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 20th, 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 19 William Henderson ) (np) Kettle Point & Stony 20 Jonathon George ) Point First Nation 21 Colleen Johnson ) (np) 22 23 Kim Twohig ) (np) Government of Ontario 24 Walter Myrka ) 25 Susan Freeborn ) (np)


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 KAREN BAKKER-STEPHENS, Resumes 6 Cross-Examination by Mr. Andrew Orkin 7 7 Cross-Examination by Mr. Peter Rosenthal 23 8 Cross-Examination by Ms. Andrea Tuck-Jackson 56 9 Cross-Examination by Mr. Ian Roland 57 10 Cross-Examination by Mr. Al O'Marra 94 11 Re-Examination by Ms. Susan Vella 108 12 13 JOHN RUSSELL KNIGHT, Sworn 14 Examination-In-Chief by Mr. Donald Worme 117 15 Cross-Examination by Mr. Peter Rosenthal 203 16 Cross-Examination by Mr. Kevin Scullion 221 17 Cross-Examination by Ms. Andrea Tuck-Jackson 226 18 19 GEOFFREY FULTON CONNORS, Sworn 20 Examination-In-Chief by Ms. Susan Vella 236 21 22 23 Certificate of Transcript 336 24 25


1 EXHIBITS 2 No. Description Page 3 P-344 Document 1004602 September 24/'97 4 Anticipated evidence of Karen Bakker 43 5 P-345 Document 1002002 Central Ambulance 6 Communication Centre logs 95-PFD-130 7 Ipperwash incident, September 06/'95 8 2134 hours to September 07/'95, 9 0700 hours. 177 10 P-346 Document 5000205 incident report PU 11 common place; Ipperwash RD Lambton 12 standby on 06 September '95, 20:56:50 273 13 P-347 Document 1001992 logger tape command 14 centre three telephone lines 06 15 September '95, 19:50 to 23:49 hours 334 16 P-348 CD-Rom of EMC Calls September 6/7, 17 1995. 335 18 19 20 21 22 23 24 25


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 MS. SUSAN VELLA: Good morning, 7 Commissioner. 8 COMMISSIONER SIDNEY LINDEN: Good 9 morning. 10 MS. SUSAN VELLA: I believe that Mr. 11 Orkin is the first solicitor to cross-examine. 12 MR. ANDREW ORKIN: Good morning, 13 Commissioner. 14 COMMISSIONER SIDNEY LINDEN: Good 15 morning, Mr. Orkin. 16 17 KAREN BAKKER-STEPHENS, Resumes 18 19 CROSS-EXAMINATION BY MR. ANDREW ORKIN: 20 Q: Good morning, Ms. Bakker. 21 A: Morning. 22 Q: My name is Andrew Orkin. I'm Co- 23 Counsel along with Mr. Klippenstein of the Dudley George 24 Estate and of the Sam George Family Members -- Sam George 25 Family Group; a number of the siblings of Dudley George.


1 I would like to ask you a few questions. This won't take 2 very long and I hope won't be too difficult. 3 You were born in 1973; is that correct? 4 A: That is correct. Hmm hmm. 5 Q: So in 19 -- September 1996 you would 6 have been twenty -- 7 A: Two (2). 8 Q: -- two (2). Sorry, 1995, twenty-two 9 (22). 10 A: That's right. 11 Q: On the night of September 6th, you 12 testified yesterday, you were handed over a patient for 13 transport and care, Cecil Bernard George by someone you 14 believed to be an OPP medic; is that correct? 15 A: Yes. 16 Q: And in the ambulance you asked Mr. 17 George did you, about the nature and extent of his 18 injuries and how they came about? 19 A: I tried to, yes. 20 Q: But Mr. George appeared to you to be 21 disoriented or not oriented at all? 22 A: I would say more disoriented. 23 Q: Disoriented. And was not able or not 24 forthcoming in telling you about his injuries? 25 A: He was not forthcoming.


1 Q: Not forthcoming. And you mentioned 2 yesterday that you examined Mr. George in the ambulance 3 as best as you could under the circumstances to ascertain 4 the nature and extent of his injuries? 5 A: That is correct. 6 Q: And you did that by palpitation -- 7 A: Yes. 8 Q: -- of his torso and limbs? 9 A: Basic, a head to toe. 10 Q: Right. And testing his pupils with 11 light and observing his responses to other stimuli? 12 A: That is correct. 13 Q: And taking his pulse and observing 14 his respiration? 15 A: Yes. 16 Q: And as best as you could under those 17 circumstances, you concluded that Mr. George had been 18 subjected to trauma and possibly significant trauma? 19 A: Yes. 20 Q: On transfer to -- to your care of Mr. 21 George at Ipperwash Park, you were given very little, if 22 any, information about what had happened to Mr. George; 23 is that right? 24 A: I was given very little by means of 25 report as to what he had by way of injury.


1 Q: Right. 2 A: I was not given any information as to 3 how he received those injuries. 4 Q: So, with respect to the injuries 5 themselves, you received very little information and as 6 to the circumstances under which the injuries occurred, 7 you received no information? 8 A: That is correct. 9 Q: So, it seems the personal persons who 10 did that handover under those circumstances either knew 11 or didn't tell you what they knew about Mr. George's 12 injuries and the circumstances in which they were caused; 13 is that fair? 14 A: Basically, they -- they may have 15 known but they did not tell me; that is correct. 16 Q: Can we go for a moment to the report 17 you completed, that ambulance unit patient report, I 18 believe it's at Tab 10 in your binder. Yes, you have it 19 open there. That's handy, yes. 20 A: Okay. 21 Q: I assume that's the same one. 22 A: It's Tab 1. 23 MS. SUSAN VELLA: It's Tab 1. 24 MR. ANDREW ORKIN: Forgive me, I've -- 25 I've written the number incorrectly. That's Document


1 1002921. 2 MS. SUSAN VELLA: P-342. 3 MR. ANDREW ORKIN: P...? 4 MS. SUSAN VELLA: 342. 5 MR. ANDREW ORKIN: P. 6 MS. SUSAN VELLA: 342. 7 MR. ANDREW ORKIN: P-342, for the record. 8 Thank you. 9 10 CONTINUED BY MR. ANDREW ORKIN: 11 Q: You were, then, in training as a 12 health professional. You were a fairly senior nursing 13 student? 14 A: Yes. 15 Q: And, to record as best as you can, 16 the salient details of a given situation comprehensively; 17 is that correct? That's part of the training -- 18 A: Yes. 19 Q: -- that a -- that a nurse receives? 20 A: Yes. 21 Q: And, also of course, a St. John's 22 Ambulance volunteer -- 23 A: That is correct. 24 Q: -- receives training to record as 25 best as you can.


1 A: Hmm hmm. 2 Q: And, also to record details without 3 regard to their non-medical implications, in other words, 4 to record clinical and -- and physiological details 5 irrespective of any other implications that they may 6 have? 7 A: That's fair. 8 Q: And, you recorded on that report that 9 an OPP officer had -- you accurately recorded on that 10 report that an OPP officer stated to you that Mr. George 11 may be an AIDS carrier; is that correct? 12 A: That is correct. 13 Q: And this was not on -- in your view, 14 an accurate report or conclusion on your part that Mr. 15 George was, in fact, HIV seropositive, but it was a 16 record about what an OPP officer had stated to you? 17 A: That is correct; it's what the 18 officer said. I had no evidence to say he was or was 19 not. 20 Q: Right. So, you simply recorded the 21 fact that an officer had told you that? 22 A: Exactly. 23 Q: And -- and recorded that for the -- 24 for the record? You also recorded that during your 25 transport of Mr. George and -- and the care you provided


1 in the ambulance to him as best as you could, that he 2 had, at one (1) point, zero pulse and zero respiration? 3 A: Exactly. 4 Q: And, that this was what you recorded 5 because you believed it to the best of your knowledge at 6 the time to be true? 7 A: Exactly. 8 Q: Ms. Bakker, some time later, your 9 reviews on this were revised after conversations with 10 your St. John's superiors and you stated that perhaps the 11 situation was really that Mr. George actually had a faint 12 pulse or respiration, but that as a result of the 13 conditions you were under, you were unable to detect 14 these; is that fair? 15 A: That's fair. 16 Q: I anticipate that there'll evidence 17 later in the Inquiry, perhaps as early as next week, 18 expert evidence including from the physicians to who -- 19 to whose care you carefully transferred Mr. George, that 20 Mr. George was, indeed, subjected to large numbers of 21 blunt instrument blows and trauma on many parts of his 22 body. 23 Are you aware of that evidence or -- 24 A: Yes? 25 Q: You are?


1 COMMISSIONER SIDNEY LINDEN: Excuse me. 2 Just hold up for a second, Mr. Roland has a... 3 MR. IAN ROLAND: My Friend used the 4 term, 'blunt instrument'. I don't think that there's 5 evidence going to be coming from any experts about blunt 6 instrument and so I'm sure that that's entirely accurate. 7 There certainly was trauma from -- from some force, but 8 the suggestion that it was a blunt instrument I don't 9 think is entirely accurate. 10 COMMISSIONER SIDNEY LINDEN: I assume you 11 were referring to some -- 12 MR. ANDREW ORKIN: I'm happy to revise 13 the question -- 14 COMMISSIONER SIDNEY LINDEN: That's fine. 15 16 MR. ORKIN: -- Commissioner, and leave 17 out the words, 'blunt instrument' and simply say bodily 18 trauma. 19 THE WITNESS: That's fair enough, yes. 20 21 CONTINUED BY MR. ANDREW ORKIN: 22 Q: You were the only person who had 23 contact with Mr. Cecil Bernard George and were in a 24 position to observe the circumstances in between the time 25 of his being handed over to a St. John's -- St. John


1 Ambulance and your handing the patient over to personnel 2 at the hospital; is that correct? 3 A: Yes. 4 Q: So, and it's accurate to say, is it 5 not, that of all of the people in this situation you're 6 the only one in -- in a first-hand circumstance to judge 7 what happened with Mr. George while he was travelling 8 from Ipperwash Park to the hospital. 9 A: Just during transport, yes. 10 Q: During transport. In your knowledge, 11 would it be possible that, with extensive bodily trauma, 12 that Mr. George's respiration and pulse may actually have 13 stopped for a short time in the ambulance. 14 OBJ COMMISSIONER SIDNEY LINDEN: We have some 15 objections. Let's hear from Ms. Vella first, Mr. 16 O'Marra. 17 MS. SUSAN VELLA: I don't believe that 18 this Witness has the expertise and medical expertise to 19 give this type of opinion evidence. 20 COMMISSIONER SIDNEY LINDEN: Mr. O'Marra, 21 were you going to say the same thing? 22 MR. AL O'MARRA: Yes. 23 MR. ANDREW ORKIN: I'll move on. 24 MR. AL O'MARRA: Just one moment, please. 25 Not only, I would submit, is it objectionable, but were


1 the question to be put, I think it an obligation on the 2 part of My Friend to satisfy the Commission that there's 3 evidence in support of such a proposition; medical 4 evidence, that would support the proposition. 5 COMMISSIONER SIDNEY LINDEN: Well, we've 6 got a little -- yes, Mr. Rosenthal? 7 MR. PETER ROSENTHAL: Mr. Commissioner, I 8 rise because I intend to explore this area as well. And 9 this person is a nurse and trained as a nurse, and she 10 should know whether or not it's possible for a heart to 11 stop and start again in those circumstances. 12 And I do expect -- I know for a fact that 13 that is possible, that a heart can stop and start again-- 14 COMMISSIONER SIDNEY LINDEN: Well -- 15 MR. PETER ROSENTHAL: -- and I could be 16 called as a witness, if necessary. But in any event, 17 sir, this is something that should be explored now and 18 we'll have expert evidence later as well but -- 19 COMMISSIONER SIDNEY LINDEN: And we're 20 going to have -- 21 MR. PETER ROSENTHAL: -- but that may 22 affect her -- her initial impression of this incident was 23 changed by her discussions with Mr. Harding; we've had 24 clear evidence of that. 25 He was not an expert, but he told her that


1 the explanation for her recording that, must have been 2 noise in the ambulance and we do have a right to revisit 3 that at this -- at this stage with this Witness, sir, in 4 my respectful submission. 5 COMMISSIONER SIDNEY LINDEN: Ms. 6 Vella...? 7 MS. SUSAN VELLA: Two (2) comments. 8 First of all, with respect to Mr. Rosenthal's comments, I 9 believe the witness testified yesterday that she could 10 not conclusively conclude whether or not there was a 11 pulse or breathing, but rather there were two (2) 12 possible explanations. So, she's already conceded that. 13 Second, she was a nursing student at the 14 time that -- that she made this transport. If My Friend 15 wishes to qualify her as an expert then he has to go 16 through the qualification process. 17 We can hear from the Witness in that 18 respect, but I think that her evidence has been quite 19 clear that she could not conclusively determine one way 20 or the other, whether or not the heart stopped or the 21 breathing stopped and I don't know how she can go beyond 22 that. 23 MR. ANDREW ORKIN: Commissioner, My 24 Friend, Counsel for the Coroner, yesterday questioned an 25 ambulance driver in this particular area as well, and he


1 was not even a person who had hands on contact or 2 observation. 3 And the question that My Learned Friend 4 for the -- for the Coroner asked was the obverse, I 5 argue, of the one that I'm asking. 6 But, I am happy, in light of the 7 controversy to move on and look forward to -- 8 COMMISSIONER SIDNEY LINDEN: Well -- 9 MR. ANDREW ORKIN: -- My Friend, Mr. 10 Rosenthal pursuing this. 11 COMMISSIONER SIDNEY LINDEN: -- it may 12 come up again, but we are going to have expert evidence 13 on this, so it may not be as significant as it seems at 14 the moment, although when Mr. Rosenthal rises, he may 15 have more to say on it. 16 If you're ready to move on, then let's 17 move on. 18 19 CONTINUED BY MR. ANDREW ORKIN: 20 Q: Ms. Baker, to move to slightly less 21 controversial arenas, you're aware that the mandate of 22 this Inquiry is to get now, finally after ten (10) years, 23 to the bottom of the events and circumstances of the 24 death of Dudley George. 25 You are aware of that?


1 A: Yes. 2 Q: And you're aware, perhaps, that there 3 has been some evidence, and I anticipate that there will 4 be more, that there may have been political pressure in 5 the days and hours before the events of the night of 6 September the 6th? 7 A: Yes. 8 Q: And as a result, there were concerns, 9 fairly widespread concerns after the events of September 10 the 6th, that the police had actually been pressured or 11 otherwise induced by politicians to use force at 12 Ipperwash Park. 13 Are you aware of that? 14 A: I understand there were concerns, 15 yes. 16 Q: Right. So, you became aware that 17 this was and remains a controversial situation and that 18 there's a lot of controversy about Dudley George's 19 shooting death and also the beating that Cecil Bernard 20 George received on the night of September the 6th? 21 A: Yes. 22 Q: Ms. Bakker, did you ever perceive or 23 feel in any way that there was pressure put on you from 24 any quarter at all to revise your conclusions that Mr. 25 George who may have been a victim of police violence at


1 Ipperwash Park, had suffered loss of his vital signs 2 while he was under your care? 3 MS. SUSAN VELLA: I believe that My 4 Friend put -- put an assumption into that question which 5 was that she had formed a conclusion or had turned her 6 mind as to whether -- how it was that Mr. Cecil Bernard 7 George received his injuries and has inserted the 8 assumption that she may have thought that it was police 9 violence; that doesn't come out in her evidence at all 10 and I don't think that that's a fair question. 11 COMMISSIONER SIDNEY LINDEN: Break your 12 question down. 13 MR. ANDREW ORKIN: I will break it down 14 and I think all of its elements, Commissioner, are 15 defensible and I'm happy to do that. 16 17 CONTINUED BY MR. ANDREW ORKIN: 18 Q: But the simple straightforward thrust 19 of my question is did you ever feel that there was any 20 pressure put on you from any quarter to revise your view 21 that you arrived at and recorded on this patient report 22 that Mr. George's vital signs may have stopped while he 23 was in your care in that -- in that ambulance? 24 A: My report reflects as accurately as 25 possible what happened in that ambulance. I have no


1 idea, really, as to how he received his injuries and I 2 can't draw a conclusion because I didn't see him get 3 hurt. 4 Q: Right. 5 A: And it would be unfair and really not 6 appropriate of me to make that conclusion. 7 Q: That's very fair. But that isn't -- 8 isn't exactly my question. 9 My question is: After the recording that 10 you did on that report, which you've just told me was 11 your best effort to accurately record what you 12 experienced in that ambulance, at some point after this 13 report was made, did you ever perceive or feel that you 14 were put under any pressure about that record? 15 COMMISSIONER SIDNEY LINDEN: Ms. Vella 16 has something. 17 MS. SUSAN VELLA: Sorry, I believe that 18 My Friend is referring to the report which is Exhibit P- 19 342. She does indicate under Nature of Injury/Illness: 20 "During transport patient loss of 21 consciousness decreased. Was unable to 22 locate vital signs due to noise." 23 So, I don't -- I think he's got his 24 chronology a little bit wrong. And perhaps he wishes to 25 rephrase his question.


1 MR. ANDREW ORKIN: Commissioner, my 2 question is really a simple one which goes to the view 3 and perceptions of this Witness about this and I'll 4 expand it slightly any other aspect of what she recorded, 5 is did she feel that in any way she was put under 6 pressure. 7 COMMISSIONER SIDNEY LINDEN: That was -- 8 if you stop there, I think that's a legitimate question 9 and perhaps she can answer that. 10 MR. ANDREW ORKIN: I'll rephrase it to 11 the Witness one last time. 12 13 CONTINUED BY MR. ANDREW ORKIN. 14 Q: Do you feel that any point after 15 recording your experience in that ambulance, that you 16 were put under pressure of any kind from any quarter to 17 change your recollection of what had happened? 18 COMMISSIONER SIDNEY LINDEN: Let's leave 19 it at that. 20 THE WITNESS: I would say no. When I 21 spoke with Mr. Harding and we reviewed the incident that 22 occurred in the ambulance, the goal for us was to be sure 23 that what happened in the ambulance was recorded properly 24 not how he received his injuries. 25


1 CONTINUED BY MR. ANDREW ORKIN. 2 Q: I thank you for that answer. And 3 also for your contribution to this -- to this Inquiry. 4 Many thanks. 5 COMMISSIONER SIDNEY LINDEN: Thank you, 6 Mr. Orkin. 7 Yes, Mr. Rosenthal? 8 MR. PETER ROSENTHAL: Thank you, Mr. 9 Commissioner. 10 11 CROSS-EXAMINATION BY MR. PETER ROSENTHAL: 12 Q: And Ms. Bakker, I hope that my 13 interjection before didn't make you apprehensive that I'm 14 going to try to test your expertise. 15 My name is Peter Rosenthal, I'm Counsel 16 for some of the people from Stoney Point under the name 17 Aazhoodena and George Family Group. 18 I was just going to explore the -- the 19 questions to what really happened in the ambulance. Was 20 it -- was it noise or was it really that he didn't have a 21 pulse and -- or he had a very, very weak pulse. And so I 22 would just like to ask you a bit about the surrounding 23 circumstances there. 24 And, perhaps, I could preface it with 25 could you consider this under the assumption and we will


1 have people more expert than you in this area to indicate 2 whether or not this assumption is true that a heart can 3 stop and spontaneously start again within a short 4 period of time? 5 COMMISSIONER SIDNEY LINDEN: Just a 6 minute, Mr. Rosenthal. 7 MR. PETER ROSENTHAL: Consider that 8 possibility as a -- as a hypothetical when I -- when I go 9 through the rest of this if you may. 10 COMMISSIONER SIDNEY LINDEN: Mr. O'Marra 11 has an objection to the question. 12 MR. AL O'MARRA: More of an observation, 13 sir. 14 COMMISSIONER SIDNEY LINDEN: Oh, okay. 15 MR. AL O'MARRA: I think if My Friend is 16 going to put a proposition in the context of the 17 objective evidence that we've heard, that he has an 18 obligation to put before the Court that there is some 19 medical evidence in support of the proposition, not only 20 testing the qualification of this Witness to answer that 21 question, but there's also medical evidence in support of 22 the proposition. 23 MR. ANDREW ORKIN: Commissioner with -- 24 wrong microphone. I'll try and speak in stereo. 25 With -- with respect, I think, that is


1 precisely what Mr. Rosenthal does not need to do in light 2 of the preface to his question. He's explicitly dealing 3 with a hypothesis and has explicitly isolated it from the 4 circum -- from the particular circumstances and evidence 5 in this Inquiry and I'm frankly quite surprised with the 6 last objection. 7 MS. SUSAN VELLA: I think that the 8 difficulty is really what -- I think what Mr. O'Marra is 9 saying is, is there evidence to support the proposition 10 in the first place, not whether it's an applicable 11 proposition to this scenario, but whether, in the 12 abstract, is it theoretically possible for a heart to 13 stop and then start. 14 And we don't have that objective evidence, 15 but on the other hand, this is a hypothetical and if the 16 assumption obviously cannot be borne out in evidence, 17 then the answers are -- are tainted by that and aren't of 18 much value. 19 But I think as a hypothetical, and 20 assuming this Witness has the medical expertise to answer 21 the question flowing from the hypothetical assumption, I 22 think the question is -- at least the beginning of the 23 question -- I haven't heard the question yet, but the 24 assumption seems to be one that can be put to the 25 Witness.


1 COMMISSIONER SIDNEY LINDEN: And, at the 2 moment, the Witness is not on the stand as an expert, 3 she's a person who has medical knowledge and medical 4 experience -- 5 MR. PETER ROSENTHAL: Yes. 6 COMMISSIONER SIDNEY LINDEN: -- but she's 7 not an expert. We've heard her qualifications and I'm 8 not sure that you want to try to qualify her as expert, 9 but you do want her to give her opinion, given the extent 10 of her knowledge and experience. 11 MR. PETER ROSENTHAL: Well, sir, perhaps 12 I should explain more fully to you and to the Witness and 13 to My Friends, the context that I wish to explore so that 14 you will appreciate my subsequent questions as well. 15 We have clear evidence that Ms. Bakker 16 recorded certain observations or obtained certain 17 observations in the ambulance and then afterwards 18 discussed them with Mr. Harding. 19 And there was concern during that 20 discussion as to how Mr. George could have had zero pulse 21 at one point and then a pulse afterward and Mr. Harding 22 suggested that was likely due to noise in the ambulance 23 and the Witness accepted that and indicated that in her 24 report. We have clear evidence to that effect. 25 Now, that --


1 COMMISSIONER SIDNEY LINDEN: As one (1) 2 possible explanation? 3 MR. PETER ROSENTHAL: As a possible 4 explanation, yes. 5 COMMISSIONER SIDNEY LINDEN: Right. 6 MR. PETER ROSENTHAL: And, apparently at 7 the time, they didn't consider the possible explanation 8 or I might ask the Witness, as to whether the heart might 9 have, in fact, stopped and started again. 10 And I wish to explore that possibility and 11 I'm trying to do that within the -- I certainly don't 12 want to go beyond this Witness' expertise. 13 COMMISSIONER SIDNEY LINDEN: Hmm hmm. 14 MR. PETER ROSENTHAL: I just want to 15 explore that. 16 17 CONTINUED BY MR. PETER ROSENTHAL: 18 Q: So, that's where -- do you understand 19 then, Ms. Bakker, as well where I'm coming from by this? 20 A: Yes. 21 Q: Now, I am correct that at the time 22 you had the discussion with Mr. Harding, you didn't 23 explore the possibility that the heart might have 24 actually stopped and started again, right? 25 You -- you assumed -- you assumed that he


1 was correct in suggesting it was noise? 2 A: No, actually Mr. Harding had said it 3 was more likely that the pulse was thready and I couldn't 4 find it because of the noise and the ground movement of 5 the vehicle. 6 Q: I see. 7 A: We never 100 percent ruled out the 8 fact the heart may have stopped. 9 Q: I see. 10 A: But, it was more likely. And the 11 more likely explanation made the most sense to me. 12 Q: I see. So, you accepted his 13 explanation and that's why in your ambulance report you 14 indicated the noise as a possibility? 15 A: Exactly. 16 Q: Yes. Now, so I'm going to suggest -- 17 explore some other factors with you if I may. 18 Now, you've us that at about the same time 19 as you recorded no pulse -- 20 A: Hmm hmm. 21 Q: -- you also found that his pupils 22 were not responsive, by shining a light in his eyes; is 23 that correct? 24 A: Yes. 25 Q: And also that he was unresponsive in


1 other ways in the sense that if you shook him, he didn't 2 respond; is that correct? 3 A: Yes. 4 Q: And in addition you, at that same 5 time, noticed him apparently not breathing? 6 A: Yes. 7 Q: And he seemed to be not conscious? 8 A: Yes. 9 Q: And in the course of trying to see if 10 he was responsive, you shook him a bit; is that correct? 11 A: Yes. 12 Q: And then, sometime shortly after 13 that, evidently, you were able to get a pulse of 62; is 14 that correct? 15 A: Yes. 16 Q: And so the first pulse that you got 17 after that episode was a slower than normal pulse-rate; 18 is that correct? 19 A: A little bit -- 20 Q: Sixty-two (62)? 21 A: -- slower, yes. 22 Q: Yes? 23 A: Yes. 24 Q: And his breathing when you again 25 noticed it, was at the low end of normal, you told us, at


1 sixteen (16) -- 2 A: Yes. 3 Q: -- breaths per minute, right? 4 A: Yes. 5 Q: And the -- the lack of response from 6 the pupils by shining a light in his eyes, that would not 7 be affected by any noise of ambulance or anything, would 8 it? 9 A: No, other than -- the only thing that 10 could have been affected by maybe -- the head moved or 11 whatever, but... 12 Q: But you shined it right in his eyes 13 and -- 14 A: Yes. 15 Q: -- his pupil didn't -- didn't expand 16 as it should have, did it? 17 A: It should have shrunk, actually. 18 Q: Should have shrunk rather. Thank 19 you, yes. You do have expertise obviously. 20 Now -- and it didn't respond appropriately 21 and that wasn't affected by the fact that it was an old 22 ambulance making a lot of noise, was it? 23 A: Right. 24 Q: And similarly, your shaking him, his 25 failure to respond to that, that wasn't affected by any


1 noise? 2 A: Not that I'm aware of. 3 Q: And his lack of breathing was -- you 4 had earlier observed him breathing -- 5 A: Hmm hmm. 6 Q: -- and recorded the number of 7 breaths, and then at this point you looked and he 8 appeared not to be breathing at all; is that correct? 9 A: Yes. 10 Q: And again, it doesn't appear that the 11 ambulance noise would have affected that, particularly. 12 A: No, but if we had gone over a bump or 13 it was shaking a bit, that could affect how well I could 14 see his chest rise -- rising and falling. 15 Q: Yes. Yes. Now, also the ambulance 16 didn't get very noisy at that point and quieter 17 afterward, did it? 18 A: No, it was pretty much the same. 19 Q: Pretty much the same. And you were 20 able to record his pulse at the other times, the other 21 three (3) times that you indicated in the ambulance call 22 report, and get a positive reading; is that correct? 23 A: Right. 24 25 (BRIEF PAUSE)


1 Q: And the first pulse you recorded 2 after you recorded zero, the next one was sixty-two (62), 3 which is a little slower than normal -- 4 A: Hmm hmm. 5 Q: -- correct? 6 A: That's right. 7 Q: And after that it was seventy-eight 8 (78). 9 A: Yes. 10 Q: And, in fact, if someone's heart was 11 beating normally in that sort of circumstance where the 12 person was -- had been through that kind of agitation, 13 you would expect a faster than normal pulse; is that 14 correct? 15 A: Eventually, yes. 16 Q: Yes. And then he regained 17 consciousness after this episode; is that correct? 18 A: Yes. 19 Q: And -- but -- but at that time, he 20 was more disoriented than he had been prior; is that 21 correct? 22 A: I can't answer that. I really -- I 23 don't remember and I didn't specify that in my report. 24 Q: You don't recall that, that he was 25 more disoriented as to time and place after that?


1 (BRIEF PAUSE) 2 3 MR. PETER ROSENTHAL: Thank you, Mr. 4 Commissioner. Thank you, that's that area. I'm not done 5 with my examination, but as far as the area that was 6 controversial that I wished to explore, I've now done so. 7 COMMISSIONER SIDNEY LINDEN: Thank you. 8 9 CONTINUED BY MR. PETER ROSENTHAL: 10 Q: Now, did I understand correctly that 11 you were indicating that the reason it didn't cross your 12 mind that a Ministry ambulance that would be better 13 equipped as an ambulance and have medics who had better 14 training should do this job, was because the OPP medic 15 did not inform you of the extent of the injuries? 16 If he had informed you of the full extent 17 of the injuries or close to the full extent, you would 18 have suggested they try for a Ministry ambulance; is that 19 correct? 20 A: Looking back on it, yes. At the 21 time, yeah. 22 Q: Yes, yes, yes, yes. At the time it 23 was a relatively casual and I think you described handing 24 over of patient that didn't seem to be a dire emergency, 25 correct?


1 A: I don't know if casual's a good word 2 but it didn't seem as -- he was as hurt as he was for 3 lack of a better phrase. 4 Q: Yes. And it didn't seem that it was 5 very urgent to get him to hospital. 6 A: Well -- 7 Q: It seemed he needed hospital care but 8 not -- not in a very urgent way? 9 A: He needed hospital care, yes. But 10 not lights and sirens as per se. 11 Q: Yes. 12 A: Or -- 13 Q: I'm sorry? 14 A: Nothing. 15 Q: I see. Now, when -- I didn't quite 16 understand the implications of what you said in response 17 to a question about someone informing you as he or she 18 turned over a patient that the patient was or was not 19 intoxicated. You said that that might bias your view? 20 A: Potentially. But, that's something I 21 should be assessing as well myself. 22 Q: Yes. But -- but, you indicated -- 23 I'm interested in what you meant by the concern about the 24 biassing your -- your view of the patient. 25


1 (BRIEF PAUSE) 2 3 A: It may bias care. And I really can't 4 answer that right now. 5 Q: Now we were told by Mr. Harding that 6 the mission that he sent you and Mr. Morgan out on was to 7 help the police maintain the communications vehicle and 8 that he didn't anticipate at that time that you'd be 9 providing any medical assistance. 10 Now were you fully aware of that as you 11 went out on this mission? 12 A: Yes. 13 Q: So, you -- you knew that you were 14 going to be involved in a police operation and not as a 15 medical person but supporting the police in the 16 communications system? 17 A: I understood we were just to 18 replenish the communications post and if someone fell or 19 scraped themselves, they needed band-aid, to give them 20 that but that was it. 21 Q: I see. Now, when you attended on 22 September 6th, you spoke to a senior officer when you 23 first attended; is that correct? 24 A: Attended where? 25 Q: Sorry. At Forest.


1 A: My colleague and I met with a police 2 officer. I couldn't tell you who it was though anymore. 3 Q: And -- but he appeared to be a senior 4 officer; is that correct? 5 A: Appeared as much. 6 Q: And that person told you that there 7 was a potential that tensions were going to be 8 increasing; is that correct? 9 A: It's possible. I don't remember the 10 conversation word for word by any means. 11 Q: With your indulgence, Mr. 12 Commissioner. 13 14 (BRIEF PAUSE) 15 16 Q: If you could please turn -- turn to 17 Tab 15 of the documents before you. And Tab 15 is a 18 statement that you gave to the Special Investigations 19 Unit? 20 A: Yes. 21 Q: Now we all appreciate, in respect of 22 all the witnesses and including you of course, that it's 23 now many years after the event and your memory now is 24 much less than it would have been ten (10) years when the 25 event happened.


1 But, evidently this statement was given on 2 Wednesday, September 24, 1997; is that correct? 3 A: Yes. 4 Q: So, that was quite a bit closer in 5 time to the events than we are now? 6 A: Hmm hmm. 7 Q: Is that correct? 8 A: Yes. 9 Q: I should turn your attention if I may 10 to page 6 of that statement. And I'll -- I'll read you 11 certain portions in page 6, if I may, starting the second 12 time the name Karen appears in the left-hand column. 13 A: Hmm hmm. Hmm hmm. 14 Q: "I had been listening to the media 15 and I knew tensions were high, but 16 that's really mainly it. I know we 17 were stopped at Forest because we 18 reported in there before we went and 19 spoke to a couple of officers and they 20 said there's a potential for tensions 21 to increase tonight, but nothing really 22 specific that I recall." 23 Then the person examining you was Ms. 24 Cuthbertson. She then says: 25 "Okay. And that would have around ten


1 o'clock?" 2 And you answer: 3 "Yeah, roughly in that time. I don't 4 know exactly anymore. 5 Ms. Cuthbertson: Do you recall who 6 you talked to while you -- while you 7 were at Forest? 8 Karen: I honestly don't recall. 9 Cuthbertson: Did you get an 10 impression as to the rank in the 11 hierarchy of the police? Was it a 12 senior officer or...? 13 Karen: He was a senior officer; he 14 sounded like he was running the show, 15 actually." 16 So, that's apparently what you said at 17 that time, would you agree? 18 A: Yes, and -- I would say that is 19 correct as it's... 20 Q: Sorry? 21 A: That's my statement from then. 22 COMMISSIONER SIDNEY LINDEN: Just a 23 minute, Mr. Rosenthal. 24 Ms. Tuck-Jackson...? 25 MS. ANDREA TUCK-JACKSON: Just in


1 fairness, if -- if Mr. Rosenthal could continue to 2 provide, for the record, the description that the Witness 3 and, indeed, whether or not she could actually provide a 4 proper description. It just continues in the transcript, 5 to be fair. 6 MR. PETER ROSENTHAL: I'm pleased to do 7 so. 8 COMMISSIONER SIDNEY LINDEN: How far -- 9 okay, carry on. 10 11 CONTINUED BY MR. PETER ROSENTHAL: 12 Q: You -- after -- My Friend wishes me 13 to continue and I shall. 14 After you said: 15 "He was a senior officer; he sounded 16 like he was running the show, 17 actually." 18 Then Ms. Cuthbertson says: 19 "I see. Can you describe him at all?" 20 You say: 21 "Like physical description? 22 Ms. Cuthbertson: Sure, grey hair, 23 dark hair? 24 You: "Dark hair. I think he had a 25 moustache. I can't remember exactly,


1 it's been a long time." 2 I hope that satisfies My Friend. I'm 3 happy to read the entire document, but I -- I would 4 prefer not. 5 COMMISSIONER SIDNEY LINDEN: I don't 6 think that's necessary. 7 8 CONTINUED BY MR. PETER ROSENTHAL: 9 Q: Now, the part that I was interested 10 in, is refreshing your memory and apparently you spoke to 11 someone who you took as -- as a senior officer; is that 12 correct? 13 A: Yes. 14 Q: And, someone that looked senior 15 enough that you, at least, concluded that he sounded like 16 he was running the show, actually? 17 A: Hmm hmm. 18 Q: Right? 19 A: As my statement here states, yes. 20 Q: And you don't have any reason to -- 21 to disbelieve that now, do you? 22 A: No. 23 Q: No. I mean, you had, obviously, no 24 vested interest in this at all, you just told people any 25 time you were asked what you honestly remembered; isn't


1 that fair? 2 A: That's fair enough. 3 Q: So -- and -- and that person, then, 4 did tell you that there's a potential for tension to 5 increase tonight, but nothing really specific, right? 6 A: As stated in my statement there. 7 Q: Yes. As you -- even with that aid, 8 you don't recall it now? 9 A: I -- like I said earlier, I really 10 don't remember the conversation well. 11 Q: Yes. So... 12 13 (BRIEF PAUSE) 14 15 Q: My Friend, Ms. Vella, suggested it 16 would be appropriate to make this document an exhibit. I 17 don't have a copy that's suitable to be made an exhibit, 18 but I'm sure Ms. Vella, in addition to making the 19 suggestion, will provide a copy. So, this is for the 20 record today -- 21 COMMISSIONER SIDNEY LINDEN: The 22 transcript of the interview, the SIU interview? 23 24 (BRIEF PAUSE) 25


1 COMMISSIONER SIDNEY LINDEN: One zero 2 zero (100) -- 3 MR. PETER ROSENTHAL: So, the document 4 that we intend to make an exhibit, then, is the SIU 5 interview of Karen Bakker headed, Anticipated Evidence of 6 Karen Bakker. It's Document Number 1004602 of the Inquiry 7 Documents. 8 THE REGISTRAR: That would be P-344, Your 9 Honour. 10 COMMISSIONER SIDNEY LINDEN: P-344. 11 MS. SUSAN VELLA: Just -- just for the 12 record, in particular, the excerpt which was recited and 13 adopted as a past recollection recorded at page 6 is the 14 excerpt, particularly, that I want this to be made an 15 exhibit for. The rest of the document has not been 16 reviewed by the -- with the Witness. 17 So, I just want to say that for the 18 record. 19 COMMISSIONER SIDNEY LINDEN: Thank you. 20 21 --- EXHIBIT NO. P-344: Document 1004602 September 22 24/'97 Anticipated evidence 23 of Karen Bakker 24 25 MR. PETER ROSENTHAL: That suggests a


1 question I should ask the Witness, actually. 2 3 CONTINUED BY MR. PETER ROSENTHAL: 4 Q: In preparation for your testimony 5 here today, did you review this document? 6 A: Yes. 7 Q: And do you accept it as an accurate 8 recording of what you would have said in September of 9 1997? 10 A: Yes. 11 Q: And would you agree that your 12 recollection then would have been more accurate and more 13 detailed, perhaps, than your recollection now? 14 A: Yes. 15 Q: Thank you. 16 17 (BRIEF PAUSE) 18 19 Q: Now, did you hear on that evening any 20 discussion of the possibility that politicians, Premier 21 Harris or any other politicians, were interested in this 22 situation and wanted the First Nations people out of the 23 Park? 24 A: I don't recall anyone even discussing 25 any politicians that evening?


