the back of the -- this particular unit -- 18 A: Yes. 19 Q: -- in the door? 20 A: Yes. 21 Q: So basically you're in a closed-in 22 environment? 23 A: Pretty much. There might have been a 24 window in a door but I had my back to that window, so. 25 Q: Approximately what time did you --


1 well, I should ask you this. Did anything else of 2 significance occur during the course of the transport of 3 Mr. George from the parking lot to the hospital? 4 A: No. 5 Q: Approximately what time did you 6 arrive at the Strathroy Hospital? 7 A: Approximately around midnight. 8 Q: What was the first thing which 9 happened upon your arrival? 10 A: We drove up and got him out to take 11 him into the emergency room. 12 Q: All right. And did -- did you get 13 assistance with respect to getting him on a stretcher and 14 rolling him in? 15 A: Well, he actually rolled in on our 16 stretcher. 17 Q: Okay. 18 A: And I think we had another OPP 19 officer there help us get him out of the van, and then we 20 just walked in with him and went straight to the trauma 21 room. 22 Q: Well, did -- and did you accompany 23 Mr. George? 24 A: Yes. 25 Q: And can you -- can you recall what


1 room you went to? 2 A: It was a large room, I assume the 3 trauma room. 4 Q: At the hospital? 5 A: At the hospital, yes. 6 Q: Was it on the first floor? 7 A: Yes. 8 Q: In the emergency department? 9 A: Yes. 10 Q: Were you asked any questions upon 11 your arrival by any of the medical personnel at the 12 hospital? 13 A: Not really. 14 Q: Did you advise them anything about 15 this patient? 16 A: I was trying to tell them, like, what 17 we would call give report of this patient, what had 18 happened during transport and to get him handed off to a 19 doctor or more qualified professional than myself. 20 Q: All right. And you said you tried 21 to? 22 A: I tried to. It just didn't seem like 23 they wanted to deal with me at that moment and it was -- 24 Q: And -- 25 A: -- due to another patient who was in,


1 by far, worst condition than Mr. George it seemed. 2 Q: All right. And so you were in the 3 trauma room? 4 A: Hmm hmm. 5 Q: And there were clearly medical 6 personnel there? 7 A: Yes. 8 Q: There were doctors and nurses? 9 A: Yes. 10 Q: And was there another patient there? 11 A: Yes. 12 Q: And you said that he was clearly in 13 more difficult -- in more difficulty than Mr. George was? 14 A: It seemed to be; there was a lot more 15 medical personnel around him. 16 Q: And did you come to know who this 17 person was? 18 A: Eventually. 19 Q: And who was that person? 20 A: Dudley George. 21 Q: Now, what position was Mr. Cecil 22 George in -- 23 A: Hmm hmm. 24 Q: -- when he was in the trauma room 25 with you?


1 A: Laying down on our stretcher. 2 Q: Okay. And were you paying any 3 attention or providing any attention to him during this 4 time? 5 A: Yes. I was holding his head so he 6 wouldn't move it. 7 Q: All right. Now, why are you holding 8 his head so he won't move it; why -- why is that a 9 concern? 10 A: There was concern because he had lost 11 consciousness and the visible head injuries that -- he 12 probably should have been stabilized with a c-collar -- 13 Q: Yes. 14 A: -- at that time, so I was just 15 keeping it stable until they were able to put one on. 16 Q: And approximately how long was Mr. 17 Cecil Bernard George laying down on your stretcher with 18 you cradling his head before any -- before he received 19 any medical attention from the personnel there? 20 A: I'm guessing probably ten (10), 21 fifteen (15) minutes, I don't -- 22 Q: And you say you're guessing, did you 23 look at your watch at all? 24 A: No. That's why I'm guessing. 25 Q: And at point in time did the medical


1 personnel turn their attention from -- from Dudley George 2 to Cecil George? 3 A: After Dudley George was pronounced. 4 Q: And did you hear that? 5 A: I could hear the monitors with a 6 steady line, flat line -- 7 Q: Yes. 8 A: -- for lack of a better word, and they 9 just seemed to back off from him. I don't remember 10 exactly if I heard them say pronounce time anymore. 11 Q: All right. Were there any other 12 patients in the trauma room while you were there besides 13 from Dudley George and Cecil George? 14 A: There may have been a younger 15 gentleman but I don't remember exactly. I -- I know there 16 was movement off to the other side of -- like, Dudley was 17 basically towards my right and then I know there was 18 movement towards my left so. 19 Q: Okay. Now were there -- were there 20 curtains or dividers between the patients? 21 A: No, which is unusual. 22 Q: How so? 23 A: Well, normally in an emergency 24 department you do have curtains and it's due to privacy 25 and they just didn't seem to be there. I don't know why.


