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 26th, 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 ) 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 ) (np) Family Group 15 16 Anthony Ross ) Residents of 17 Kevin Scullion ) (np) 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 ) (np) 25 Michelle Pong )


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 ) (np) Ontario Provincial 21 Karen Jones ) 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 LIST OF APPEARANCES (cont'd) 2 3 Kelly Graham ) Malcolm Gilpin, Mark Watt, 4 Jill Sampson ) John Tedball, Cesare 5 DiCesare and Robert Kenneth 6 Scott 7 Ian Dantzer ) Dr. Marr and Dr. Saettler 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25


1 TABLE OF CONTENTS 2 Page 3 Exhibits 6 4 5 ALISON JANE MARR, Affirmed 6 Examination-In-Chief by Ms. Susan Vella 8 7 Cross-Examination by Mr. Andrew Orkin 155 8 Cross-Examination by Mr. Peter Rosenthal 164 9 Cross-Examination by Mr. Anthony Ross 185 10 Continued Cross-Examination by Mr. Andrew Orkin 189 11 Cross-Examination by Mr. Jonathan George 194 12 Cross-Examination by Ms. Andrea Tuck-Jackson 199 13 Cross-Examination by Ms. Karen Jones 206 14 Cross-Examination by Mr. Al O'Marra 260 15 Re-Examination by Ms. Susan Vella 271 16 17 ELIZABETH SAETTLER, Sworn 18 Examination-in-Chief by Mr. Donald Worme 285 19 20 Certificate of Transcript 339 21 22 23 24 25


1 EXHIBITS 2 No. Description Page 3 P-355 Curriculum vitae of dr. Alison J. Marr 9 4 P-356 Document 1000043 Strathroy Middlesex 5 General Hospital Emergency Record of 6 Nicolas Cottrelle September 07/'95 28 7 P-357 Document 1005045 Strathroy Middlesex 8 General Hospital history and physical 9 examination of Bernard George September 10 07/'95 49 11 P-358 Document 5000244 Strathroy Middlesex 12 General Hospital history and physical 13 examination of Anthony George September 14 07/'95 63 15 P-359 Document 1002016 report of post mortem 16 examination of Anthony O'Brien George 17 at Victoria Hospital, London September 18 08/'95 86 19 P-360 Document 5000250 92 20 P-361 Document 1005237 Strathroy Middlesex 21 General Hospital, Department of 22 Diagnostic Imaging Report of Mr. Cecil 23 Bernard George September 07/'95 95 24 25


1 LIST OF EXHIBITS (cont'd) 2 Exhibit No. Description Page No. 3 P-362 Front and back view of Cecil Bernard 4 George September 08/'95 9:00 a.m. 5 document injuries by Dr. Alison Marr 112 6 P-363 Document 1005327 Strathroy Middlesex 7 General Hospital, Summary sheet of 8 C. Bernard George September 7,8/'95 115 9 P-364 Progress notes made by Dr. Alison Marr 10 re Cecil Bernard George 116 11 P-365 Document 1005660 January 23,'96 computer 12 record of letter to Mr. Cottrelle from 13 Dr. Alison Marr sent to investigator 14 J. Kennedy SIU 143 15 P-366 Duplicate copy of a letter sent to 16 Nicholas Cottrelle by Dr. Alison Marr 17 September 22/'95 144 18 P-367 Letter to Jeffry A. House, barrister & 19 Solicitor from Alison J. Marr, M.D. 20 December 03/'97 re Cecil Bernard George 163 21 P-368 Document 1000047 neurological vital sign 22 flow sheet of Cecil Bernard George 23 September 07/'95 starting at 00:30 hours 281 24 P-369 Curriculum vitae of Dr. Elizabeth 25 Saettler 286


1 --- Upon commencing at 9:03 a.m. 2 3 COMMISSIONER SIDNEY LINDEN: Good morning 4 everyone. 5 MS. SUSAN VELLA: Good morning, 6 Commissioner. 7 The Commission calls as its next witness 8 Dr. Alison Marr. 9 10 (BRIEF PAUSE) 11 12 THE REGISTRAR: Good morning, Dr. Marr. 13 DR. ALISON MARR: Good morning. 14 THE REGISTRAR: Do you swear on the bible 15 or affirm? 16 DR. ALISON MARR: I prefer to affirm. 17 THE REGISTRAR: Very good. Would you 18 please state your name in full please. 19 DR. ALISON MARR: Alison Jane Marr. 20 THE REGISTRAR: Thank you. 21 22 ALISON JANE MARR, Affirmed 23 24 EXAMINATION-IN-CHIEF BY MS. SUSAN VELLA: 25 Q: Good morning, Dr. Marr.