1 Q: You don't recall any such 2 conversation. 3 Did you get the understanding before you 4 went to the scene, that the police were going to be doing 5 something about First Nations who were in the Ipperwash 6 Park? 7 A: No. 8 Q: I see. 9 10 (BRIEF PAUSE) 11 12 Q: Now, before the OPP medic spoke to 13 you with respect to Mr. Cecil Bernard George, he had 14 spoken to you earlier, indicating that the situation had 15 changed; is that correct? 16 A: It's possible. 17 Q: Well, perhaps it would be useful to 18 look at that same document again that we just did, at Tab 19 15 of your materials. 20 And page 6 of that document, again, but 21 this time I should begin where I left off. Maybe I will 22 have to read the entire document, Mr. Commissioner. 23 Looking at the bottom of page 6, then. 24 ˘Ms. Cuthbertson: Okay, and who was 25 it that you talked to when you first


1 got there? 2 Karen: The OPP paramedic. I don't 3 remember his name. 4 Cuthbertson: Okay. And it was that 5 officer that informed you that your 6 status had now changed from, sort of, 7 being helpful, refuelling the command 8 post, to someone who was on standby?÷ 9 Then, continuing to page 7, your answer: 10 ˘Yes.÷ 11 And then to -- so that My Friend doesn't 12 require me to: 13 ˘Ms. Cuthbertson: Can you provide a 14 description?÷ 15 And then you say: 16 ˘He was a forty (40) year old, 17 Caucasian. He was a big guy. 18 Cuthbertson: Tall? 19 Karen: Tall and just broad across the 20 shoulders. I don't remember much else. 21 Sorry, it was dark. 22 Cuthbertson: Do you remember what he 23 was wearing? 24 Karen: He was in a bulletproof vest, 25 kind of like a uniform but not, it was


1 like a SWAT team. 2 Cuthbertson: Camouflage? 3 Karen: Yes, I believe so. Again, it 4 was so dark. It was dark, so... 5 Cuthbertson: And he identified 6 himself as the paramedic? 7 Yes.÷ And so on. 8 Now, what I was interested in, 9 particularly, was the part on page 6 where Ms. 10 Cuthbertson asked you: 11 ˘Was that officer that informed you 12 that your status had now changed from, 13 sort of, being helpful to someone who 14 was on standby?÷ 15 And you answered: ˘Yes÷. 16 A: Hmm hmm. 17 Q: Does that help refresh your memory? 18 A: Yes. 19 Q: So, and this is the same officer who 20 later asked you to take over the care and transport of 21 Mr. Cecil Bernard George; is that correct? 22 A: Yes, I think so. 23 Q: Now, what was your understanding of 24 what the role is of a person who is an OPP medic, as 25 opposed to a St. John's Ambulance medic, as opposed to a


1 Ministry of Health ambulance medic? 2 What does an OPP medic -- what did you 3 understand his role to be that evening? 4 A: I understood he was an OPP officer 5 with a paramedic background as well. 6 Q: I see. And as such, he would have 7 different responsibilities from you and from a Ministry 8 medic, right? 9 A: Yes. 10 Q: As an OPP officer, you understood his 11 responsibility would be to the Force and your 12 responsibilities and the Ministry's resp -- Ministry 13 medic's responsibilities would be somewhat different; is 14 that correct? 15 A: Yes. 16 Q: Now, turning then to the time when 17 Mr. Cecil Bernard George was turned over to your care, 18 your colleague Mr. Morgan testified that he believed that 19 Mr. Cecil Bernard George's hands were restrained in the 20 front of his body. 21 Do you recall that? 22 A: It is possible. 23 Q: At this point you don't recall either 24 way but it's possible? 25 A: I'm saying it's possible because I


1 really -- I don't want to say one way or the other 2 because I'm not 100 percent sure. 3 Q: I see. But, it -- it sounds like you 4 think it's more likely that it's correct? 5 A: It is more likely that it's correct. 6 Q: But, you're not absolutely sure? 7 A: Exactly. 8 Q: Is that fair? 9 A: That's fair. 10 Q: Thank you. Now, Mr. Morgan also 11 testified that he believed that some OPP officers said 12 certain words to him and I would like to ask you if you 13 overheard these words being said; words to the effect: 14 "It's standard when transporting a 15 Native casualty that we have a police 16 officer accompanying us." 17 Do you recall hearing words to that effect 18 by some OPP officer to Mr. Morgan? 19 A: I honestly don't remember. 20 Q: Don't remember. I believe yesterday 21 you told us that you weren't sure whether or not the OPP 22 medic officer had informed you that Mr. Bernard George 23 had been losing consciousness from time to time, right? 24 A: Right. 25 Q: Now, I would suggest to you that if


1 he had told you that, that this patient was losing 2 consciousness from time to time that would have alerted 3 you to the fact that this patient was a patient in too 4 serious a condition for St. John's Ambulance to handle 5 and you would have inquired at least about Ministry 6 ambulances; isn't that fair? 7 A: Fair enough looking back on it. 8 Q: Yes. And you would have then 9 realized that this patient should have a collar when he 10 was transported and you would have added a collar if -- 11 if you'd been told someone was losing consciousness, 12 right? 13 A: When we debriefed and took a look at 14 the situation, that would be a fair assumption. 15 Q: I'm sorry? 16 A: When we took a look at the situation 17 to see what we could have done better, that would be a 18 fair assumption. 19 Q: Yes. No, but I'm suggesting that if 20 you had been informed by the OPP medic that he was losing 21 consciousness, and you're not sure whether he were or not 22 and that I'm suggesting to you that had you been, you 23 would have thought a Ministry ambulance -- I'm also 24 suggesting to you, had you been so informed you would 25 have certainly thought of a collar then if he told you


1 that, right? 2 A: We would have considered it, yes. 3 Q: Yes. So, I'm suggesting that the 4 fact that you didn't consider at that point, the question 5 of whether a Ministry ambulance should have been called 6 and the question of whether or not a collar should be put 7 on suggests that probably the officer did not inform you 8 that Mr. Bernard George was losing consciousness? 9 A: I would say probably. 10 Q: Yes. In any event, the officer who 11 advised you of the patient's condition conveyed the 12 impression that he was not very badly hurt; isn't that 13 fair? 14 A: That's fair. 15 Q: Now, you may not recall this but -- 16 and -- but you didn't ask the officer how the injuries 17 happened and he didn't inform you of that fact, right? 18 A: That's fair. 19 Q: But, I believe you indicated in an 20 earlier statement that -- that you normally would ask a 21 person -- if you're getting a patient turned over to you, 22 you normally ask, how did this patient suffer this 23 problem, right? 24 A: Yes. After my experiences. 25 Q: Because -- because it can be


1 important and especially for the immediate medical 2 diagnosis of the patient to know what happened to him to 3 get him in that circumstance, right? 4 A: Yes. 5 Q: If someone tells you he was hit in 6 the back of the head, then you look at the back of the 7 head first thing, right? 8 A: Right. 9 Q: And so on. So -- but you didn't ask 10 on this occasion because of the fact that the person 11 turning him over was a police officer; isn't that right? 12 A: That could be one (1) reason, yes. 13 Q: Well if we could turn again to -- to 14 the same statement at Tab 15 at page 10 and it should now 15 be referred to My Friend reminds me as Exhibit P-344. 16 Thank you. 17 18 (BRIEF PAUSE) 19 20 I'll read to you, beginning about a third 21 of the way down from that page. Ms. Cuthbertson asked 22 you, I'll read your statement right in the middle of the 23 page: 24 "Karen: Not at all. I had no idea how 25 these injuries happened.


1 Ms. Cuthbertson: Just from my 2 previous experience with the unit and 3 talking with ambulance drives, 4 generally speaking when they go to pick 5 up a patient one of the first questions 6 they ask is, what happened?" 7 And your answer is recorded: 8 "Normally I would say yes but because 9 he was a police officer, I didn't ask 10 any questions and I just took him in 11 and did my job. I didn't want to get 12 involved." 13 So, does that refresh your memory now? 14 A: Yes. 15 Q: So, it was because he was a police 16 officer that you didn't ask what would be a natural 17 question? 18 A: Hmm hmm. 19 Q: And why did his being a police 20 officer stop you from asking that natural question and 21 what did you mean when you said you, "didn't want to get 22 involved"? 23 A: To answer the first question, quite 24 frank I was a lot younger then and you didn't ask 25 questions of police officers, you just did what you were


1 told. 2 Q: I see. Right. 3 A: And that was my lack of experience at 4 the time. 5 Q: Right. 6 A: The second question I -- as to why I 7 didn't want to get involved, I'm not 100 percent sure as 8 to why I said that. 9 Q: I see. 10 A: It's probably more to the case of he 11 was a police officer, I took the patient and I was 12 instructed to get him to hospital and that was it. 13 Q: I see. So, you were at the time 14 somewhat in awe of police officers in the sense that you 15 -- you didn't want to question a police officer? 16 A: That's a pretty fair statement. 17 Q: But then not wanting to get involved, 18 was it because you realized that there was some 19 altercation apparently between the police and this 20 gentleman and you didn't want to get involved in that, 21 you just wanted to deal with him medically; is that 22 perhaps what you meant? 23 A: I just wanted to deal with him 24 medically and get him to hospital is probably what I was 25 thinking at the time so...


1 Q: Now, Mr. Morgan indicated, your 2 colleague, that there was some consideration of the 3 possibility of Sarnia Hospital versus Strathroy Hospital 4 as the destination for Mr. George. 5 I gather the Sarnia Hospital at the time 6 was a much better equipped hospital than the Strathroy 7 Hospital; was that your understanding? 8 A: To be honest with you I can't really 9 answer that. I was more familiar with Strathroy. I'd 10 never been into Sarnia so I couldn't evaluate either -- 11 like I couldn't compare them. 12 Q: I see. Do you recall a discussion as 13 to which hospital would be appropriate to take Mr. George 14 to? 15 A: There was a very brief discussion and 16 I don't remember much of it. Just that we talked about 17 the two (2) hospitals. 18 Q: Could you assist us with whatever you 19 do remember? 20 A: What I do remember was, basically 21 they were looking at which is faster to get to and we 22 were about the middle so it was, 6 of 1, half dozen of 23 the other. 24 Q: So, it was just -- the evaluation was 25 which is closest, not -- not which has better possibility


1 of assisting Mr. George? 2 A: Exactly. 3 Q: I see. Thank you very much. Thank 4 you, Mr. Commissioner. 5 COMMISSIONER SIDNEY LINDEN: Thank you, 6 Mr. Rosenthal. 7 I think, Mr. Scullion...? 8 MR. KEVIN SCULLION: I'd be overlapping 9 with Mr. Rosenthal's questions, so I'll exercise my 10 option, or less, and say I have no questions at all, Mr. 11 Commissioner. 12 COMMISSIONER SIDNEY LINDEN: Thank you, 13 Mr. Scullion. 14 I think Mr. George is up. 15 MR. JONATHAN GEORGE: I don't have any 16 questions, Your Honour. 17 COMMISSIONER SIDNEY LINDEN: All right. 18 Aboriginal Legal Services...? Mr. 19 Eyolfson...? No? 20 MR. BRIAN EYOLFSON: No, sir. 21 COMMISSIONER SIDNEY LINDEN: That brings 22 us to Mr. Roland I think. 23 You have a question? 24 MS. ANDREA TUCK-JACKSON: Yes, I'm here. 25 COMMISSIONER SIDNEY LINDEN: Ms. Tuck-


1 Jackson has a question. 2 3 CROSS-EXAMINATION BY MS. ANDREA TUCK-JACKSON. 4 Q: Good morning, Ms. Bakker-Stephens. 5 My name is Andrea Tuck-Jackson. I'm counsel for the OPP. 6 I just wanted to follow up on one area 7 that Mr. Rosenthal questioned you about and that was your 8 understanding of the OPP medics' responsibilities -- 9 A: Hmm hmm. 10 Q: -- and in particular, Mr. Rosenthal 11 asked you about your understanding of his obligations to 12 the police and that they were, perhaps, different from 13 your obligations and the obligations of -- of the 14 Ministry of Health ambulance attendants and I just wanted 15 to -- to make it clear what the import of your answer 16 was, which means that we have to explore the question 17 that was asked. 18 Was it your understanding that the OPP 19 medic -- 20 A: Hmm hmm. 21 Q: -- only was required to provide 22 medical support to OPP officers? 23 A: No. 24 Q: All right. This is what I wanted to 25 clarify. It was your understanding that the OPP medic


1 was required to provide medical support to anyone at the 2 scene who required it? 3 A: I believe so. 4 Q: Thank you. 5 COMMISSIONER SIDNEY LINDEN: Thank you, 6 Ms. Tuck-Jackson. 7 Now, Mr. Roland. 8 9 CROSS-EXAMINATION BY MR. IAN ROLAND: 10 A: Good morning, Ms. Bakker-Stephens. 11 My name's Ian Roland, I act on behalf of the Ontario 12 Provincial Police Association. I have a few questions 13 for you this morning. 14 To begin, I'd like to explore a little 15 bit, your training as a nurse or a practical nurse. I 16 just want to understand your evidence about that. 17 You told us yesterday in response to 18 Commission Counsel's questions that you -- do I have it 19 right, you completed two (2) of three (3) years of a 20 registered nursing course at Fanshawe College? 21 A: Two-and-a-half (2 1/2), yes. 22 Q: Two-and-a-half (2 1/2) years? 23 A: Hmm hmm. 24 Q: All right. So, in September of '95 I 25 take it you had completed two (2) years, had you, or you


1 were about to start the third year? 2 A: In September of '95 I was repeating a 3 semester. 4 Q: You repeat -- were repeating a 5 semester? 6 A: Yes. 7 Q: Okay. That's because you hadn't been 8 successful in the earlier semester? 9 A: In the one from January until the 10 spring, yes. 11 Q: And then, I take it, you switched 12 from the RN course, was it shortly thereafter, to the RPN 13 course? 14 A: Yes. 15 Q: And that's a one (1) year course, 16 normally? 17 A: Normally. 18 Q: Not a three (3) year course. So, you 19 didn't complete the three (3) year RN course; you, 20 instead, switched to the one (1) year RPN course, but in 21 the end it took you a total of three (3) years at 22 Fanshawe College to get that? 23 A: Yes. 24 Q: All right. And, so you never did 25 actually qualify as a Registered Nurse? You're not a


1 Registered Nurse and you've never been a Registered 2 Nurse? 3 A: Exactly and I've never presented 4 myself to be that way. 5 Q: All right. In the course of your 6 training -- the course of your education, while you were 7 taking the Registered Nurse's course, do I understand it 8 that generally in the first year of such course, it's 9 mostly classes; basic anatomy, nutrition, body systems, 10 things like that? 11 A: It is that with some clinical, yes. 12 Q: Yes. And do you -- in the second 13 year, do you -- you do classes and a practicum I take it, 14 do you? 15 A: At Fanshawe College, at the time, you 16 actually classes and practicums since the first day you 17 walked in the door. 18 Q: All right. And when you're -- when 19 you're doing practicums I -- I take it you're working in 20 very restricted controlled areas and circumstances? 21 A: Yes. 22 Q: And you're -- you're working with 23 nurses -- registered nurses? 24 A: Most definitely. 25 Q: And, you're doing the usual thing


1 that students do; feeding and cleaning patients; you 2 might take some vital signs under supervision? 3 A: Yes. 4 Q: But it's -- it's a highly structured 5 and controlled setting in -- your generally in a 6 hospital? 7 A: Yes. 8 Q: And, you rotate, I take -- I gather, 9 in the practicums through some -- some various areas of 10 the hospitals; one of them would not generally be 11 Emergency, would it? 12 A: Definitely not. 13 Q: No. And, so you don't have any 14 practicum and any kind of first-hand experience in -- 15 even as a student, working in an Emergency Department? 16 A: No. 17 Q: And, I take it in the training that 18 you -- you would go through as a -- a student nurse, you 19 learned CPR? 20 A: That's mandatory prior to entering 21 the program. 22 Q: Yeah, but you don't do it on a 23 person, you do it on a dummy, right? 24 A: Exactly. 25 Q: And this is basic CPR training, isn't


1 it? 2 A: Yes. 3 Q: The kind of training that you'd take, 4 for instance, if you were taking a babysitting course? 5 A: Well, the babysitting course only 6 covers part of the basic CPR course. 7 Q: Yes. All right. And I gather, then, 8 you -- you've never worked, obviously, as a registered 9 nurse, and working as a registered practical nurse, do I 10 have it from what you've told us that you've not worked 11 in any emergency situation? 12 You've not worked in an emergency 13 department? 14 A: No, I'm a community nurse. 15 Q: You're a community nurse? You 16 haven't worked with people in crisis or in trauma? 17 A: No. 18 Q: No. That's not any of your practical 19 experience as a working registered practical nurse? 20 A: No. 21 Q: And so you don't have any experience, 22 then, treating ill or injured patients, even as a 23 registered practical nurse who are -- who are presenting 24 with illness or injury? 25 A: Well no, as a registered practical


1 nurse, you're still dealing with ill people, but they are 2 patients that have a predictable outcome. 3 Q: Yes. 4 A: And if a patient does end up becoming 5 ill suddenly, then I would exercise my option to either 6 call 911 depending on the situation or call an RN for 7 some assistance and some guidance or call the doctor. It 8 really depends on the situation. 9 Q: Yeah. But, you're working in a 10 controlled setting with, as you say, predictable and -- 11 and anticipated outcomes. 12 A: When I'm working in my nursing 13 function, yes. 14 Q: Yes. In your -- in your practical 15 nursing function? 16 A: It's strictly a practical nursing 17 function, yes. 18 Q: Okay. And so when any help is needed 19 because there's a person's illness turns in some 20 direction unpredicted, you get help? 21 A: Exactly. 22 Q: Now, in terms of your experience with 23 St. John's Ambulance, do I understand it that -- or is it 24 fair, from what you've said, that this was the first 25 occasion on September 6th, '95, that you found yourself


1 in an ambulance transporting an injured patient from the 2 scene of the injury? 3 A: Yes. 4 Q: That had never happened to you 5 before? 6 A: Never. 7 Q: I take it it hasn't happened to you 8 since? 9 A: Nope. 10 Q: And so -- and you hadn't been trained 11 or shown any of this in any -- any of the time that you 12 were with St. John's Ambulance either, had you? You'd 13 never, ever been taken on a ride with a sick patient in 14 an ambulance before? 15 A: Not in real life, no. 16 Q: No. I take it it was a pretty scary 17 experience for you, then? 18 A: That's an understatement. 19 Q: Yeah. I mean, is it fair to say -- 20 you've told us about the -- about the -- the fact that 21 the adrenaline -- your adrenaline was really flowing -- 22 A: Hmm hmm. 23 Q: -- that it was, looking back, a 24 really quite a terrifying experience, given your -- given 25 your lack of training and lack of knowledge about this


1 kind of situation? 2 A: Yes. 3 4 (BRIEF PAUSE) 5 6 Q: And had you ever previously taken 7 vital signs of a patient with a depressed level of 8 consciousness, even -- obviously you'd not done it in an 9 ambulance transport, but otherwise where there's a 10 patient who's got a depressed level of consciousness; 11 someone who's seriously injured, not a cut or a scrape, 12 and taken vital signs? 13 A: Not in the context of an injury, no. 14 Q: No. To the extent you've done it, 15 you've done it in a controlled setting, I take it, with - 16 - by training? 17 A: Yes, and there's always -- 18 Q: For the purpose of training? 19 A: For the purpose of training, yes. 20 Q: Yes. And I gather you recognize as 21 the, I think the literature indicates, that it's -- it's 22 often difficult to get a carotid pulse? 23 It takes some skill and some training to 24 be able -- to be able to -- 25 A: To get a carotid --


1 Q: -- identify and get a carotid pulse? 2 A: Yes. 3 Q: It's not something that's easy to do, 4 even for people who -- who are practising it? 5 A: In that situation, yes. 6 Q: All right. And in that situation, 7 even getting a radial pulse can be a challenge, can it 8 not? 9 A: Yes. 10 Q: And did -- do I understand from the 11 answers you gave just momentarily to Mr. Rosenthal that - 12 - that Cecil Bernard George may have been handcuffed with 13 his hands in front of him while you were transporting 14 him? 15 A: Not while we were transporting him. 16 Q: Okay. He wasn't handcuffed while you 17 were transporting him? 18 A: No. 19 Q: Okay. Sorry, I misunderstood that. 20 Now, let's talk a little about -- about 21 respiration. 22 And I gather we've agreed that normal 23 respiration is when you're at rest? 24 A: Right. 25 Q: And, that's between twelve (12) to


1 sixteen (16) or twelve (12) to eighteen (18)? 2 A: In my schooling, it was actually 3 sixteen (16) to eighteen (18) or -- 4 Q: I see. 5 A: -- sixteen (16) to twenty (20) but -- 6 Q: You know, for example, that -- that 7 it depends very much on the individual. 8 A: Yes. 9 Q: And, such is also the case with 10 respect to pulse? 11 A: Yes. 12 Q: That it's individually variable? 13 A: Definitely. 14 Q: And, you put a normal pulse ran -- 15 range of seventy (70) to a hundred (100). 16 A: Hmm hmm. 17 Q: The literature indicates -- in some 18 literature that I've seen, a normal range of sixty (60) 19 to ninety (90). 20 A: That's fair. 21 Q: That's fair? 22 A: That's fair. 23 Q: All right. And, we know for the -- 24 the individual variabilities is shown as extreme as by 25 someone like Lance Armstrong. We all know Lance


1 Armstrong who, I'm told, has a -- has a pulse -- sorry, 2 he has a pulse rate at rest of thirty-two (32); it's 3 extraordinarily low. It's what -- one (1) of the things 4 that allows Lance to do what he can do. 5 A: He's a very athletic man, yeah. He's 6 a very athletic man, so... 7 Q: Yeah, and he has a -- he has a pulse 8 rate at maximum of two hundred and twenty (220), which 9 again, is an extreme end, isn't it? 10 A: Hmm hmm. 11 Q: Yeah. So, these -- the pulse rate is 12 variable. The norm, though, we know is around -- 13 somewhere around seventy (70) or eighty (80). 14 A: Hmm hmm. 15 Q: Fair? 16 A: Fair. 17 Q: Okay. And, in extreme exercises 18 individuals, even who aren't great athletes, can get up 19 as high as two hundred (200)? 20 A: Fair enough. 21 Q: Yeah. Now, did you recall that you 22 had a stethoscope with you on the ambulance or not? 23 A: I probably did. 24 Q: Because I looked at the -- at the 25 inventory of equipment that was, I think exhibited with


1 Mr. Morgan when he testified and there didn't seem to be 2 a stethoscope indicated on the inventory. 3 A: But, it may have been my personal 4 stethoscope. 5 Q: I see. And, that surprises me a bit, 6 because I understand that when you were -- when you went 7 to Forest -- 8 A: Hmm hmm. 9 Q: -- being assigned there, you were 10 there to provide assistance for the communications unit; 11 you weren't there, as you understood it when you -- when 12 you went to Forest -- 13 A: Hmm hmm. 14 Q: -- to do any kind of patient 15 treatment or assessment? 16 A: Well, it was probably old habit, 17 because I had a bag at home that was St. John's stuff, so 18 if I was going to deal with St. John, that contained my - 19 - I had a tie, a beret and I usually had my stethoscope 20 with that bag. 21 Q: I see. 22 A: So, if I was going out on any duties, 23 I had everything. 24 Q: I see, okay. So, you think you took 25 your bag with you?


1 A: I would assume so, because I would 2 have had to have been in uniform that night. 3 Q: Yeah. All right. What I gather is, 4 you don't remember actually using your stethoscope? 5 A: No. 6 Q: All right. And, to determine 7 respiration, you said that you put your hand on the chest 8 of Cecil Bernard George? 9 A: I don't recall saying, "Put my hand 10 on the chest," I remember saying, "visually." 11 Q: Oh, you visually -- I'm sorry, you 12 visually looked at it? I'm sorry. 13 A: That's generally how you -- 14 Q: I see. 15 A: -- count breaths is visual. 16 Q: I see, you don't -- you didn't put 17 your hand on his chest? 18 A: I don't recall testifying that, I -- 19 Q: No, I -- no, I'm -- 20 A: -- and, I don't believe I did, 21 either, so -- 22 Q: I'm not suggesting you did. Do you 23 recall doing that? Is that something that you would do? 24 A: Not usually on an adult. 25 Q: All right. And, did -- one (1) of


1 the things I understand that is normal in determining 2 respiration is not only putting a hand on the chest, but 3 also putting your cheek close to his mouth to see if 4 there was respiration from his mouth; did you do that? 5 A: I can't remember that part. The only 6 time I would do that is if I could hardly see it 7 visually, that I would get that close -- the cheek part. 8 Q: Well, you've told us that you 9 couldn't see it visually at one (1) stage, but I gather 10 not being able to see it visually, you don't recall 11 putting your cheek to his -- his mouth to see if you 12 could feel breath? 13 A: I -- I probably did, then, at that 14 point. 15 Q: You -- you don't recall one (1) way 16 or the other? 17 Did -- is that something you'd ever done 18 before? 19 MR. PETER ROSENTHAL: She had given an 20 answer, she said she probably did she said. 21 THE WITNESS: That part was such a blur, 22 I was so -- when I couldn't find it, to be honest with 23 you I panicked and -- 24 25 CONTINUED BY MR. IAN ROLAND:


1 Q: All right. Okay. Fair enough. 2 Now, when -- when a person stops 3 breathing, that's -- in your panic you thought he'd 4 stopped breathing? 5 A: Yes. 6 Q: They become cyanotic, don't they? 7 A: If they stop breathing long enough. 8 Q: Yeah. But, they start to turn white? 9 A: They can. 10 Q: Pale? Blue around the lips? 11 A: They can. 12 Q: You look -- you can look at their 13 nail beds and see that they're discoloured? 14 A: If you have time to. 15 Q: Yes. And I take it from your report 16 you didn't identify any of those signs? In fact, your 17 report says he that was, as I see it, pink throughout the 18 trip. 19 A: I would go with what's in the report. 20 Q: Yeah. 21 22 (BRIEF PAUSE) 23 24 Q: If you look at the report, you'll see 25 you've written --


1 A: Are you talking the one at Tab 1? 2 Q: Tab 1, yes, at the bottom far right. 3 Skin, there's vital signs and there appears to be on this 4 words that are above the -- the form, skin temperature, 5 but it's hard -- you can't really tell them. 6 But, they are -- but you've written: 7 ˘warm, pink and moist÷. 8 A: Okay. That was a general statement 9 for the whole ride, like -- 10 Q: Yeah. 11 A: -- I didn't specify as to when it was 12 warm, pink and moist. 13 Q: And I take it, if you had -- if you 14 had identified that he was cyanotic, that he was white, 15 pale blue around the lips, all that sort of stuff, you 16 would have put that in? 17 A: Probably. 18 Q: All right. 19 A: But, you need to note as well, the 20 lighting in the back of the ambulance was not that great. 21 Q: I see. Okay. 22 23 (BRIEF PAUSE) 24 25 Q: Now, when we -- when we look at -- at


1 your readings, apart from the second reading staying 2 with -- 3 A: Hmm hmm. 4 Q: -- Tab 1, being your ambulance unit 5 patient report, we see at the bottom that the three (3) 6 readings that you do record, the first, sec -- the third 7 and fourth readings, I take it you agree are within 8 normal range? 9 A: Yes. 10 Q: And in fact, for a patient they're 11 quite consistent, aren't they, amongst themselves? 12 A: If you just take those -- the three 13 (3) -- 14 Q: Yes. 15 A: -- then yes. 16 Q: They're -- they're quite consistent. 17 They're certainly not consistent with someone who's gone 18 into shock or -- and come out of shock, are they? 19 A: Well, to be quite honest with you, I 20 don't have a lot of experience treating patients that 21 have gone in and out of shock. 22 Q: Yeah. In fact, have you ever? 23 A: Nope. 24 Q: All right. Not that you have not a 25 lot of experience, you have no experience, do you?


1 A: In that case, no. 2 Q: Okay. And I take it, then, you don't 3 realize that when someone is going into shock, that their 4 pulse and respiration... 5 MR. PETER ROSENTHAL: This Witness has 6 very candidly given her evidence and indicated the limits 7 of her expertise and Mr. Roland gets an answer to a 8 question, You don't know anything about shock, and then 9 he proceeds to continue to ask her more about the affects 10 of going into shock. 11 I would respectfully request that she not 12 be made to feel further uncomfortable by these kind of 13 questions. 14 MR. IAN ROLAND: Let me rephrase it a 15 bit. 16 COMMISSIONER SIDNEY LINDEN: That's fine. 17 18 CONTINUED BY MR. IAN ROLAND: 19 Q: I anticipate there's going to be 20 evidence called from medical experts that when a person 21 goes into shock, they become pale and ashen and their 22 heart and respiration become very rapid, hundred and 23 twenty (120) heart, twenty (20) plus respiration, and 24 that's because of a lack of tissue profusion; there's no 25 -- there's not exchange of oxygen going on.


1 A: Exactly. 2 Q: And so to compensate, the heart and 3 breathing speed up. 4 A: Correct. 5 Q: I take it you didn't -- you didn't 6 observe any of that? 7 A: I can't say I observed a lot of that, 8 but you've got to remember too, when you're in an 9 emergency room you have bright lights, you have machines, 10 you have patients hooked up. I didn't have those 11 options. 12 Q: I understand. I'm not being 13 critical. I'm just saying -- just I wanted just the fact 14 that you didn't observe any of the phenomena that go with 15 a person going into shock as I've described it? 16 A: The other thing you need to remember, 17 I have not specified those times those vitals were 18 taken -- 19 Q: Yes. 20 A: And I could have taken that first 21 set, started my assessment, he could have gone into shock 22 after that set was taken, and I wouldn't have seen those 23 other phenomena for lack of a better phrase, for the 24 pulse going up et cetera. 25 Q: But, in any event what you're telling


1 me -- telling us, I take it, is you didn't observe -- you 2 didn't observe him being pale or ashen, you didn't 3 observe a rapid heartbeat or rapid respiration, you 4 didn't observe any of those things did you? 5 A: Not generally and not specifically. 6 Q: No. And I take you don't know one 7 way or the other whether a person who's going into shock 8 can recover from shock without intervention? That's not 9 something you're aware of? 10 A: Not really. 11 Q: No. I think we'll have some expert 12 evidence on that as well. 13 14 (BRIEF PAUSE) 15 16 Q: Now, with respect to your examination 17 of Cecil Bernard's pupil's you note in your report... 18 A: Hmm hmm. 19 Q: On the second page, you write: 20 "Pupils were not pearl." 21 And then -- is it -- I can't read that, is 22 that, "when" -- 23 A: Hmm hmm. 24 Q: -- "unable to assess."? 25 A: Hmm hmm.


1 Q: Okay. And so you've already told us 2 yesterday that this period of time that you were unable 3 to assess, that is the second -- the time of the second 4 reading or attempt when you couldn't get a pulse or 5 respiration and the third one of sixty-two (62) and 6 sixteen (16) was less than a minute? 7 A: Probably, I didn't look at my watch. 8 I couldn't tell you. 9 Q: Yeah but you -- you -- you told Ms. 10 Vella yesterday that you -- in your estimation was less 11 than a minute. 12 A: Probably. 13 Q: And so I take it that this -- this 14 evaluation of his pupils was in that -- in that minute 15 period was it? 16 A: Hmm hmm. 17 Q: In that less than a minute period? 18 A: Yes. 19 Q: All right. And then after you were 20 able to get the third reading, I take his pupils were 21 reacting, were they? 22 A: Yes. 23 Q: All right. And of course we -- 24 'pearl' means, 'pupils equal and reactive to light'? 25 A: Right.


1 Q: Right. Now you've told us this 2 morning in response to Mr. Rosenthal's question that you 3 may have mistaken that because he moved his head? 4 A: He may have -- that's what I said to 5 him, yes. 6 Q: Yes. And I gather that -- did you -- 7 did you note or did you think you noted his pupils 8 dilated and fixed? 9 Is that what you thought you saw? 10 A: No they didn't respond to light. 11 Q: I see. So, that means they're 12 dilated? 13 A: No. That means they didn't go to a 14 pinpoint. 15 Q: Yes, which means they're dilated, 16 right? 17 A: Slightly, but dilated could also mean 18 that they get bigger and they did not get bigger. 19 Q: They didn't? 20 A: No. 21 Q: Okay. And were they fixed? 22 A: Well, if they didn't respond to 23 light. 24 Q: All right. Do you -- do you -- have 25 you had a -- have you been required in the past to


1 examine a patient's pupils in these circumstances and 2 conditions? 3 Have you ever had to do that before this? 4 A: Not in those conditions. 5 Q: Okay. So, this was the first time 6 you had ever to do that? 7 A: I've examined pupils but in a 8 hospital setting. 9 Q: In a controlled lighted condition? 10 A: Yes. 11 Q: Not in a moving ambulance with -- 12 A: I've never done a patient transport 13 before. 14 Q: -- with as you say, poor -- poor 15 lighting? Fair enough. 16 And how long did you observe the pupils; 17 for how many seconds in this less than a minute? 18 A: Not very long. It doesn't take long 19 to do that. 20 Q: How long would it be; a couple of 21 seconds or what? 22 A: It's hard to quantify but probably. 23 Q: All right. And you recognize, I take 24 it, that from time to time the eye is -- or with some 25 people, the eye is sluggish in responding to light?


1 A: Yes. 2 Q: In fact we all experience it don't we 3 when we go from a -- from a dark room into light, it 4 takes some time for the eye to adjust? 5 A: In that case it adjusts quite 6 quickly; if we go from a dark room into a light room. 7 Q: Yes. 8 A: But -- 9 Q: But it -- with some people, it can be 10 a bit sluggish, can't it? 11 A: Not really. 12 Q: No. All right. And likewise when 13 you're going from a light room to a dark room, it takes a 14 bit of time to adjust, doesn't it? 15 A: A couple of seconds at most. 16 Q: Yeah, all right. Now, do you -- do 17 you all -- did you also recognize at the time, that 18 sometimes it's difficult to assess pupils where the 19 person's iris is dark; the same colour as the pupil -- 20 dark eyes? 21 A: Yes, but I could tell the difference 22 that -- 23 Q: You could? 24 A: -- night? 25 Q: You could. All right. But you


1 recognize that if, for example, for -- for persons with 2 light blue irises or brown irises, it's easier to -- to 3 observe the dilation of the pupils or the constriction of 4 the pupils than it is with someone with dark eyes -- with 5 dark irises? 6 A: To a point. 7 Q: Yes. 8 9 (BRIEF PAUSE) 10 11 Q: Now, we know from an anticipated 12 statement of Cecil Bernard George, this is Document 13 Number 1004620, it's his anticipated statement of July 14 18, 1996 at page 8 that he -- he recalls being put in the 15 ambulance and a lady asking him questions. 16 Sorry, I don't think it's part of your 17 documents, but take it from me that his anticipated 18 evidence says that he remembers a lady asking him 19 questions, things on his arm and he was sleepy and he 20 wanted to sleep. 21 A: That's fair enough. 22 Q: And there was a lady in the 23 ambulance, there were bright lights, and she said, come 24 back, you're not going anywhere. 25 Do you remember saying anything to him


1 like that? 2 A: No. 3 Q: No. Could it be that you said that 4 when you thought he was losing consciousness? 5 A: Could have. I don't remember exactly 6 what I said to him. I was more concerned about losing 7 him at that point. 8 Q: All right. But, that, at least from 9 his account, it -- it -- there's a sense that he has some 10 orientation to place and a person in that account, 11 doesn't he? 12 A: No, because when I asked him, What is 13 your name, do you know where you are, he did not answer. 14 Q: Hmm hmm. I see. 15 16 (BRIEF PAUSE) 17 18 Q: There was -- there's been a good deal 19 of discussion about the OPP medic. Let me tell you, and 20 the -- my Counsel will notice from looking at the 21 documents available to them that -- that the OPP medic is 22 named Ted Slomer and he was not, and is not, an OPP 23 police officer. 24 It's a fair mistake on your part, because 25 I assume he was dressed much like the other officers that


1 were there, but rather he's a -- he's a -- was a medic, 2 and he is a medic, who was there assisting the OPP. 3 I'm not criticizing you at all, believe 4 me, about not knowing he's a police officer, but just so 5 that you understand that we were -- you were -- who you 6 were dealing with was not a policeman but a medic, who 7 had worked as an ambulance officer attendant, worked in 8 the military reserve in a medical unit, was a graduate 9 registered nurse in 1980 and at the time that these 10 events were -- were happening, he was employed as a 11 flight nurse and medic, flying on helicopters and fixed- 12 wing aircraft out of London. 13 He described himself -- he will describe 14 himself when he comes to testify -- I want to -- 15 COMMISSIONER SIDNEY LINDEN: I take it 16 there's a question in there? 17 MS. SUSAN VELLA: Yeah, I mean, I'm not 18 sure what the build-up of -- of this medic who 19 transferred this -- 20 COMMISSIONER SIDNEY LINDEN: Yes. 21 MS. SUSAN VELLA: -- injured man to her 22 is -- is relevant. 23 COMMISSIONER SIDNEY LINDEN: Well -- 24 MS. SUSAN VELLA: I mean, if this is an 25 attempt to intimidate the Witness, then it's not


1 appropriate. 2 COMMISSIONER SIDNEY LINDEN: Right. And 3 if there is a -- 4 MS. SUSAN VELLA: If he would -- 5 COMMISSIONER SIDNEY LINDEN: -- question-- 6 MS. SUSAN VELLA: -- just go to the 7 question. The fact that he wasn't a police officer is 8 one thing. He was a medic -- 9 COMMISSIONER SIDNEY LINDEN: That's fine. 10 MR. IAN ROLAND: Yeah. Well, he's not 11 only a medic. He was a very highly qualified medic and I 12 want to contextualize this when I come -- when we come to 13 this Witness then better understanding who she was 14 dealing with, when she was getting information. 15 COMMISSIONER SIDNEY LINDEN: Well, ask 16 the question now. 17 MR. IAN ROLAND: All right. 18 19 CONTINUED BY MR. IAN ROLAND: 20 Q: And -- and what he, I gather, will 21 say in the course of his evidence, we've -- we've got 22 statements from him, is that he -- he will say: 23 "I briefed the attendants as to my 24 findings [that's you and Mr. Morgan] 25 stating that the bottomline was that


1 he, Cecil Bernard George, had a 2 decreased level of consciousness and he 3 should be taken to hospital for 4 evaluation." 5 Now, do you remember that, telling him 6 that he -- telling you that he had a decreased level of 7 consciousness? 8 A: I believe I already answered that. 9 Q: Sorry? You don't -- well, I -- I 10 must have missed it, maybe you can help me. 11 MR. ANDREW ORKIN: Mr. Commissioner, I 12 believe she -- the Witness is correct. She answered that 13 question when I asked it. 14 She said that she was told or believed she 15 was told nothing about the circumstances of the injury 16 and little or nothing about the nature and extent of the 17 injuries. 18 MR. PETER ROSENTHAL: And respectfully, 19 Mr. Commissioner, I explored it further, suggesting if 20 she had been asked that question, she would have done 21 several things and she indicated she probably would have. 22 COMMISSIONER SIDNEY LINDEN: And she did. 23 MS. SUSAN VELLA: No, I know, but I 24 think more -- and -- and perhaps as relevant in my 25 questioning, I put this anticipated evidence to her and


1 it did not alter her recollection. 2 MR. IAN ROLAND: Well, that's what I'm -- 3 this particular evidence, I don't think was put by My 4 Friend from -- from Ted Slomer. 5 MS. SUSAN VELLA: I'm sorry, I beg to 6 differ. It was. 7 I indicated that we anticipated hearing 8 evidence from the medic that he, in fact, did advise the 9 -- the attendants of the loss or decrease of 10 consciousness. I believe I did say that. I stand to be 11 corrected, but I believe I did say that. 12 MR. IAN ROLAND: All right. Well, then 13 that's fine if that's the case. Thank you. 14 15 CONTINUED BY MR. IAN ROLAND: 16 Q: I've given you a brief outline of Mr. 17 Slomer's qualifications. 18 I -- I take it you agree that he is more 19 qualified than you to deal with the situation that 20 confronted you concerning Cecil Bernard George? 21 A: I -- most definitely. 22 Q: All right. Do you know what a 23 Glasgow Coma Scale is? 24 A: Yes. 25 Q: And, we're going to evidence that he


1 performed a Glasgow Coma Scale assessment. Would that 2 give you more comfort about -- about the condition of Mr. 3 Cecil Bernard George as he was turned over to you by the 4 medic? 5 A: He didn't tell me what the Glasgow 6 Coma Scale rating was on this gentleman. 7 Q: All right. He -- he did a basic 8 trauma life support evaluation; do you know what that is? 9 A: Not anymore no. 10 Q: No. Now, the indication from Mr. 11 Slomer's statements is that he was informed that you were 12 a nurse. 13 Did you inform him that you were a nurse? 14 A: No, I said I was a nursing student. 15 Q: I see. 16 A: I have never let on that I was a 17 nurse at the time. I'm not an RN, I'm just an RPN. 18 Q: So, you told him that you were a 19 nursing student? 20 A: Hmm hmm. 21 Q: And, why did you do that? 22 A: I believe I was asked what my 23 background was and I wanted to be sure he was aware I was 24 not a paramedic or an EMT or anything to that extent. 25 Q: All right. Now, as I understand your


1 evidence, you were told by Ted Slomer that you -- that 2 Cecil Bernard George, from his assessment, hadn't been 3 consuming alcohol? 4 A: That's what he said, yes. 5 Q: Yes. And, if -- you don't recall 6 being told this, but if the concern of -- of the medic, 7 Ted Slomer, was a decreased level of consciousness, it 8 would be of some significance to know whether or not that 9 was due to the use of alcohol -- the imbibing of alcohol? 10 A: That's a fair assumption. 11 Q: And, so that this patient being 12 passed over to you for transport, if he had -- and the 13 concern was, a reduced level of consciousness, it would 14 be significant for you to know whether or not that was 15 due to alcohol or not? 16 A: It may have been helpful, yes. 17 COMMISSIONER SIDNEY LINDEN: Are you 18 going to be much longer, Mr. Roland? 19 MR. IAN ROLAND: Not too much longer. A 20 bit longer. 21 COMMISSIONER SIDNEY LINDEN: You 22 estimated fifteen (15) minutes and it's been a half hour. 23 I'm just wondering how much longer you're going to be so 24 we can decide when to break. If you're not going to be 25 much longer, I'd like you to finish.