1 Q: Did you overhear any of the medical 2 treatment or any of the conversations that occurred as 3 between the doctors and nurses when they were attending to 4 Dudley George? 5 A: None that I can recall. 6 Q: All right. Were you concentrating 7 primarily on your patient? 8 A: Yes. 9 Q: Did you receive any concern or 10 criticism from any of the doctors or nurses at the 11 hospital with respect to the -- the state of -- of Cecil 12 Bernard George when you presented him? 13 A: The major criticism was why he didn't 14 have a c-collar on -- just the stabilizing collar. 15 Q: Did you provide a -- did you provide 16 an explanation? 17 A: Very briefly. 18 Q: What was that? 19 A: We had said we saw him sitting up and 20 he had been talking and able to move around a bit. So we 21 felt it wasn't really necessary -- 22 Q: All right. 23 A: -- initially. 24 Q: Were you asked any questions about the 25 patient's history -- about Cecil Bernard George's history?


1 A: They asked me if I knew who he was and 2 at the time I couldn't because he -- he couldn't tell me 3 anything. 4 Q: You didn't know who he was at the 5 time? 6 A: At the time. 7 Q: And did they ask you for any 8 information about what gave rise to the injuries that they 9 were now assessing him for? 10 A: I believe I was asked but I couldn't 11 tell them exactly how he got them. 12 Q: All right. And were any OPP officers 13 present during the course of this discussion? 14 A: I don't remember. 15 Q: Fair enough. Do you recall whether 16 any OPP officers relayed any patient history or any -- or 17 the circumstances under which he received these injuries 18 in your presence? 19 A: I did not receive any information from 20 OPP officers as to how he got his injuries. And in my 21 ambulance unit report there is a notation here and that's 22 from Tab 1. 23 Q: Yes. That's Exhibit P-342, Inquiry 24 Document Number 1002921. 25 A: There is a statement in here that


1 says: 2 "In hospital an OPP officer stated that 3 he may have maybe an AIDS carrier." 4 And to be quite honest with you I don't 5 remember that conversation but I've written down so it 6 must have occurred. 7 Q: All right. And have you been advised 8 that Mr. Cecil Bernard George might be an AIDS carrier 9 prior to you transporting him? 10 A: No. 11 Q: And is this information that would 12 normally be imparted to you upon presentation of the 13 patient? 14 A: No. 15 Q: Would you have acted any differently-- 16 A: No. 17 Q: -- as a result of receiving this? 18 A: No. 19 Q: Do you have any basis or understanding 20 as to what the source -- what the basis of the officer's 21 statement is here? 22 A: To be honest with you, no, and it 23 appears as hearsay and I probably shouldn't have written 24 it. 25 Q: Well, --


1 A: It's too late now. 2 Q: Let me ask you this then. What type 3 of information do you -- were you expected to record in 4 this document? 5 A: I was expected to record what I saw 6 and what I did from what I was told. 7 Q: And were you expected to record any 8 information that you thought was important in relation to 9 the patient treatment and condition? 10 A: Yes. 11 Q: And is this a form that you are 12 required to fill out? 13 A: Yes. 14 Q: And who requires you to fill this form 15 out? 16 A: St. John Ambulance. 17 Q: All right. So it's part of the 18 protocol at the St. John's Ambulance organization? 19 A: Yes. 20 Q: And did you make any alterations to 21 this document after you finalized and signed it? 22 A: Not to this document. 23 Q: Now how long did you stay with the 24 patient after the doctors took over? 25 A: I left the emergency room at that


1 point. 2 Q: All right. And did I -- did you say 3 that was about ten (10) to fifteen (15) minutes after your 4 arrival? 5 A: Approximately. 6 Q: And were you provided with any 7 information by the doctors about the state of Mr. -- Cecil 8 George's health when you left? 9 A: No. 10 Q: And where did you go after you left 11 the emergency department? 12 A: I remember getting a document from the 13 police for their report and I filled it out in the 14 hospital. 15 Q: Okay. Was this for the OPP? 16 A: Yes. 17 Q: Would you kindly look at Tab 2. 18 A: Hmm hmm. 19 Q: And it's Inquiry Document Number 20 1005723 and perhaps you would look at the second page of 21 that document. 22 A: Hmm hmm. 23 Q: It's called, "Interview Report, 24 Ontario Provincial Police." Is that your handwriting? 25 A: Yes.