1 A: Good morning. 2 Q: What is your current place of 3 residence? 4 A: I live in -- in London, Ontario. 5 Q: What is your occupation? 6 A: I'm a family physician. 7 Q: I understand that you have produced 8 to the Commission a curriculum vitae which reflects your 9 -- your qualifications and employment from 1973 to 1995; 10 do you have that document in front of you? 11 A: Yes, I do. 12 Q: And is the information accurately 13 reflected on it for that period? 14 A: Up until that time, 1995, yes; it 15 hasn't been updated since then. 16 Q: Thank you. Commissioner, I'd like to 17 make that the first exhibit this morning, please. 18 COMMISSIONER SIDNEY LINDEN: Thank you. 19 THE REGISTRAR: That's Exhibit P-355, 20 Your Honour. 21 COMMISSIONER SIDNEY LINDEN: 355. 22 23 --- EXHIBIT NO. P-355: Curriculum vitae of dr. 24 Alison J. Marr 25


1 CONTINUED BY MS. SUSAN VELLA: 2 Q: I understand that you obtained your 3 Bachelor of Arts Honours in biochemistry from the 4 University of Oxford in England in 1973? 5 A: Yes. 6 Q: You, then, graduated with your MD cum 7 laude from the University of Western Ontario in 1979? 8 A: That's correct. 9 Q: And, you then completed a rotating 10 internship at St. Joseph's Hospital in London from 1979 11 to 1980? 12 A: Hmm hmm. 13 Q: You can just say yes or no for the 14 record? 15 A: Yes. 16 Q: Thank you. You then completed a 17 residency in internal medicine at the University of 18 Western Ontario from 1980 to 1981? 19 A: Yes. 20 Q: And, in October of 1981, you began a 21 family practise in association with the Strathroy Medical 22 Clinic in Strathroy? 23 A: Yes. 24 Q: I understand that you had, at that 25 time, acquired admission or admitting privileges at the


1 Strathroy Middlesex General Hospital? 2 A: Yes. 3 Q: And you continue to have -- enjoy 4 those privileges? 5 A: Yes. 6 Q: And you continue to be engaged in 7 family practise with the Strathroy Medical Clinic? 8 A: Yes, I still am in practise there. 9 Q: I understand that in 1990 to 1995, 10 you were the head of Obstetrics at Strathroy Middlesex 11 General Hospital? 12 A: Yes. 13 Q: And, when did you complete that term? 14 A: In '95. 15 Q: All right. Thank you. And, in 1995 16 you were appointed Chief of Medicine for the Strathroy 17 Middlesex General Hospital? 18 A: Yes. 19 Q: How long did have that appointment 20 for? 21 A: Two (2) years. 22 Q: All right. Do you have experience as 23 a emergency department physician? 24 A: Yes. I worked in the Emergency Room 25 from 1981 onwards as soon as I set up practise in the


1 town. 2 Q: All right. And, was that at -- which 3 hospitals was that -- were those? 4 A: Just at the Strathroy Middlesex 5 General Hospital. 6 Q: All right. And you continue to be an 7 emergency physician there? 8 A: No. 9 Q: When did you finish that? 10 A: 1997. 11 Q: Thank you. So, in -- as of 1995, 12 you'd had some fourteen (14) years experience as an 13 emergency physician at -- 14 A: Yes. 15 Q: -- the Strathroy Hospital? 16 A: Yes. 17 Q: And, what -- did -- did you have a 18 routine shift in the Emergency Department? 19 A: Yes, at that time we did twenty-four 20 (24) hour shifts; that the -- the physician was 21 designated responsible for a twenty-four (24) hour period 22 from eight o'clock in the morning til eight o'clock the 23 next morning. 24 For the most part, the daytime is not very 25 busy and most of the work, then, was at five o'clock


1 onwards through the evening hours and then through the 2 night. 3 Q: All right. And, how frequently did 4 you -- did you engage in a shift? 5 A: I would have one (1) shift every week 6 or two (2). 7 Q: All right. Are you familiar with the 8 Sarnia General Hospital facility? 9 A: Well, I'm aware of it; I've never 10 been there. I don't know a lot about its facilities. I 11 understand it's a slightly larger hospital than ours. 12 Q: All right. Thank you. I understand 13 you were the emergency physician on call at Strathroy 14 Middlesex General Hospital on September the 6th, 1995? 15 A: Yes. 16 Q: Can you tell me what does it mean to 17 be 'on call?' 18 A: It means that I'm expected to be 19 available within the Emergency Room within five (5) or 20 ten (10) minutes of the request and -- and the primary 21 physician responsible for the care that night or that -- 22 during that time period. 23 Q: When did your shift start on that 24 day? 25 A: Eight o'clock in the morning.