1 MR. IAN ROLAND: I think I'll be a bit 2 longer. I think probably another ten (10) minutes. 3 COMMISSIONER SIDNEY LINDEN: Well, I 4 think we should try to finish it before we break. 5 MR. IAN ROLAND: All right. 6 7 CONTINUED BY MR. IAN ROLAND. 8 Q: And one of the other things that your 9 note indicates that Mr. Slomer told you was that Cecil 10 Bernard George was responding to pain. 11 A: Hmm hmm. 12 Q: And I -- I take it that was something 13 important to know? 14 A: Yes. 15 Q: Yeah. In terms of level of 16 consciousness? 17 A: Yes. 18 Q: Now, upon arrival in the emergency 19 room, the medical hospital chart for Cecil Bernard 20 George, that's Document 1000047, indicates that he 21 arrived at eight (8) minutes after midnight. 22 I think that's probably a little earlier 23 recording than your recollection; isn't that right? 24 A: It could be. I didn't look at my 25 watch when we arrived.


1 Q: And on arrival, he -- it is said that 2 he was stuporous, rousable to questioning but giving 3 unfocussed response at first but gradually becoming more 4 coherent over the subsequent half hour. 5 As I understand it you were there and I 6 take it observed all that, did you? 7 A: Yes. 8 Q: And is that what you observed? 9 A: It's a fair assumption. 10 Q: And his blood pressure was taken at - 11 - and was one thirty over seventy (130/70) with a pulse 12 of eighty (80) and reasonably strong; did you observe 13 that? 14 A: Probably. I don't remember if it was 15 done by machine or done manually though. 16 Q: All right. And his pupils were equal 17 and reacted to light? 18 A: At that point. 19 Q: Yes. And the nursing notes show that 20 at twenty (20) minutes after, his pulse was ninety (90), 21 respiration twenty (20) and blood pressure one forty- 22 eight over eighty-eight (148/88) and he was conscious and 23 following verbal commands; did you observe that? 24 A: No disrespect, but those are the 25 nursing notes. Those were not my assessments and I may


1 have watched her take them but I didn't know her values 2 were -- 3 Q: All right. 4 A: -- or what she was writing down. 5 Q: Right. But from your observation, I 6 take it none of that -- none of that is inconsistent with 7 what you observed? 8 A: Again I don't know what values she 9 got. She took the pulse and didn't tell me what she got, 10 so how can I make an answer on that. 11 Q: But, isn't it fair to say that what - 12 - what appears is that on his arrival he was in much the 13 same condition as he was when you first took him into the 14 ambulance? 15 A: That's fair. 16 Q: All right. 17 18 (BRIEF PAUSE) 19 20 Q: Actually that's -- I think that will 21 do it. Thank you very much. 22 COMMISSIONER SIDNEY LINDEN: Thank you, 23 Mr. Roland. 24 MR. IAN ROLAND: Oh, sorry, there is one 25 (1) other question.


1 COMMISSIONER SIDNEY LINDEN: One (1) 2 other question? 3 MR. IAN ROLAND: Sorry, excuse me. 4 5 CONTINUED BY MR. IAN ROLAND. 6 Q: Just -- just so that we've got it 7 clear on the record, when you were taken yesterday by Ms. 8 -- Ms. Vella to the correction that you made to -- to 9 your earlier statement with respect to snipers. 10 A: Hmm hmm. 11 Q: Just above that, this is at Tab 15, 12 there's another correction that wasn't put to you 13 although I think Ms. Vella may have touched it in other - 14 - in some other way. If you look at that page 1 -- 15 COMMISSIONER SIDNEY LINDEN: Sorry, I'm 16 not -- which is -- 17 MR. IAN ROLAND: This is Tab 15. 18 COMMISSIONER SIDNEY LINDEN: Fifteen 19 (15). 20 MR. IAN ROLAND: It's the Document 21 1004602. 22 COMMISSIONER SIDNEY LINDEN: Yes. 23 24 CONTINUED BY MR. IAN ROLAND. 25 Q: Exhibit 344 at the very bottom of the


1 first page Ms. Vella took you to -- to a correction 2 concerning the -- being caught between snipers, but you 3 actually have two (2) corrections. And the first one has 4 to do with your statement that" 5 "At approximately 24:00 hours, the 6 patient had no pulse and no response. 7 I just want to correct that and 8 basically say at approximately 24:00 9 the patient was unresponsive and I 10 could not locate a pulse." 11 And I take it that's another correction 12 you wanted to make from the earlier statement? 13 A: I was -- well, yeah, I was clarifying 14 what I saw. 15 Q: Yeah. All right. Okay. 16 17 (BRIEF PAUSE) 18 19 Q: Thank you, those are my questions. 20 COMMISSIONER SIDNEY LINDEN: Thank you, 21 Mr. Roland. I think we'll take a break. 22 Mr. O'Marra, I presume you still some 23 questions? 24 MR. AL O'MARRA: Yes, sir. 25 COMMISSIONER SIDNEY LINDEN: I think this


1 would be a good time to take a break anyway. 2 THE REGISTRAR: This Inquiry will recess 3 for fifteen (15) minutes. 4 5 --- Upon recessing at 10:35 a.m. 6 --- Upon resuming at 10:52 a.m. 7 8 THE REGISTRAR: This Inquiry is now 9 resumed. Please be seated. 10 11 (BRIEF PAUSE) 12 13 COMMISSIONER SIDNEY LINDEN: Yes, Mr. 14 O'Marra...? 15 MR. AL O'MARRA: Yes, thank you, 16 Commissioner. 17 18 CROSS-EXAMINATION BY MR. AL O'MARRA: 19 Q: Good morning, Ms. Bakker-Stephens. 20 A: Morning. 21 Q: My name is Al O'Marra and I appear on 22 behalf of the Chief Coroner for the province of Ontario. 23 We are assisting in the Inquiry. 24 I only have a few questions because most 25 of the ground, of course, has been well covered by all


1 the Counsel who've already asked you questions. 2 But, let me -- let me -- and my focus is, 3 of course, is what went on in the ambulance primarily, 4 and your observations. 5 Just to put it into context, it's fair to 6 say that you were in a highly stressed situation? 7 A: Yes. 8 Q: And a situation for which you were 9 not trained? 10 A: Exactly. 11 Q: Okay. And at one point, perhaps 12 because of that, the situation and -- and your lack of 13 training, and I don't say that critically, but being 14 placed in that situation you panicked and you've 15 acknowledged that? 16 A: Yes. 17 Q: Okay. And you've also acknowledged 18 that, based on your own observations in retrospect, that 19 your adrenaline was -- was really pumping? 20 A: Yes. 21 Q: Yeah. And you -- you've heard that - 22 - that that makes it difficult for people to conduct 23 assessments because of that very factor of being stressed 24 and having the adrenaline pumping, which really means, in 25 turn, your heart is racing, your pulse is racing?


1 A: Yes. 2 Q: Your respirations are racing? 3 A: Yes. 4 Q: Okay. But, notwithstanding that, 5 trained as a first aid provider, you're trying to -- to 6 conduct as best an assessment, under the conditions, as 7 you possibly can? 8 A: Yes. 9 Q: Now, with respect to the vital signs 10 that you did take -- 11 A: Hmm hmm. 12 Q: -- so we're clear on that; they're in 13 the normal range, those that you were able to obtain? 14 A: Pretty much. 15 Q: Okay. They're not abnormal? 16 A: Not grossly abnormal, no. 17 Q: Okay. Well, in a healthy person or 18 even an injured person, they're not abnormal are they? 19 A: No. 20 Q: No. Now, just focussing on that -- 21 on Tab 1, you -- 22 A: Hmm hmm. 23 Q: -- have it before you there, in terms 24 of the -- the pulse and respirations, did you record 25 these at the time or are these all in retrospect, once


1 you've been at the hospital and -- and you're sitting 2 down, trying to gather your thoughts and recollections? 3 A: I would have recorded them in the 4 ambulance, as soon after, as possible, that I took them. 5 Q: Okay. So, during the -- during the 6 course of transport, you're actually making note of 7 these? 8 A: Yeah, just on a piece of paper that I 9 had had at the time. 10 Q: Okay. And then subsequently you put 11 it on this chart? 12 A: Yes. 13 Q: Okay. Now, when you have the -- the 14 zero, when you're unable to -- 15 A: Hmm hmm. 16 Q: -- find a pulse or observe 17 respirations, you began to get concerned, right? 18 A: Yes. 19 Q: Okay. And as a result of that 20 concern, you realize, based on your training, you have to 21 take steps to try to affect whatever life saving 22 interventions you're trained for? 23 A: Right. 24 Q: Okay. And, when you palpate for -- 25 did you do it at the carotid or -- or wrist?


1 A: I can't remember exactly. I 2 probably did both that night. 3 Q: Okay. And -- and you make your 4 observations concurrently in terms of the respirations. 5 You're not doing one after the other, you -- you can do 6 both at the same time, correct? 7 A: To a point. 8 Q: Yeah. Just -- just look to see 9 whether the chest is rising and falling while you're 10 taking the...? 11 A: Yeah. 12 Q: Okay. And, when you observed that 13 you're -- you're -- you're unable to detect it, is it 14 fair to say that you're concerned because if there's no 15 pumping action -- 16 A: Hmm hmm. 17 Q: -- there's no oxygenation -- 18 A: Hmm hmm. 19 Q: -- of the brain, right? 20 A: Exactly. 21 Q: Okay. And, what's your response to 22 that? 23 A: If there's no oxygen to the brain, 24 you try and get that happening as quickly as possible. 25 Q: How do you do that?


1 A: Normally, we would do CPR. 2 Q: Okay. And those -- chest 3 compressions? 4 A: Normally. 5 Q: Okay. Because you're trying to 6 circulate that blood -- 7 A: Normally. 8 Q: -- and the same time provide 9 oxygenation yourself to -- to -- 10 A: Hmm hmm. 11 Q: -- to make sure that there's no 12 damage to the brain? 13 A: Right. 14 Q: Okay. And, you want to do that as 15 quickly as possible? 16 A: Definitely. 17 Q: Because brain damage can occur 18 rapidly? 19 A: Within four (4) minutes, yes. 20 Q: Right. And, so did you -- did you 21 reach a point where you had to -- where you felt you had 22 to do that? 23 A: I was ready to and then he -- it 24 seemed that he came back again. 25 Q: Okay. Well, when you say, "came back


1 again," you were able to detect a pulse? 2 A: Yes. 3 Q: Okay. And, that's not to -- to say 4 that he didn't have a pulse, you were just able to detect 5 a pulse? 6 A: Exactly. 7 Q: Okay. And, that's the bottomline? 8 A: Yes. 9 Q: You were just able to detect a pulse? 10 A: Yes. 11 Q: You can't say that there wasn't a 12 pulse? 13 A: That's right. 14 Q: Okay. Because if there wasn't a 15 pulse, then -- 16 A: I would -- 17 Q: -- you'd want -- you'd be pumping and 18 blowing to try and save his life? 19 A: Exactly, as quickly as possible. 20 Q: And, you never had to do that? 21 A: I got lucky. 22 Q: Okay. Well, you never had to do 23 that? 24 A: No. 25 Q: You never had to do any form of


1 medical intervention? 2 A: No CPR on this gentleman, no. 3 Q: Okay. And, no lifesaving 4 intervention of any form? 5 A: No lifesaving, no. 6 Q: No, and that's -- that's what I'm -- 7 I'm asking about. 8 A: Okay. 9 Q: You never had to perform any 10 lifesaving intervention throughout this entire transit? 11 A: No lifesaving, no. 12 Q: No. Now, I just wanted to -- 13 reference has already been made to the statements that 14 you've given in the past? 15 A: Hmm hmm. 16 Q: And, there's the one at Tab 15 that 17 attention has been drawn to, both by Ms. Vella and 18 recently by Mr. Roland. 19 A: Hmm hmm. 20 Q: That's at page 1 where you add the 21 correction about him being unresponsive, that you could 22 not locate a pulse? 23 A: That's right. 24 Q: Okay. And, that sometimes happens if 25 -- if a pulse is -- is what is called, 'thready'.


1 A: That is correct. 2 Q: Okay. And, that doesn't mean there's 3 no pulse, it's just it's thready and it's difficult to -- 4 to ascertain? 5 A: Exactly. 6 Q: And, you're -- you're acknowledging 7 that this was less than an ideal environment -- 8 A: Yes. 9 Q: -- to -- to do that? In fact, it was 10 certainly far removed from any training you had in a -- 11 in a room -- controlled environment with -- with trainers 12 and -- and either colleagues that you were training on or 13 dummies, right? 14 A: That is correct. 15 Q: Now, if I could ask you just to turn 16 to page 12 of that statement that you gave to the SIU 17 investigators, Exhibit Number -- yeah, P-344 -- that's 18 Document 1004602. 19 Did you make reference to this correction 20 again at -- at that point with the investigators and I'll 21 draw your attention just towards the last reference to 22 your name, Karen, on that page? 23 A: Yes, I did, and that reference really 24 talks about my discussion with Mr. Harding. 25 Q: Right. And, you talk -- you got a


1 very brief description of the injuries and -- and I won't 2 read through all that because you've -- you've 3 characterized, but the one (1) part I -- I just wanted to 4 ask you about is that you notice -- you said that: 5 "I agreed with him." 6 A: Hmm hmm. 7 Q: "He had to have a pulse to get him 8 back." 9 Right? 10 A: Hmm hmm. 11 Q: And then you go: 12 "He came back, so, he also winced too a 13 couple of times on examination of 14 injuries, but I did not know." 15 Now, what I'm curious about, just with 16 respect to that reference, is that when you're in this 17 panic -- 18 A: Hmm hmm. 19 Q: -- because you can't detect it, you 20 said he had a very tender abdomen -- 21 A: Hmm hmm. 22 Q: -- indications of -- of injury. 23 A: Right. 24 Q: Was he wincing? 25 A: Not at the pulse issue moment, no.


1 Q: Okay. Well, I'm just curious as to 2 why you added that in there? 3 A: That -- well, that was a general 4 statement dealing with the secondary assessment as a 5 whole -- 6 Q: Right. 7 A: -- not so much dealing with strictly 8 the lack of -- were unable to detect that pulse. 9 Q: Okay. But, I take it that certainly 10 when you were able to detect a -- a pulse or read a 11 pulse -- 12 A: Hmm hmm. 13 Q: -- he was -- he was wincing and -- 14 A: At that point, yes. 15 Q: And just so -- you talked about -- 16 you talked about a minute and less than a minute and it's 17 fair to say this is really compressed time, right? 18 A: Yes. 19 Q: You're -- you're in a full panic and 20 you're doing everything before you have to embark upon 21 CPR? 22 A: Right. 23 Q: Because time is of the essence? 24 A: It is of the essence, yes. 25 Q: Right. And so it may have seemed


1 like not just minutes, perhaps even hours to you, 2 frankly, at that time. 3 But, really in retrospect, this was really 4 compressed time; perhaps even seconds? 5 A: Exactly. 6 Q: Because when you -- when you do get 7 some indication that there's a pulse, you're relieved 8 right? 9 A: Yes. 10 Q: Yeah. Because you -- okay. So -- 11 and you record it, make a note of it -- 12 A: Hmm hmm. 13 Q: -- so it may be within seconds that 14 you've actually been able to detect a pulse? 15 A: Yes. 16 Q: Okay. Now, the last -- second last 17 area I just want to ask you about, have you heard of the 18 concept in your training of evidence based medicine? 19 A: Yes. 20 Q: Okay. And is it fair to say that -- 21 that it has an objective concept to it? 22 A: Yes. 23 Q: Okay. So, that what you're looking 24 at are symptoms and indicators that anyone else seeing 25 would be able to arrive at the same conclusion?


1 A: Yes. 2 Q: So, it's an objective assessment? 3 A: Yes. 4 Q: Okay. And in terms of your entire 5 involvement with Mr. Cecil George, was there any 6 objective based evidence that indicated that he had no 7 pulse? Or that you -- 8 A: Are you meaning anything further that 9 -- that's not in my report? 10 Q: Yes. 11 A: I put as much in my report as 12 possible. 13 Q: Okay. So, the only thing in your 14 report that indicated that you were unable to find a 15 pulse, is what you recorded with the two (2) zeros at 16 that time? 17 A: At that time, yes. 18 Q: Yeah. And that within seconds, you 19 have -- you have a pulse recording? 20 A: I believe so. I have to... 21 Q: Okay. Now, when you got to the 22 hospital, you had a per -- continued period of time with 23 Mr. -- Mr. George -- 24 A: Hmm hmm. 25 Q: -- and he was, as you indicated in a


1 response to Mr. Roland, he was in the same sort of 2 stuporous state that he was when you first got him? 3 A: Pretty much. 4 Q: Okay. And do you have any 5 recollection as to how long that you did stay with him 6 before the nurse was there to do her assessment and take 7 her -- record her values? 8 A: Not 100 percent, no. 9 Q: Did you continue to take any -- any 10 further vitals assessing Mr. -- Mr. George? 11 A: Well, I was in -- not really. 12 Q: Okay. So, you didn't -- you didn't - 13 - you didn't check to see the strength of his pulse, you 14 didn't check to see if he was continuing to breathe 15 regularly and respirations were at a standard rate? 16 A: I probably did subconsciously but 17 not -- 18 Q: But, nothing occurred during that 19 time that gave you any alarm? 20 A: Exactly. 21 Q: Okay. And you never reported to -- 22 to the nurse that he was vital signs absent? 23 A: I attempted to. 24 Q: Okay. And this is the information 25 that attempted to provide --


1 A: Yes. 2 Q: -- that you were unable to find a 3 pulse momentarily -- 4 A: Yes. 5 Q: -- during transit? Okay. And that's 6 all that you could say? 7 A: That's all I could say, yes. 8 Q: That's right. 9 Okay, thank you very much, Ms. Bakker- 10 Stephens. Those are my questions. 11 COMMISSIONER SIDNEY LINDEN: Thank you 12 very much. 13 Any re-examination? 14 15 RE-EXAMINATION BY MS. SUSAN VELLA: 16 Q: I just want to revisit briefly the 17 vital sign issues since it's had such attention in the 18 cross-examinations. 19 Is it fair to say that at the time of the 20 transport, you formed a clinical impression that Mr. 21 Cecil Bernard George lacked vital signs, that is lacked a 22 pulse and lacked respiratory function? 23 A: To the best of my ability at the 24 time. 25 Q: All right. And a clinical impression


1 is something that you would have formed on the basis of 2 your observations? 3 A: Hmm hmm. 4 Q: And on the basis of having tried to 5 feel for a pulse? 6 A: Yes. 7 Q: My Friend, Mr. O'Marra, asked if you 8 had any objective evidence and then he defined that term, 9 I believe, by saying were there any signs or symptoms 10 which you saw at the time of transport and when you were 11 taking the pulse, that would support your clinical 12 impression that there were no vital signs that you could 13 detect. 14 Now, would the fact that you placed your 15 hand on his wrist and couldn't feel the palp -- the 16 bumping -- 17 A: Yeah -- 18 Q: -- if you will -- 19 A: -- that's fine. 20 Q: -- is that objective evidence? 21 A: That is objective, yes. 22 Q: All right. And is the fact that you 23 couldn't see his chest rising up and down, is that 24 considered objective evidence? 25 A: Yes.


1 Q: Thank you. Now, I'd like to know, to 2 your knowledge, as a member of the St. John's Ambulance 3 organization, was it the St. John's Ambulance practice to 4 engage a police officer or require a police officer to 5 accompany a native casualty with St. John's Ambulance 6 personnel in 1995? 7 A: It had never come up prior to that 8 incident. 9 Q: All right. But, when you say, "it 10 hadn't come up prior to that incident", were you aware of 11 a requirement that you have a police officer with you 12 when attending a native casualty? 13 A: No. 14 Q: And you also indicated that when you 15 spoke with the medic, who you assumed was associated with 16 -- well, I should ask you this, you assumed this medic 17 was associated with the Ontario Provincial Police? 18 A: Hmm hmm. 19 Q: What -- why did you assume that? 20 What were the -- what did you base your 21 assumption on? 22 A: We were led to believe that he was 23 the OPP medic and that he would be the one assessing the 24 individuals in determining whether or not they needed to 25 go to hospital.


1 Q: And who led you to that impression? 2 3 (BRIEF PAUSE) 4 5 A: I don't remember 100 percent, but I 6 believe it was the gentleman at Forest. 7 Q: During the course of your briefing at 8 the Forest OPP Detachment -- 9 A: Yes. 10 Q: -- by an OPP officer? 11 A: Yes. Again, I don't remember a 100 12 percent. 13 Q: All right. Was there anything in 14 terms of the dress of the medic that led you to believe 15 that he was an OPP officer? 16 A: Well, I stated in my SIU report, he 17 was wearing a bullet-proof vest and had dark clothing on. 18 In fact, I even alluded to it a bit of camouflage and he 19 seemed to blend in as other officers. 20 Q: Okay. Now, you indicated that you 21 made a point of advising the medic, Mr. Slomer, that -- 22 that you were a nursing student and not a nurse. 23 A: I believe I did that night. 24 Q: And you also indicated in your 25 evidence that you were wearing a uniform?


1 A: Yes. 2 Q: Can you describe the uniform that you 3 were wearing that evening? 4 A: It would be a white shirt with St. 5 John Ambulance flashers on the shoulder and black pants 6 and black shoes. 7 Q: All right. And can you contrast that 8 with a typical nursing uniform? 9 A: A typical nursing uniform would be 10 hospital scrubs and they could be in any colour. 11 Q: Okay. 12 13 (BRIEF PAUSE) 14 15 Q: Now, Mr. Roland asked you about the 16 signs and symptoms of a patient becoming cyanotic? 17 A: Hmm hmm. 18 Q: Would you first define that term for 19 me, please? 20 A: Cyanotic is a lack of oxygen to body 21 tissues. 22 Q: All right. And based on your 23 learning in your nursing programs and your training as a 24 St. John's Ambulance first aider, are you able to advise 25 me as to approximately how long a person has to be


1 without oxygen in order to exhibit the features of being 2 cyanotic? 3 A: Are you asking how long? 4 Q: Yeah. 5 A: Yeah. It doesn't take long. I can't 6 tell you exactly, even today off the top of my head, but 7 it doesn't take long. 8 Q: All right. And when you say, "not 9 long" can you tell me more or less than a minute? 10 A: It's very quickly and depending on 11 the person, too. 12 Q: All right. Mr. Roland also asked you 13 some questions about the pupil assessment that you 14 conducted -- 15 A: Hmm hmm. 16 Q: -- and you already told us that you 17 used a flashlight -- 18 A: Yes. 19 Q: -- and you put it -- you pointed it 20 in Mr. Cecil Bernard George's eyes and they didn't 21 respond. 22 Did you hold it there long enough to 23 account for possibility of Mr. George having a sluggish 24 pupil? 25 A: I believe I did.


1 Q: Is that something that you would know 2 to do? 3 A: Definitely. 4 Q: And, Mr. O'Marra asked you very 5 specifically about whether or not you had to perform any 6 lifesaving intervention during the course of the 7 transport and you were very careful to emphasize that you 8 -- you did not perform any lifesaving intervention, can 9 you just give me a sense as to what -- how -- how we 10 distinguish lifesaving intervention from the type of 11 intervention you did provide to Mr. George during 12 transport? 13 A: Okay. Basically, most of what I did 14 with Mr. George during transport is assess and stabilized 15 any areas that were causing him pain and that was 16 basically done after the fact of the crisis that we had, 17 for lack of a better phrase. 18 Q: All right. Now, you were also asked 19 some questions in relation to your observations, I guess, 20 versus the observations of hospital personnel -- 21 A: Hmm hm. 22 Q: -- once you delivered Mr. George to 23 the hospital. 24 When you entered -- how -- how soon after 25 you entered the hospital did any medical personnel from


1 the hospital perform any kind of assessment on Mr. 2 George? 3 A: I can't remember exactly. But, I 4 know I did say that it took a while, because it seemed to 5 be the first ten (10) to fifteen (15) minutes they really 6 weren't listening to me and they really didn't want to 7 even look at him hardly. 8 They, kind of said, Hi, took a really 9 quick look at him and left, but that was pretty much it. 10 It was very, very brief. They were dealing with the 11 other individual. 12 Q: And, you indicated their full 13 attention was on Mr. Dudley George at that time? 14 A: That's right. 15 Q: And, as a result, you held Mr. Cecil 16 Bernard George's head, I think you said for -- for 17 several minutes. 18 A: Hmm hmm. 19 Q: I thought it was maybe as long as 20 twenty (20) minutes. 21 A: Yes. 22 Q: And, was it after that, that a -- 23 that a more formal assessment was conducted? 24 A: Yes. 25 Q: Thank you. Those are all my


1 questions. And I want to thank you very much for your 2 testimony to the Inquiry. 3 COMMISSIONER SIDNEY LINDEN: I want to 4 repeat that. Thank you very much for coming here and 5 giving us your evidence. 6 I can tell it hasn't been a lot of fun for 7 you. Thank you very much, you did a good job. 8 THE WITNESS: Thank you. 9 10 (WITNESS STANDS DOWN) 11 12 COMMISSIONER SIDNEY LINDEN: Thank you. 13 Where are we now? 14 MR. DONALD WORME: We're prepared to call 15 the next witness, Mr. Commissioner, and with your leave, 16 I would go ahead and do so. 17 COMMISSIONER SIDNEY LINDEN: 11:15. Yes, 18 let's just go on to the next witness. 19 MR. DONALD WORME: And, would it be your 20 intention, sir, to go to approximately 12:30 today or do 21 you wish to break at our regular time at 12:00? 22 COMMISSIONER SIDNEY LINDEN: 23 Approximately. Does that work for you? How long...? 24 MR. DONALD WORME: I'm in your hands. 25 COMMISSIONER SIDNEY LINDEN: Okay, 12:30


1 is about a good time to break for lunch. It's 11:15 now; 2 that's an hour and fifteen (15) minutes. 3 MR. DONALD WORME: Then, we would call 4 next, John Russell Knight. 5 COMMISSIONER SIDNEY LINDEN: Thank you. 6 7 (BRIEF PAUSE) 8 9 THE REGISTRAR: Good morning, Mr. Knight. 10 THE WITNESS: Good morning. 11 THE REGISTRAR: Please take the Bible in 12 your right hand, it's to your right there, sir, and state 13 your name in full for us. 14 THE WITNESS: John Russell Knight. 15 THE REGISTRAR: Thank you, sir. 16 17 JOHN RUSSELL KNIGHT, Sworn 18 19 EXAMINATION-IN-CHIEF BY MR. DONALD WORME: 20 Q: Good morning, Mr. Knight. 21 A: Good morning. 22 Q: I'm going to ask you if you might 23 just turn the microphone up there just a bit as well so 24 that your voice is picked up. 25 A: Okay.


1 Q: And, as you know everything is 2 recorded and transcribed. 3 A: Right. 4 Q: Mr. Knight, you were born January 5 29th, 1941 and making you sixty-four (64) years young 6 today? 7 A: Well, not today, but yes. 8 Q: All right. You were born and raised 9 in Wyoming, Ontario but have resided in Sarnia -- in 10 Sarnia, Ontario since 1959. 11 A: Yes. 12 Q: I understand, sir, from 1960 to 1970 13 that you have been employed with the Sarnia Ambulance 14 Service in Sarnia, Ontario. 15 A: Yes. 16 Q: And you were employed there as an 17 ambulance attendant from 1960 to 1970? 18 A: Yes. 19 Q: In terms of an ambulance attendant, 20 we've heard a little about that, sir, and I wonder if I 21 just might have you explain even in brief, what it is 22 that the ambulance attendant -- at least in that period 23 of time, were responsible for as frontline persons and 24 perhaps the kind of training you had with respect to 25 providing those services?


1 A: Well, at -- at the start in '60 there 2 was no formal ambulance service in the province. A lot 3 of them where smaller communities were run by funeral 4 homes. Larger communities, they would have private 5 operations. 6 There was no formal training programs, you 7 had first aid training, CPR was not available at that 8 time. And in the mid '60's the Ontario Government got 9 involved in training and involved in the ambulance 10 service right across the province. 11 And shortly after that, they set up a 12 training program at Base Borden which was a one (1) month 13 cram course in anatomy, physiology, first aid training, 14 rescue work and this sort of thing. 15 And that -- there was some CPR training at 16 the time but when we were trained in that, we were told - 17 - after we passed all the training, we were told we 18 couldn't do it until -- unless there happened to be a doc 19 -- a medical doctor standing beside us telling us to do 20 it. 21 And that's basically where it sat in -- up 22 to about 1970 and then they -- some of the community 23 colleges had set up a training course of one (1) year and 24 it went in further depth. And shortly after that you had 25 to have community college in order to get hired into an


1 ambulance service. 2 Q: All right. Now you did have some -- 3 some training. You say when the Ontario Government 4 introduced a program of training, I take it that you were 5 still employed at that point -- 6 A: Yes. 7 Q: -- with the -- as an ambulance 8 attendant and -- 9 A: Yes. 10 Q: -- you had occasion to attend 11 Fanshawe College for the purposes of upgrading your -- 12 A: Yeah. 13 Q: -- skill level. 14 A: They would run weekend courses on 15 respirations, training and different programs, bleeding 16 courses, oxygen therapy, this sort of thing. And I did 17 attend a number of them. 18 Q: All right. And a majority of your 19 training, if I can -- if I can suggest that, sir, would 20 have come basically on the job? 21 A: Yeah, a lot of it was on the job 22 training with a senior person. 23 Q: Following your service as an 24 ambulance attendant, then in 1970 and up until 1990, you 25 then managed an ambulance service?


1 A: Yeah. I managed the service in 2 Sarnia for the -- at that time it was the Emergency 3 Health Services and I ran that for a year for them. 4 And the director of Emergency Health 5 Services, he wanted all ambulance services in Ontario out 6 of hospitals. So we then became a department of Sarnia 7 General Hospital and I managed the service for them until 8 1990. 9 Q: And -- and during the 1970's in 10 approximately in the mid 1970's you also managed a 11 satellite base that was established here in Forest, 12 Ontario. 13 A: Yeah, in 1968, the private operator 14 in Sarnia, he set up a service in Forest and took over 15 from the funeral homes that were running service here. 16 And when we became a department of the 17 hospital, they stayed with us until mid-'70's when the 18 emergency health services decided, well, it was too 19 expensive to operate a twenty-four (24) hour service 20 here, so they cut our budget and we had to -- because we 21 had a union, we had to cut staffing hours and... 22 Q: All right, and from 1990, sir, up 23 until 1997, you've been employed with the Wallaceburg 24 Central Ambulance Communications Centre? 25 A: Yes.


1 Q: We've heard the acronym CACC here, 2 C-A-C-C? 3 A: Right, Central Ambulance 4 Communications Centre. 5 Q: And all told, sir, that you have some 6 thirty-five (35) years experience in working both in 7 management, in fleet, that is to say as an ambulance 8 attendant, and as well as a dispatch? 9 A: Right. 10 Q: All right, now in our -- in our 11 meetings earlier, sir, you had raised with me some of the 12 reasons why you had took your leave from employment, from 13 full-time employment in 1997. 14 I just want to lay those on the record if 15 I may, sir, and it's obviously not an attempt to -- to 16 diminish your expertise, but you do have some significant 17 health issues. Is that fair? 18 A: Yes. 19 Q: And that you had a heart attack and, 20 indeed, had open heart surgery. Is it on two (2) 21 occasions, sir, in 1990 -- 22 A: Yes. 23 Q: -- as well as 1996? 24 A: 1980 and 1986. 25 Q: Pardon me, 1980 and 1986?


1 A: Yes. 2 Q: And you had advised that the second 3 open heart surgery was much more difficult in the sense 4 that your recovery time was considerably longer? 5 A: Yes. 6 Q: And that as a result of being on the 7 heart/lung machine during the course of that surgery, you 8 had suffered some memory loss as a result of that? 9 A: Yes, short term memory, yes, in 10 particular, yeah. 11 Q: All right, you had also, sir, advised 12 that you have been diagnosed as a diabetic since 1996? 13 A: Yes. 14 Q: And it was shortly thereafter that 15 you took your retirement? 16 A: Yes. 17 Q: And more recently, sir, you have been 18 diagnosed with familial essential tremors which you've 19 described to me as something similar, but not the same, 20 as Parkinson's? 21 A: Yes. 22 Q: And as a consequence of these various 23 ailments, you take upwards to twenty (20) different types 24 of medications daily? 25 A: Yes.


1 Q: And these various medications, 2 together with the physical ailments that you have 3 confirmed for us, together with the blood pressure issues 4 has had an effect, not only on your stamina but also on 5 your memory? 6 A: Yes, to a degree it has, yes. 7 Q: All right, so just with those on the 8 record, sir, I just want to go back then and I wonder if 9 you might tell us about the -- your last stint of 10 employment, that is at the CACC centre or at the CACC 11 Wallaceburg Communications Centre. 12 A: Well, I was there for seven (7) years 13 before I retired. And I did dispatching and call taking, 14 worked different shifts and with call taking it involves 15 answering 911 calls, hospital calls, different types of 16 calls that way. 17 And on the dispatching side, you dispatch 18 all the different priority of calls and -- 19 Q: Okay. The Wallaceburg Communications 20 Centre, it's owned and operated by whom? 21 A: Well, technically it's owned by the 22 ambulance services branch and its ran through the 23 Sydenham District Hospital in Wallaceburg. 24 We're not on premises. We were in a 25 separate building and the hospital didn't have a lot of


1 role in operation. They had a manager there, plus it 2 came under the regional officer out of London. 3 Their people had a lot of say in the 4 operation. 5 Q: And what -- what area does the 6 Wallaceburg CACC service? 7 A: All of Lambton and Kent Counties. 8 Q: And in terms of population, sir, what 9 would your estimate be as -- as to the population in 10 those two (2) counties? 11 A: Two hundred and fifty (250) -- two 12 hundred and seventy-five thousand (275,000), I guess. 13 Q: All right. And, the Wallaceburg 14 CACC, then, is responsible for the dispatch of all 15 ambulances within those two (2) counties -- 16 A: Right. 17 Q: -- to service that population? 18 A: Yes. 19 Q: And, aside from ambulances, are there 20 other services that are provided, you mention the 911? 21 A: Yeah, 911. After we'd be in 22 operation for a while, we took over dispatching fire 23 departments in Lambton County. 24 There are something like twenty-one (21) 25 departments, which basically -- all the departments with


1 exception of the City of Sarnia. And 911 was not on 2 premises, it was answered, in 1995, all 911 calls in 3 Lambton County went into the Sarnia Police Station and in 4 Kent County, they went into the Chatham Police 5 Department. 6 And I understand in the last two (2) 7 years, 911 is now answered in Orillia for Lambton County 8 and if I'm not mistaken, Kent County, too. 9 Q: All right. 10 A: But Sarnia had a tiered response in 11 effect and they refused to give up 911, so it's now -- it 12 stayed in Sarnia for the City of Sarnia only. 13 And a tiered response is just the -- when 14 a 911 call came in, if they required an ambulance, it 15 went into the police station and they push a button; it 16 came down to the dispatch centre and we took all the 17 information. And the 911 operator would listen in on the 18 call. 19 And if she heard certain things, such as 20 difficulty breathing, severe bleeding or unconsciousness, 21 they would dispatch the closest fire department in -- or 22 fire station in the city and the closest ambulance or 23 fire department would be the -- or police officer would 24 be the first one there in order to start treatment. 25 Q: All right. And then just to -- just


1 to get some -- some clarification, in 1995, if I were to 2 pick up the phone here in Lambton County and call 911, 3 that call would go directly to Sarnia at that time? 4 A: Right, to the Sarnia Police 5 Department. 6 Q: And the Sarnia Police Department 7 would then re-direct the call depending on whether it was 8 fire, ambulance, police, that sort of thing. 9 A: Right, yes. 10 Q: All right. And, if it was ambulance, 11 it would be routed directly to the -- 12 A: Wallaceburg. 13 Q: -- Wallaceburg CACC? 14 A: Right. 15 Q: All right. And, would the police 16 monitor the -- the call as it had gone through? Would 17 they stay on the line, that is to say? 18 A: Yes. And, if they were dispatching a 19 fire department or one (1) of the fire stations in the 20 city or a police officer, they would let -- usually let 21 us know that they had done that, so that then we would 22 alert the crew that there was another fire truck or a 23 police car responding. And that would alert them to be - 24 - be on the lookout for a police car or a fire truck so 25 that would cut down any risk of an accident.