1 Q: Is this the report that you filled out 2 at the hospital? 3 A: Yes. 4 Q: And at the request of the OPP? 5 A: Yes. 6 Q: And it's dated September the 7th, 7 1995? 8 A: Yes. 9 Q: And, what were you asked to convey in 10 this report? 11 A: Just basically what had happened and 12 what I did. 13 Q: And so this was written very close to 14 the events in question? 15 A: It was written right after Mr. George 16 was released to the medical staff at Strathroy? 17 Q: All right. I'd like to make this the 18 next exhibit, please? 19 THE REGISTRAR: P-343, Your Honour. 20 COMMISSIONER SIDNEY LINDEN: P-343. 21 22 --- EXHIBIT NO. P-343: Document Number 1005723 Sept. 23 07/'95, Will State of Karen 24 Bakker. 25


1 CONTINUED BY MS. SUSAN VELLA: 2 Q: All right. And, did you make any 3 changes or alterations to the contents of this statement? 4 A: Yes, when I was interviewed by the 5 SIU, the last line, the sniper piece, I had -- it's the 6 very last line in that document, I -- 7 Q: All right. 8 A: -- I had changed and that's part of 9 the SIU report. 10 Q: Right. So, I think that the last line 11 reads: 12 "No history of incident other than he 13 was caught between snipers." 14 A: Right. 15 Q: And you clarified that statement when 16 you were subsequently interviewed by the SIU? 17 A: Yes. 18 Q: And that interview occurred, I believe 19 in 1997? 20 A: Yes. 21 Q: And perhaps you'd look at Tab 15, 22 which is Inquiry Document Number 1004602 and it's 23 entitled, "Anticipated Evidence of Karen Bakker taken 24 September 24, 1997," 25 Does that appear to be a transcript of the


1 interview you had with the Special Investigations Unit? 2 A: Yes. 3 Q: All right. And did you make the 4 correction at the bottom of the page -- page 1, there? 5 A: Yes. 6 Q: Perhaps you can -- I'll just read it. 7 It says: 8 "Due to the noise in the ambulance, and 9 the other statement or part of the 10 statement I wish to change, the last 11 line, 'No mention of incident other than 12 he was caught between snipers. I'd like 13 to rephrase that, there was -- there is 14 no mention of the incident other than he 15 was caught in the middle. I don't know 16 anything about snipers." 17 Does that reflect your -- your current 18 state of recollection? 19 A: Yes. 20 Q: Do you know why it was you used the 21 term, "snipers" that night on September the 7th? 22 A: I haven't a clue. 23 Q: All right. 24 A: It was probably adrenalin that night. 25 Q: Fair enough, but you made the


1 correction. 2 A: Yes. 3 Q: Okay. I just want to go back to your 4 report at Tab 1. This is Exhibit P-342, the ambulance 5 unit, St. John's Ambulance Report. And I just want to go 6 through some of the information with you. 7 Now, first of all, up at the top under 8 "Unit Number", it says "Unit Number 100." Can you tell me 9 what that means? 10 A: Each unit in the London brigade had a 11 call number and that was the number for it. 12 Q: But is it the ambulance unit number? 13 A: Yes. 14 Q: Okay. And then the occurrence number 15 relates to... 16 A: The occurrence. 17 Q: Identifying this particular incident? 18 A: Yes. 19 Q: All right. And then under "Patient 20 Data" you've noted that the patient was Cecil Bernard 21 George. 22 A: Hmm hmm. 23 Q: And that the occurrence was at 24 approximately 23:45, so quarter to 12:00? 25 A: Yeah.