1 Q: All right. So, there was a basic 2 protocol that was in place? 3 A: Yes. 4 Q: And, I wonder, sir, if you might tell 5 us what the protocol was once a call was re-routed from 6 Sarnia Police Station then to the Wallaceburg CACC? What 7 would happen when -- when you're on the job there? 8 A: Well, when they transferred the call 9 through to us, it would go to a call-taker station. And 10 with the enhanced 911, a screen would come up and it 11 would give us an address, phone number, and the name of 12 the person living there. 13 And, the call-taker would ask three (3) 14 basic questions, if there was difficultly breathing, 15 uncontrolled bleeding or unconsciousness. And based on 16 that, was how we would determine the immediate priority. 17 And if any one (1) of those three (3) were 18 answered positively, then they would just hit a button, 19 the call would transfer over to the dispatcher's computer 20 and come up in front of him with all this information. 21 You'd take a look at it and you decide where the closest 22 vehicle was and you would dispatch them. 23 Q: All right. 24 A: And if they were -- say it was into 25 Forest and a crew was at their base, then we would page


1 them and tell them they had a priority call and give them 2 a basic address. 3 They would then respond to their vehicle 4 and let us know that they're on the air and we would give 5 them the rest of the information, double check the 6 address with them that they had the proper one and what 7 was happening. 8 And if there was any more information that 9 become available to the call-taker, that would be passed 10 onto the dispatcher on the computer and the crew would be 11 updated on that. And quite often the crew would be 12 updated while they were en route to -- as to what was 13 happening. 14 Q: Okay. So that capability existed in 15 1995? 16 A: Yes. 17 Q: And the dispatch would -- how would 18 that occur? That would be by radio transmission I'm 19 assuming? 20 A: Radio transmission to the vehicles, 21 yes. 22 Q: Okay. 23 A: The crews carried a portable radio on 24 them so if they were out of the vehicle, there was a 25 repeater from the mobile radio that would repeat it to


1 the portable. So they were in contact all the time. 2 Q: And part of the dispatcher's job 3 would be to know where your various resources, where your 4 various ambulances are so -- 5 A: Yes. 6 Q: -- that you would know which would be 7 the closest location to -- to send the car over from? 8 A: Yeah. And with the computer 9 dispatch, you could get a lot better location on where 10 the calls were coming from. 11 Q: In 1995, sir, is it -- is it also 12 true that the computer system that you've just described 13 for us, was in fact just coming on line that you were 14 switching over? Or had that transition already been made 15 from paper copy? 16 A: Well, we had switched over prior to 17 '95, but it was being upgraded. And since I've left 18 dispatch it's been upgraded even more, so that when a 19 call comes up on the dispatch console, he has mapped, 20 he's got two (2) or three (3) computer screens and he has 21 a map on one. And it showed him exactly where it is on 22 the map. 23 Q: So it become -- it has become more 24 sophisticated -- 25 A: Oh, yeah.


1 Q: -- as time is going on. 2 A: Definitely, definitely. 3 Q: And in 1995 when you were there as 4 either a dispatcher or a call-taker, now perhaps I should 5 just backup, I take it that when you were working at -- 6 at Wallaceburg CACC, you were either a dispatch or a 7 call-taker, is that fair? 8 A: Yeah. We took -- there was two (2) 9 positions and if we're working a day shift, if you 10 started out in the morning on call-take, at noon hour we 11 would switch over and take over the dispatch. The 12 dispatcher would take over call-taking. 13 If you're running the number of calls that 14 we were, there's a lot of work going through your mind 15 all the time. It's not physical but it is mental. And 16 you're -- all the time you have to remember where these 17 vehicles are, where the call is. 18 And you have to be able to sort that all 19 out in your mind as to where the closest ambulance is 20 going to be, what part of the county is it in, or is it 21 in the city, part of the city. 22 So there was a number of things going on 23 and we also did what was called "transfer work," which is 24 patients between nursing home and hospital, hospital to 25 hospital for treatments.


1 And that committed vehicles so you had to 2 know what -- make sure that you kept vehicles free to 3 handle emergency calls. So there was a great deal of 4 juggling going on all the time to keep vehicles free. 5 We'll pull them off one (1) call and put 6 them on another. So there was a big mental drain. At 7 the end of the day you'd go home and your mind is just 8 going around in circles from making all these constant 9 changes all day long. 10 Q: Okay. You've described for us, sir, 11 the sophistication of today's operation in dispatch. 12 That is that they would have maps that would come on 13 screen. 14 A: Hmm hmm. 15 Q: Did you have at that point in 1995, 16 such visual aids that would assist you in keeping these 17 things straight. 18 A: No. We had maps and we would spend 19 time going out around the areas and making up our own 20 maps because there just wasn't up to date maps. 21 We would -- we would do that, and we -- 22 oh, for three (3) or four (4) years myself and a couple 23 of other fellows, we made these maps up. We sent them 24 through the Ministry. 25 They had people then that would do some


1 mapping for us and they'd send them back for us for 2 corrections and we'd send them back with the corrections 3 on them. 4 It was a big -- a big job trying to get 5 the maps that crews are using today. 6 Q: All right, and going back to again, 7 just the dispatch protocol, so the call would come in and 8 the call taker would have certain information that would 9 be supplied, I think you've said as -- from the 911 10 system? 11 A: Yes, the address and phone number 12 and, yes. 13 Q: But -- 14 A: But when that call was put to the 15 dispatcher, it also had a priority on it. 16 Q: And that's what I was going to ask 17 you, sir. Who assigned that priority and on what -- what 18 was the basis? 19 A: The call taker assigned the priority 20 based on the first three (3) questions he asked. If 21 anyone of them were there, then it was assigned as an 22 emergency priority which was a Priority 4. 23 Q: All right. 24 A: And that meant that that call took 25 priority over everything else.


1 Q: All right. 2 A: So you had so much time to get that 3 call out and -- 4 Q: All right. 5 A: -- the crew responded on it. 6 Q: And I take it from that, that there 7 were various codes -- 8 A: Yes. 9 Q: -- you've mentioned 4, was there a 1, 10 2, 3 and so on? 11 A: Yeah, code 1 was a transfer. It was 12 deferrable, there was no danger to anybody, they could be 13 done any time. Maybe it was somebody going home from the 14 hospital. 15 Priority 2 was a booking. You had to be 16 at a certain place at a certain time. Maybe they were 17 going from one hospital to the other for a CAT scan that 18 was booked. 19 Priority 3 was an urgent call, but not 20 life threatening. And, again, it had to be out within a 21 certain amount of time. 22 Priority 5 was a -- an obvious death, 23 which we didn't use too often but sometimes a crew would 24 end up using it to a move a person from the street if 25 they couldn't confirm. And we had to -- had to move it,


1 they had to perform CPR or whatever and transport it. 2 And a Priority 6 was a -- a legally dead. 3 It's one that had been pronounced dead by a Coroner. And 4 normally they didn't move them but if it was out in a 5 public place then you obviously couldn't just leave it. 6 So, we would end up move -- sometimes moving them to the 7 County Morgue. 8 And Priority 7 was down-staffing. If, on 9 a day shift, at the start of a shift if you were usually 10 up-staffing more cars than what you'd had overnight, so 11 if a crew didn't show up or someone was late, that car 12 was put on a priority 7, meaning it was down-staffed. 13 And today the problem they run into is 14 hospitals not accepting patients and they sit on the 15 ambulance stretcher for two (2) hours, three (3) hours 16 and in those cases, that ambulance is out of service. 17 Q: All right. 18 A: And it's now used as a down-staff 19 vehicle. 20 Priority 8 is a standby which simply means 21 that we put a vehicle in a certain point to cover an 22 area. Maybe an ambulance has been pulled out of say, 23 Forest, but the area still has to be covered. 24 So, another vehicle would be moved in 25 closer in order to cover that area --


1 Q: All right -- 2 A: -- in case of a call. 3 Q: -- and -- 4 A: Priority 9 was a maintenance call. A 5 vehicle had to go in for servicing or any of a number of 6 things. 7 And a Priority 0 was the dispatcher's 8 discretion. We could send a vehicle out for any one of a 9 number of different things, as long as the vehicle wasn't 10 committed on a call, and he wasn't leaving his area, he 11 could go out and do something that had to be done. 12 Q: All right. And in any one of these 13 instances, you've indicated, for example, when the -- the 14 transfer work -- 15 A: Hmm hmm. 16 Q: -- an ambulance would be out of 17 service, you still have an area that requires a certain 18 amount of coverage? 19 A: Right. Well, you wouldn't commit all 20 your vehicles to low-priority calls. You would always 21 keep vehicles available for emergencies. 22 Q: All right. And similarly, with 23 respect to those vehicles that were assigned a Priority 24 8, that is to say standby, part of your job or the job of 25 the dispatch would be to ensure that there's backfilling,


1 that there are, perhaps, units from other areas that are 2 brought in -- 3 A: Oh, definitely. 4 Q: -- to ensure adequate coverage? 5 A: Sometimes you could have two (2) or 6 three (3) cars shifted around because of one (1) leaving 7 to cover -- end up covering an area. 8 Q: And would the priority that's been 9 assigned to it, would that change at all if it's been 10 assigned, for example, a Priority 2, could that be 11 upgraded to -- to an urgent call, a three (3) or perhaps 12 to a four (4), an emergency? 13 A: Definitely. If they were free and 14 they were the closest vehicle, you can be guaranteed 15 they're going to be upgraded to a Priority 4 or whatever. 16 And then their patient would -- would just call the 17 hospital and let the patient -- the staff know their 18 patient is going to be sitting there waiting for another 19 hour, we had to pull that vehicle for an emergency and -- 20 Q: Okay. And just so that we might be 21 able to understand how this protocol works, I'm going to 22 ask you if you could refer to Tab Number 16 in that book 23 of documents before you, and that is Inquiry Document 24 1002002. It is some ninety-eight (98) or ninety-nine 25 (99) pages in total. And I certainly don't intend to


1 take you through that, sir; ninety-seven (97) pages in 2 total. 3 First of all, do you recognize the first 4 several pages on this document at all? 5 A: Yes, they're from September 6th. 6 Q: And I'm going to -- I'm going to 7 direct your attention firstly just to the -- to the very 8 first page at Tab Number 16. Right. It's that -- that 9 page and the next page. 10 I was just going to ask you if that is 11 anything that you recognize? 12 A: Well, just at Tab, Central Ambulance, 13 Communication Centre Logs, and -- 14 Q: Okay. And if you can refer -- 15 A: -- '95 -- 16 Q: I'm sorry. 17 A: -- I'm not sure what PPD is, 1 -- 18 dash 130; page 130, I guess. 19 Q: And I -- I don't -- I'm sorry if I 20 gave you the impression I was asking you to explain 21 those. It's simply if you recognize -- 22 A: Yeah. 23 Q: -- them at all? 24 A: Yes, they are. 25 Q: The next page is a series of


1 handwritten notes and there's number 2 at the top right- 2 corner. 3 Is that a document that you created, sir? 4 A: No. 5 Q: All right. 6 A: But it's come from the dispatch 7 information. 8 Q: All right. On page 3 there's a -- a 9 Central Ambulance Communication Centre title? 10 A: Hmm hmm. 11 Q: It's dated September the 8th. 12 There's a heading, Ipperwash Incident, September 6, 1995, 13 21:34 hours, to September 7th, 1995, 07:00 hours, 14 Ambulance Commitment; do you recognize that? 15 A: Those were the vehicles that were 16 assigned on that night and -- 17 Q: If we can just perhaps take a look 18 very quickly at them, the Service, first of all, in the 19 first column, Service, CACC Wallaceburg -- 20 A: Right. 21 Q: -- that would be the dispatch? 22 A: That's our dispatch centre, yeah. 23 Q: We then have three (3), under, 24 Service -- pardon me, three (3) notations under, Forest? 25 A: Under, Forest, yes. Normally, there


1 will just be one (1) on that night shift but -- 2 Q: And the unit numbers on that -- 3 A: Right, three (3) different units. 4 The 1146 number, that was the actual Forest vehicle. The 5 45 was a vehicle that was in Watford during the day, but 6 it was brought back to Forest at night. Watford was just 7 -- sat from 8:00 until 6:00. Then there's -- 8 Q: Just if I may interrupt you there 9 briefly, sir. 10 A: Hmm hmm. 11 Q: 1146 you've indicated is the unit 12 that would typically be -- 13 A: Sat in Forest. 14 Q: -- in Forest? 15 A: Yes. 16 Q: And that was operated by Malcolm 17 Gilpin? 18 A: Yes. 19 Q: All right. Go ahead. 20 A: Fifteen zero five (1505), that was a 21 regional spare vehicle that was used for replacing anyone 22 of the other vehicles that's off being serviced. It was 23 just a replacement vehicle. 24 It could be loaned to Sarnia or it could 25 be in Thetford or even Strathroy would borrow it if they


1 had -- needed a vehicle because one of theirs was off the 2 road for any particular reason. 3 And then if you look on the far right 4 side, Time Committed, that was the amount of time that 5 the vehicle was committed over the -- 6 Q: You're looking at the column -- 7 A: -- leaving -- 8 Q: -- on the far right hand side? 9 A: Far right-hand side -- 10 Q: You can see there's two (2) -- 11 A: Time column. 12 Q: -- there's two (2) columns. Time 13 committed. 14 But, you're looking at the one at the 15 far -- 16 A: Yes. 17 Q: -- right side, four (4) hours and 18 forty-six (46) minutes -- 19 A: Yeah. 20 Q: -- for example, on the first unit? 21 A: Right. That was his committal time 22 for the -- for the evening that he was -- that that 23 vehicle was staffed. 24 Normally the vehicle at night wasn't 25 staffed, the crew was on call-back, and if we got a call


1 for them they would be paged and they had ten (10) 2 minutes to get to the base and get in that vehicle. 3 Normally, they weren't that long, but we 4 had to allow them that much time and if they didn't 5 respond then, we would take the next closest vehicle and 6 page them out. 7 Q: All right. 8 A: And if these people showed up 9 afterward, well they'd be answering why they were late 10 and -- and then it would depend on who was closest as to 11 who we would have respond to a call, whether it would be 12 the new vehicle we had paged out or they would -- 13 Thetford vehicle is one one four seven (1147) there. 14 It's, again, staffed during the day only, 15 with call-back at night. Petrolia vehicle is the same, 16 staffed from 8:00 until 6:00. 17 Brigden, staffed again 8:00 until 6:00, 18 then we get into the London CACC which is outside our 19 area -- 20 Q: All right, so -- 21 A: -- but these vehicles were used at 22 night also. 23 Q: I see. 24 A: They were used for standbys. 25 Q: So, the unit numbers would refer to


1 the actual ambulance? They were assigned a -- 2 A: They had a number on the windshield 3 and that -- and another one on the back door, so if 4 anybody had any complaints they had a number they could 5 refer to. 6 Q: And when we look at this chart, the 7 next column under, Code, that would be the code that 8 would have been assigned -- 9 A: Right -- 10 Q: -- I take it, when the ambulance was 11 dispatched. 12 A: Right. 13 Q: And we see that they -- at least the 14 -- well, all of those on the chart all have an eight (8) 15 and I take it that they were all on standby? 16 A: Yes, they all started out on standby 17 that night. 18 Q: Okay, and the Code 4, for example, if 19 we look at eleven forty-five (1145), it has an eight (8) 20 then it has a four (4). I take it that it -- that was an 21 emergency -- 22 A: Yes. 23 Q: -- situation? 24 A: Right. 25 Q: And there's another four (4) and that


1 again was another emergency? 2 A: Yeah. 3 Q: And then eight (8) -- 4 A: And then they were put back on 5 standby again -- 6 Q: Back on standby. 7 A: -- after they completed them. 8 Q: Similarly with respect to Unit 1146, 9 it starts out with a Code 4, which you've told us is an 10 emergency, goes to an 8 which is a standby and back to 1, 11 the transfer work? 12 A: Yes. 13 Q: And the next column -- pardon me, we 14 might as well look at the third Forest Vehicle, 1505, it 15 started out on a standby and what does unrelated Code 4 16 mean? 17 A: I -- 18 Q: If you think of it, sir? 19 A: I can't remember just what that was 20 now, offhand. 21 Q: All right. Perhaps we can look, 22 then, at the next column; it's the time committed. And 23 if we look at eleven forty-five (1145), the time 24 committed, twenty one thirty four (2134); and what would 25 that tell us?


1 A: That would be the time he was put on 2 that Code 4. 3 Q: Okay. 4 A: That first Code 4. 5 Q: And the time cleared on that first 6 Code 4 would be zero four twenty (0420)? 7 A: Well, that could be -- the four 8 twenty (4:20) time cleared, that could be the end of that 9 Code 8, last -- 10 Q: All right. 11 A: -- that last -- 12 Q: And similarly with respect to the 13 others, the twenty-three eleven (2311) and twenty-three 14 forty-four (2334) -- 15 A: Right. 16 Q: -- those would be indications of the 17 time that those units were put on the codes that are 18 indicated that are the Code 4's. 19 A: Right. 20 Q: All right. If I can ask you to turn 21 to the next page, sir, page number 4 and there is a 22 document there that has a number of different entries. 23 And can you tell us first of all where this comes from 24 and what does it indicate? 25 A: That's the dispatch form. This is


1 the first page -- when this pa -- this is printed out, 2 there's actually several pages come with it. 3 But, this is the first page only and you 4 look at the first line up there, Emergency Details Part 5 1, you'll see a number 37450. 6 Q: And that's towards the right side of 7 the page? 8 A: Yes. 9 Q: 37450 refers to? 10 A: That person is one of the 11 supervisors, Rob Stewart and you'll see on some of the 12 other -- on the start there was he gave information and 13 he printed this form out. He had it printed out. And it 14 was done on the 13th of September. 15 Q: So 37450 is the call number of the 16 individual who would have printed the material? 17 A: Yes. That's -- instead of putting a 18 name on it he's got -- everybody is assigned a number -- 19 Q: All right. 20 A: -- based on their qualifications. 21 Q: The next entry is 13 September '95? 22 A: Yeah. That's when it was printed 23 out. That's when he was digging information out and he 24 did that at 6:02 p.m. -- 25 Q: Okay.


1 A: -- 18:02. It's all done with the 2 twenty-four (24) hour clock. 3 Q: And the next line R? 4 A: Okay. This is the -- I'm not sure 5 what that R number is for now. 6 Q: Okay but -- 7 A: But, it's just for details on the 8 call. 9 Q: Okay. Then let's go to the next 10 line. 11 A: The next line is call number and in 12 brackets, it's (WA) which stands for Wallaceburg. And 13 then the dispatch number. And the call-taker and his 14 number that -- 15 Q: 98761? 16 A: -- that happens to be Geoff Connors. 17 Q: Right. And you understand that Mr. 18 Connors will be testifying after you and -- 19 A: Yes. 20 Q: -- will be providing some of the 21 detail that you may not be able to recall for us today? 22 A: Right. 23 Q: All right. 24 A: Plus he happened to be the call-taker 25 that night so he's got -- he was on the phone a lot.


1 Q: And I'm sure we'll about that. 2 A: Yes. 3 Q: The date on that is 06 September '95. 4 A: Right. 5 Q: I take it that's the date then that 6 the call was taken? 7 A: Right. And then we have the time 8 that it come in and then we go down to -- 9 Q: And just -- just for the record, Mr. 10 Knight, the time that that came in 23:27 and 59? 11 A: That's when it came into the centre. 12 That's when the 911 call came in. 13 Q: And is that an automatic time stamp 14 on this document? 15 A: Yes. 16 Q: All right. 17 A: And that should correspond -- time 18 should correspond with the time on the 911 computer in 19 the police station when they sent that call down to us. 20 Q: So, if we -- if we go down here it 21 then would appear that there is address, they ask for a 22 concession for the lot, the city -- 23 A: Yeah. 24 Q: -- township. The township there is 25 indicated as Lambton.


1 A: Right. 2 Q: Street number 6840, the name Nauvoo. 3 A: Nauvoo Road. 4 Q: The type is road. 5 A: Yes. 6 Q: All right. 7 A: It could be avenue, street, whatever. 8 It could be cul-de-sac -- 9 Q: All right. 10 A: -- concession road. 11 Q: There's no entry with respect to 12 apartment. I take it that's apartment or unit? 13 A: No. Direction would be east, west, 14 north, south. 15 Q: All right. I'm sorry, I got ahead of 16 you a litte bit. The next line -- 17 A: The next one is apartment. If it's 18 an apartment building which this didn't happen to be, 19 it's not a common place. Common place would be like this 20 Forest Arena, could be a common place. 21 Q: All right. 22 A: Intersection. Now, if it's an 23 intersection it could be -- when the call come in it 24 wouldn't come in from an intersection, it would come in 25 from a residence usually or a personal cell phone.


1 But, that intersection would be -- when he 2 takes that call if it's an accident, they say it's at the 3 corner of such and such. Well, that's where that 4 intersection would come in. 5 Or if that address was put in into the 6 Bell Telephone equipment, then it could come up with the 7 intersection as being the closest intersection to that 8 address. 9 Q: And you've described for us earlier, 10 sir, that there was an upgraded 911 system in place? 11 A: Right. 12 Q: And I take it, from what you're 13 telling us, that some of this information would come 14 automatically, would it? 15 A: Yes. Yes. It's basically just -- 16 it's there, and if a call comes in on that system and 17 it's not there, then we would fill out a form and put 18 that information on it, send it into Bell Telephone, and 19 they would update their enhanced 911 system. 20 So, the next time we got a call from that 21 address, that information would come up. Now we could 22 have a -- a wrong phone number, which also had to be 23 corrected, so we would ask these questions and make sure 24 that information is right, before the ambulance is 25 dispatched, because there's no sense in sending them if


1 that information's not right. 2 Q: Okay. If we look at the next line, 3 the Phone Number, I take it that would be the phone 4 number from where the call originated? 5 A: Right. From where it originated, and 6 it's a Lambton 911 residence, -- 7 Q: The -- 8 A: -- Time; zero. That is when that 9 call was given to the dispatcher. He -- the call taker 10 had enough information to dispatch, so he hits the 11 button, it goes to the dispatcher. 12 Q: Okay. Let me just draw your 13 attention then, what would appear to be a -- a 14 discrepancy, and perhaps you can explain this for me: 15 You've indicated that the time stamp at the top right- 16 hand corner, the time there is 23:27 -- 17 A: Yeah. 18 Q: -- and fifty-nine (59) seconds; do 19 you see that, sir? 20 A: Yeah, I do. 21 Q: And then, Time: zero, 23:27 and 22 forty-nine (49) seconds, there would appear to be a ten 23 (10) second dis -- 24 A: Yeah, ten (10) seconds sooner, than 25 when I come down, yeah. I don't know why.


1 Q: So, I think that -- that indicates to 2 us that there is not, at least in 1995, 100 percent 3 reliability on those figures; is that fair? 4 A: Well -- 5 Q: Or if you can explain it. You may 6 not be able to. 7 A: Sir, I can't explain it. From my 8 recollection of how these worked, that time at the top is 9 when that -- maybe I'm reversed on them two (2). Geoff 10 may be able to answer that question for you this 11 afternoon. 12 Q: Thank you, sir. 13 A: But, that could be that I just have 14 those two (2) times reversed. 15 Q: All right. And the date, Date zero; 16 that corresponds to the date at the top, not the printed 17 date but the date -- 18 A: Yeah. 19 Q: -- that the call was received. 20 A: Yeah. And then we have the 6 21 September '95. 22 Q: The entries; there's nothing under 23 Duty, or UT -- 24 A: UTM. That is a mapping system. 25 Like, the whole province is broke down into ten (10) mile


1 squares, and then it's into five (5) mile squares, and 2 one (1) mile squares, and then quarter (1/4) mile 3 squares. And that's where this number comes from. And 4 that just pinpoints that address down to a location in 5 the Province. 6 Q: All right. And then you've indicated 7 that some of the first questions that are asked, it would 8 appear that those are the -- 9 A: Yes. Difficulty breathing -- 10 Q: -- places where that would be 11 entered? 12 A: Right. And you just put a yes or no 13 for difficulty breathing when you're asking those 14 questions, and if you have a Y in it, then it becomes an 15 emergency call. 16 Q: So, you have "yes" in all three (3) 17 instances -- 18 A: Yes. 19 Q: -- that is under -- I take it the 20 first one is, Unconscious? 21 A: Difficult breathing, and then 22 Uncontrolled Bleeding, and Unconscious. Yeah. And it's 23 not showing here right now, on this particular one, but 24 there is a complaint, Number 27, which is a Wound. 25 Q: All right.


1 A: So, the dispatch -- or the call taker 2 got some information saying that there was -- indicate 3 that there was a wound there. 4 Q: And hence the code? 5 A: Right. And from that Number 27, he 6 could get information to give to the call taker, or to 7 the caller, on what to do for that person. Do we want 8 him to put a bandage on it, it depends on the type of 9 wound, to stop the bleeding. Or maybe we just want him 10 to put his hand over top of it, it's a -- an arterial 11 bleed, so you stop it the quickest way you can. 12 The quickest way is, what have you got 13 handy? It's your hand. So, you put your hand over it 14 and put the pressure on it and that will stop it, until 15 you can get a dressing or whatever to put on it. 16 But if you don't then with -- with an 17 arterial bleed, they're going to bleed out pretty quick. 18 So, you have to act fast and that's a -- and if you had 19 somebody -- some member of your family fall or something 20 and cut an arm and you have an arterial bleed, you panic 21 and so this is the quickest way to get the information to 22 them. 23 Q: And this would be done by the call- 24 taker? 25 A: By the call-taker, yeah.


1 Q: All right, and then this information 2 would be transmitted to the dispatcher -- 3 A: Right. 4 Q: -- who would follow the code -- 5 A: Right. 6 Q: -- and dispatch the nearest units? 7 A: Right. Then when that form comes 8 over to me, I've got this information that it's a wound 9 and... 10 Q: And let me just refer you, then, to 11 the next page, which is number 5, unless there's any 12 further comments -- 13 A: No. 14 Q: -- you have with respect to number 4. 15 A: No. 16 Q: At page number 5, it -- it starts out 17 at the top of the page, Dispatch Details. 18 Is this part of the same form that you'd 19 described for us earlier -- 20 A: Yes, it is -- 21 Q: -- you said it comes in a number of 22 pages? 23 A: Right. 24 Q: Okay. So, this would be the second 25 page, would it?


1 A: Yes. And it, again, the first line 2 tells you that it was done on September 13th and come up 3 at 18:03 was when it was printed out. 4 Q: All right. 5 A: And we have the Wallaceburg dispatch 6 number on top of the wound, and the date and the time and 7 then we have a pick up location of 6840 Nauvoo Road in 8 Lambton. 9 We don't have a name on that particular 10 call, because we don't know who it is. 11 And the ambulance number, 1145, and then 12 we have the crew's number and name; their last name only. 13 And the dispatch Code is 4 and we haven't got a return 14 code on this one because it hadn't happened. 15 Q: And just if I -- if I can interrupt 16 you there, briefly -- 17 A: Hmm hmm. 18 Q: -- the return code would speak to 19 what? 20 A: Well, when you go out on a call, you 21 have time 1; call received, time 2; crew notified, time 22 3; is when they are en route and they've left the base or 23 were standby, wherever they were, they're on their way. 24 Time 4 is arrived; which obviously hasn't 25 happened when -- on this form. And then we have a depart


1 -- depart scene; that's when they leave the scene. 2 They've picked up the patient and they're taking the 3 patient someplace, hospital or wherever. 4 Arrived destination; is when they arrive 5 at the hospital, nursing home or wherever they were 6 going -- 7 Q: And just for the record, you're 8 reading through those various time entries? 9 A: Yes. 10 Q: All right. 11 A: Cleared destination; that is when 12 they leave the hospital or -- and they're back in 13 service. And they -- when they clear there, it means 14 they're available for another call. 15 Now, if I needed them before that, then I 16 would just call them on their portable radio and ask them 17 if they were clear, and if they are clear, they just 18 haven't left the hospital yet, then I could -- I can 19 reassign them right there, so... 20 Q: Right. The next entry is -- 21 A: Cancelled. 22 Q: -- cancelled. 23 A: The time is cancelled. Again, we 24 have the date and the time and the time elapsed from the 25 last timeframe that happened on that.


1 Return base; that's just when they get 2 back to base or to their standby or wherever they were -- 3 Q: To the standby -- 4 A: -- going. 5 Q: -- location -- 6 A: Yes. 7 Q: -- or their home base? 8 A: Right. 9 Q: I'm going to come back to this form 10 in a bit, but perhaps maybe we can just on a -- on a 11 couple of matters right at this moment, sir. 12 A: Okay. 13 Q: The 6840 Nauvoo Road, Lambton, we are 14 told that, through others that have testified in this 15 Inquiry, that that is the residence of Hank and Mary 16 Veens -- 17 A: Right. Go over to the next page, 18 page 6. 19 Q: Okay. 20 A: You'll see down at the bottom under, 21 Original 911 Details, and there is Hank Veens, his 22 address and it's Arcona, Warwick (phonetic) township. 23 Now, he doesn't live in Arcona but he does 24 live in Warwick township. But, Arcona is the closest 25 place and that's part of his mailing address probably.


1 Q: All right. Now, you've told us 2 earlier -- 3 A: Their post office -- 4 Q: I'm sorry, go ahead. 5 A: Their post office is here and it 6 happens to be close by where he lives. It's the closest 7 place so that's a Bell Telephone thing, they have their 8 locations. 9 Q: Okay. And you told us earlier that 10 these forms are -- are subjected to be continually 11 upgraded as more information comes in. 12 A: Right. 13 Q: I take it that this would -- this is 14 an example of that and it has upgraded to the point where 15 we now have the name of the residence at -- 16 A: Yes. 17 Q: -- 6840? 18 A: Hmm hmm. 19 Q: Okay. And in fact you seen now the 20 wound where it's -- it's indicated, Card 27, is the 21 signature or a code for wound, is it? 22 A: Yeah. For a -- 23 Q: Then the injury is now clearly -- or 24 clearer in the sense that it's detailed as a chest 25 injury?


1 A: Chest injury, yes. And you'll also 2 see just above that, an Address Comment. Is it go north 3 from Brick Yard Line which crosses Nauvoo Road. And so 4 it's between Brick Yard Line and Burnham Line. 5 Q: And so this information is meant to 6 give the dispatched ambulance all the information it 7 needs to get there as rapidly as possible? 8 A: Yeah. Then I can update the crew and 9 tell them where it is so they've now got it narrowed down 10 to a one mile location on Nauvoo Road. Instead of Nauvoo 11 Road running from Townshead Line through down south of 12 Alvinston. 13 So, they don't have to go the full length. 14 They -- 15 Q: They have a -- they have a better 16 idea. 17 A: They know right where it's -- where 18 they're going, yeah. 19 Q: And I take it that many of the 20 ambulance drivers, they would be familiar with the area 21 that they were stationed in in any event. 22 A: Yeah. They -- this crew, in 23 particular, would know that because they go down Nauvoo 24 Road when they went from Forest to Watford; they went 25 right by that residence. So, they're well familiar with


1 that. 2 Q: Is that the end of this form, sir, or 3 does it continue onto the next page? 4 A: Well -- no, there is another page; 5 page 7. 6 Q: All right. 7 A: In which we have emergency call 8 narratives. And this is stuff that has been updated as 9 the call has progressed. And again, we got the address 10 at the top and that it's a wound. 11 Go into the narratives and you'll see 12 notes by CACC and then all those zeros and 911. That 13 happened to be our CACC number. 910 is a London CACC. 14 912 happened to be the Windsor CACC. 15 But you will see reference on other calls 16 between CACC number 910 and 911 where we ask for standbys 17 from the other CACC. 18 Q: And let's just look at that narrative 19 if we -- if we may, Mr. Knight. The first narrative it 20 says: 21 "Notes made by CACC, 911 by 98761." 22 You've told us earlier that that was 23 Geoffrey Connors? 24 A: Yes. 25 Q: "On" And that gives you the date and


1 the time. 2 A: Time -- 3 Q: 23:38:19. 4 A: -- that he updated. And that was 5 information that he had received that someone had showed 6 up and asked for them to call for an ambulance. 7 Q: Right. 8 A: And that's what time that -- 9 Q: And the next note that we have -- 10 A: -- he put that in. 11 Q: -- the only difference on that is 12 23:41 and forty-seven (47) seconds; some three (3) 13 minutes later thereabouts. 14 A: Right. And that's by Connors again 15 and the LL residence; he landlined the residence. He 16 made a phone call to them. 17 Q: The next entry, again, it's your -- 18 it's your CACC. 19 A: Yeah. 20 Q: It's Mr. Connors. 21 A: Connors. And again the time. 22 Q: Less than a minute later. 23 A: And the landline, and the phone 24 number that he called. 25 Q: All right. And the last -- the next


1 entry. 2 A: The last one. 3 Q: At 23:54 and thirty-three (33). So, 4 it would be just about five and a half (5 1/2) minutes 5 before midnight. 6 A: That was when the call was cancelled. 7 Q: And then the last entry on there. 8 "Cancelled unit by 11330." 9 A: Yeah, that's my number. 10 Q: All right. 11 A: And the time. But, technically I 12 didn't cancel that. Geoff cancelled that call but he 13 didn't get it stamped. We were so busy in there at the 14 time, there was just the two (2) of us and there was -- 15 we had people on hold on the phones, radios going, 16 telephones ringing, we had OPP on line and we were just 17 going crazy. 18 And, looking, back, we should -- there 19 should have been someone else there to help us that 20 night, but there wasn't. And normally, two (2) 21 people handle a -- a night shift without -- without any 22 effort at all, but this particular night, it was -- it 23 was not normal. 24 Q: Okay. But it's indicated in any 25 event, this --


1 A: That -- 2 Q: -- form would show -- 3 A: -- that I did it. 4 Q: -- that it was cancelled by you -- 5 A: Yeah. 6 Q: -- at 23:55 -- 7 A: I did the actual stamp -- time stamp. 8 Q: And, then the -- it says, Other 1145; 9 What does that mean? 10 A: That's a -- the other is a vehicle 11 number. That was the vehicle that was doing that call 12 and the patient was moved by other means and call 13 cancelled. 14 Q: And, the last entry on that notes by 15 CACC -- 16 A: Notes by -- by Connors and that was 17 at a later -- later time because we -- it took time over 18 night to go back through all these and double-check them 19 all to see what was -- 20 Q: Okay. And, is -- 21 A: -- what did we miss and what didn't 22 we miss? 23 Q: And, is page 8 a carry-over of that 24 narrative; just the next page? 25 A: Yes, it would like it, it says, More,


1 at the bottom there, yeah. And, again, we have the basic 2 information that's been on all of them and the narrative 3 was evidently: 4 "A male and female showed up at the 5 residence asking for an ambulance to be 6 called for a gunshot victim. 7 The party ended up departing the scene 8 in a white car with a flat tire. It 9 was unknown which way the car 10 departed." 11 And those notes were by Connors and at the 12 request of OPP Sergeant Cousineau that he called -- 13 Connors called back and asked if the party had had any 14 weapons and the caller stated that he hadn't noticed any. 15 Q: All right. You wouldn't have been 16 privy to those calls? You didn't know -- 17 A: No, I wasn't on the line there, no. 18 Q: All right. But, that's the 19 information that you can gather from reviewing these 20 forms? 21 A: Yeah, from the call dispatch form, 22 yeah. 23 Q: And, let me just take you -- take you 24 back if I may, sir, to page 5 and it runs along the same 25 lines of the area that we're talking about right now.


1 A: Hmm hmm. 2 Q: So, the unit we know dispatched was 3 1145; that was the unit operated by Malcolm Gilpin and 4 Ceasor Diceasor. 5 A: Right. 6 Q: The time zero, 23:27:49, and we will, 7 obviously seek an explanation from Mr. Connors on that, 8 but the assumption that you were -- that you're operating 9 now is that that would be the time that you were 10 dispatched -- 11 A: I was thinking that was the time that 12 he put it me, yes. 13 Q: And, the, Notified, if we just go 14 down that column a bit, at 23:31:03, elapsed time three 15 (3) minutes and four (4) seconds, is that... 16 A: That's right. 17 Q: And, that would be three (3) minutes 18 and four (4) seconds from the time that the call came in? 19 A: Yeah. And I have a maximum of two 20 (2) minutes to have that car on the road. 21 Q: All right. 22 A: So, obviously when I called them, 23 they didn't answer me right off the bat and we later 24 found out why. 25 Q: And, perhaps, you can tell us about


1 that now? 2 A: Because -- well, the two (2) crews 3 for -- crew for 1145 and 1146 were actually at the main 4 gate of the Army Camp and they were both out of their 5 vehicles treating the patient. Now, I haven't got the 6 name of the patient. 7 Q: No, that's fine -- 8 A: And normally, I wouldn't get it, but 9 they were both out of their vehicles treating the patient 10 and when I called them, the repeater would go through to 11 their portable radio that they had on their belt. 12 But, they didn't answer me right away, 13 because they were busy treating the patient and then as 14 soon as they -- one of them got free, they called in -- 15 called me and I give them the information. You would 16 call -- 17 Q: And that's when you would time-stamp 18 it? 19 A: That's when I time-stamp it. 20 Q: Okay. Just with respect to the time- 21 stamping matter, sir, is it a matter simply of pressing a 22 button in order to time-stamp it or did you have to 23 actually enter in manually? 24 A: Well, you have to have the particular 25 car number up for that call. You'd have to have that


1 call up and then you can just hit the button to time- 2 stamp it. 3 Q: All right. So -- 4 A: If you don't have the right car, 5 you're going to be stamping the wrong form. So, you have 6 to make sure you have the right car. 7 Q: I see. But I guess what -- what I'm 8 just wanting to make sure that I'm clear on in terms of 9 the actual timestamp, for example, Notified 23:31:03, you 10 didn't have to manually enter those numbers -- 11 A: No, I don't enter that. No. That's 12 all done automatically. 13 Q: And if you follow straight along on 14 that line, it says, OPP notified" -- 15 A: Right. 16 Q: -- at 23:35:42. 17 A: Right. They wanted to be notified of 18 all calls and so they were. 19 Q: All right. 20 A: And that was the time that they were 21 notified. 22 Q: Okay. Let me just ask you about 23 that, when you say the OPP wanted to be notified of all 24 calls that came in? 25 A: Yeah. Any calls, they wanted to be


1 notified of because they were concerned for the safety of 2 our crews, as we were too because of the Occupational 3 Health and Safety Act. And the crews have a right to 4 know if they're going to be in any danger and they can 5 refuse. 6 So, they wanted to make sure that they -- 7 everything was -- was clear for them, that there was not 8 going to be anybody getting injured. 9 Q: All right. And was this the usual 10 practice -- 11 A: Oh yeah. 12 Q: -- that dispatch would be -- 13 A: Different times -- if I took a call 14 and I thought there's a chance a crew's going to get 15 injured here, for any reason or other, I would get on the 16 phone and notify the police department that was involved 17 and say, We want an officer there now because there is a 18 danger to our crews. 19 And you let them know as much information 20 as you can at the time. 21 Q: All right. 22 A: And most police departments were good 23 and reasonable. You work back and forth with them and if 24 they had a call and there was danger there that they 25 felt, they would say, Don't let your crew go into that


1 residence until we arrive, because, they -- they say, We 2 don't know if there's a gun there, or what's going to be 3 there, or why the crew would -- could be injured. 4 So, it's just a common courtesy that you - 5 - you notify them. And then if something does come out 6 of it, you've already got the police department there. 7 You don't have to go back and say, Well, this is what 8 happened. 9 They were there to see what happened. And 10 it just saves a lot of headaches and a lot of questions 11 later on. So it's very important. 12 And under, Agencies Notified; besides the 13 OPP, we would notify the -- the emergency department, 14 say, at the hospital. In one (1) particular case I had - 15 - we have a gas leak, went in and we ended up with about 16 forty (40) or fifty (50) patients. 17 Well, as soon as we find out what's going, 18 we get on the phone and we notify the hospital. And we 19 say, Hey, we've got forty (40) or fifty (50) patients, 20 whatever it is, They're going to be coming in to you with 21 such and such a type of injury. 22 And we'd also go back to the police 23 department and say, Hey, block that road off in front of 24 the emergency department in the hospital, we don't want 25 John-Q-Public driving in there when we're trying to get


1 in with ambulances and get out again. So, it's only 2 common courtesy to let them be prepared. 3 And when the crew was transporting the 4 patient to the hospital, if the patient's condition 5 deteriorated they would let us know that they were 6 upgrading their call. We would let the hospital know 7 they were upgrading their call. 8 Ad the crew would do a patch into the 9 emergency and talk to the doctor in emergency, tell him 10 what the condition of the patient is. And the doctor, he 11 may say, Well, I want you to do such and such a thing, 12 start an IV or give him a certain drug. 13 Q: Okay. And part of your job was to 14 ensure that this communication -- 15 A: This communication happened. 16 Q: -- flowed, so that the patients were 17 attended to -- 18 A: That it happened. 19 Q: All right. The next entry under, 20 Notified is En route; and I take it that that is when 21 your crew would call back, the ambulance that you've 22 dispatched would let you know that they are -- 23 A: Right. 24 Q: -- answering the call you've 25 dispatched them on?


1 A: As soon as they -- when they get in 2 their vehicle and they start out, they have to radio in 3 to let me know that they're en route so I can time stamp 4 it, and that -- 5 Q: And then you time stamped that as one 6 (1) minute and twenty-five (25) seconds after -- 7 A: After, yeah. 8 Q: -- after notification. 9 A: Hmm hmm. Right. 10 Q: We see that there is no entry for, 11 Arrive, Depart, and so on, except when we go down to, 12 Cancel, then that was cancelled at 23:55 -- 13 A: Right. 14 Q: -- and fifty-nine (59) minutes. 15 A: Yeah. It was -- 16 Q: Some twenty-three (23) minutes and 17 thirty-one (31) seconds after that. 18 A: Yes, that's what it says. 19 Q: All right. 20 A: Technically it wasn't though. 21 Q: Okay. 22 A: And, -- 23 Q: What is your -- 24 A: -- if you go in -- 25 Q: -- answer for that?


1 A: There's a -- also another thing in 2 here from -- a notice from the crew that were there, that 3 said, well, we were cancelled out at twelve (12) or 4 thirteen (13) minutes. 5 Q: Okay. 6 A: And -- 7 Q: And I guess the only thing I'm 8 asking, -- 9 A: -- time -- 10 Q: -- sir, is -- is, the time stamp 11 there would be something that you would have put on? 12 A: Yeah, we had to cancel it out. But, 13 I can't understand why the time that call is cancelled, 14 is not on our tape. It should be there, because all the 15 radio transmissions are taped. 16 Q: And Mr. Connors may well speak to 17 that, but I'm just -- 18 A: Yeah. 19 Q: -- trying to -- 20 A: So -- 21 Q: -- ask you about the time stamp 22 here -- 23 A: -- that's the only way we could -- I 24 could -- I can verify that other time. 25 Q: All right.


1 A: Yeah, I don't -- I haven't heard the 2 tapes so -- at that particular time, so I can't, you 3 know, say, well it was definitely twelve (12) or thirteen 4 (13) minutes; that just happened to be a statement that I 5 read. 6 Q: Fair enough. But you'll -- you'll 7 agree with me that as it is, the time stamp on this -- 8 A: That's too long. 9 Q: -- being cancelled some twenty-three 10 (23) minutes later -- 11 A: Yeah, it's too long. 12 Q: -- and there were -- there was -- do 13 you have an explanation for that I guess, and that's 14 perhaps what I can ask? 15 A: Well, the only thing I can say is, 16 Geoff took the call to cancel it, and I understand he 17 cancelled it. I mean, he didn't -- for some reason or 18 other, we were so busy that he just never got the 19 opportunity to cancel it at the time. 20 Q: Just so I'm clear then, when a call 21 comes in, and you mean to cancel a dispatch, the time- 22 stamp won't actually show up until you press the button; 23 is that fair? 24 A: That's right. 25 Q: To show that it's cancelled?


1 A: Yes. 2 Q: And so are you suggesting that it may 3 -- the call may well have come in, and the -- 4 A: Oh, it came -- 5 Q: -- the button to cancel it was not 6 pressed until the time that it's actually stamped? 7 A: I have no doubt that that call did 8 come in, because I know Geoff, and he wouldn't cancel a 9 call for no reason at all, just up and cancel it. That's 10 just not his way of doing business; he's too honest. 11 Maybe I shouldn't say that he's too honest, but -- but 12 he -- 13 Q: I've been described that way. 14 A: -- I've never seen -- I've never seen 15 Geoff ever fudge a time or anything on a call, so -- 16 Q: And I'm not suggesting that that -- 17 that that has happened. 18 A: -- and it's difficult to do it, with 19 the tapes. 20 Q: All right. And I'm just trying to 21 get, I guess, some -- some explanation -- 22 A: Hmm hmm. 23 Q: -- as to why it would appear that 24 there was some twenty-three (23) minutes elapsed from the 25 time that the call was received to the time that it was -


1 - pardon me, from the time that it was dispatched -- 2 A: Yeah. 3 Q: -- to the time that it was cancelled. 4 A: Time it was cancelled, yes. 5 Q: And that's something that we will ask 6 Mr. Connors about. 7 A: Yeah. Well he took the call, he was 8 call-taker, he took the call to cancel it and that's how 9 I found out it was cancelled. But, for some reason or 10 other, he just didn't get it stamped. 11 Q: Okay. Commissioner, I have about 12 twenty (20) or so minutes to go and I wonder if this 13 might be a good spot to break? 14 COMMISSIONER SIDNEY LINDEN: A good time 15 to have a lunch recess. 16 THE WITNESS: Okay. 17 COMMISSIONER SIDNEY LINDEN: We'll break 18 now for an hour and a quarter. Thank you very much. 19 THE REGISTRAR: This Inquiry stands 20 adjourned until 1:45. 21 22 --- Upon recessing at 12:25 p.m. 23 --- Upon resuming at 1:47 p.m. 24 25 THE REGISTRAR: This Inquiry is now


1 resumed. Please be seated. 2 MR. DONALD WORME: Good afternoon, 3 Commissioner. 4 COMMISSIONER SIDNEY LINDEN: Good 5 afternoon. 6 7 CONTINUED BY MR. DONALD WORME: 8 Q: When we had left off, Mr. Knight, you 9 had completed telling us about the protocol at the 10 dispatch offices. You had taken us through the various 11 documents, the -- the log from the -- the CACC centre log 12 and, as a matter of fact, Mr. Commissioner, that document 13 that appears then, under Tab 16, Inquiry Document 14 1002002, the ninety-seven (97) or so odd pages, I would 15 ask that that be made our next exhibit, I believe that to 16 be 345. 17 THE REGISTRAR: P-345, Your Honour. 18 COMMISSIONER SIDNEY LINDEN: P-345. 19 20 --- EXHIBIT NO. P-345: Document 1002002 Central 21 Ambulance Communication 22 Centre logs 95-PFD-130 23 Ipperwash incident, September 24 06/'95 2134 hours to 25 September 07/'95, 0700 hours.


1 2 CONTINUED BY MR. DONALD WORME: 3 Q: I want to take you then, Mr. Knight, 4 to September the 6th of 1995 and you were on shift that 5 day. 6 A: Yes. 7 Q: I understand that you had worked the 8 evening shift from 19:00 hours to 07:00; that is from 9 eight o'clock in the evening, am I right? 10 A: It's seven o'clock. 11 Q: Seven o'clock to 7:00 in the morning? 12 A: Yes. 13 Q: And, that would be in -- at the 14 offices at Wallaceburg that you've described for us? 15 A: Yes. 16 Q: And, for those that are 17 geographically challenged, as I am, Wallaceburg is about 18 thirty (30) miles or so from Sarnia; that's correct? 19 A: Yes. 20 Q: South? 21 A: South of Sarnia. 22 Q: All right. And, on arriving at work 23 that evening, what can you tell us about what was going 24 on, what was your practise at that particular time? 25 A: Well, we went into the office, we'd


1 get a quick rundown from the day shift what had happened. 2 We'd check the shift log and acknowledge it that we'd 3 seen everything for any events that had happened during 4 the day. 5 And then we'd -- we'd have to sign in and 6 we would be signing crews on. They had to call in and 7 make sure we knew who was working and we'd assign them to 8 their cars and that before the shift really started. 9 Q: All right. And, you were aware that 10 there was something going on in the vicinity? 11 A: Yes. 12 Q: And, what was that and how was it 13 that you became aware? 14 A: Well, there'd been news coverage 15 about police officers all over the area, different 16 things, and that's how -- basically how I knew about it. 17 Q: You would have seen in through the 18 media? 19 A: Through the media, yeah. 20 Q: All right. You were -- you had told 21 us earlier when you came onto your shift that, as between 22 you and whoever it was that you would be working with -- 23 on this occasion, I understand that your partner was 24 Geoffrey Connors? 25 A: Yes.


1 Q: And, you would have decided as 2 between yourselves who would be the call taker and who 3 would be the dispatch? 4 A: Yes. 5 Q: And, on that particular evening, you 6 were the dispatcher? 7 A: Yes. 8 Q: And, I understand that -- that -- 9 that evening, at around 21:00 hours or so, you received a 10 request and I wonder if you could take it from there, Mr. 11 Knight, and tell us what the request was and who it came 12 from? 13 A: Well, the request came from the OPP, 14 I believe it was Sergeant Cousineau or Sergeant Reid, one 15 or other and they wanted two (2) ambulances on standby 16 for the parking lot at the Ministry of Natural Resources 17 at Ipperwash. 18 Q: And, the location of that parking 19 lot, the Ministry of Natural Resources near Ipperwash? 20 A: Parkway Drive east. 21 Q: Okay. Was it explained to you why 22 they wanted two (2) ambulances on standby at that 23 location? 24 A: No, I -- not directly. We knew there 25 was -- something was going to happen, but we didn't know


1 what and they wanted the vehicles in case anybody got 2 injured. 3 But, other than that, we had no -- no real 4 knowledge of what was going to come down. 5 Q: All right. And what did you do as a 6 result of getting this request? 7 A: We dispatched two (2) -- two (2) 8 ambulances up to the parking lot. 9 Q: And do you recall which two (2) units 10 those would be? 11 A: 1145 and 1146. 12 Q: And you've told us earlier that that 13 was the vehicle operated by Mr. Gilpin? 14 A: Yes. 15 Q: And 1146 would be? 16 A: The Forest vehicle. 17 Q: All right. And do you know who the 18 operator of that was? 19 A: Of 1146? 20 Q: Yes. Do you have an independent 21 recollection, first? Perhaps I can ask you that. I see 22 you're referring to a document. 23 A: John Tedball and -- 24 Q: And a Mr. Watt, perhaps? 25 A: Yeah, Mark Watt.


1 Q: All right. As a result of having to 2 move these ambulances, you've told us earlier in order to 3 assure that there's adequate coverage for the area of 4 responsibility, you told us that you were able to call an 5 ambulance from elsewhere in order to backfill? 6 A: Yes. 7 Q: And did you do that on that -- on 8 this occasion? 9 A: There was a crew put on standby for 10 call- back. That'd be the crew from 1505. 11 Q: And we've seen that indication and -- 12 and what is now -- 13 A: In that list -- 14 Q: -- marked as -- as P-345 -- 15 A: Right, in that list of vehicles. 16 Q: All right. During the course of that 17 evening, Mr. Knight, did you receive any contact from the 18 911 service? 19 A: We received a call from 911 for an 20 ambulance at 9780 Army Camp Road, which was the store at 21 Ipperwash. 22 Q: At Ipperwash Provincial Park? 23 A: Right. 24 Q: Okay. And what happened as a result 25 of receiving that 911 call?


1 A: When we received the call, the OPP 2 wanted to be aware of any calls that we received, so they 3 were notified of that, that we had received a call. 4 And, as a result of that, they didn't want 5 us to respond into the store and the impression I got was 6 they were kind of surprised there was something happening 7 there. 8 And -- because we had another call and 9 they hadn't mentioned that there were shots and the 10 police had been shooting. 11 And -- so we never dispatched the 12 ambulance to the store immediately, but very, very 13 shortly thereafter we had another call for Army Camp Road 14 and 21 Highway which we dispatched vehicles to; because 15 we had tried -- tried to call back to the store. 16 With a 911 you can ring back the phone 17 that's called you as long as the connection hasn't been 18 broken and Connors called -- got through to that phone 19 and there was someone answered the phone. 20 They said, Oh, we don't need them here. 21 But, we did have a call for the Army Camp Road and we 22 dispatch -- and 21 Highway, so we dispatched the two (2) 23 vehicles up there. 24 Q: Okay. Let me just interrupt you 25 before we go into that.


1 You had mentioned that you received this 2 call to attend to 9780 Army Camp Road. I want to refer 3 you to Tab 16 -- 4 A: Hmm hmm. 5 Q: -- which is P-345, and at page 9 6 there's a log record there. You've already explained to 7 us, sir, the -- how to read these, I think, or how to 8 interpret the information on that. 9 A: Hmm hmm. 10 Q: And if you look down the, Common 11 Place Ipperwash Park Store -- 12 A: Right. 13 Q: -- and the originator, Lambton 911; 14 this is the same incident that you've just described for 15 us? 16 A: Right. 17 Q: And a Code 4. 18 A: Right. 19 Q: And, if we turn over then, to the 20 next page on page 10 of that, is there any indication 21 here that an ambulance was not dispatched? 22 23 (BRIEF PAUSE) 24 25 A: Nothing there that says it wasn't


1 dispatched. 2 Q: And if we turn over to page 11, the - 3 - in the narrative, there's an indication that the call 4 was disconnected, that there was an attempt to try the 5 party on the land line or on the number listed, there was 6 no answer -- 7 A: Right. 8 Q: -- and ultimately that information 9 was passed along to Sergeant Cousineau? 10 A: Right. 11 Q: Okay. 12 A: That was done by Mr. Connors. 13 Q: All right. You then went on, sir, to 14 state that an ambulance was dispatched to Highway 21 and 15 Army Camp Road? 16 A: Yes, sir -- 17 Q: And, how did that call come in if -- 18 if you can recall for us today, sir? 19 Firstly, do you have an independent 20 recollection of that? 21 A: Not -- not a good clear recollection. 22 Not at the time -- 23 Q: And, having -- having a chance to 24 look at -- 25 A: -- time, though we did have a call


1 from OPP and they were asking us where the car -- the 2 vehicles were and I told them that they were at the 3 parking lot at their command post. 4 Q: Okay. 5 A: And, he said -- he asked if we had 6 communication with them; I told them we did. And I 7 checked to see what was happening and I asked them if 8 they were still sitting there or were they moving and -- 9 because we had the -- it just seem something funny going 10 on, and I felt that the OPP didn't really know what was 11 going on at the store at the time. 12 And, when they found out there had been 13 shooting there, they were at a loss and then we moved the 14 -- in fact, I have a feeling that they -- if I'm not 15 mistaken -- that they directed those vehicles to move 16 down towards the Army Camp Road and 21 Highway. 17 Q: All right. That's nothing that you 18 did as a dispatcher? 19 A: No, not as such. I had asked the 20 vehicles if they were moving to the store or what and 21 they seemed to be moving towards the -- directed towards 22 the 21 Highway, the main -- towards the main gate of the 23 Army Camp. 24 Q: And, part of your job, you told us as 25 a dispatcher is to know the location of your resources --


1 A: Right. 2 Q: -- the ambulance at -- 3 A: Yeah. 4 Q: -- at your disposal. 5 A: Yes. And -- 6 Q: And, your advice to them or your 7 instructions to them were to be on standby at the MNR 8 parking lot. 9 A: Right. Right. 10 Q: And, were you surprised when you 11 found out that they were not at that location? 12 A: Yes, because that can really throw a 13 monkey wrench into everything if they're not where 14 they're supposed to be. 15 Like, any crew that goes out and tells you 16 they're at one (1) location and they're not, then that 17 really screws things up when you come to -- you're 18 counting on them being in a certain point and if they're 19 not, then you have to start back from square-one and 20 figure out what's going on here. 21 The job can be stressful enough without 22 crews moving around on you. 23 Q: Once you found out that your two (2) 24 crews, then, were at Highway 21 and Ipperwash Road, what 25 -- what did you do?


1 A: Well, I tried to contact them. That 2 was when we had another call come in. 3 Q: By then you had the 911 call you've 4 described to us earlier. 5 A: From Nauvoo Road. 6 Q: From Nauvoo Road. 7 A: From Nauvoo Road. And I tried to 8 call them and that gave us a delay on the dispatch. 9 Q: We've seen that delay to be something 10 just -- 11 A: Right. 12 Q: -- over three (3) minutes. 13 A: And when I finally got a hold of the 14 crew, they said, Well, we're both here at this location 15 and we were treating this patient at the -- who had been 16 shot. And I advised them that they had another Code 4 17 call to Nauvoo Road and they got on it within a minute or 18 so; they were enroute on that call. 19 But, there was an initial delay of three 20 (3) or four (4) minutes -- 21 Q: Right. 22 A: -- getting that information to them, 23 and their reasoning when I found out was that they were - 24 - both crews were attending to the patient. 25 Q: All right. So you dispatch one (1)


1 of the crews and -- 2 A: One (1) of the crews -- 3 Q: -- we've already gone through the 4 documents that -- 5 A: Right. 6 Q: -- have indicated that, to Nauvoo 7 Road. 8 A: Right. 9 Q: And in the course of that dispatch, 10 did you learn anything further? 11 A: Well, the other crew would have 12 updated and told me what they were doing, where they were 13 going to and all that from, I believe it was, 1146 -- see 14 which car it was that went over to -- took the patient. 15 I believe it was 1146 that took the car -- 16 the patient over to Strathroy. I would have had an 17 update from them and -- and Connors got some updates on 18 the Nauvoo Road call. 19 Q: Okay. And am I correct in 20 understanding that there was a patient to be attended to 21 at Army Camp Road and 21? 22 A: Right. 23 Q: And another emergency call from 24 Nauvoo Road at the same time? These were simultaneous -- 25 A: Yes.


1 Q: -- virtually? 2 A: Pretty close to being simultaneous. 3 4 (BRIEF PAUSE) 5 6 Q: As a result of receiving the 911 call 7 from Nauvoo Road and knowing that both of your crews were 8 now at 21, and you dispatched one of them to Nauvoo Road? 9 A: Yes. 10 Q: And as I -- as we understand, 11 subsequent information was received and that call was 12 then cancelled? We've gone through those -- 13 A: Yes. 14 Q: -- documents, sir. Okay, you mention 15 that the OPP were advised of these calls. 16 I think you also indicated that they had 17 wanted to be advised of these? 18 A: Yes. 19 Q: And you mentioned earlier, sir, that 20 this was often a matter of courtesy, of professional 21 courtesy that these things -- 22 A: Yes. 23 Q: -- would be known -- 24 A: Yes. 25 Q: -- as between --


1 A: And to protect the crews and 2 everybody involved, yes. 3 Q: So, this wasn't an extraordinary 4 happening -- 5 A: No. 6 Q: -- where they would ask -- 7 A: No. 8 Q: -- to be informed of what calls came 9 in? 10 A: No. 11 Q: All right. And do you know how the 12 information came in that the Nauvoo Road call was no 13 longer, or people had left or whatever the case was? 14 A: We received a call back from the 15 residents stating that the people had left. They had 16 left, gone out of the driveway and had left and they had 17 no idea which direction they had gone or where they were 18 going. 19 Q: Okay. 20 A: They just weren't there any more 21 and -- 22 Q: And this inform -- 23 A: -- there was no sign of them. 24 Q: I'm sorry? 25 A: And there was no sign of them.


1 Q: All right. And I suppose the 2 question may be asked, well if they were still gone, 3 could you not have continued the ambulance to perhaps 4 inter -- intercept this vehicle? 5 A: Where did they go? Which way do we 6 go? You know, we could have gone any place, there's -- 7 Q: Okay. 8 A: -- if they're going to Strathroy did 9 they go south on Nauvoo Road? We didn't know. How far 10 south on Nauvoo Road? Did they go down into the edge of 11 Watford and go into County Road 13? Did they take the 12 402 Highway? Did they take County Road 22 down, and then 13 turn south into Strathroy? We don't know. 14 Q: All right. And I understand that 15 from the dispatch office, from the CACC, calls were made 16 to alert the hospitals? 17 A: Yes. 18 Q: All right. And which hospitals were 19 contacted? 20 A: Sarnia General and Strathroy. 21 Q: And they were advised and provided 22 the information -- 23 A: Right. 24 Q: -- that you had received -- 25 A: That there was someone in a car with


1 a gunshot wound and we didn't know the condition, where 2 they were going or any information. Just told them what 3 we could. 4 Q: All right. It may come up as well, 5 sir, that there were inquiries made by the OPP to CACC to 6 perhaps contact the 911 caller on Nauvoo Road to 7 determine whether there were any arms present. 8 Do you recall anything like at all? 9 A: I believe there was. It wasn't 10 through me. 11 Q: All right 12 A: It was -- 13 Q: You don't have any direct experience 14 in -- 15 A: No. 16 Q: -- that, though? 17 A: No, it was through the call-taker. 18 He did call the residents back, as we've seen on one of 19 the forms there. 20 But, you know, to say, Well, why didn't 21 you do it, chase the -- try and chase them down, well, 22 when you don't know where they're going, that's not our 23 job to be out chasing around looking for something and 24 you don't know what you're looking for and we did 25 dispatch the OPP down there.


1 Now, I don't know whether they ever 2 arrived down there or not; I never -- I never heard. 3 Q: And, a result -- as a result of 4 dispatching these vehicles which you had, was there a 5 need at that point, then, to up staff or to backfill for 6 any more ambulances at that time? 7 A: Yes, we did. We brought the Thedford 8 vehicle and the other one from Forest. We brought them 9 up here to Ipperwash and we moved a vehicle from Petrolia 10 up to Forest and another Brigden -- or unit from Brigden 11 into Petrolia to cover that area. 12 We also brought a vehicle from Parkhill 13 over to Northville (phonetic) to cover the north part of 14 that area over there. And we also made arrangements for 15 a vehicle from Strathroy to be moved over towards Arkona 16 and Dashwood (phonetic), I understand, was moved down 17 from -- down this way, too, by London dispatch. 18 Q: All right. And, aside from 19 performing those many tasks you've just described, taking 20 the 911 calls, speaking with the OPP, you also had 21 occasion to connect a call from the Strathroy Hospital to 22 the vehicle that you had dispatched from Highway 21 and 23 Army Camp Road? 24 A: That would be -- when that vehicle 25 left, he went down Nauvoo Road, I believe, and I'm not


1 sure how he went from there, whether he went over onto 2 County Road 22 and then into Strathroy, but when he hit 3 the County line, protocol calls that he let us know when 4 he's at that location; he's leaving our dispatch area and 5 going into London's, so we transfer that dispatch form to 6 London Dispatch. It's all done electronically; they pick 7 up on it. But we did notify Strathroy Hospital. 8 Q: All right. 9 A: And, the crew would ask for a patch 10 into -- through London Dispatch into the hospital where 11 they give the patient's condition to the staff in 12 Emergency. 13 Q: And, they might get some information 14 and advice on how to treat the patient enroute? 15 A: Sure, they could get feedback from 16 the doctor in Emergency and London Dispatch would then 17 stamp that form that they had done a patch through to the 18 hospital, plus they would keep track of their times and 19 punch all their times for us. 20 Q: Okay. 21 A: Then, when they -- the crew comes 22 back, they notify London Dispatch that they're leaving 23 their area and coming back to ours and that dispatch form 24 is transferred back to us. 25 Q: And, I get the impression from what


1 you've told us so far, that there was a great deal of 2 things occurring within a fairly compressed timeframe? 3 A: Oh, yes, there sure was. 4 Q: And, we have come to learn that there 5 were also other resources, specifically, the St. John's 6 Ambulance had a -- a medical vehicle there. 7 Were you aware of that at all, sir? 8 A: No, we didn't know about it until 9 afterwards, until, I believe, it was the next day. 10 Q: And, just on that note, was there any 11 protocol as between CACC and St. John's Ambulance? 12 A: No, we had no contact. We had no 13 knowledge of them even being there. I think -- 14 Q: One (1) of -- 15 A: -- I think the first time we knew 16 about was when we seen it on the news that it was St. 17 John Who (phonetic) on the television; that was, I think, 18 the first we knew about. 19 Q: And, you've told us earlier as well, 20 sir, that aside from the ambulance dispatch function, you 21 also were responsible for dispatching the twenty-one (21) 22 or so fire departments in the -- 23 A: Right. 24 Q: -- two (2) counties? 25 A: In Lambton County.


1 Q: In Lambton County. Now -- 2 A: Yes, and we did have a -- a request 3 for Thedford Fire Department to be called in, which we 4 did and we paged the crews and we told them to report to 5 their hall. Normally, we would tell them where they were 6 required at, but the Chief had called us and he said, I 7 don't want them going anywhere but to the hall. 8 So, we had them report to the hall. And 9 he, apparently, had been in touch with, I believe, 10 Sergeant Cousineau. 11 Q: So they were -- 12 A: At that -- 13 Q: -- simply put on alert, is that -- 14 A: Right. They didn't want them 15 responding. And we also had another call for a fire at 16 the Ipperwash curve for, I believe it was, a brush fire 17 and they didn't want the -- that would be under Forest 18 Fire Department, and they didn't want them responding. 19 They knew about the fire, but they didn't 20 want them responding. 21 Q: All right. You've told us, sir, that 22 the ambulances were prevented from responding to the 23 Park. 24 And can you tell us why that was so? 25 A: Well, they didn't know what was


1 happening there and they had heard that -- shots fired; 2 and I wasn't talking to them, Connors was -- was talking 3 to them. 4 And so they weren't dispatched 5 immediately, but they were within a very, very short 6 time. 7 Q: You -- 8 A: They were dispatched because the 9 people, apparently, had left. We tried to contact the -- 10 Q: Park store, you've told us. 11 A: -- phone -- phone at the store and 12 they were told that they weren't there, there was no one 13 there, that we weren't needed. 14 And that's when we found out they had gone 15 up to the front entrance. 16 Q: And you've told us well, sir, that 17 the OPP wished to be advised of any calls that came into 18 the area -- 19 A: Right. 20 Q: Did they say why they wanted this 21 information? 22 A: No. They just wanted to know and -- 23 which is normal practice. If they're in a situation like 24 that, they want to know what's happening in the area. 25 Q: If I can just direct your attention


1 to Tab Number 3 of the book of documents in front of you, 2 Mr. Knight; that is Inquiry Document 1002300. 3 It's a statement of anticipated evidence 4 that you reportedly had given to a Mr. Kennedy and a Mr. 5 Muir on the 21st of September, 1995. 6 A: Hmm hmm. 7 Q: And you've had occasion to review 8 that earlier? 9 A: Yes. 10 Q: And you'll note on page 7 of that, 11 that your response was that any calls that were sent into 12 the area, the OPP advised us to contact them so they 13 would provide us with an escort. 14 Does that -- does that help you at all, 15 sir, in terms of refreshing your memory? 16 17 (BRIEF PAUSE) 18 19 A: Yeah, they -- let's see. 20 21 (BRIEF PAUSE) 22 23 Q: Do you recall, sir, that is why the 24 OPP had requested -- 25 A: Yeah. Well, they were concerned


1 about the crew's protection. 2 Q: All right 3 A: And we did respond crews without -- 4 before we notified the OPP, like the one on Nauvoo Road. 5 We had responded the crew without or before we had 6 notified the OPP. 7 But, this was just something that they 8 wanted for protection of the crews and that, and if they 9 had any other reasons for it, they never really come out 10 and told us. 11 Q: Okay. But, do you recall your 12 response at page 7, in response to Mr. Muir, you said 13 that; 14 "so they would provide us with an 15 escort." 16 Does that at all assist you? 17 A: No. 18 Q: All right 19 A: Not really. No. 20 Q: And I'm interested in the balance of 21 that comment as well -- 22 A: Yeah -- 23 Q: -- Mr. Knight. It says: 24 "The crews for the three (3) Thetford 25 or three (3) Forest Vehicles; and the


1 Thetford, I understand had been 2 provided with flag (sic) jackets." 3 A: It'd be flak jackets. 4 Q: And I take that to mean a bullet- 5 proof vest type of -- 6 A: I -- 7 Q: -- armament. 8 A: I wasn't told that directly. I've -- 9 I got that, I believe, from one of the crews or someone 10 after -- after the fact and I never was told that 11 directly. But, that was an understanding that I had, 12 that they had been given. 13 Because there was a mention of this 14 concern about the crew's safety and all that; they were 15 going to provide escorts. And that just happened to fall 16 in line, that if they were -- had been issued with flak 17 jackets, then that would seem to fall in line with it -- 18 Q: Okay. Is that something in your 19 experience -- 20 A: I've never -- 21 Q: -- is usual? 22 A: -- come across it where we've had 23 flak jackets given to us, no. 24 Q: And, again, just generally on that 25 evening, sir, did you have any concerns at all about the


1 resources in terms of ambulances that you had available? 2 A: No, we had enough vehicles. 3 Q: In terms of the operation of -- of 4 CACC, did you have any concerns there, and I note that 5 you made -- 6 A: Only that we were busy and we sure 7 could have used another person in the dispatch centre to 8 help with phone calls, because we still had the rest of 9 the two (2) counties to look after. So, it was a busy 10 night. 11 Q: All right, sir. I think those are 12 all the questions that I have for Mr. Knight at this 13 point, Mr. Commissioner. 14 COMMISSIONER SIDNEY LINDEN: Thank you 15 very much, Mr. Worme. 16 Does anybody wish to examine Mr. Knight? 17 Mr. Rosenthal, how long might you be? 18 MR. PETER ROSENTHAL: Approximately half 19 an hour, sir. 20 COMMISSIONER SIDNEY LINDEN: Half hour? 21 MR. PETER ROSENTHAL: Yes, sir. 22 COMMISSIONER SIDNEY LINDEN: Mr. 23 Scullion...? 24 MR. KEVIN SCULLION: I'll reserve fifteen 25 (15) minutes and see how it goes.


1 COMMISSIONER SIDNEY LINDEN: And, Ms. 2 Tuck-Jackson? 3 MS. ANDREA TUCK-JACKSON: Five (5) to ten 4 (10) minutes, sir. 5 COMMISSIONER SIDNEY LINDEN: Five (10) to 6 ten (10) minutes? Okay. 7 I guess that means you're up first, Mr. 8 Rosenthal. 9 MR. PETER ROSENTHAL: Thank you. 10 11 CROSS-EXAMINATION BY MR. PETER ROSENTHAL: 12 Q: Good afternoon, sir. My name is 13 Peter Rosenthal, I represent some of the First Nations 14 people under the name, Aazhoodena and George Family 15 Group. 16 A: Okay. 17 Q: I should begin by suggesting many 18 people have had problems with memory at this Inquiry, we 19 all know that it's been ten (10) years since the events 20 and many people have had difficulties and -- 21 A: Well, mine happens to be legit. 22 Q: Yeah, but -- and us older people 23 maybe don't have quite as sharp memories, but we make up 24 for it in wisdom, right? 25 A: Yeah.


1 Q: Now, sir, in 1995 when you were 2 working on or about this day, if there was a call for a 3 medical emergency where someone satisfied one (1) of the 4 three (3) criteria for it being very serious would, in 5 addition to dispatching an ambulance, would you often 6 dispatch the fire department? 7 A: Yes. 8 Q: Yes? That -- that seems to be the 9 practise in Toronto, but I'm -- 10 A: That's what they call a tiered 11 response. 12 Q: Yes. And, the Fire Department, in 13 Toronto at least, they seem to get there first usually, 14 is that picture -- 15 A: Well, they have more stations. 16 Q: Yes. 17 A: That's the reason for it. Like, in 18 Sarnia, there's one (1) ambulance station, cars are sure 19 put on standby, but there's five (5) or six (6) 20 firehalls. 21 Q: Yes. 22 A: So, it's obvious they're going to -- 23 or should be able to arrive sooner, but if we happen to 24 have a car driving by or an ambulance driving by, we're 25 going to be the first one there and it's quite often that


1 we are the first one there. 2 Q: Yes, but if the Fire Department 3 arrives first, they do whatever first aid they can -- 4 A: Right. 5 Q: -- and so that by the time the 6 ambulance people arrive, the person is, perhaps, a little 7 bit aided -- 8 A: Yeah. 9 Q: -- a little bit more stable. 10 A: Right. And they carry 11 defibrillators. 12 Q: But, on -- on this evening, for 13 example, it doesn't appear that you dispatched any -- any 14 fire. 15 A: No. 16 Q: And, I gather from reading one (1) of 17 your previous documents that that was because of 18 instructions from the OPP not to dispatch fire -- 19 A: No, it's logical. We had two (2) 20 vehicles right there, why would we dispatch the Fire 21 Department so much further? 22 Q: I see. 23 A: No, we're going to be there long 24 before the Fire Department gets there. 25 Q: I see. Okay. Now, we've looked a


1 bit at Exhibit 345 as it now is your Tab 16 -- 2 A: Hmm hmm. 3 Q: -- and I should like to refer you to 4 page 3 of that if I could, sir? 5 And, page 3 of that document is the -- the 6 listing of the ambulances that were involved in this 7 incident and -- 8 A: Right. 9 Q: -- you've spoken about it. Now, all 10 of the ambulances listed there appear to have been on 11 standby at some point and -- 12 A: Right. 13 Q: -- most of them, that was the only 14 duty they did that night as indicated by Code 8, correct? 15 A: Right. 16 Q: So, you answered a few moments ago to 17 Mr. Worme, you had plenty of ambulances around that night 18 and this confirms that right? 19 A: Yes. 20 Q: And they were there on standby. Were 21 they all fairly close to Ipperwash Park then? 22 A: The Thedford unit -- well the two (2) 23 originally were brought into the Ministry parking lot -- 24 Q: By -- 25 A: -- then Thedford unit and the 1505


1 from Forest, they were brought into the Ministry parking 2 lot. The Petrolia vehicle was moved to Forest. The 3 Brigden (phonetic) was moved to Petrolia. Parkhill was 4 moved to Port Franks. And Strathroy was asked -- or 5 London was asked to send Strathroy into the Arcona area. 6 And they also moved Dashwood down, I 7 believe, and they also moved a Luken (phonetic) vehicle 8 over towards Parkhill because you have to backfill all 9 the areas because work still has to go on. 10 Q: So, you were well organized in that 11 sense, certainly? 12 A: Oh yes. But we only had two (2) 13 vehicles at a time there and they wanted -- when the two 14 (2) vehicles were put in use they wanted two (2) more and 15 that's what we did; we brought two (2) more in. 16 Q: Yes. But you had others in case some 17 more were required? 18 A: We had others there. 19 Q: And that decision as to how many 20 ambulances to deploy was your decision rather than the 21 police decision; is that correct? 22 A: No, they told us they wanted at least 23 two (2). 24 Q: Yes. 25 A: They wanted two (2) there -- two (2)


1 vehicles there at all times. 2 Q: Yes, but having the -- the large 3 number of others on standby was a decision that was made 4 by you -- 5 A: He asked for these other vehicles, 6 yes. 7 Q: Yes. And did the officers indicate 8 when they requested ambulances nearby that -- it was a 9 possibility of gunshot wounds? Did they specifically -- 10 A: No, they didn't know what was 11 happening. We found that out from the 911 calls. 12 Q: Yes. Now, as far as which hospital 13 an ambulance in that kind of situation would take people 14 to, I gather that there would be two (2) candidates at 15 least, Strathroy and Sarnia General; is that correct? 16 A: Yes, they were the two (2) main ones. 17 Yes. 18 Q: The two (2) -- the two (2) likely 19 possibilities? 20 A: Right. 21 Q: And how would it be determined which 22 one an ambulance would go to? 23 A: Well Mr. Connors and Mr. Gilpin, they 24 discuss that which one was going to be used and it was 25 apparently decided that Strathroy would be the logical


1 one to use. 2 Q: At the time Sarnia was a more fully 3 equipped hospital; is that correct? 4 A: Yes. It's a larger hospital. They 5 have more stuff there but on the other hand depending on 6 the injuries, Strathroy's closer to London who has even 7 more. 8 Q: Yes. So, if a person were to be 9 initially assessed at Strathroy and it was decided that 10 more serious intervention was needed than was available 11 at Strathroy, they could be transported to London? 12 A: Yes. Plus, we could have a crew 13 right on -- from the scene, they could have called into 14 the doctor in emergency at Sarnia General Hospital and 15 give him the information and then he could have made a 16 decision whether he wanted that patient to go to Sarnia 17 or go directly to London rather, and even Strathroy. 18 Q: I see. Was there a discussion that 19 evening that there might be both some officers injured 20 and some First Nation's people injured and it might be 21 desirable to take them to separate hospitals if they were 22 -- if there were injuries of both types? 23 A: No. 24 Q: No. 25 A: No, it was just -- there was a


1 conversation that Connors had with the doctor in Sarnia 2 General Emergency that, you know, depending on how many 3 that it may be wise to split them up which is logical. 4 Q: Now, I believe, if I understood you 5 correctly, that you first learned that it was a -- that 6 there was shootings involved from a 911 call that 7 mentioned a shooting? 8 A: Right. Yeah. 9 Q: And that had indicated that the 10 shooting was by a police officer of a non-police officer; 11 is that right? 12 A: That was the impression we got, yes; 13 that it was the police that was doing the shooting. 14 Q: Police doing the shooting? 15 A: Yeah. That was from a female I 16 believe at the -- up at the -- I'm just trying to think 17 now, whether it was from the Ipperwash building or from 18 the main gate; it was one or the other. 19 Q: But -- but, in any event you -- there 20 was a female caller -- 21 A: Yeah. 22 Q: -- that gave the understanding that 23 the police -- 24 A: Yeah. 25 Q: -- were shooting at people and at


1 least one (1) person had been -- 2 A: Well they said, We didn't know the 3 police were doing the shooting, they just said that was - 4 - the police were shooting. 5 Q: Yes. 6 A: So, we didn't have any more 7 information than that and we can't really start assuming 8 that the police were all out with -- in force. 9 Q: So, you didn't know for sure what was 10 going on -- 11 A: No. 12 Q: -- you just had that report? 13 A: We take -- take what you get and at 14 that point you have to take it with a grain of salt and 15 say, Well, this is what it appears to be but I can't 16 prove it so... 17 Q: Yes. 18 A: ...so. 19 Q: But you didn't have any indication 20 that anybody had been shooting at the police? 21 A: Not to my knowledge there wasn't, no. 22 Q: No. And as far as the -- you 23 mentioned about the call from the Park for an ambulance 24 and it was the OPP that instructed you not to send your 25 crews to that area; is that correct?