1 Q: That the time -- clear time -- is 2 forty-five (45) minutes. What does that relate to? 3 A: That would be about quarter to 1:00 4 and that would be when I released him to the doctors and 5 nurses at Strathroy General. 6 Q: Okay. So, it's not the time you 7 arrived at the hospital, it's the time you released him to 8 the doctors. 9 A: Yes. 10 Q: And so the total time spent with Mr. 11 George, then, was approximately an hour? 12 A: Approximately. 13 Q: All right. All right. And under the 14 "Vital signs," at the bottom of page 1, -- 15 A: Hmm hmm. 16 Q: -- it indicates the pulse was seventy 17 (70) what's -- what's the symbol, seventy (70) what...? 18 A: Beats per minute. 19 Q: Thank you. And the respiration was 20 sixty (16)...? 21 A: Breaths per minute. 22 Q: Okay. And what is the normal range 23 for a pulse and respiration rate? 24 A: Normally between seventy (70) and one 25 hundred (100).


1 Q: For a pulse? 2 A: For a pulse. And for respiration, 3 it's between sixteen (16) and twenty (20). 4 Q: Okay. The second notation is where 5 you could not detect the vital signs? 6 A: That is correct. 7 Q: And let me just pause at that. At one 8 (1) time, did you make the statement that there were no 9 vital signs? 10 A: As soon as I couldn't find them. 11 Q: All right. And did you change that 12 statement at some subsequent time? 13 A: After our conversation with Mr. 14 Harding. 15 Q: And in what way did you change your -- 16 your statement? 17 A: Well, originally, I thought that there 18 was no vital signs, and when I spoke with him, he said, 19 you know, you need to take a look at the factors such as 20 road noise, the vehicle moving, those sorts of things, 21 because you can't always hear that. 22 Q: Yes. 23 A: And it could have been a very thready 24 pulse and he could have been chalky, which I believe he 25 was now, so it's difficult when you have all those factors


1 on top of each other; it seems like you can't find them. 2 Q: All right. And so how -- in what way 3 did you change your statement? What was the clarification 4 you made? 5 A: The clarification was I could not 6 palpate or detect these vital signs, but this is -- this 7 could be why. 8 Q: Okay. And did you have any -- were 9 you able to conclusively determine whether or not there 10 were vital signs present on the second time you checked 11 for them? 12 A: Not conclusively. 13 Q: All right. And I see the third time 14 you checked the vital signs, the pulse was at sixty-two 15 (62); now, is that a little low? 16 A: I would consider it a little low. 17 Q: All right. And sixteen (16) again, 18 breaths per minute? 19 A: It's the low end of normal. 20 Q: And then the last time you checked it, 21 his pulse was up to seventy-eight (78) beats per minute? 22 A: Yeah, it was. 23 Q: And his breathing was up to eighteen 24 (18) breaths per minute? 25 A: That is correct.


1 Q: So, does that reflect a general 2 improvement? 3 A: Definitely. 4 Q: Now, over on page 2, you indicate 5 halfway down, under Equipment Data, that you used tape. 6 Was that the only equipment you used on this gentleman 7 that night? 8 A: Actually, there's a checkmark there 9 for a triangle bandage. There's a little line, just above 10 tape, -- 11 Q: Yes. 12 A: -- that we could check things off. So 13 there was gauze, -- 14 Q: Okay. I see it in the middle. 15 A: -- a triangle bandage, other and 16 savalon (phonetic) -- I -- savalon is a cleaning agent 17 much like normal saline is, -- 18 Q: Okay. 19 A: -- they don't use it as much anymore. 20 But I was trying to clean some of the blood off to get a 21 better look at where his cuts were and those sorts of 22 things. 23 Q: All right. And then the other is the 24 tape. 25 A: Is the tape, yeah.


1 Q: And that was the total of the 2 equipment you used, or the medication that you used that 3 night? 4 A: Pretty much. There is no medication 5 on those ambulances. 6 Q: All right. And at the bottom here, 7 under Additional Information, you note: 8 "During transport patient stated, quote, 9 'Don't worry, I won't hurt you.' 10 numerous times." 11 Now why did you think that was a relevant 12 piece of information? 13 A: Because that's the only thing he said 14 to me during the whole transport, and it also gave an 15 understanding as to why I didn't get a very good verbal 16 history from him. 17 Q: Okay. Fine. And I think you 18 indicated that was an indicator to you that he wasn't very 19 well oriented. 20 A: Exactly. 21 Q: Now, the last thing is, at the very 22 bottom, right corner, there is a number that appears, 1125 23 (eleven twenty-five); can you tell us what that number 24 means? 25 A: That is our Volunteer Number, much the


1 same if you were employed, you'd have an Employee Number. 2 Same idea. 3 Q: So if we see anything with 1125 4 (eleven twenty-five) in the St. John's Ambulance record, 5 we know that's you? 6 A: Yeah. 7 Q: Okay. Now did you also have occasion 8 to testify at the trial of Cecil Bernard George? 9 A: Yes. 10 Q: And if you go to Tab 10 of your brief, 11 it's Inquiry Document Number 1004978, and the pages of the 12 transcript are 160 to 175, and does that appear to reflect 13 the evidence you gave at that trial? 14 A: Yes. 15 Q: Did you keep any handwritten notes or 16 any duty notes or recordings with respect to these events? 17 A: Basically, any scratch notes I may 18 have had would have gone on to our reports which are -- 19 are here in the binder. 20 Q: Yes. 21 A: And it was just taking information 22 from those scratch notes and that was it; they were 23 identical pieces and I don't know what I've done with 24 those. 25 Q: Okay. Were you required though to


1 make any entries into a duty notebook or a handbook of 2 some sort? 3 A: Our duty notebook was the ambulance 4 log. 5 Q: Okay. And the ambulance log was which 6 document? 7 A: That's the Tab 1. 8 Q: All right. So P-342. 9 A: That's where we did all our 10 documentation, was on that log -- 11 Q: All right. 12 A: -- of anything. 13 Q: Now, in -- did you have any 14 opportunity to -- you indicated that you had an 15 opportunity to debrief with Superintendent Harding? 16 A: Hmm hmm. 17 Q: And when did that briefing or 18 debriefing happen in relation to preparing the document 19 which is Exhibit P-342, at Tab 1; was it before or after? 20 A: It was around the same time. 21 Q: All right. 22 A: Because he saw us when we writing up 23 those documents, so. 24 Q: Did you have any other debriefings 25 with any other individual about the events of that night?


1 A: I spoke briefly with Paul Harding, 2 that was at the hospital. 3 Q: And who was Paul Harding? 4 A: That's Mr. Peter Harding's son. 5 Q: Okay. And -- and why was he there? 6 A: He came to check on us. 7 Q: To check on you, okay. 8 A: I mean, us, Glen and I. 9 Q: Fair enough. Now, after you left the 10 hospital did you go back down to Forest? 11 A: No. 12 Q: Do you know what happened to your 13 ambulance unit? 14 A: After seeing the news. 15 Q: No, I mean the one you drove? 16 A: Oh, the one we drove, I believe we 17 took that one back with us and Paul had brought another 18 one, another mode of transportation with him so he could 19 get back. 20 Q: To your knowledge, were -- were you 21 replaced down at the parking lot that evening? 22 A: I don't believe so. 23 Q: All right. 24 A: At least not by St. John. 25 Q: That's what I'm asking.


1 A: Yeah. 2 Q: Okay. Now, in retrospect and with the 3 benefit of the knowledge you acquired during the transport 4 of -- 5 A: Hmm hmm. 6 Q: -- Mr. Cecil Bernard George and at the 7 hospital, should you and -- and Mr. Morgan have agreed to 8 transport Mr. George in the first place? 9 A: In retrospect, no. 10 Q: Why not? 11 A: His injuries were beyond our 12 limitations as first-aid responders, and we really didn't 13 have the equipment or the newer ambulance either, so. 14 Q: Fair enough. And what key information 15 do you believe that you were missing which perhaps 16 hampered your decision to transport Mr. George? 17 A: How he received his injuries and the 18 full extent of his injuries. 19 Q: Now, to be clear, are you saying that 20 under no circumstances would you have agreed to transport 21 a person with the injuries of Mr. George's nature to a 22 hospital? 23 A: No. I would -- we would have done 24 what we had done if there were absolutely no other 25 Ministry of Health units in the general vicinity, but