1 A: Yeah. I wasn't on the -- when Geoff 2 called the OPP in the Park, I wasn't on the line with 3 him, but that was the impression that I was given, yes; 4 not to respond in there yet. 5 And then it seems like when we found out 6 that there was some shooting. And it appeared to me in 7 hindsight from what I heard and all that, that they were 8 kind of taken by surprise by that. 9 Q: Sorry, who was taken by surprise? 10 A: The OPP. 11 Q: I see. 12 A: The communications centre. 13 Q: I see. 14 A: They didn't -- at that point I didn't 15 think they knew about it. 16 Q: I see. 17 A: So, I thought, well, gee, we're 18 giving them some new information here. 19 Q: Now, we heard -- you told us that you 20 had two (2) crews in the Ministry of Natural Resources 21 parking lot on -- 22 A: Right. 23 Q: -- standby, and they left that 24 parking lot and you were not aware that they'd left? 25 A: Not right off the bat, no.


1 Q: And so I take it they should 2 certainly have radioed to you that they were leaving, if 3 they were going to leave; is that correct? 4 A: Well, I asked them if they were 5 stationary or what act -- and then we had the other calls 6 to the 21 Unit. 7 Q: Yes. But, you told us that, as a 8 dispatcher, it's very important for you to know where all 9 your ambulances -- 10 A: Yes. 11 Q: -- are -- 12 A: Yes. 13 Q: -- at all times; is that -- 14 A: Yes. 15 Q: -- correct? 16 And -- and their failure to inform you of 17 that fact meant that when you phoned them for assistance, 18 you didn't realize that they were out of the cars 19 assisting someone else? 20 A: Right. 21 Q: And presumably, had you known that, 22 you would have called upon one (1) of the other 23 ambulances that was on standby and had them do this new 24 job while they -- 25 A: We would have --


1 Q: -- finished the old one. 2 A: -- we would have moved the other 3 vehicles in there quicker. 4 Q: Yes. 5 A: A couple of minutes sooner, yes. 6 Q: Yes, and then -- but when the Nauvoo 7 Road call came, if you had known that the vehicles that 8 had been in the parking lot were now engaged with a 9 patient near Army Camp Road, you would have called upon 10 one of the other vehicles on standby to do the Nauvoo 11 Road -- Nauvoo Road matter? 12 A: Well, I would have had to have page 13 in a crew into Forest -- 14 Q: Yes. 15 A: -- to come and get their vehicle and 16 to respond and they have up to ten (10) minutes to 17 respond. And we found out there was only one (1) patient 18 at Army Camp Road, so I wanted that other crew, because 19 then I could get them on the road right away; I don't 20 have to wait for them to respond. 21 Q: Yes, no I appreciate that in the 22 circumstances, sir, but -- 23 A: Yeah. 24 Q: -- I was suggesting if you had known 25 ahead of time, if they had informed you as they should


1 have that they were off doing something else, the two (2) 2 crews that had been at the parking lot, they're off 3 dealing with something else, then you would have thought 4 of looking for another ambulance to do the Nauvoo Road -- 5 A: Yes. 6 Q: -- right? Now -- but they didn't 7 inform you of that, so that's why you didn't do it, 8 right? 9 Is that correct, sir? 10 A: That sounds reasonable. 11 Q: Sounds reasonable to me, too. 12 A: Yeah. 13 Q: Now -- 14 A: But I don't -- but they were in the 15 area. I had no question that they were in the area doing 16 whatever, but they were not -- when you say they -- they 17 were -- had gone on their own, that they hadn't left to 18 do something else, that they were still available. 19 Q: Oh yes, yes. Now, related to that, 20 we've had some evidence and you may be somewhat aware of 21 it that, in fact, at the MNR parking lot where they had 22 been, there was a person there with some serious injuries 23 who, because they had left that area, was sent by St. 24 John's Ambulance -- 25 A: Yes --


1 Q: -- to -- 2 A: -- we heard -- 3 Q: -- Strathroy Hospital. 4 A: -- we heard that after. 5 Q: You learned that afterward? 6 A: Yeah, in fact, quite a bit after. 7 Q: Yes. And I take it, sir, that if you 8 had been informed by the crews that had been in the MNR 9 parking lot that they were leaving, you told us you would 10 have assigned some other standby vehicles to the MNR 11 parking lot, and then likely one of them would have 12 transported Mr. Cecil Bernard George to Strathroy 13 Hospital? 14 A: Well, one of them could have done it 15 themselves, and the other one gone to the Army Camp. 16 Q: Yes. 17 A: And what -- and they -- 18 Q: And you -- you recognized that, you 19 knew that you offered much better service in general, for 20 a seriously injured patient -- 21 A: Oh -- 22 Q: -- than St. John's Ambulance could 23 offer. 24 A: Crews were much better trained, yes. 25 Q: Much better trained, and the


1 ambulances were -- 2 A: And they had the equipment too. 3 Q: That had much better equipment as 4 well. 5 A: Right. 6 Q: Now, about how long would it take 7 when an ambulance responding on a Code 4 away, to have 8 gotten say, from Army Camp Road at the location where the 9 two (2) crews went to, to the address on Nauvoo Road to 10 attend at that call? 11 A: Well, road conditions that night were 12 -- were good. I have to assume, from what I've -- in the 13 report, one report I had seen that they were cancelled at 14 twelve (12) to thirteen (13) minutes, that they would 15 have been onsite within another two (2) minutes. 16 Q: So, it shouldn't take more than say, 17 fifteen (15) minutes or so? 18 A: I wouldn't think so. 19 Q: Yes. Mr. Veen's testified that, in 20 his view it shouldn't have taken more than ten (10) 21 minutes, but the person -- 22 A: Well -- 23 Q: -- lives there, but -- but your -- 24 your view would be fifteen (15)? 25 A: Well, I'm just -- I'm basing that on


1 the fact that the crew had said that they had been 2 cancelled after twelve (12) to thirteen (13) minutes, and 3 they were on Nauvoo Road at that point -- 4 Q: Yes. 5 A: -- at Townshead Line. 6 Q: Well, there appears to be, I gather, 7 some question as to exactly how long it was that -- 8 A: Hmm hmm. 9 Q: -- from the cancellation -- 10 A: Right. 11 Q: -- we have very different numbers. 12 Some number suggest over twenty (20) minutes and some 13 less and so on; is that fair? 14 A: Right. And, I can't -- I -- 15 Q: Yeah. And if you don't know the 16 explanation -- 17 A: -- can't give you an accurate answer 18 on that, because it all depends on so many things. 19 Q: Yes. 20 A: The only good thing going was, the 21 road conditions were good that night -- 22 Q: Yes. 23 A: -- and the crew knows the area like 24 the back of their hand. 25 Q: Yeah.


1 A: And if I would bring another crew in 2 from another area, they're not going to know the roads as 3 well -- 4 Q: Yes. 5 A: -- the condition of roads and all 6 that, so... 7 Q: Certainly. So, you told us you based 8 your estimate of fifteen (15) minutes on your 9 understanding of the numbers that actually happened that 10 night. 11 A: Yeah. 12 Q: But, if you just -- with your 13 knowledge of the area, just if you forget the numbers, 14 because we don't know exactly those numbers -- 15 A: Right. 16 Q: -- what would you estimate; and just 17 your knowledge of the area, getting in a Code 4, 18 travelling as fast as one should on a Code 4, that 19 distance? 20 A: Well, we lost three (3) minutes right 21 off the bat -- 22 Q: Right. 23 A: -- in their time when they left, 24 because they were out looking after that other patient. 25 But, fifteen (15) minutes max, and that's just a guess.


1 Q: Thank you. Now, you explained why 2 the ambulance would have been cancelled, rather than 3 continuing the call once the person Mr. Veen said -- 4 informed your dispatch that the people had left. 5 But, if they were within a couple of 6 minutes of that location, in retrospect, would it not 7 have been reasonable for them to try to catch-up? 8 A: Well, hindsight is wonders. 9 Q: Yeah. No, it -- 10 A: But, when that man said the people 11 had left, he had no idea which direction they have gone-- 12 Q: Right. 13 A: -- there was no one in sight; and 14 what are you chasing? We -- a white car with a flat 15 tire; you don't -- we didn't go chasing them but the OPP 16 also apparently didn't -- 17 Q: Yeah. 18 A: -- apparently, didn't chase them 19 down. 20 Q: Yeah. 21 A: And we had an ambulance go down that, 22 apparently down that same route afterwards, and they 23 never come across anybody either. 24 Q: Yeah. 25 A: So, I don't know, as I say, hindsight


1 is -- it does wonders, but it -- you can't be chasing 2 people all over the country either. If they had stayed 3 at, even at the main gate, at Ipperwash, or at the Army 4 Camp, we had an ambulance right there. 5 Q: Yes. Although we -- we have heard, 6 as you indicated and from other evidence, that the 7 ambulances were not entering into the premises there at 8 the Park or the Camp. 9 A: Not into Ipperwash Provincial Park, 10 no. 11 Q: Yes, or the Army Camp area, so... 12 A: But they were just -- when they went 13 up to the Army Camp Road, they were right there by the -- 14 very close to that entrance to Ipperwash. 15 Q: Thank you very much, sir, for your 16 evidence. Thank you, Mr. Commissioner. 17 COMMISSIONER SIDNEY LINDEN: Thank you, 18 Mr. Rosenthal. 19 Mr. Scullion...? 20 21 CROSS-EXAMINATION BY MR. KEVIN SCULLION: 22 Q: I think I may be fairly quick, Mr. 23 Commissioner. 24 At the end of your Examination-in-Chief, 25 Mr. Worme had mentioned flak jackets, do I take it you're


1 not able to help us in any way -- 2 A: No. 3 Q: -- as to whether those were used or 4 not? 5 A: No, I can't, for the life of me, 6 remember where I got that from; whether it was from a 7 crew member afterwards or what. 8 Q: All right. So -- 9 A: And, it would kind of fit in with the 10 idea that the police were concerned about the crew's 11 safety, as we were, and I've never had it happen, but 12 it's possible they gave them flak jackets. 13 Q: Sure. 14 A: It's something you'll have to ask the 15 crews. They -- 16 Q: All right. It may have fit in with 17 that concept, but we'll ask the crews that question. 18 A: Yeah, for a definite answer. 19 Q: Okay. And, if I heard you correctly, 20 you indicated that when the ambulance was called off to 21 the response to Nauvoo Road, you -- you still had 22 notified the police of what was going on. They knew that 23 that car had left? 24 A: They knew the call was there -- 25 Q: Okay.


1 A: -- and they knew we had -- I believe 2 they knew we had -- knew we had cancelled. 3 Q: All right. And -- and -- 4 A: I believe Connors mentioned that to 5 them that we had cancelled, but -- because the people had 6 left. 7 Q: But, that wasn't you notifying the 8 police, that was Mr. Connors? 9 A: No, I didn't; that was Connors, yes. 10 Q: All right. And, I just wanted to, I 11 guess, clarify, you'd indicated that the 911 call would 12 first go to the Sarnia Police. 13 A: Right. 14 Q: And, then the Sarnia Police would 15 determine whether or not it goes out to the -- your 16 ambulance, the stat -- the dispatch or the Fire or the 17 Police? 18 A: Right. 19 Q: Is that correct? 20 A: Well, at that time, we were the only 21 off-premise service that they would send it to. 22 Q: Okay. 23 A: If it was the Fire Department -- the 24 City Fire Department, the 911 centre dispatched them and 25 the Police.


1 Q: Okay. But, it went through the 2 Police Department first -- 3 A: Yeah. 4 Q: -- to Sarnia, then it came to you? 5 A: Yeah, they'd just punch a button and 6 it comes through to our centre. 7 Q: Right. It was your decision to make 8 as to who to send out by way of dispatch to take care of 9 whatever call had come in? 10 A: Right. 11 Q: And, on top of that, you also had 12 instructions to contact, is it the Command Centre? 13 A: The Command Centre; they wanted to 14 know, yes. 15 Q: And, was there a contact there, 16 specifically? 17 A: Cousineau. 18 Q: You were to deal with Cousineau? 19 A: There was Sergeant Cousineau. I 20 believe it was Sergeant Reid that started and then the 21 next I knew it was, well, don't talk to Reid, talk to 22 Cousineau; he's in charge. 23 Q: Okay, who told you that? 24 A: I believe it was Cousineau. 25 Q: All right. He said, Don't talk to


1 Reid, talk to me? 2 A: Yeah. 3 Q: All right. 4 A: And then, I think Reid agreed to 5 that, that yeah, he would... 6 Q: And, what time did you start your 7 shift that night, was it seven o'clock or eight o'clock? 8 A: Well, seven o'clock the shifts 9 normally start -- 10 Q: Right. 11 A: -- but, habit of driving thirty (30) 12 miles, so I usually arrived around 6:30. 13 Q: Okay. 14 A: If I had a flat tire on the way, I'd 15 have time to change it and... 16 Q: Okay. I won't get into that. 17 A: And, you know, you break down or 18 something, so... 19 Q: Did you recall, generally, the time 20 that you got there? 21 A: Generally, I was there around 6:30. 22 Q: Okay. And, at that point in time, 23 did you have a directive from the Police that they wanted 24 two (2) ambulances down in the Ministry parking lot? 25 A: No. Nope.


1 Q: When did you receive that particular 2 directive? 3 A: Oh, I didn't have that until, gosh, 4 21:00 anyway, I would thing. 5 Q: About nine o'clock? 6 A: Yeah. 7 Q: Okay. Thank you. 8 Those are all my questions, Mr. 9 Commissioner. 10 COMMISSIONER SIDNEY LINDEN: Thank you, 11 Mr. Scullion. 12 Ms. Tuck- Jackson...? 13 14 CROSS-EXAMINATION BY MS. ANDREA TUCK-JACKSON: 15 Q: Good afternoon, Mr. Knight. My name 16 is Andrea Tuck-Jackson and I am going to ask you some 17 questions on behalf of the OPP. 18 A: Okay. 19 Q: And, I'd like you if you would, sir, 20 if you'd turn to Tab 3 of the materials in front of you. 21 22 (BRIEF PAUSE) 23 24 Q: And for the record, that's Document 25 Number 100230.


1 And you'll see, Mr. Knight, at the 2 beginning of the document it appears to be a transcript 3 of a taped interview that you gave on September the 21st, 4 1995 -- 5 A: Right. 6 Q: -- to a gentleman by the name of Jim 7 Kennedy, whom I trust you understood was speaking to you 8 on behalf of the SIU? 9 A: Yes. 10 Q: And you recall, sir, that that tape - 11 - excuse me, that the interview was obviously tape 12 recorded? 13 A: Yes. 14 Q: All right. And in particular it's 15 one (1) area that I want to revisit in your evidence and 16 that was, again just to clarify the reasons as you 17 understood it, as to why the OPP did not want, first of 18 all, ambulance crews to be responding to calls to the 19 Park. 20 And to that end, I'd ask you to turn to 21 page 3. Actually, we'll begin at the bottom of page 2, 22 sir. 23 A: Okay. 24 25 (BRIEF PAUSE)


1 Q: And about six (6) lines up from the 2 bottom, you are recorded as saying: 3 "We received a call on 911 for the 4 store at Ipperwash, and at this time we 5 asked the crews if they were moving to 6 that location and my partner, Geoff 7 Connors, who was doing call taking, he 8 called the command post and asked if we 9 should be moving into that location. 10 They advised us not to go into that 11 area. And they, the crews, on the 12 vehicles at that time said they were 13 then moving to the Ipperwash Army camp 14 where the injured people were supposed 15 to be." 16 Now, pausing there for a moment, and 17 before -- 18 A: Hmm hmm. 19 Q: -- I go on further, the date that you 20 gave this interview was approximately two (2) weeks after 21 the -- 22 A: Hmm hmm. 23 Q: -- events in question, and I trust 24 that the events were much fresher in your memory at the-- 25 A: Yeah.


1 Q: -- at that time than they are -- 2 A: Hopefully they were, yeah. 3 Q: -- than they are now. Fair enough, 4 all right. 5 Now, when you were giving this account to 6 Mr. Kennedy, I trust that, given the close proximity that 7 no -- no doubt you and Mr. Connors were in on September 8 the 6th, you were able to overhear some of this -- 9 A: Yes. 10 Q: -- exchange? All right. 11 Then taking that, I want to move on to 12 page 4 if I can, sir. 13 A: Hmm hmm. 14 Q: And you'll notice about a third or a 15 quarter of the way down, Mr. Kennedy picks up on that 16 passage that I just read out to you, and he says: 17 "You said that you were advised that 18 not to go in by the OPP. Could you 19 elaborate as to what they said and for 20 what reason they felt you shouldn't go 21 in?" 22 And you are recorded as replying: 23 "Well, they were concerned for the 24 safety of the crews." 25 And pausing there, sir, that was clearly


1 the impression that you had. 2 A: Hmm hmm. 3 Q: The reason the police were directing 4 ambulance not to go in was that the police had concerns 5 at that point -- 6 A: Right. 7 Q: -- for the safety of the ambulance 8 attendants? 9 A: Yes. 10 Q: Okay, going on. 11 "We had lost contact on the 911 call to 12 the store and we had to call that back. 13 Now that was not done by myself, but by 14 Geoff Connors and how close the crews 15 actually got to the store, I don't 16 know. They were rerouted to the Army 17 camp and if I am not mistaken, they 18 were rerouted there by the OPP." 19 And I anticipate we'll hear further 20 evidence on that point. 21 A: Hmm hmm. Yes. 22 Q: So, quite clearly again, sir, the 23 only reason as far as you knew as to why the OPP were 24 saying, Hang on, we don't want you going in there, was a 25 concern for the safety of the ambulance crew?


1 A: Yes. 2 Q: Okay. Now -- good. 3 And along the same theme, I'm going to ask 4 you to turn to page 6. 5 A: Can I just make a comment? When we 6 talked to the OPP when they were at that command centre 7 in the parking lot, the OPP called and says, Where are 8 your crews? And I told them they were in your parking 9 lot. 10 And, oh, so -- and he asked me if we had 11 communication with them and I said, Yes, we do. And so 12 at that point I tried calling the crew to find out what 13 they were doing. 14 Are you still there or are you moving; and 15 basically that was -- was it there. And I think they 16 were -- someone had said something about, Well, maybe you 17 shouldn't be moving -- moving here. 18 But, I also had the impression from what 19 was being said in -- by Connors and from what I was 20 getting from the phone, from the command centre, that 21 they weren't sure they -- they weren't aware of the 22 shooting at the time. 23 Q: I understand that, sir, and I 24 anticipate we will hear from the very officer who was 25 communicating with you from time to time and with Mr.


1 Connors from time to time. 2 A: Oh, okay. So -- 3 Q: And in particular we -- we may find 4 out where physically he was situated when all of these 5 calls are going back and forth and it might shed some 6 light on -- on -- 7 A: Yeah. 8 Q: -- some of the issues you've raised. 9 A: Yeah. Because I have no idea how 10 they were situated on the parking lot so... 11 Q: That's a fair comment, sir. Let's go 12 back to page 6 if I can. 13 A: Okay. 14 Q: And I'm interested and again you've 15 already touched on it briefly, sir, about contact you had 16 with the Thedford Fire Department that night. And you'll 17 see, sir, towards, it begins actually about half way 18 through that page, you are noted as having said: 19 "We received a call from the fire chief 20 of Thedford to call in his crews to the 21 fire station in Thedford because he as 22 he said there I believe he put it that 23 Ipperwash was on fire." 24 And dropping down to a comment that is 25 attributed a Mr. Muir:


1 "Okay. Did you contact the OPP and 2 advise them that the fire department 3 was on call or on standby?" 4 And you reply: 5 "They had already talked to the fire 6 chief there and he was at the hall. 7 Okay. 8 And apparently from what we had heard, 9 that they would not let them respond 10 into the Ipperwash Park because of 11 their safety." 12 A: Hmm hmm. 13 Q: Turning the page, Mr. Muir then 14 proceeds: "Okay who. So the OPP 15 [excuse me] the Ontario Provincial 16 Police would not [I'm sure that's 17 supposed to say not] allow the fire 18 department to respond there because of 19 their concerns for their safety?" 20 And you reply: 21 "That was my understanding." 22 And then you go on to deal with the other 23 issues. 24 A: Hmm hmm. 25 Q: So, clearly it was your understanding


1 that night your relation to both fire and ambulance, the 2 police had concerns letting that personnel in towards an 3 area where the police had some concerns about their 4 safety. 5 A: Right. Yes. 6 Q: Thank you, sir, very much for your 7 time. 8 COMMISSIONER SIDNEY LINDEN: Thank you 9 very much. 10 Mr. Worme...? 11 MR. DONALD WORME: I don't have any 12 further questions about re-examination and I wish to 13 thank Mr. Knight for his attendance and his testimony. 14 COMMISSIONER SIDNEY LINDEN: Thank you 15 very much, Mr. Knight. 16 I understand you want to take a short 17 break now and give Ms. Vella a chance to set up the next 18 witness. 19 MR. DONALD WORME: Just an opportunity to 20 set up for the next witness. 21 COMMISSIONER SIDNEY LINDEN: Well, we'll 22 take a short break now. 23 MR. DONALD WORME: Thank you, sir. 24 THE REGISTRAR: This Inquiry will recess. 25


1 --- Upon recessing at 2:50 p.m. 2 --- Upon resuming at 3:10 p.m. 3 4 THE REGISTRAR: This Inquiry is now 5 resumed. Please be seated. 6 COMMISSIONER SIDNEY LINDEN: Thank you. 7 MS. SUSAN VELLA: Thank you, 8 Commissioner. 9 COMMISSIONER SIDNEY LINDEN: Yes, Ms. 10 Vella. Good Afternoon. 11 MS. SUSAN VELLA: The Commission calls as 12 its next witness, Geoffrey Connors. 13 THE REGISTRAR: Good afternoon, Mr. 14 Connors. 15 MR. GEOFFREY CONNORS: Hello. 16 THE REGISTRAR: Do you prefer to swear on 17 the Bible or affirm, sir? 18 MR. GEOFFREY CONNORS: Swear on the 19 Bible. 20 THE REGISTRAR: Swear on the Bible? 21 MR. GEOFFREY CONNORS: Yes. 22 THE REGISTRAR: The Bible is there on 23 your right, please, sir. Take it in your right hand. 24 State your name in full for us please. 25 MR. GEOFFREY CONNORS: My name is


1 Geoffrey Fulton Connors. 2 THE REGISTRAR: Thank you, sir. 3 4 GEOFFREY FULTON CONNORS, Sworn 5 6 EXAMINATION-IN-CHIEF BY MS. SUSAN VELLA: 7 Q: Mr. Connors, I understand that you 8 were born on May the 25th, 1958? 9 A: That's right. 10 Q: And can you tell us what your current 11 occupation is? 12 A: Presently I'm a shift supervisor, 13 primary paramedic with some parlay emergency services 14 serving Kent County. 15 Q: Kent County? 16 A: Kent County. We're based out of 17 Chatham. 18 Q: Okay. What is your current 19 residence? 20 A: In Chatham, Ontario. 21 Q: I understand you graduated in 1982 22 from Conestoga College with a diploma in Ambulance and 23 Emergency Care? 24 A: That's correct. 25 Q: And, how long was that program of


1 study? 2 A: At that time it was one (1) year. 3 Q: Can you tell me what the basic 4 elements of this program consisted of? 5 A: Ambulance -- basic ambulance 6 operations, anatomy, physiology, biology, dealing with 7 the sick and injured. 8 Q: As part of its program of study, did 9 you deal with the process of dispatching? 10 A: At the time no, we did not. 11 Q: All right. And, what does this 12 program or degree qualify you to do? 13 A: Twenty (20) years ago, back in 1982 14 we were commonly know as Ambulance Attendants. Since 15 that time, I believe it was the early '90's, the Ministry 16 evolved to a point of advanced care. to the point of 17 primary and advanced care paramedics. 18 About 70 percent of the attendants in -- 19 in Ontario are primary care paramedics and the advanced 20 care, primarily in the larger cities. 21 Q: All right. And, which level of care 22 are you qualified to provide? 23 A: I'm a primary care paramedic. 24 Q: Have you had any upgrading of your 25 qualifications or your training since 1982?


1 A: Yes, I've -- since 1982 when I 2 graduated as an ambulance attendant, I was in that field 3 for approximately ten (10) years, and in that period, 4 1990 I went into the ambulance dispatch as a shift 5 supervisor. 6 It was a necessity at that time to get out 7 of the fleet side of the business and just stay in the 8 dispatch. My qualifications lapsed and then at that 9 time, came 1995, I re-certified, gathered all my 10 qualifications to enable to me to get back into the field 11 as a paramedic. 12 Q: All right. Now, in terms of your 13 employment history, I understand that from 1982 to 1990, 14 you were employed by the Chatham District Ambulance as an 15 Ambulance Attendant? 16 A: That's right. 17 Q: And, in this capacity, were you 18 qualified to -- to attend under the rubric of the 19 Ministry of Health regulated ambulance service? 20 A: Yes, I did. 21 Q: What geographical jurisdiction did 22 this ambulance service between 1982 and '90? 23 A: We were -- I was based out of Chatham 24 and we basically covered anything within the County of 25 Kent.


1 Q: Okay. I understand that in 1990, 2 then, you became a supervisor with the Central Ambulance 3 Communication Centre in Wallaceburg? 4 A: That's right. 5 Q: And you held that position until July 6 of 1999? 7 A: That's correct. 8 Q: And, what service does this 9 Communication Centre provide? What's its function? 10 A: This Communication Centre is overseen 11 by the Ministry of Health and, at that time, we 12 dispatched ambulances for Kent and Lambton County and 13 also provided dispatching for Lambton County Volunteer 14 Services -- Volunteer Fire Departments, rather. 15 Q: What were your main responsibilities 16 as supervisor at the Central Ambulance Communication 17 Centre in Wallaceburg? 18 A: My general responsibilities were 19 overseeing the operations for -- ambulance operations 20 throughout the both counties and the volunteer fire 21 services. 22 Q: Okay. Can you describe the main role 23 and function of the -- well, let me ask you this, did 24 dispatchers operate under your supervision? 25 A: Yes, they did.


1 Q: And, can you describe the main role 2 and function of a dispatcher? 3 A: The main role of a dispatcher, it's - 4 - in the operations room itself, at the period of time, 5 we had -- we had generally three (3) people; a call- 6 taker, a dispatcher and then a supervisor. That was 7 during the day shift and we were -- had a reduced staff 8 in the night shift. 9 We would have a -- one (1) of us would act 10 as a dispatcher or the call-taker and then there -- there 11 was a supervisor to oversee the operations. 12 Q: And so, the supervisor took on a dual 13 function in the night shift? 14 A: Yes, exactly. 15 Q: And, that dual function could be 16 either that of the -- the call-taker or the dispatcher? 17 A: That's right. 18 Q: And, so you had experience with 19 respect to both positions at this centre? 20 A: That's right. 21 22 (BRIEF PAUSE) 23 24 Q: And just to be clear, the 25 geographical jurisdiction served by this service included


1 the Forest and Ipperwash areas? 2 A: Yes, it did. 3 Q: Can you just describe for us in a 4 very general way what process was followed when a -- when 5 the centre receives a 911 call for assistance? 6 A: When our centre receives a 911 call, 7 if it originates within Lambton County, the -- when 8 someone dials 911 it goes from -- it goes directly to the 9 Sarnia police service and they, in turn, branch it out to 10 -- they distribute it to ambulance, OPP or if it's for a 11 volunteer fire nature, it'll come to our centre as well. 12 But, they'll come in on various lines so 13 we can identify which -- generally, which service is 14 required; not all the time, but just most of the time. 15 Q: All right. So, the 911 call by the 16 person making the call goes to the Sarnia police service? 17 A: That's correct. 18 Q: And then that, in turn, gets patched 19 over to you? 20 A: It gets routed to us. 21 Q: Routed to you and to the OPP? 22 A: No, routed -- if it's OPP nature, if 23 it's -- if it's for an accident, they may be -- may come 24 to us and then we, in turn, notify the OPP or it has 25 happened before that the OPP is notified prime -- as a


1 primary service -- 2 Q: All right. 3 A: -- and they, in turn, notify us. 4 Q: All right, and whoever is on duty as 5 the call-taker during that particular shift is the one 6 who will receive the call at first instance? 7 A: That's right. 8 Q: And then normally the -- the call- 9 taker would do what? 10 A: They would answer the call in the 11 fashion they have been trained for; police, fire 12 ambulance. And once it's -- once the caller identifies 13 which service they need, the call taker would identify 14 where they are, what's required, what service is required 15 and as soon as they determine, as an example, if it's an 16 emergency call for the ambulance, they just determine the 17 priority. 18 They can establish the priority of it and 19 then while the caller is still on the line, they will set 20 the -- activate the system and the call is entered into 21 the computer system and it would show up on their 22 partner's computer screen. 23 Q: So, the information gets transmitted 24 to the dispatcher? 25 A: That's correct.


1 Q: Okay. And then what happens? 2 A: At that time, the call taker, if it 3 was myself, would continue speaking with the caller, 4 advising them that the ambulance is on the way. 5 At this time, the dispatcher is 6 determining where it is within the County, they're 7 determining their resources, which ambulance is closest 8 or is it going to be assigned to a particular station, 9 and then they are paged-off and they respond. 10 Q: All right. 11 12 (BRIEF PAUSE) 13 14 Q: Now, I will certainly we'll come back 15 to your time at the Central Ambulance Communications 16 Centre, but I just want to finish off your employment 17 chronology. 18 As I understand it, from July of 1999 to 19 February of 2001, you were employed by the Chatham, Kent 20 police service as an emergency communicator in their 21 police communications centre? 22 A: That's right. 23 Q: Can you just tell me what your -- 24 your main roles and responsibilities in that position 25 were?


1 A: I was an emergency dispatcher within 2 the communications centre of the Chatham police service. 3 Q: Hmm hmm. And is this with respect to 4 dispatching police units? 5 A: Dispatching police units only. 6 Q: Okay. And I understand that you are 7 currently employed by the Sun Parlour (phonetic) 8 Emergency Services of Chatham, Kent in the role as a 9 paramedic and shift supervisor? 10 A: That's right. 11 Q: All right. When did you first learn 12 of the occupation of Camp Ipperwash by First Nations 13 individuals? 14 A: I learnt it probably -- well, most 15 likely with my recollection being through the media. 16 Q: Through the media. 17 So, in or around the time it occurred or 18 commenced, I should say? 19 A: Around early 1990 sometime. 20 Q: Right. And to your knowledge, was 21 any contingency plan being developed in relation to the 22 occupation with an emergency response service component? 23 A: Yes, there was a -- an element of 24 planning in place. That was compiled basically by senior 25 members of management from our centre, Wallaceburg


1 Communications Centre, as well as owner/operators of 2 ambulance services within North Lambton, as well as head 3 office -- I'm sorry, regional office in London and head 4 office out of Toronto dealing with the Ministry of 5 Health. 6 Q: All right. And did this -- do you 7 know over what period of time this contingency plan was 8 developed? 9 A: No, I don't. 10 Q: Do you know whether it was closer to 11 the event of the Ipperwash Park occupation in '95 or 12 closer to the event of the Camp Ipperwash occupation in 13 '93? 14 A: I would -- I would believe it would 15 be closer to 1995. 16 Q: All right. Were you -- did you 17 participate in the -- in the development of this plan? 18 A: I -- I guess I could say I 19 participated. Only I have a very minor role in it. As I 20 stated earlier, the people that were generally involved 21 in these meetings were the senior people of regional 22 office, head office, owner/operators of the Adona 23 (phonetic) Services, my manager, maybe his administrative 24 assistant. 25 We were aware that these were going on but


1 the details weren't made available to us. 2 Q: All right. So, were you briefed at 3 any time with respect to the particulars of this 4 contingency plan? 5 A: No. It -- see with the ambulance 6 business you basically -- you're to be prepared for 7 everything all the time. There are contingencies set 8 aside which are -- are developed through the Ministry of 9 Health for their paramedics that in the event a large 10 scale incident involving a number of patients, a number 11 of victims, we have set protocols set aside. 12 Now, as far as the occupation or dealing 13 with the Ipperwash incident, there was nothing specific 14 made available to us. We just knew that sure it was 15 possible that there could be a number of victims. We 16 didn't realize the -- the extent of what was going on. 17 But, we had -- like I said it just wasn't 18 in -- in black and white saying this is what we could be 19 dealing with and in the event something's going to 20 happen, this is when it will occur. 21 Q: All right. And when you said that -- 22 that you were aware that there could be a number of 23 victims, is this specifically with respect to September 24 the 6th or was this with respect to the possibility that 25 there could be some kind of victims in relation to the


1 occupation? 2 A: This is just a general statement. 3 When the Ministry plans ahead, they basically; worst case 4 scenario. 5 Q: All right. And was this contingency 6 plan then being developed under the authority of the 7 Ministry of Health? 8 A: It was through conjunction with -- 9 oh, with the Ministry of Health, yes. 10 Q: So, it sounds to me that there was a 11 contingency plan being developed at the high managerial 12 levels but that persons who were actually dispatching and 13 -- and call taking and doing the supervising wasn't 14 provided with details of this plan; is that right? 15 A: That's -- that's right. And as far 16 as every -- every meeting that was scheduled whether 17 representatives from regional office or head office in 18 Toronto whether they attended, I don't know. 19 But, I would just presume that something, 20 that they forecast, of this nature you would think that 21 someone would be representing their -- their best 22 interest. 23 Q: All right. And do you know who then 24 from the Wallaceburg Central Ambulance Communication 25 Centre, who were the primary contacts who would have been


1 apprised of the details of this contingency plan? 2 A: I only -- could only name one right 3 now and that would have been the manager at the time. 4 That would be Gerry Kane (phonetic). And possibly his 5 administrative assistant at that time which was Judy 6 Carnegie. 7 Q: June...? 8 A: Judy Carnegie. 9 Q: Carnegie? 10 A: Yes. 11 Q: Thank you. Now were you on duty at 12 the Wallaceburg Ambulance Communication Centre on 13 September the 6th, 1995? 14 A: Yes, I was. 15 Q: And what was the start of your shift 16 time? 17 A: 19:00 hours; 7:00 p.m. 18 Q: And how long was the shift? 19 A: It's normally twelve (12) hours. 20 Q: And was it twelve (12) hours that 21 evening? 22 A: No, it was -- I think I left 23 approximately 8:30 the following morning. 24 Q: Had you been on duty on either 25 September the 4th or the 5th, 1995?


1 A: I can't -- well the 5th I was. I 2 started at 19:00 but prior to that I -- I'm not sure of 3 my schedule. 4 Q: All right. And had you received any 5 information from the police or otherwise with respect to 6 the Ipperwash occupation on September the 5th? 7 A: No. To the best of my knowledge 8 there was nothing stating that -- something was going to 9 occur, basically, you mean? 10 Q: Yes. 11 A: No. 12 Q: All right. Alternatively did you 13 receive any requests for ambulance services to the 14 Ipperwash Park or Army Camp area on September the 5th 15 that you can remember? 16 A: Yes. 17 Q: Okay. Do you recall what the 18 specifics of those were? 19 A: At approximately 9:00 p.m., 21:00 20 hours, we received a call from the communications centre 21 or the command post, from a Sergeant Reid, asking for an 22 ambulance to attend down to the MNR parking lot. 23 Q: All right, and this is -- this would 24 be which date? 25 A: That was the 5th.


1 Q: The 5th or the 6th? 2 A: It would be the 6th, I guess -- 3 Q: All right. 4 A: Yes. 5 Q: Just before we get to that, I was 6 wondering whether you had received any request for 7 ambulance services the day prior to the Ipperwash Park or 8 Army Camp? 9 A: I don't -- if we did, I don't recall 10 it now. 11 Q: All right, fair enough. Then let's 12 move back, then, to September the 6th, 1995. 13 A: Okay. 14 Q: My first question is: What 15 particular roles were you discharging that evening? 16 A: I was the shift supervisor, basically 17 in charge of all the operations -- 18 Q: Did you -- 19 A: -- for the County of Lambton as well 20 as the County of Kent. 21 Q: And given that this was a night duty 22 shift, did you have to perform any other functions? 23 A: I was -- we have to -- we sometimes - 24 - well, there's two (2) positions. The call taker or the 25 dispatcher, as I explained earlier.