1 really he should have gone into a Ministry of Health 2 ambulance -- 3 Q: Yes. 4 A: -- and be taken by emergency medical 5 technicians who -- or assistants I should say, who have 6 the experience, who have the extra training. We were just 7 volunteers and we don't have all the training they do, so. 8 Q: Did it cross your mind back in the 9 parking lot to ask the OPP medic whether he could obtain 10 another -- an MOH, Ministry of Health, ambulance unit? 11 A: At the time, no. 12 Q: And, as I understand it, at this -- at 13 the point in time when you agreed to transport Mr. George 14 there were no other Ministry of Health ambulance units 15 remaining in the MNR parking lot, at least to your 16 knowledge? 17 A: Not to our knowledge, and we agreed 18 that we would be the last to be called. 19 Q: You agreed that you would be the last 20 to be called? 21 A: Yeah. And when I say that, that the 22 Ministry of Health units would always be called first and 23 if there's absolutely no one else there, that we were to 24 be called on. 25 Q: And is that a matter of procedure or


1 protocol or was that specifically addressed that night 2 with the OPP? 3 A: My understanding, it was addressed; 4 and it is normal procedure even for everyday things. 5 Q: All right. So it was addressed that 6 night with the OPP and it was your understanding that it 7 was normal procedure -- 8 A: Hmm hmm. 9 Q: -- that using your ambulance unit to 10 transport an injured party -- 11 A: Hmm hmm. 12 Q: -- was a unit of last resort -- 13 A: Exactly. 14 Q: -- that if there were any MOH units 15 that could respond, they were to be used first? 16 A: Yes. 17 Q: All right. That concludes my 18 questions, thank you very much. And, Commissioner, I see 19 that it's -- it's about 4:30. 20 It would be helpful, perhaps, to canvass 21 Counsel for their estimates of cross-examination. 22 COMMISSIONER SIDNEY LINDEN: Would you 23 keep a note of it, Mr. Murray (phonetic). 24 Does anybody wish to examine Mrs. Bakker- 25 Stephens?


1 Yes, Mr. Orkin...? 2 MR. ANDREW ORKIN: Fifteen (15) minutes or 3 less, Mr. Commissioner. 4 COMMISSIONER SIDNEY LINDEN: Mr. 5 Rosenthal...? 6 MR. PETER ROSENTHAL: Approximately half 7 an hour, sir. 8 COMMISSIONER SIDNEY LINDEN: Possibly half 9 an hour? Mr. Scullion...? 10 MR. KEVIN SCULLION: Fifteen (15) minutes 11 or less. 12 COMMISSIONER SIDNEY LINDEN: And Mr. 13 George...? 14 MR. JONATHON GEORGE: Fifteen (15) 15 minutes. 16 COMMISSIONER SIDNEY LINDEN: Mr. 17 Eyolfson...? 18 MR. BRIAN EYOLFSON: Five (5) minutes or 19 less. 20 COMMISSIONER SIDNEY LINDEN: Mr. 21 Roland...? 22 MR. IAN ROLAND: About fifteen (15) 23 minutes seems to be popular. 24 COMMISSIONER SIDNEY LINDEN: Mr. 25 O'Marra...?


1 MR. AL O'MARRA: I'll bid a little lower; 2 ten (10) minutes. 3 COMMISSIONER SIDNEY LINDEN: So, that's 4 it. So I think we'll put it over to tomorrow morning. 5 MS. SUSAN VELLA: I think that would be 6 advisable -- 7 COMMISSIONER SIDNEY LINDEN: I think 8 that's a good idea. 9 MS. SUSAN VELLA: I know that you have a 10 small infant with you today, so -- 11 THE WITNESS: That's okay. 12 MS. SUSAN VELLA: -- perhaps that would be 13 advisable. 14 COMMISSIONER SIDNEY LINDEN: We have a 15 pretty good idea of what to expect and we can line up the 16 next witness. 17 MS. SUSAN VELLA: I appreciate that. So, 18 if you could return for nine o'clock tomorrow. 19 THE WITNESS: Okay. 20 21 (WITNESS RETIRES) 22 23 COMMISSIONER SIDNEY LINDEN: Thank you 24 very much, we'll see you tomorrow morning at nine o'clock. 25 We're adjourned now until tomorrow morning at nine


1 o'clock. 2 THE REGISTRAR: This Public Inquiry is 3 adjourned until tomorrow, Wednesday, April 20th at 9:00 4 a.m. 5 6 --- Upon adjourning at 4:30 p.m. 7 8 9 10 Certified Correct, 11 12 13 14 15 __________________ 16 Dustin Warnock 17 18 19 20 21 22 23 24 25