1 And sometimes it just comes down to which 2 side do you want to take. One of us to has to do one job 3 or the other, and we're -- most of us are pretty easy to 4 work along with and I guess I just selected the call 5 taker position. 6 Q: All right. And who was your 7 dispatcher that evening? 8 A: My dispatcher was Jack Knight. 9 10 (BRIEF PAUSE) 11 12 Q: And just as -- by way of a general 13 information, did you take all of the calls that occurred 14 that night? 15 A: I wouldn't have taken all of them. 16 If was able to take them, physically, if I was -- if I 17 was not busy, I would have taken them. 18 Q: All right. 19 A: But if I was tied up, Jack would have 20 taken them. 21 Q: Fair enough, and conversely, did Mr. 22 Knight dispatch all of the ambulance units that night? 23 A: Pretty much the same thing. If he 24 was available to do it, if he wasn't tied up doing 25 another -- another task, he took -- that was his job,


1 that was his performance. 2 Q: Okay. Now you were indicating 3 earlier that, in terms of the procedures involved, that 4 there was a procedure for the call taker, taking certain 5 information and inputting it into a computer -- 6 A: That's right. 7 Q: -- format or program, and then that 8 information would be transferred to the monitor, or it 9 would pop up on the monitor of the dispatcher, so he 10 could then take it from there, so to speak? 11 A: After I input the information onto 12 the computer screen, as soon as I entered it into the 13 computer system, it would go over to Jack's computer, 14 Jack's monitors. 15 Q: All right, and so is it -- is it fair 16 to say that the information that you inputted into the 17 system that night, was inputted either at or close to the 18 time of the events that occurred that you were-- 19 A: Yes. 20 Q: -- that you were recording. 21 A: Yes. 22 Q: And similarly were you obliged by 23 your job to create these -- or to make these records, 24 input this information, at the time? 25


1 A: That's right. 2 Q: And did you so input that information 3 as part of your job -- 4 A: I did. 5 Q: -- that night? 6 7 (BRIEF PAUSE) 8 9 Q: Now, when you arrived for your shift 10 at about 19:00 hours, then, on September the 6th, were 11 there any arrangements in place to supply ambulance 12 service at the request of the OPP for the Ipperwash Park 13 occupation? 14 A: No. 15 Q: Were you given any briefing about the 16 possible need by the OPP to have special arrangements for 17 ambulance services and emergency response generally, to 18 Ipperwash Park or that area that evening? 19 A: No, I was not notified prior. 20 Q: Okay. And just to confirm, the 21 contingency plan of which you spoke of, that was not 22 implemented as far as you know, when you started your 23 shift on that evening? 24 A: That's correct. Had it been -- had 25 it been as -- for lack of a better term, scheduled, we


1 certainly have been made aware. 2 Q: Right, because you're the ones who's 3 -- who are actually dispatching -- dealing with the 4 police that night. 5 A: Exactly. 6 Q: And did you have a number by which 7 you were identified in the ambulance dispatch logs and -- 8 and records? 9 A: As an employee number, yes. 10 Q: And do you recall what that number 11 was? 12 A: At that time it was 98761. 13 Q: So if we see that number attached to 14 the record, then that -- the information was inputted by 15 you? 16 A: Yes. 17 Q: And, do you recall did Mr. Knight 18 have a separate number? 19 A: Yes, his number was 11330. 20 Q: All right. Now, I'm going to take 21 you to a number of taped telephone conversations shortly, 22 but before I get to that, in order to review the 23 specifics -- 24 A: Hmm hmm. 25 Q: -- of the occurrences that evening,


1 first of all, in the general level, how busy were you on 2 September the 6th relative to what -- what you would 3 consider to be a standard day in the job? 4 A: Extremely busy. 5 Q: Did you have regular contacts with 6 the OPP that evening? 7 A: Yes, we did. 8 Q: And who -- who would have originated 9 these calls or made -- initiated these calls? 10 A: To the OPP? 11 Q: Well, as between yourselves and the 12 OPP? 13 A: Oh, it was either the OPP Command 14 Post contacting us or myself contacting them. 15 Q: And, in general terms, what type of 16 general information were you conveying to the OPP when 17 you were initiating calls to them? 18 A: Basically, anything of relevance to - 19 - to ambulance operations, which would involve the 20 police. That could have been calls that we had received 21 or concerns that we had, just asking them regarding 22 staffing levels of ambulances where they -- what minimum 23 did they want us to observe, that sort of nature. 24 Q: All right. And what general type of 25 information were you, in turn, receiving from the OPP


1 over the course of that evening? 2 A: They were -- they were concerned with 3 the locations of our ambulances and the -- the number of 4 ambulances that we had available for the situations. 5 Q: All right. And I gather that there 6 were two (2) staff working in the office that evening? 7 A: At my -- my location? 8 Q: At your office? 9 A: Yes. 10 Q: And over the course of the evening 11 were you also maintaining some level of contact with 12 other organizations besides from the OPP? 13 A: Many others. 14 Q: And can you recall the primary ones? 15 A: London Dispatch, that's -- we are 16 notified -- we are referred to as Wallaceburg Central 17 Ambulance Communication Centre and then there was the 18 London Central Ambulance Communication Centre. 19 Obviously, they're located in London. They're 20 responsible for a geographical area including Middlesex, 21 which would be a neighbouring county to Lambton. 22 Q: Okay. And why would you keep -- be 23 keeping them in the loop? 24 A: Well, the -- the ambulance service is 25 basically a -- a seamless -- what's the word I'm -- I'm


1 looking for? 2 Q: Organization? 3 A: Organization and in the event there's 4 an emergency, it doesn't matter which ambulance service 5 you belong to, whether it's Hamilton, Niagara, Sarnia, 6 Forest, wherever the ambulance is required for emergency, 7 that ambulance responds. 8 We also have -- we were also communicating 9 with them because with the ambulances in our own 10 catchment area that were being used, and possibly 11 committed, we required some of the use of -- of theirs. 12 And so we would basically request them 13 through the computer system as well as speaking with them 14 over the telephone, apprising them of what's going on in 15 our area. And we would basically borrow their -- their 16 services. 17 Q: All right. So, if you found yourself 18 in a shortfall, you would call London and request them to 19 dispatch some of their units to your area? 20 A: Right. 21 Q: All right. What other organizations 22 were you in -- in contact with? 23 A: Besides London Dispatch, we were 24 communicating with two (2) hospitals as well as the day- 25 to-day basis -- day-to-day operations, I specifically --


1 once the -- this incident got underway, I made it known 2 to two (2) hospitals that there may be a possibility of 3 casualties. We had no idea how many due to the forces of 4 what, but it was always our mandate to keep everybody 5 made aware of the worst-case scenario, basically. 6 Q: And so this was a precautionary 7 measure once you had some notice that there was possibly 8 going to be an increased demand on your ambulance 9 service? 10 A: It's a precautionary and it's a 11 professional courtesy, basically. 12 Q: And which hospitals did you notify? 13 A: I notified Sarnia General Hospital 14 Emergency Department and spoke with Dr. Madison there. I 15 briefed him on the situation. And I also spoke with, I 16 believe her name was Lisa at -- at Strathroy. 17 I also let her know what was going on, the 18 same information, and there was a possibility of 19 receiving injured parties. 20 Q: And so was -- did you make these 21 calls prior to actually affecting a transport of any of 22 the injured parties that night? 23 A: Quite -- quite a bit before. 24 Q: All right. 25 A: I also notified them after the


1 initial reports of -- of some injured parties. The two 2 (2) hospitals were once again notified. 3 Q: All right. 4 A: I also notified upper management from 5 my service as well as the regional office. 6 Q: And did you also have contact with a 7 911 operator from time to time that night? 8 A: Yes. 9 Q: Are those the primary organizations 10 then with whom you had contact that evening? 11 A: As well as the OPP, yes. 12 Q: Okay. Now was a decision made at 13 some point during the evening as to what hospital a 14 particular patient would be taken to by your service? 15 A: I -- oh, another person that I didn't 16 mention was Mac Gilpin. Mac was a service owner operator 17 of Forest among others and Mac is very knowledgeable in 18 that -- in that area. 19 We have -- basically it's understood that 20 the ambulance dispatch centre has ultimate control over 21 all the land ambulances. Now I may have been in the 22 business for -- for a while but I certainly don't want to 23 do something on my own because there's other people that 24 have -- you have to share the knowledge. 25 He has more expertise in various things


1 and he can think of something that I don't. And so I 2 kept him updated. And at one (1) point we even -- I even 3 conferenced -- did a conference call with Mac Gilpin and 4 Bob Cousineau at the command post. 5 Q: The Sergeant Cousineau. 6 A: Sergeant Cousineau, sorry. Just to 7 keep everybody up on the -- 8 Q: All right. 9 A: -- the facts. 10 Q: And you said that it was the -- your 11 -- your offices responsibility for determining which 12 hospital a particular party -- patient would be 13 transported to? 14 A: It's not so much my responsibility. 15 It's -- everybody takes an interest in the patient and 16 there are times when we co-ordinate and we discuss even 17 openly over the air if necessary. 18 It's not the -- it's not the most optimum 19 situation but if -- if I decided that it was Sarnia 20 General was closest and somebody from within the area 21 that knew the area better thought it might have been 22 Strathroy then we would've gone to Strathroy. But after 23 looking at a map it looked Strathroy was the closer of 24 the two (2). 25 Q: All right. And so who made the


1 decision that night that these patients would be 2 transported to -- that if there were any patients, they 3 would be transported to Strathroy Hospital? 4 A: I did. 5 Q: Who made that call? 6 A: I did. But I didn't -- I don't think 7 that was conveyed to the ambulance crews. There -- they 8 were experienced enough and when -- when the first 9 ambulance crew left with a patient, I don't believe we 10 instructed them where to go. 11 Q: Would you have expected the -- the 12 OPP to have made that call without your input? 13 A: No. 14 Q: That wouldn't be the practice or 15 protocol in place? 16 A: That's certainly not their -- their 17 practice and they're -- they pretty much leave us to make 18 our decisions. It's not their field. 19 Q: All right. And did you consult with 20 Mr. Gilpin in respect of determining that -- that the 21 Strathroy Hospital would be used? 22 A: I believe I did. 23 Q: And you say you didn't communicate it 24 to your land crews. So how would they -- how would -- 25 obviously Mac Gilpin was one of the attendants that


1 night, wasn't he? 2 A: Mac is very communicative and when we 3 were -- oh, sorry, Mr. Gilpin's very communicative and 4 I'm sure that once our conversation was finished anything 5 of relevance would have been passed onto his crews, 6 without a doubt. 7 Q: And I wanted to ask you what factors 8 you took into account in ultimately determining that the 9 Strathroy General Hospital would be the hospital of 10 choice if you will, over the Sarnia Hospital? Because I 11 know you called both. 12 A: The Ministry of Health has a -- a 13 very strong reference to an emergency goes to the closest 14 facility. However, it's -- it's -- it's appropriate care 15 that if you have a number of victims who are severely 16 injured, depending on the -- if -- even if Strathroy is 17 closer than Sarnia General it doesn't make sense to have 18 everyone go to Strathroy. You would basically split 19 them. 20 And we have an opportunity, as well, to 21 have a consult with the base hospital physician, who 22 basically governs our practices within the county, of 23 paramedics. 24 They would -- they could ultimately decide 25 where the patients are going to go.


1 Q: All right, now as I understand your 2 answer, I think you're saying that if there was an 3 abundance of patients, that -- then you would consider 4 splitting them between the two (2) hospitals? 5 A: That's right. 6 Q: And did you speak with either of the 7 -- the contacts at Sarnia or Strathroy, and did you 8 receive input in that respect from them? 9 A: Dr. Madison (phonetic) mentioned that 10 if there is an opportunity that there was -- if it did 11 present to us that there was a number of patients 12 involved in this situation, that they should be split. 13 Q: All right, and he was from the Sarnia 14 hospital? 15 A: That's right. 16 Q: I'd still like to know, though, why 17 your -- the preference was to be given to, as it sounds 18 like, to Strathroy general hospital as the first hospital 19 to send patients to, over Sarnia? 20 A: The geographical area. I believe 21 it'd be closer. 22 Q: All right, so it was just -- 23 A: In time. 24 Q: -- a question of distance and time? 25 A: And time, yes.


1 Q: All right, were you knowledgeable 2 about the respective capabilities of those two (2) 3 hospitals? 4 A: When you -- when you look at an 5 emergency department, they can basically handle the same 6 as far as it goes as life threatening intervention, 7 saving a life and maintaining a life. 8 As far as specialized features that were 9 offered by Sarnia General, they had more -- more to 10 offer. It's a bigger community, it's a larger hospital, 11 more staff, more available tools to use. CT scanners is 12 an example. 13 I don't believe Strathroy has one (1) now, 14 even if they did back then and the number of staff at 15 Strathroy would have on, would be, I'm presuming, less 16 than Sarnia General. 17 But a lot of it comes back to, if there's 18 only a few victims, they would go to the closest 19 facility. 20 Q: All right, now I guess your -- your - 21 - you'd expect your paramedics attending on the injured 22 person to do an initial assessment of the severity of 23 their injuries? 24 A: Right. 25 Q: And if they felt that it was more


1 appropriate to go to the Sarnia hospital because of the 2 particular equipment and facilities they had there, what 3 would happen? 4 Would they call you or...? 5 A: They would have called me or they 6 would have just gone mobile to Sarnia and said we believe 7 that this patient could require better services, 8 possibly, at -- at the Sarnia General hospital. 9 Q: All right, so as I understand it, you 10 had two (2) hospitals in mind that night, the Sarnia and 11 the Strathroy. Generally speaking, patients would be 12 sent to Strathroy because of the -- it was closer, but in 13 the final judgment you expected the paramedic to exercise 14 some form of judgment with respect to the severity of the 15 injuries? 16 A: I guess I -- I didn't expect them to. 17 I think that's just a given. I don't mean to be -- I'm 18 not criticizing them or expecting them to do anything 19 more than they would normally do. 20 We have a lot of confidence in the people 21 on the road. I'm on the road now and at the time I was 22 in the dispatch office, but we had a lot of confidence in 23 the people on the road that they would make the 24 appropriate decision. 25 Q: All right, now at some point in time


1 during your shift on September the 6th, did you receive a 2 request for ambulance service in relation to the 3 Ipperwash Park occupation? 4 A: Yes, we did. 5 Q: Do you recall by whom? 6 A: I believe it was Sergeant Reid out of 7 the command post. 8 Q: And are you certain that he was with 9 the command post? 10 A: Right now, I -- no, I can't be 11 certain. I believe he was, though. 12 Q: And he was an OPP officer? 13 A: Yes, he identified himself as. 14 Q: Right. 15 16 (BRIEF PAUSE) 17 18 A: No, sorry, he just identified himself 19 with his rank. 20 Q: Okay, fair enough. 21 22 (BRIEF PAUSE) 23 24 Q: I'd like to refer you to Tab 5 and 25 it's Inquiry Document Number 1002002 and it's -- I


1 believe it's been filed as Exhibit P-345, Mr. Registrar? 2 THE REGISTRAR: Yes. 3 4 CONTINUED BY MS. SUSAN VELLA: 5 Q: And I'll first of all ask you, are 6 these records familiar to you? 7 A: Is this the ambulance commitment 8 form? 9 Q: That's -- that's one (1) of the pages 10 and it should be a series of pages -- 11 A: Oh, okay. 12 Q: -- which includes dispatch records 13 and incident reports et cetera -- 14 A: Yes. 15 Q: Do you recognize those documents? 16 A: Yes. 17 Q: And are these amongst the documents 18 that you had inputted information over the course of your 19 job that evening? 20 A: Yes, I did. 21 Q: Everyone will have to bear with me a 22 little bit, we're going to be jumping around quite a lot, 23 so we're going to take our time with this. 24 I'd ask you to go... 25


1 (BRIEF PAUSE) 2 3 Q: I'm going to ask you to go -- it's 4 faster to do it from the -- the end, five (5) pages from 5 the end of that document, or six (6) pages, I should say. 6 It's entitled, Wallaceburg CACC Disaster Notification 7 List. 8 A: Right. 9 Q: And, is this a document that you are 10 familiar with? 11 A: Yes, it is. 12 Q: Do you know who filled out that 13 document? 14 A: That would have been me. 15 Q: And it indicates that September the 16 6th, 1995 at 21:00 hours you were notified by Sergeant 17 Reid concerning occupation of Camp Ipperwash? 18 A: That's right. 19 Q: And does that information appear to 20 you to be accurate with respect to your first request of 21 that evening? 22 A: There was no reference made regarding 23 the occupation of Camp Ipperwash, but... 24 Q: Okay, but there was a request for 25 assistance at 21:00?


1 A: That's right. 2 Q: And, that was the first request that 3 you received from the police? 4 A: That's the first one I can recall. 5 COMMISSIONER SIDNEY LINDEN: I may be 6 wrong, Ms. Vella, but I don't think this part of the 7 document was part of the exhibit. 8 MS. SUSAN VELLA: Oh, all right, I wasn't 9 here to see that. 10 THE REGISTRAR: Yes, it was. 11 MS. SUSAN VELLA: All right. Mr. Worme 12 advises me that the entirety of the document would have 13 been put in as an exhibit. 14 COMMISSIONER SIDNEY LINDEN: Including 15 this part? 16 MS. SUSAN VELLA: It's all part of the 17 same Inquiry Document number. 18 COMMISSIONER SIDNEY LINDEN: I don't 19 remember seeing this part of it, so it's in there 20 somewhere. 21 MS. SUSAN VELLA: Well, we can 22 certainly -- 23 COMMISSIONER SIDNEY LINDEN: The pages 24 went up to 98 or something like that. I just didn't -- 25 MS. SUSAN VELLA: Up to 96?


1 COMMISSIONER SIDNEY LINDEN: If it's in 2 there, fine. 3 MS. SUSAN VELLA: And it's also on the 4 screen for these -- 5 COMMISSIONER SIDNEY LINDEN: I know it's 6 on the screen, but I just want to make sure it's part of 7 the exhibit. Is it? Okay. 8 THE REGISTRAR: I believe it is. Yes, it 9 is. 10 MS. SUSAN VELLA: Thank you very much for 11 that clarification. Thank you. 12 THE REGISTRAR: Page 92, Your Honour. 13 MS. SUSAN VELLA: In any event, I'm now 14 going to proceed to another document, if that's all 15 right? 16 17 (BRIEF PAUSE) 18 19 MS. SUSAN VELLA: I might proceed. Can 20 we go to Inquiry Document Number 5000205, please? 21 THE WITNESS: Where do I find that, 22 Susan? 23 MS. SUSAN VELLA: It's Tab 2, Tab 2 of 24 your binder. 25


1 (BRIEF PAUSE) 2 3 CONTINUED BY MS. SUSAN VELLA: 4 Q: Excellent, thank you very much. 5 Now, this is an incident report and I 6 believe it's also part of the prior exhibit. 7 Do you recognize this incident report? 8 A: Yes, I do. 9 Q: And is this something that -- that 10 you inputted the information onto? 11 A: Yes, I did. 12 Q: And looking at the report, when -- 13 when did you input it, the time? 14 A: I started the incident report 15 September the 7th at 00:25 hours. 16 Q: All right. So, twenty-five (25) 17 minutes after midnight? 18 A: Right. 19 Q: Okay. And in the first paragraph, 20 perhaps you can just refer to that. It says that -- I 21 can't read the first word, but was: 22 "A call was received from Sergeant 23 Steve Reid of the OPP advising that 24 there was an ongoing situation at 25 Ipperwash and he was requesting one (1)


1 ambulance on site at the Forest 2 Ambulance base." 3 A: That's right. 4 Q: All right. And did -- did you comply 5 with that request? 6 A: Yes. 7 Q: It indicates then that the crew was 8 paged. And do you recall which crew it was that was 9 paged for this particular attendance? 10 A: That's right. 11 Q: Do you recall which crew it was? 12 A: Oh, sorry. Off-hand, I believe it 13 was Watt and Ted Ball. 14 Q: All right. And they were Unit 1146? 15 A: That's right. 16 Q: And do you recall approximately what 17 time they were dispatched or at least that they -- yes, 18 dispatched or notified I should say? 19 A: Notified? 20 Q: Let's see if I can help you. 21 A: I'm going to go to Tab 5 if that's 22 okay. 23 Q: First of all, can we make this 24 document the next exhibit, please? 25 THE REGISTRAR: P-346.


1 COMMISSIONER SIDNEY LINDEN: P 346. 2 3 --- EXHIBIT NO. P-346: Document 5000205 incident 4 report PU common place; 5 Ipperwash RD Lambton 6 standby on 06 September '95, 7 20:56:50 8 9 CONTINUED BY MS. SUSAN VELLA: 10 Q: And I'm going to refer you to page 14 11 of that document, the 14th page in. The front number on 12 -- the front number is -- ends in 9531 if that helps. 13 Do you have that? 14 A: 9531? 15 Q: Yeah. It's fourteen (14) pages in. 16 A: Oh, sorry, okay. Yes. 17 Q: All right. And this indicates -- 18 well perhaps you can just tell us what -- firstly, is 19 this a form that you inputted the information into? 20 A: That's -- this is part of the form. 21 The -- the initial -- the initial form that I complete is 22 the page prior to that -- 23 Q: Right. 24 A: -- which is Font Number 9530. 25 Q: Okay. So page 13?


1 A: When we want to initiate a call and 2 put a -- put an ambulance on top of a call in order to 3 have them move, we complete this -- this page which is on 4 our computer screen, we fill in the -- basically we fill 5 in the blanks. 6 Q: Right. 7 A: And commit it to the system -- 8 Q: Yes. 9 A: -- and in this case it was put 10 Ipperwash Road, that was just a -- a general term. 11 Q: Okay. 12 A: And then the next page indicates it's 13 a dispatch details. Dispatch meaning the location -- 14 Q: Right. 15 A: -- the unit that involved as well as 16 the times and the crew which was associated with that 17 ambulance. 18 Q: All right. So Unit 1146 of a crew of 19 Watt and Ted Ball were dispatched pursuant to Sergeant 20 Reid's request? 21 A: That's right. 22 Q: All right. And if I'm looking at the 23 times here it sounds like -- that you -- that they were 24 notified at approximately 8:56 p.m.? 25 A: That's right.


1 Q: Or 20:56. And then they're en route 2 at 21:41 or 9:41 p.m. So does that mean that that's the 3 time that they confirm they're actually on their way on 4 the road and on their way? 5 A: No. Sometimes when -- there are 6 times when -- if the dispatcher is busy, he doesn't get a 7 chance to advance the ambulance to the next position. 8 Q: Yes. 9 A: Just to indicate from received, the 10 call is notified, the crew is notified, the ambulance 11 advises they are on route or advise -- or arrive rather. 12 And if you could see at the bottom just to 13 the right of the remarks area, it says en route and 14 arrive scene are the same as 1145. 15 Q: Yes. Okay. 16 A: So basically the times will reflect 17 the time from 11:45. 18 Q: Okay. So that's another route -- or 19 unit? 20 A: Yes. And that would be found on page 21 on Font Number -- the top left number is 9536. 22 23 (BRIEF PAUSE) 24 25 Q: That's page 19 of the document. And


1 we see here Unit 1145 with Diceasor and Gilpin -- 2 A: That's right. 3 Q: And the indication is that the 4 arrival time -- 5 A: The arrival time there would be 21:53 6 hours. 7 Q: In other words, these two (2) units 8 arrived at the same time? 9 A: Pretty much, yes. 10 Q: Okay. And as I look at the two (2) 11 documents, it appears to be. 12 A: Right. 13 Q: Now, let me ask you this: The time - 14 - how do the times actually get recorded? 15 A: They get recorded -- as soon as a 16 request for ambulance is requested by a caller, if I can 17 remember correctly, it's a complex system with the 18 computer. I'm a very non-techie person, but in an 19 instance like this, we're trained on the computer and 20 it's -- there's a variety of steps and procedures we go 21 through. 22 Now, as an example, when a 911 come -- 911 23 call comes through the system, there's a sequence of keys 24 that we hit and what it does is it brings the page from 25 the first exhibit for the transfer, for the call details,


1 up on the screen. 2 And what we do, the information which 3 comes through the telephone lines from Sarnia police, the 4 911 server, it's quite complicated sometimes. 5 We hit another button and what it does, it 6 downloads or drops all that information into our -- our 7 screen, and that'll be the -- the caller's -- caller's 8 telephone number, where they're calling from, like their 9 address -- 10 Q: Yes. 11 A: And then from there we go on to make 12 an assessment and the priority that which has to be given 13 to the -- to the call. 14 Q: Okay. Just going back to how the 15 time gets actually -- how the time is determined -- 16 A: That's what I'm getting to, too. 17 Q: Okay. 18 A: Once it's -- as soon as we activate 19 that call to the system, as soon as we know that a call 20 is required -- 21 Q: "A call," meaning a request for -- 22 A: A request for -- 23 Q: -- an ambulance -- 24 A: -- ambulance -- 25 Q: Yeah.


1 A: For lack of a better term, we hit the 2 enter button -- 3 Q: Yes. 4 A: -- it's committed to the system. At 5 that time, the time on the upper right hand corner, not 6 at the very top, but the one underneath that, just above 7 the -- the word 'NARR', no, sorry, we should be on 9530, 8 then. 9 Q: This is the time -- would be -- 10 A: I'm on the -- 11 Q: -- 21:34:32, according to the 12 document behind you. 13 A: Okay, we're going to go by this one. 14 Okay, that's fine. 15 Q: All right -- 16 A: I was going by the -- the initial 17 one, but that's quite all right. As soon as it's 18 committed to the system -- is there a pointer? 19 Q: Yes, you should have a laser pen 20 there. 21 A: I told you, I'm not techy. 22 Q: No, me neither -- 23 A: Okay. 24 Q: -- as everyone will attest to here. 25 A: I think I have it.


1 Q: Okay. 2 A: This time right here, 21:34 -- 3 Q: Yeah. 4 A: As soon as the call is committed to 5 the system -- 6 Q: Right -- 7 A: After hitting enter -- 8 Q: Yeah. 9 A: That's the time that shows up, 21:34 10 and it's to the second. 11 Q: So the time is something that you 12 don't manually put in. It comes up automatically on -- 13 on the log from the computer system? 14 A: That's right. 15 Q: But that time is not crystallized 16 until you hit the enter button? 17 A: That's right. 18 Q: And so if there's a delay between the 19 taking of the information and the hitting of the enter 20 button, you wouldn't necessarily be able to tell from 21 this document? 22 A: Not on this document, but there are 23 other documents which would advise you that, yes, it is - 24 - there was a delay. 25 Q: Okay, fair enough.


1 A: And that gets more complicated. 2 Q: Well then, let's hold it. It's four 3 o'clock in the afternoon, so -- no, thank you very much 4 for that explanation. 5 The -- both of these units, then were -- 6 arrived at the scene at 21:53 approximately? 7 A: That's right. 8 Q: So that's 9:53 p.m? 9 A; Hmm hmm. 10 Q: Now where were they actually -- 11 where's the site they went to? 12 A: I believe them to be -- I believe 13 it's Parkway Drive. It's north of the intersection of 14 Highway 21 and Ipperwash Road. 15 Q: Right -- 16 A: Just -- 17 Q: Did you -- did you understand that to 18 be an MNR parking lot? 19 A: Yes. 20 Q: And that's where the two (2) units 21 were as of, approximately five (5) to 10:00 that evening. 22 A: Exactly, yes. 23 Q: All right. 24 25 (BRIEF PAUSE)


1 Q: Now, the initial request was for one 2 (1) ambulance, correct? 3 A: Right. 4 Q: Did you, then, subsequently receive a 5 request for a second ambulance? 6 A: Yes, we did. 7 Q: And, was that request from Sergeant 8 Reid as well? 9 A: I believe it was. 10 11 (BRIEF PAUSE) 12 13 A: I'm not certain, but I -- believe it 14 would have been. 15 Q: And I noticed on the documents that 16 this was a Code 8 response? 17 A: A code -- that's right. 18 Q: Meaning? 19 A: A Code 8 is a standby detail for 20 coverage. 21 Q: In other words, as far as you knew, 22 they weren't to be transporting patients at that time, 23 this was to be on standby in the event that they were 24 needed for transport? 25 A: That they were required, that's


1 right. 2 Q: Okay, fair enough. And just so that 3 everyone understands, behind you under "cancelled" dated 4 September 6th, 1995, there's a time of 2344, so 5 approximately sixteen (16) minutes to midnight, 11:45 is 6 cancelled. What does that mean? 7 A: That means that this detail here is 8 cancelled and it is no more. They are either reassigned 9 on another -- another detail, another call, or they're 10 cleared from this -- this detail; their -- their coverage 11 has been complete and they are -- have been requested to 12 return back to their station. 13 Q: All right. This document, though, 14 doesn't tell you, does it, whether they were at the MNR 15 parking lot for the entire time between 2153 and 2344? 16 A: No, it doesn't. 17 Q: All right. What I'd like to do next, 18 Commissioner, is play a series of conversations on 19 telephone. We'll have the Witness identify them. We'll 20 stop from time to time and there may be some counter -- 21 cross-reference to the documents. 22 I'll just explain to everyone. There are 23 excerpts of the transcripts in your documents, but 24 they're not comprehensive or complete and I'll try to 25 refer you to them. And you can come see me at 4:30 if


1 you need them further reference, okay? 2 3 (BRIEF PAUSE) 4 5 MS. SUSAN VELLA: Yeah, unfortunately, 6 that's beyond my capabilities. Ours are all on the 7 Supertech system. Kevin knows. Okay, Kevin knows. 8 Great, okay, just give me a second here. 9 COMMISSIONER SIDNEY LINDEN: How long are 10 these tapes, just -- 11 MS. SUSAN VELLA: Well, the first -- the 12 first conversation is approximately sixteen (16) minutes. 13 I shouldn't say conversation -- it's a series of 14 conversations. 15 16 CONTINUED BY MS. SUSAN VELLA: 17 Q: Would you go, Mr. Connors, to Tab 6, 18 please? And, it's Inquiry Document Number 1001992; it's 19 the logger tape Command Centre telephone logs. They're 20 probably on Volume 1 -- is it 1? Yeah, Volume 1 and, if 21 you would go to -- for everyone, it's page 63 of that 22 document. It's an entry dated 2300 hours. 23 We'll try to put it up on the screen as 24 well and it's -- Mr. Connors are you there? It's -- 9226 25 is the front number.


1 A: I'm here. 2 Q: Great. 3 A: Obviously, I don't have that page 4 number that you have there. 5 Q: No, I'm giving it various ways so 6 that people can -- 7 A: Okay. 8 Q: -- try to follow. 9 A: All right. 10 COMMISSIONER SIDNEY LINDEN: I'm sorry, 11 Ms. Vella, I'm not with you yet, you said page 63? 12 MS. SUSAN VELLA: Well, it's the sixty- 13 third page in. If you look for the entry 2300, sixty- 14 three (63) pages in and we're going to have it up on the 15 screen as well. 16 COMMISSIONER SIDNEY LINDEN: I just can't 17 find it. There's no page numbers on this. 18 19 (BRIEF PAUSE) 20 21 COMMISSIONER SIDNEY LINDEN: Thank you. 22 MS. SUSAN VELLA: All right. Is 23 everybody more or less together? Okay. 24 MR. ANDREW ORKIN: Page number? 25 MS. SUSAN VELLA: It's page number 966.


1 COMMISSIONER SIDNEY LINDEN: It's up on 2 the screen now. 3 MS. SUSAN VELLA: Okay. Okay, here we 4 go. 5 6 (BRIEF PAUSE) 7 8 MS. SUSAN VELLA: Let me just note that 9 the time comes from the OPP logger tapes, which I'm told 10 is -- is fairly accurate. 11 12 (911 CALL TRANSCRIPTION) 13 {SQUARE BRACKETS USED TO IDENTIFY BACKGROUND SPEAKERS} 14 15 911 OPERATOR: OPP in Chatham, can I 16 help you? 17 COUSINEAU: Yeah, I want to talk -- 18 talk to Dave. 19 911 OPERATOR: Okay, hold on. 20 21 (BRIEF PAUSE) 22 TEWKSGURY: Yeah. 23 COUSINEAU: Dave? 24 TEWKSGURY: Yeah. 25 COUSINEAU: You've got to send --


1 TEWKSGBURY: How many ambulances? 2 COUSINEAU: Send two (2) ambulances 3 down, okay? I'll give you directions. 4 They've got to go to the parking area 5 number 1, just off of Parkway Drive, 6 Ipperwash Beach, they have to... 7 8 (911 CALL TRANSCRIPTION ENDS) 9 10 CONTINUED BY MS. SUSAN VELLA: 11 Q: Now, do you -- do you recognize that 12 voice? 13 A: Yes. 14 Q: And who is that? 15 A: Sergeant Cousineau. 16 Q: Thank you. 17 18 (911 CALL TRANSCRIPTION CONTINUES) 19 20 COUSINEAU: ...come in on Ipperwash 21 Road -- 22 [(INAUDIBLE) you two go ahead] 23 COUSINEAU: -- and stay away from Army 24 Camp Road. 25 [That's 10-4 do you want to


1 (INAUDIBLE)] 2 TEWKESBURY: Okay. 3 COUSINEAU: They have to come in the 4 back way. 5 [Yeah, okay, I think we've got an 6 ambulance here already, I've just got 7 to find out where to send him.] 8 TEWKESBURY: Okay. 9 COUSINEAU: Okay. Well, get the two 10 (2) rolling anyways. 11 TEWKESBURY: Is it not easier for to do 12 it direct out bob, I'm not questioning 13 but (INAUDIBLE). 14 COUSINEAU: Okay, what -- just give me 15 a number. I don't have a direct line. 16 [(INAUDIBLE)] 17 TEWKESBURY: Get me a number for 18 Sarnia ambulance (INAUDIBLE). 19 [(INAUDIBLE)] [Well, we can't fucking 20 not go in now, not after they fucking 21 shot at us] 22 TEWKESBURY: Yeah, are they going to 23 come from Strathroy or Sarnia? 24 COUSINEAU: I have no idea, it's up to 25 CICC to decide.


1 TEWKESBURY: 337-2318. 2 COUSINEAU: 337? 3 TEWKESBURY: Yeah, 2318. 4 COUSINEAU: 2318? 5 TEWKESBURY: Cause directions are 6 getting screwed up. 7 COUSINEAU: Yeah, all right, I'll call. 8 Bye. 9 TEWKESBURY: Thank you, bye. 10 11 (911 CALL TRANSCRIPTION ENDS) 12 13 CONTINUED BY MS. SUSAN VELLA: 14 Q: Now, do you know what phone number 15 that is, the number that -- 16 A: That's -- that's referred to as a 17 public access line. 18 Q: Sorry. 19 A: It's referred to as a public access 20 number that the residents of the Sarnia area stretching 21 out as -- I -- I don't know how far out it would go but 22 they can access an ambulance by using that number or 911. 23 Q: All right. Thank you. We'll 24 continue on then. 25


1 (911 CALL TRANSCRIPTION) 2 3 KNIGHT: Ambulance 2307. 4 COUSINEAU: Hi, it's Ontario 5 Provincial Police in Forest calling. 6 KNIGHT: Yeah. 7 COUSINEAU: With the incident going on 8 in Ipperwash. 9 KNIGHT: Right. 10 COUSINEAU: We need two (2) ambulances 11 dispatched to our location. 12 [Inaudible] 13 KNIGHT: Two, where do you want them 14 at? 15 COUSINEAU: Okay, what they have to do 16 is they have to come in off 21 Highway 17 to go in down Ipperwash Road. 18 KNIGHT: Okay, they're at your 19 checkpoint now, up on Ipperwash Road. 20 COUSINEAU: Do you have comms with 21 them? 22 KNIGHT: Yeah. 23 COUSINEAU: Okay, can you check with 24 them... 25


1 (911 CALL TRANSCRIPTION ENDS) 2 3 CONTINUED BY MS. SUSAN VELLA: 4 Q: All right. Do you recognize the two 5 (2) voices, one (1) that -- on that tape? 6 A: Yes. Sergeant Cousineau -- 7 Q: Yes. 8 A: -- from the OPP and Jack Knight, the 9 previous witness -- 10 Q: So your dispatcher? 11 A: Right. 12 Q: And just for the record, the time 13 that this part of the call -- this call started is 23:02. 14 And I'll just continue through with it. 15 16 (911 CALL TRANSCRIPTION CONTINUES) 17 18 COUSINEAU: ...see if they need any 19 more because they've asked for two (2) 20 ambulances. 21 [(inaudible) ambulance is on their way] 22 KNIGHT: They've asked for two (2) and 23 that's all. 24 COUSINEAU: And that's our guys have 25 asked for two (2) and...


1 KNIGHT: Okay, at the checkpoint or 2 where do you want them? 3 COUSINEAU: Well, do you have comms 4 with your guys? 5 KNIGHT: Yeah. 6 COUSINEAU: Have -- find out where 7 they are. 8 KNIGHT: Yeah, okay. 9 COUSINEAU: Okay. 10 [POLICE UNIT: The ambulance. Don't 11 send the ambulance forward. 12 SPEAKER 1: They got it, it's right at 13 the (inaudible) 14 SPEAKER 2: There was a guy down 15 there. 16 SPEAKER 3: I've got ambulance on the 17 phone. 18 SPEAKER 2: So do I. Who you talking 19 to? 20 SPEAKER 3: I'm with Dispatch right 21 now. 22 SPEAKER 2: 1146 (inaudible). 23 UNIT 1146: (inaudible) 24 SPEAKER 2: 1146. Are either of you 25 moving at this time?


1 UNIT 1146: That's negative, just 2 getting in position here, we're -- we 3 could be sent, but it's (inaudible).] 4 5 (911 CALL TRANSCRIPTION ENDS) 6 7 CONTINUED BY MS. SUSAN VELLA: 8 Q: All right. Now we just heard some 9 background transmissions; did you recognize the -- the 10 name of the two (2) people in that transmission, 11 involving the reference to 1146? 12 A: Jack -- Dispatcher Jack Knight and 13 one of the crew members from 1146. 14 Q: All right. And he said that they 15 were in a -- they could be transporting and that they 16 were at the scene. 17 A: That's right. They were in position. 18 Q: And where was the scene? At the 19 scene? 20 A: Later on we -- we learned that, I 21 believe, they were at Army Camp Road and 21 Highway. 22 Q: And -- okay. Just hang on here. 23 This is still at 2300 though. 24 A: Right. 25 Q: All right. Just carry on.


1 (911 CALL TRANSCRIPTION CONTINUES) 2 3 [SPEAKER 3: We'll do that (inaudible). 4 Okay, John.] 5 KNIGHT: You want two (2) of them 6 there? 7 COUSINEAU: Okay. How many do you 8 have? 9 KNIGHT: There's two of them up there. 10 COUSINEAU: They already have two (2) 11 ambulances there and you have what? 12 KNIGHT: The one is on scene now. 13 COUSINEAU: One is on scene. 14 KNIGHT: And we're just trying to find 15 out whether they're both going to be 16 transporting or not. 17 [POLICE UNIT: We have gunfire. 18 (inaudible)] 19 COUSINEAU: Okay. 20 KNIGHT: You need the two (2) of them 21 there. 22 COUSINEAU: Well, yeah. Okay. What - 23 - what initially what we got was the 24 information was: Get two (2) 25 ambulances here, okay.


1 KNIGHT: Yeah. 2 COUSINEAU: We didn't know where they 3 were, we had an idea that they were 4 down at our TOC van. 5 KNIGHT: Yeah. 6 COUSINEAU: So you have two (2) on 7 scene? 8 KNIGHT: Yeah, they're... 9 COUSINEAU: Okay. 10 [POLICE UNIT: (inaudible) you can 11 handle (inaudible) telling them to back 12 off. 13 KNIGHT: Checking inaudible) they're 14 now apparently. 15 COUSINEAU: Right. Okay. That's why 16 we're calling. 17 KNIGHT: Okay. 18 COUSINEAU: Just make sure that -- 19 KNIGHT: Okay, you're...this is who? 20 COUSINEAU: This is Sergeant Cousineau 21 and I'm in the Command Post. 22 KNIGHT: Yeah, we've got Sergeant 23 Reid, I think, on the other line. 24 COUSINEAU: Yes, okay. You can tell 25 him to disregard. We're handling it


1 out here. 2 KNIGHT: Okay. Don't hang up. 3 COUSINEAU: Okay. 4 [SPEAKER 4: Tac 1, are you 10-4 on 5 the backup? 6 TAC 1: 10-4. We're backing out now, 7 over, it's covered by TRU. 8 SPEAKER 5: Shots were fired from the 9 bus. 10 SPEAKER 2: From what, from a vehicle? 11 SPEAKER 5: (inaudible)] 12 KNIGHT: Do you need more than two (2) 13 ambulances where you're at there? 14 COUSINEAU: Are -- are you talking to 15 your guy? 16 KNIGHT: Yes. 17 COUSINEAU: Okay. 18 KNIGHT: Yeah, no, you. 19 COUSINEAU: All I got was from our guys 20 that: Get two (2) ambulances. Okay. 21 You have two (2) ambulances there, 22 that's fine. 23 KNIGHT: Yeah, they should be there, 24 but they don't want you to hang up 25 either, for a second.


1 COUSINEAU: Okay. 2 KNIGHT: Does he need more out there 3 (inaudible) yet, than the ones we have? 4 [SPEAKER 3: I realize what's going 5 on. Can you find out if they need more 6 than two ambulances? One, two?] 7 KNIGHT: Well, they want two. 8 [We have no casualties.] 9 [We have them all. So they can cancel. 10 SPEAKER 2: (inaudible) says the 11 ambulance is not required, so cancel. 12 SPEAKER 3: That's -- okay. 13 SPEAKER 2: Oh yeah. We haven't 14 rolled any more. What they want to do 15 is, they already know they have two (2) 16 there, they want to know if we want any 17 more. 18 SPEAKER 3: No. 19 SPEAKER 2: So, okay. 20 SPEAKER 3: Just doing a checkpoint. 21 Is checkpoint Delta still there, 22 (inaudible) our guys? 23 SPEAKER 1: We got enough ERT people to 24 go back to those checkpoints.] 25 KNIGHT: Yeah. We're just trying to


1 make sure the code committed to move 2 another one up. 3 COUSINEAU: Yeah. I was going to say, 4 don't let the staffing level at that 5 location go down any lower than two 6 (2), okay? 7 KNIGHT: You don't want it any lower 8 than two (2)? 9 COUSINEAU: No. 10 [SPEAKER 2: We have ten (10) 11 uniforms, and (inaudible) six (6) 12 uniforms and ten ERT at Delta. 13 SPEAKER 3: Did you call John?] 14 COUSINEAU: Well, we had some shots 15 fired, but it's our understanding 16 nobody's been hit, so. 17 18 (911 CALL TRANSCRIPTION ENDS) 19 20 MS. SUSAN VELLA: Could you stop it? 21 Okay. 22 23 CONTINUED BY MS. SUSAN VELLA: 24 Q: Sorry about that. I'm a little bit 25 further than I intended to. Where was your understanding


1 as to the location of 1145 and 1146, the two (2) 2 ambulance units -- 3 A: That's -- 4 Q: -- as at this time, there was, at the 5 conversation here? 6 A: Initially we believed them to be at 7 the staging area, the MNR. 8 Q: Yes. MNR parking lot. 9 A: Right. And so back here we heard 10 from -- from the ambulance and they're trying to -- 11 whether or not -- to determine whether they're going to 12 be transporting. So I think we were caught off-guard 13 that we didn't realize that they -- their position had 14 moved. 15 Q: All right. And where did their 16 position move to? 17 A: I believe it was Army Camp Road and 18 21 Highway. 19 Q: All right. So where the Army Camp -- 20 Camp Ipperwash is located? 21 A: Correct. 22 Q: And you're indicating that you had 23 not been given advice, so in other words, you did not, or 24 Mr. Knight did not, or Mr. Knight did not dispatch your - 25 - crews to that particular location?


1 A: That's right. 2 Q: Do you have any information how, or 3 who directed the dispatching? 4 A: I can only presume that it would have 5 been -- the ambulance crews would -- definitely wouldn't 6 have done that on their own. It's my -- I can only -- I 7 can picture the situation that they would have been 8 directed by the OPP in the area. 9 And there -- there may have been reasons 10 for that but I'm not aware of them. 11 Q: Now is there any protocol with 12 respect to how it is, in the policing operation, how it 13 is ambulances are to be dispatched? In other words who 14 is supposed to do the dispatching? 15 A: The ambulance dispatch is supposed to 16 be the dispatcher. 17 Q: And not the OPP? 18 A: Right. 19 Q: Can you think of any exceptions to 20 that proposition? 21 A: Likely in a situation like this when 22 it's quite -- it could be a volatile situation. We're 23 not -- we're up in our office and we're not sure exactly 24 what's going on. We can certainly paint a mental 25 picture.


1 And we are very busy in this -- at this 2 point. We're trying to determine what's going on. We're 3 trying to keep our -- our staffing levels up and we're 4 just -- it's very -- it's very tense, we're just not sure 5 what's going to happen next. 6 The OPP may have moved them for a reason 7 being that if there was communication from the ambulance 8 to our dispatch centre -- 9 Q: Yes. 10 A: -- it might have been picked up or 11 intercepted by a scanner. The crews are well aware that 12 their -- all their movements are supposed to be 13 coordinated with the dispatch centre. 14 However, at the time, if the OPP was to 15 instruct them not to use communication, they would have 16 complied with that. There's obviously a good reason for 17 it. 18 Q: Fair enough. All right. Perhaps we 19 can -- now the -- let's proceed with the tape and perhaps 20 you can tell me, has there been a change in who's 21 communicating with the OPP at this point? 22 A: Okay. 23 24 (911 CALL TRANSCRIPTION CONTINUES) 25


1 [BACKGROUND: It's part of their team. 2 We better maintain that road block. 3 We got (inaudible) 4 Do you want to put through -- 5 Well, we got -- we got (inaudible) 6 right of way -- 7 No, they're in further..see we got six 8 on 21 Highway and ten down here why the 9 guys. 10 Why don't we head down here. 11 These are the guys -- 12 Why don't we put these guys up here, 13 never mind down here, put them up here. 14 Well you got a couple of places they 15 could get in there. 16 Well, you better (inaudible)] 17 COUSINEAU: All right. 18 [(inaudible) left open here on that 19 highway (inaudible). 20 Yes. Bring them all up. Just bring 21 all the (inaudible) back. 22 The 21 highway. 23 Get the (inaudible) 24 They still got no cover there. 25 Let's -- let's start with that.


1 Bring the ten ERT back out to the 2 corner and get the blue shirts in. 3 Lima one to Delta. Lima one to Delta. 4 The other ambulance should be okay 5 with -- 6 We've got lots of bodies down there We 7 got TRU down there. 8 We need another fucking TRU team. 9 I'm going to call Tony right now and 10 talk to him. 11 Yeah 12 (inaudible) calls, trying to phone me 13 right now from Thedford, right? 14 Absolutely. I mean -- and two ERT 15 (inaudible) at least call and say, hey, 16 you guys... 17 Now these calls they -- 18 You don't want the built up? Lima one 19 to Delta? Lima one Delta 20 Yeah, we got our fucking hands full 21 here.] 22 CONNORS: Sergeant Cousineau? 23 SERGEANT COUSINEAU: Yes. 24 CONNORS: Have you got two (2) people 25 shot up there? I'm getting another


1 call in here. 2 SERGEANT COUSINEAU: We had shots 3 fired but we have not been told of any 4 casualties or anybody had been hit. 5 CONNORS: Okay. I've got a 911 6 operator on here saying that there's 7 somebody on the phone right (inaudible) 8 two (2) people have been hit. 9 [Lima 2, Lima 1...lima 2, lima 1] 10 CONNORS: Now, two people have been 11 hit. 12 COUSINEAU: From where? Where -- 13 what's the... 14 15 (911 CALL TRANSCRIPTION ENDS) 16 17 CONTINUED BY MS. SUSAN VELLA: 18 Q: Okay, sorry. Do you recognize the 19 voice that's attributed to ambulance at this point? 20 A: That would be myself. 21 Q: All right, thank you. Carry on. 22 23 (911 CALL TRANSCRIPTION CONTINUES) 24 25 COUSINEAU: ...address location.


1 CONNORS: I've got it as 9780 Army Camp 2 Road. 3 [Do the two (2) of you have 4 (inaudible)] 5 COUSINEAU: 9780. 6 [Unit 2 do you have (inaudible) 7 9780. 8 COUSINEAU: Okay. Someone at 9780 is 9 on 911 saying two (2) people have been 10 shot. 11 CONNORS: Hang on. 12 (inaudible) 13 COUSINEAU: The 911 operator has got a 14 call from 9780 saying that they've got 15 two (2) people shot. 16 (Two conversations going on at same 17 time... second conversation in 18 parenthesis) 19 PARKIN: (Hello) 20 LINTON: (Tony) 21 PARKIN: (Yes) 22 LINTON: (Yeah, it's heating up we 23 got...) 24 COUSINEAU: What's the address? 25 CONNORS: It's -- it's a 901 address.


1 COUSINEAU: Which street? 2 LINTON: (Two guys were fired on from a 3 vehicle inside the park) 4 COUSINEAU: Are you there? 5 [Lima 2 Delta.] We want you to back 6 off to where the uniforms are. Back 7 off to where the uniforms are.] 8 CONNORS: Sergeant? 9 LINTON: (And the school bus tried to 10 run them over) 11 COUSINEAU: Yeah. 12 CONNORS: Okay apparently they hung 13 up. 14 COUSINEAU: They hung up? 15 CONNORS: Yeah. 16 COUSINEAU: Okay. 9780 what? Army 17 Camp or Parkway? 18 LINTON: (And they returned fire but 19 they don't believe they hit anybody 20 none of our people have been hit) 21 CONNORS: Army Camp Road. 22 COUSINEAU: Army Camp Road. 23 LINTON: (And they've backed off now) 24 COUSINEAU: And they've hung up? 25 CONNORS: Yeah.


1 LINTON: (And going back to the -- to 2 TOC) 3 COUSINEAU: Can they do a call back? 4 LINTON: (And John is...) 5 [(inaudible) Delta confirmed.] 6 Okay. 7 CONNORS: They know the (inaudible) 8 that number. 9 COUSINEAU: Okay. 10 LINTON: (We got the TRU team down, 11 we've sent the Barrie Team down) 12 Hang on. 13 [Delta and Lima 1 back off to where the 14 uniforms are at -- at the highway. Ten 15 four (10-4)] 16 LINTON: (We got volatile situation to 17 say the least and we can't have them 18 coming out of the park...) 19 [Lima 1 from Delta, 10-4] 20 LINTON: (In the work area obviously 21 and now they're shooting) 22 [(inaudible) 911 now.] 23 [They already advanced a ten four (10- 24 4).] 25 [Yeah. 9780 Army Camp Road. Just


1 follow the number of...] 2 3 CONTINUED BY MS. SUSAN VELLA: 4 Q: I'll just maybe pause it here. Now 5 this indicates that you received a 911 call or at least 6 your service did? 7 A: Right. 8 Q: From 9780 Army Camp Road requesting 9 assistance? 10 A: That's right. 11 Q: And that there had been gunshots -- 12 two (2) gun -- or two (2) people shot? 13 A: We had received information, the 911 14 line rang. Now, when -- ordinarily when we receive a 911 15 call, there's a reason that it's -- it's intercepted, not 16 intercepted, it's directed to the police initially. 17 Q: Yes? 18 A: And, then the police decide, 19 according to the caller, what service is required; 20 remember I spoke earlier that it's either OPP, Fire 21 Department or Ambulance? 22 Q: Right. 23 A: It's -- it's policy that the police 24 remain on the line just to listen, see if they're 25 required or -- and just for the -- just to monitor the


1 call. 2 And, at this time, when I accessed the 3 call, I was informed by the 911 operator, Sarnia Police, 4 in that case, that the caller had disconnected; they had 5 hung up. They had said they needed an ambulance and then 6 disconnected. 7 Q: All right. And, what does that mean 8 when they disconnect? What's the ramifications to you? 9 A: The -- the line has been -- the 10 physically hang the -- if it's a pay phone, they hang the 11 phone up in the cradle, we receive a steady tone 12 indicating that the line has gone dead because the caller 13 has hung up the phone. We have the ability to, at that 14 point, ring back to the -- to the pay phone or wherever 15 it originated and see if someone picks it up. 16 Now, as busy as we were in there, I 17 disconnected the line for a few reasons. 18 Q: What do you mean, you disconnected 19 the line? 20 A: Oh, I -- I hung up. Just let me 21 think about this. 22 Q: Perhaps we -- would you like to go 23 through your logs at this time to refresh your memory 24 about the sequence of events, or... 25 A: Sure.


1 Q: Okay. If everyone bears with me, 2 we'll go to -- back to Tab 5 of your documents. This is 3 Inquiry Document Number 1002002. We probably should -- 4 Exhibit 345. 5 A: What would be the font number, then? 6 Q: Sorry? 7 A: What would be the font number, then? 8 Q: Yeah, it's page 5 into that document 9 or 9522 and, in particular, pages 5 through 10, so the -- 10 up to font number 9527. 11 A: Starting at 9522, you said? 12 Q: 9522. 13 A: No, that's -- that's the other call. 14 Q: All right. Is this the later -- this 15 is the later call? 16 A: That's the later call, yeah. 17 Q: Okay. Okay, sorry about that. 18 A: That's all right. 19 Q: Sorry, keep going to page 8, then, 20 9525? 21 A: Okay. Actually, I'll find out for 22 you because that's the duplicate call. I'll explain that 23 one later, too. 24 Q: Okay. 25


1 (BRIEF PAUSE) 2 3 Q: I'm just looking at pages 8, 9 and 4 10. Is that all the -- the duplicate call? 5 A: What's that, 95... 6 Q: 25, 26, 27. 7 A: Right. We could use this one, as a 8 matter of fact. 9 Q: All right. Let's use this one. 10 A: We could use this one, okay. 11 Q: Okay. Is the information the same? 12 A: Yes, it is. 13 Q: All right. Let's use this one, then. 14 A: Okay. Remember earlier I said this 15 is even a more complicated example? 16 Q: I do recall something to that effect. 17 A: Do you want me to go through that? 18 Q: I -- what I want to know is, what 19 does this information tell you? 20 A: The -- the information -- okay, the 21 information on this screen, this is when the individual 22 that called from 9780 Army Camp Road -- 23 Q: Yes? 24 A: -- that information, basically, was 25 dropped down into our -- into our template on the screen,


1 then it was committed to our system; the telephone number 2 243-1255, that's in the left-hand side, and the 3 originator, obviously, we don't know who called from the 4 pay phone, so it just comes up as a Lambton 911 call. 5 Q: So, that's how you know it's a pay 6 phone? Okay? 7 A: No, we can't distinguish between -- I 8 know it's a pay phone now, but back then I didn't; I had 9 an idea it was, but I couldn't confirm it. 10 Q: All right. And in the next page, 11 does that give you the time it came in; 2311 on the 12 right-hand side? 13 14 (BRIEF PAUSE) 15 16 A: 2311? 17 Q: Gives you a phone -- 18 A: Yes, sorry -- 19 Q: -- number? 20 A: Yeah, pardon me, yes. 21 Q: All right. So, this call came in to 22 you at approximately -- 23 A: At 23:11. 24 Q: 23:11 -- 25 A: You're right.


1 Q: -- which gives us a sense as -- 2 A: Yes. 3 Q: -- to where we're at in the other 4 conversation? All right? 5 A: Now, after -- 6 Q: And then you can go to the next page, 7 with your narrative; the explanation. 8 A: Okay. After the call was received, 9 the Sarnia -- I'm just going to read that, I'm sorry. 10 Q: Sure. 11 A: "The Sarnia police dispatcher stated 12 the caller had hung up. The call was 13 disconnected at the time. I tried to 14 contact the party at the number listed, 15 but there was no answer." 16 Now, I didn't keep that line open. I 17 could have just put her on hold, or put the call on hold, 18 and just froze that line, basically. 19 Q: Meaning that they couldn't use it to 20 call out -- 21 A: Exactly. 22 Q: -- and no one else could call in? 23 A: Now, being in the business for a 24 number of years you that -- you realize that if 25 somebody's desperately needs help, they are going to call


1 back. 2 They did call in, Sarnia police advised 3 that they had hung up. Now, if I was going to try and 4 ring back and they didn't answer and, as busy as it was 5 in our dispatch centre, if I continued to let that ring 6 while I actioned another task, and that kept ringing, if 7 somebody really needed to call back and use that 8 telephone as a source, they wouldn't have been able to. 9 Q: So, in other words -- 10 A: So -- 11 Q: -- they couldn't have called you 12 back? 13 A: That's right. So, I made a decision 14 to sever the line. 15 Q: All right. 16 A: And it's a decision that had to be 17 made right away, but my thought was that if they called 18 once, they can call again -- 19 Q: All right. 20 A: -- without being impeded that if I 21 kept -- if I froze that line and they weren't able to 22 call back. 23 Q: Now, is this standard procedure that 24 you would sever the line so that they -- 25 A: No.


1 Q: -- can call you back? 2 A: No, it's not. 3 Q: Normally you'd keep it -- 4 A: Normally we -- 5 Q: -- frozen? 6 A: -- we keep it frozen and call back 7 and try and call back, actually. 8 Q: All right. 9 A: But, like I said, as busy as we were, 10 if I was doing something else -- 11 Q: Hmm hmm. 12 A: -- and somebody was trying to call 13 for help, it would have gone unanswered. 14 Q: Okay, fair enough. 15 A: Okay. 16 Q: Thank you. All right. So, let's go 17 back to the -- the telephone conversation. 18 19 (BRIEF PAUSE) 20 21 A: Susan, what's my -- what's the font 22 number again, please? 23 Q: It's 0009234. 24 A: Okay. 25 Q: Or page 7 of that conversation.


1 (BRIEF PAUSE) 2 3 (911 CALL TRANSCRIPTION CONTINUES) 4 5 LINTON: (So I think we'll if you 6 concur we'll activate the Barrie TRU 7 team to come down) 8 PARKIN: (Yeah.) 9 LINTON: (Jesus you know I don't ...) 10 PARKIN: (Do you want me to try and --) 11 COUSINEAU: What is the number? 12 CONNORS: 243-1255. 13 COUSINEAU: 2 -- 243? 14 CONNORS: 1255. 15 COUSINEAU: 1255? 16 CONNORS: Yeah. 17 LINTON: (They had arrested one guy by 18 the fence) 19 COUSINEAU: Are you going to ring 20 back? 21 CONNORS: I can't, I've already 22 disconnected. 23 COUSINEAU: Oh, you've already 24 disconnected? Okay, all right. 25 LINTON: (Right, right at the same


1 location, right as you go down the hill 2 there) 3 PARKIN: (All right, have we still got 4 the guy they arrested or did we lose 5 him?) 6 LINTON: (No, they -- they still...) 7 (INAUDIBLE) 8 [Yeah, I know. If I can find police 9 (INAUDIBLE). 10 (INAUDIBLE) right here, further on. 11 COUSINEAU: Do they still have 1092? 12 [Yeah.] 13 [(INAUDIBLE) I'm still up here. 14 (INAUDIBLE) have a car 15 FEMALE: (INAUDIBLE) still wait up 16 here (INAUDIBLE) 17 Right -- 18 FEMALE: (INAUDIBLE) got a call that 19 has nothing to do with that. 20 Well, two (2) people are shot. 21 Well, it (INAUDIBLE) here. 22 FEMALE: It's way in -- 23 (INAUDIBLE) 9780's up here. 24 No, it's off on Army camp road, so it's 25 got to be -- there's got to be a


1 problem there. 2 Well, yeah, well, that's what we're 3 telling you. 9780 is up here. Army 4 Camp Road is down here. 5 UNKNOWN MALE SPEAKER 1: Are you still 6 there? I just want to confirm that 7 address, you said 9780? I'm looking at 8 the map and that -- that number 9 shouldn't even be on there, like, 9780 10 puts it way up -- way up by -- it's up 11 by Stoney Point. 12 UNKNOWN: Well, you're not near Stoney 13 Point, are you? 14 UNKNOWN: Well, no, we're at Ipperwash 15 Beach. 16 UNKNOWN: Yeah, that's Stoney Point. 17 UNKNOWN: No, I -- I thought you were 18 exactly at location. All right. There 19 was a male caller and then he hung up. 20 UNKNOWN: A male caller that hung up? 21 UNKNOWN: Yeah. 22 UNKNOWN: Try calling the number back. 23 UNKNOWN: Army Camp Road, the 91 -- 24 911 but it's a cluster fuck there, 25 there's no such thing as --


1 UNKNOWN: Well, no -- 2 UNKNOWN: Well, that doesn't mean the 3 number's right. 4 UNKNOWN: Army Camp Road, Delta 5 whatever they are? Okay, we'll do that 6 through here? 7 UNKNOWN: No -- 8 UNKNOWN: We'll get back to you, okay? 9 Okay, got it. 10 UNKNOWN: (INAUDIBLE) is going to a 11 call back on that number. 12 UNKNOWN: You got it? Let me... 13 UNKNOWN: Breaker, Delta, we read you 14 over by (INAUDIBLE) go ahead. 15 UNKNOWN: Delta, we're coming up Army 16 Camp Road, Dave's at the Army Base. 17 We are in a low speed pursuit. Do you 18 wish us to continue to attempt to stop 19 this vehicle. 20 UNKNOWN: (INAUDIBLE) pursuing, 21 continue to form a wall. 22 UNKNOWN: 10-4, license 9-3-5 23 (INAUDIBLE) Tango, Ontario marker. 24 25 (911 CALL TRANSCRIPTION ENDS)


1 2 CONTINUED BY MS. SUSAN VELLA: 3 MS. SUSAN VELLA: I'm just pausing it 4 there. What we're hearing is -- is background radio 5 transmissions from the OPP end, is that right? 6 A: That's right. 7 Q: It's not from the ambulance end so -- 8 A: No, the ambulance is not included in 9 that. 10 Q: So, what we've just heard is that 11 there is pursuit going on -- 12 A: Right. 13 Q: -- and -- and a license plate number 14 was -- was identified. Do you know which pursuit that 15 was? 16 A: I'm believing it was, I think her 17 name's Marcie. I'm -- I can't remember. 18 Q: Marcie? So, that would be Marcia 19 Simon? 20 A: Yes. 21 Q: Thank you. And, just for record, 22 this is at the marker eleven (11) minutes fifty-eight 23 (58) seconds approximately into this tape. 24 25 (911 CALL TRANSCRIPTION CONTINUES)


1 UNIDENTIFIED SPEAKER: Continue to 2 follow (inaudible). 3 UNIDENTIFIED SPEAKER: Sure. 4 UNIDENTIFIED SPEAKER: We've got a 5 pursuit now. 6 UNIDENTIFIED SPEAKER: We've 7 deactivated our lights and we're 8 continuing to follow. 9 UNIDENTIFIED SPEAKER: Who (inaudible) 10 that, you? 11 UNIDENTIFIED SPEAKER: No, I can't. 12 UNIDENTIFIED SPEAKER: I'll do it. 13 UNIDENTIFIED SPEAKER: I'm not getting 14 an answer. 15 UNIDENTIFIED SPEAKER: (inaudible) 16 pursuit, the radio (inaudible) pursuit, 17 you? 18 UNIDENTIFIED SPEAKER: Sergeant 19 Cousineau? 20 COUSINEAU: Yes. 21 UNIDENTIFIED SPEAKER: I'm not getting 22 an answer there. 23 COUSINEAU: You're not getting any 24 answer? Okay. 25 UNIDENTIFIED SPEAKER: See if they can


1 find 97 whatever if there's a number on 2 there. There's two (2) people shot, 3 we're going to have to go. 4 UNIDENTIFIED SPEAKER: We called that 5 number back and there's no answer, 6 (inaudible) the number. 7 8 (911 CALL TRANSCRIPTION ENDS) 9 10 CONTINUED BY MS. SUSAN VELLA: 11 Q: Now, at this point, you're still on 12 the line, right? 13 A: That's right. 14 Q: You're waiting for them to try to 15 reach this number? 16 A: No, he asked me to try it. 17 Q: Okay. 18 19 (911 CALL TRANSCRIPTION CONTINUES) 20 21 UNIDENTIFIED SPEAKER 1: Okay. 22 Ipperwash is on Army Camp Road and they 23 got a number in the Provincial Park, 24 can we call somebody there? What's the 25 911 address for Ipperwash Provincial


1 Park and that will give us some sort of 2 feel for where we're at? 3 UNIDENTIFIED SPEAKER 2: That'll be 4 right down at the bottom. 5 UNIDENTIFIED SPEAKER: Where is the -- 6 where's the phone number, let's call 7 the superintendent of the Park there, 8 Kobayashi. 9 UNIDENTIFIED SPEAKER: Kobayashi, 10 there he is. 11 OPERATOR: We've got (inaudible) 12 information if you need it. 13 UNIDENTIFIED SPEAKER: (inaudible). 14 OPERATOR: '90 Dodge Spirit, four (4) 15 door. 16 UNIDENTIFIED SPEAKER: Cousineau. 17 UNIDENTIFIED SPEAKER: Go ahead. 18 COUSINEAU: So, you tried the number 19 and no luck, eh? 20 UNIDENTIFIED SPEAKER: I'll try it 21 once more for you, sir. 22 COUSINEAU: Thanks. 23 (INAUDIBLE) 24 UNKNOWN: That's Rob Graham from the 25 OPP.


1 UNKNOWN: But, listen I got an 2 altercation down there. 3 UNKNOWN: What's the (inaudible). 4 UNKNOWN: (INAUDIBLE) 5 UNKNOWN: We need an ambulance here at 6 21. 7 UNKNOWN: (inaudible) ambulance at 21 8 (inaudible) required an ambulance for 9 her son. 10 UNKNOWN: 530 -- 11 12 MS. SUSAN VELLA: Pause it. 13 14 (911 CALL TRANSCRIPTION ENDS) 15 16 CONTINUED BY MS. SUSAN VELLA: 17 Q: Did you hear that, that bit? And 18 who's saying that there's -- or a need for an ambulance 19 at 21 and Army -- and the Army Camp? 20 A: I'm not sure who it is but it's not 21 ambulance. 22 Q: All right. So, you presume it's the 23 police? 24 A: Right. 25 Q: Okay.


1 (911 CALL TRANSCRIPTION) 2 3 UNKNOWN: (INAUDIBLE) at the camp? 4 UNKNOWN: Yeah. 5 UNKNOWN: Okay. 6 UNKNOWN: (Inaudible) 7 UNKNOWN: Yeah, Delta from Lima 1. 8 UNKNOWN: Okay, there's going to 9 (inaudible). 10 UNKNOWN: How many? 11 UNKNOWN: Just one (1) ambulance and 12 we'll get it rolling, that's 10-4. 13 (inaudible) Ipperwash Road. 14 UNKNOWN: Okay, so this takes us -- 15 this is enroute. Mark? 16 (inaudible) 17 UNKNOWN: We should have someone to go 18 with that ambulance. This guy 19 (inaudible). 20 UNKNOWN: Hello? 21 UNKNOWN: Hi. 22 UNKNOWN: Yeah. Okay, apparently 23 somebody is coming out at the front of 24 the Army Camp Base and 21 Highway. 25 UNKNOWN: Yeah.


1 UNKNOWN: Reporting somebody's been 2 shot, okay? 3 UNKNOWN: From? 4 UNKNOWN: So, apparently somebody from 5 down at the scene is going to come 6 around and go to that scene, so you're 7 going to have to scramble another 8 ambulance out to the scene for 9 coverage. 10 UNKNOWN: 114 (inaudible). 11 12 (911 CALL TRANSCRIPTION ENDS) 13 14 THE WITNESS: At the time, that was Jack 15 Knight speaking with Sergeant Cousineau. 16 17 CONTINUED BY MS. SUSAN VELLA: 18 Q: All right. With respect to the 19 request for an ambulance to go to the Army Camp Base at 20 21 and Army Camp Road? 21 A: That's right. And, at the same time 22 -- so he got a -- I'm obviously committed doing something 23 else. 24 Q: You're trying to reach the Park 25 store?


1 A: I'm doing that, as well as I'm 2 probably doing day-to-day -- or day-to-day business as 3 well, like, in another county, doing ambulance work. 4 Q: Right. Okay. 5 A: And so Jack has basically taken over, 6 waiting for Sergeant Cousineau to come back on the line 7 and he's speaking with his ambulances. 8 Q: All right. And just that -- for the 9 record, that's at approximately the sixteen (16) minute 10 marker of this particular taped conversation. Okay. 11 Thank you. 12 Let's play out the rest of the 13 conversation. 14 15 (911 CALL TRANSCRIPTION CONTINUES) 16 17 UNKNOWN: (Inaudible) Ambulance going 18 up Ipperwash Road around (Inaudible) 19 UNKNOWN: Yeah, they're both heading 20 up -- 21 (Inaudible) 22 UNKNOWN: -- heading up to the Army 23 Camp main entrance. 24 UNKNOWN: Okay. Both the ones down at 25 the scene?


1 UNKNOWN: Yeah. 2 UNKNOWN: Okay, so you're going to 3 have to scramble a couple more down. 4 UNKNOWN: Yeah, and you want them up 5 on Ipperwash Road, at the checkpoint? 6 UNKNOWN: Yeah, please. 7 UNKNOWN: Okay. 8 UNKNOWN: Okay? 9 UNKNOWN: Yeah. 10 UNKNOWN: Thanks. 11 UNKNOWN: Okay. 12 UNKNOWN: Bye. 13 14 (911 CALL TRANSCRIPTION ENDS) 15 16 CONTINUED BY MS. SUSAN VELLA: 17 Q: All right. That's -- that's the end 18 of that -- the conversation. Now, as I understand it, 19 then at this point there's a call to go to the Army Camp 20 Base in relation to a particular request for transport of 21 an injured party, that Jack Knight is handling? 22 A: Okay. 23 Q: Is that right? 24 A: You're talking about the ones that -- 25 Q: The one we've just heard?


1 A: Oh, sorry, yeah. I -- I was thinking 2 ahead of you. 3 Q: No -- 4 A: You're right. 5 Q: -- we're still on this tape -- 6 A: Sorry. 7 Q: -- and then we're going to end there 8 for the day. 9 A: You're right. 10 Q: So -- all right. And the indication 11 is that two (2) more -- is it two (2) more units need to 12 go -- 13 A: For coverage to the area -- 14 Q: -- for coverage to where? 15 A: Presuming the MNR. 16 Q: The MNR parking lot? 17 A: That's right. 18 Q: To replace the two (2) units, 1145 19 and 1146, that have left and now are enroute to Army Camp 20 Road and 21? 21 A: That's right. 22 Q: Okay. And I just want to take you to 23 -- to the logs in this situation. 24 If you'd go back to Tab 5, please. And if 25 you would look at -- it's twenty-five (25) pages in but


1 it's Font Number 9542. You should see the name 2 identified, Nick Cotrelle on it? 3 A: Right. 4 Q: And I'll just wait until it gets up 5 on the screen. 6 7 (BRIEF PAUSE) 8 9 Q: All right we've just put it up on the 10 screen there. 11 And from pages 25 through to 30 12 consecutively so up to font number 9547. This is the 13 detail with respect to the attendants to transport Nick 14 Cotrelle. 15 16 (BRIEF PAUSE) 17 18 Q: Is that correct? 19 A: Sorry. Yeah, yes, that's correct. 20 Q: Yes, thank you. And it looks like if 21 we go to the first page of that, that is 9542 that the 22 call came in to you, that is the request for an ambulance 23 at about 2311 that evening? 24 A: I can tell that this wasn't received 25 from an outside source, being a telephone line. We


1 created this call ourself. 2 Q: Yes. Because you received the 3 information from a police officer? 4 A: That's right. 5 Q: Right. And did you receive this 6 information at about 2311 or that vicinity? 7 A: We received the information from the 8 ambulance crew, that they may be transporting. 9 Q: Okay. 10 A: And the police, they did say move 11 your ambulances towards that area -- 12 Q: All right. 13 A: -- but at the time we had no idea 14 that we would be transporting in here. 15 Q: Then let's go to the next page, 9543 16 is the last four (4) numbers of the front number. It 17 indicates that Unit 1145 with the Ceasor and Galpin were 18 -- now you say you created this; maybe you should just 19 tell us what this information tells you with respect to 20 the time of dispatch and arrival? 21 A: At 2311 we created the call when we 22 realized that at least one (1) ambulance may be 23 transporting a victim. At 2311 they -- we put them on 24 scene. As you can see the -- the ambulance call was 25 created, they were notified en route and arrived all at


1 the same time. 2 Q: Right. 3 A: The one underneath that -- 4 Q: 1146? 5 A: 1146. 6 Q: Yes. 7 A: -- the times don't reflect at 2316; 8 they don't reflect 2311, but they were together. 9 Q: Okay. 10 A: As -- normally the time for change to 11 -- to reflect each other. As you can recall in an 12 earlier exhibit, the -- the time -- it did say there was 13 a narrative that says that the time is the same as 1145. 14 We were very busy in there and a lot of 15 things can slip your mind sometimes and Jack just didn't 16 change the time on that. 17 Q: All right. Well, let's go to -- do 18 you recall which of these units actually transported Mr. 19 Cotrelle? 20 A: Unit number 1146. 21 Q: All right. So let's go to the next 22 page, 9544 and this -- this indicates the activities of 23 1146. 24 A: That's right. 25 Q: Indicates that they departed the


1 scene -- so they arrived at the scene at 2316 and then 2 departed at 2339. 3 In other words does that mean that they 4 arrived at the Army Camp Base corner at about 2316, but 5 that they didn't start transporting Mr. Cotrelle until 6 approximately 2339? 7 A: Right. But you have to remember that 8 2316 time is actually 2311. 9 Q: How do you know that? 10 A: Because on this one (1) here there's 11 an asterisk -- 12 Q: Yes. 13 A: Right here. 14 Q: Yeah. 15 A: Now when that time is changed the 16 computer will -- flags that basically with an asterisk to 17 indicate to whoever's reviewing it, that the time has 18 been altered. 19 Q: Does that mean that the -- would a 20 logical explanation mean -- be that Mr. Knight entered, 21 pushed the enter button for the arrival information at a 22 later time -- 23 A: Well -- 24 Q: -- than it actually -- 25 A: I would've -- I would've believed


1 that the two (2) crews would have been together. 2 Q: Yes. 3 A: In a situation like this, I don't 4 think they would have been independently, one (1) goes 5 and then another one (1) follows five (5) minutes later. 6 I think they would have been together. 7 Q: All right. 8 A: On the very bottom in the Remarks 9 area right here, we utilize a number of short forms. And 10 PIE, this means 'punched in error'. 11 Q: Okay. 12 A: And there's an explanation that it 13 came from a crew member, Mark Watt. 14 Q: All right, so that -- that's the 15 basis of -- 16 A: But I would presume that it's -- the 17 arrive scene should be 2311. 18 Q: All right, thank you. 19 A: Actually, you know what? The -- the 20 one preceding that, 2311 should have been changed to 21 reflect 2316, so I would say 2316 is more accurate 22 because it probably took them four (4) minutes to get 23 from where they were on Ipperwash Road over to Army Camp 24 Road. I had them backwards. 25 Q: All right, fair enough. I appreciate


1 that clarification. 2 So, likely both units arrived at the 3 corner of 21 and Army Camp Road at around 2316 and then 4 Unit 1146 started the transport of Mr. Cotrelle at 5 approximately 2339? 6 A: Correct. 7 Q: Thank you, and perhaps on -- well, 8 let me do the following. I'd like to enter the logger -- 9 the logger tape command centre document, which is 1001992 10 as an exhibit, because we'll continue to refer to this 11 document. 12 THE REGISTRAR: P-347, your Honour. 13 COMMISSIONER SIDNEY LINDEN: P-347. 14 15 --- EXHIBIT NO. P-347: Document 1001992 logger tape 16 command centre three 17 telephone lines 06 September 18 '95, 19:50 to 23:49 hours 19 20 CONTINUED BY MS. SUSAN VELLA: 21 Q: And I'd like to make the -- the CD 22 which contains a number of tracks and we're listening to 23 it right now, as the next exhibit, please. 24 THE REGISTRAR: P-348, your Honour. 25 COMMISSIONER SIDNEY LINDEN: P-348.


1 --- EXHIBIT NO. P-348: CD-Rom of EMC Calls September 2 6/7,1995. 3 4 MS. SUSAN VELLA: And, Mr. Commissioner, 5 I would suggest that we break for the day, as we'll be 6 commencing with a second taped transcription tomorrow. 7 COMMISSIONER SIDNEY LINDEN: Sounds good 8 to me. 9 THE WITNESS: Hmm hmm. 10 COMMISSIONER SIDNEY LINDEN: Okay, we'll 11 adjourn now until nine o'clock tomorrow morning. 12 MS. SUSAN VELLA: Thank you very much. 13 THE WITNESS: Thank you. 14 COMMISSIONER SIDNEY LINDEN: Thank you 15 very much. 16 17 (WITNESS RETIRES) 18 19 THE REGISTRAR: This Inquiry stands 20 adjourned until tomorrow, Thursday April 21st, at 9:00 21 a.m. 22 23 --- Upon adjourning at 4:49 p.m. 24 25


1 2 Certified Correct 3 4 5 6 7 __________________ 8 Dustin Warnock 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25