1 Q: On September the 6th? 2 A: Yes. 3 Q: All right. And, so it was to 4 complete, then, at eight o'clock in the morning on 5 September the 7th? 6 A: Yes. 7 Q: And, did you spend the full shift at 8 the hospital? 9 A: In the day time we don't stay at the 10 hospital, I run my office in the daytime, but I would 11 have been at the hospital from five or six o'clock 12 onwards and I didn't leave. 13 Q: Thank you. And, what are your main 14 roles and responsibilities as the emergency physician on 15 call? 16 A: To attend to patients that present to 17 the Emergency Room. 18 Q: Now, as a family physician, what are 19 the limitations on your ability to deal with severe 20 trauma cases such as chest gunshot wounds, for example, 21 as the emergency physician? 22 A: Emergency physicians in community 23 hospitals like Strathroy are usually family physicians in 24 training; in fact, that's true of all the physicians that 25 take shifts there. We are all experienced and re-


1 certified on a regular basis in basic life support and 2 advanced cardiac life support, and re-certified, as I 3 say, every two (2) or three (3) years in that training 4 program. 5 So, for basic resuscitation we're well 6 qualified. More sophisticated surgical approaches would 7 not be our responsibility; we would refer to other 8 physicians in the hospital. Or in multiple trauma 9 situations we would stabilize and transport the patient 10 to London. 11 Q: To London Hospital? 12 A: Yeah. 13 Q: Where there are more surgeons 14 available? 15 A: And a -- and a full trauma team. 16 Q: Hmm hmm. 17 A: But still, it would be appropriate 18 for a trauma patient to come to our hospital for 19 stabilization first and then transfer on as soon as they 20 can be stabilized. 21 Q: When you arrived for your shift that 22 evening, at five or six o'clock, were you provided with 23 any information with respect to the possibility of 24 Ipperwash Park related casualties or injuries? 25 A: Not at that time, no.


1 Q: As of September the 6th were you 2 aware of the ongoing occupation of the Ipperwash Park? 3 A: I wasn't, no. 4 Q: Were you aware of any contingency 5 plan in place at the Strathroy Hospital responsive to the 6 Ipperwash Park occupation? 7 A: No, I wasn't aware of the Ipperwash 8 event and I wasn't aware of any hospital plans to be 9 involved in it at that time. 10 Q: All right. When were you first 11 notified of the possibility of Ipperwash related 12 casualties? 13 A: I'm unclear about the time. It was 14 sometime between 11:00 and 11:30 that evening that I was 15 told, I believe by a nurse in the emergency room, that 16 there had been a phone call to the hospital. 17 Q: And did she impart any further 18 information than that? 19 A: My best recollection is that she told 20 me that there was an event going on at Ipperwash that 21 anticipated that there might be some casualties, and they 22 wanted to know -- wanted to inform us, that this is the 23 case, as we would be the hospital that such casualties 24 would be sent to. 25 Q: All right. And to be clear, at that


1 time did you have knowledge of any specific casualties 2 enroute? 3 A: No. 4 Q: As a result of that information, did 5 you take any steps in preparation for that possibility, 6 that possible event? 7 A: I think it was more a nursing staff 8 preparation in terms of informing the staff that will be 9 called extra to the hospital -- to the -- to the 10 emergency room, and preparation in terms of setting up 11 areas within the emergency room to deal with more than 12 one (1) casualty. 13 Q: All right. 14 A: Getting IV's all ready to go, that 15 sort of thing. 16 Q: And these were things that you 17 assumed that the nursing staff did? 18 A: No. They did them. They -- I saw 19 them doing them. 20 Q: All right. Thank you. At some later 21 point did you receive advice that the situation, the 22 possible situation had turned into an -- an actuality? 23 A: Yes. And I'm not clear of the timing 24 but before anybody -- any of the casualties arrived at 25 the hospital I had heard, and I don't know from whom but


1 indirectly from nursing staff, that there was an 2 ambulance enroute with someone that they thought might 3 have had a gunshot wound, and that there was another 4 injured person had left the scene by car. 5 And I am not sure whether we thought that 6 -- or had any information about whether he had been shot 7 but I think that was mentioned too. 8 Q: All right. So, you recall being 9 advised of there being possibly two (2) -- well, one (1) 10 patient definitely enroute with a gunshot wound, from an 11 ambulance -- or in an ambulance, and another possible 12 injured person by gunshot wound by -- attending by car? 13 A: Yes, the -- the second gunshot wound, 14 I'm not sure of, or that we just knew it was injured and 15 left the scene by a car. 16 Q: All right. Thank you. And can you 17 advise approximately how many minutes prior to receiving, 18 sorry, prior to the first patient arriving, you received 19 this information? 20 A: My memory would be that it was only 21 about ten (10) minutes of that order before the arrival. 22 In looking at the information that you've provided to me, 23 I think one of the nurses clocked that phone call as 24 being at 11:56. 25 Q: And does that sound about right to


1 you? 2 A: Yeah, it's actually a shorter 3 interval than I would have thought, but yes. But it's 4 about ten (10) minutes, isn't it, yeah. 5 Q: All right. And what if anything, did 6 you do in respond to this new information? 7 A: Just increase the level of 8 preparedness just in the trauma room and made sure that 9 any other patients that were around had been moved away 10 and weren't going to take up space that would be needed. 11 Q: All right. Did you call in any new 12 staff to the emergency department with respect -- as a 13 result of this new information? 14 A: No. 15 Q: Why not? 16 A: We have other staff available, other 17 physician staff available at very short notice; that 18 would be a general surgeon and an anaesthetist and a 19 backup physician that are available within five (5) 20 minutes of being called. 21 And generally, the policy is to do an 22 initial assessment and see what we're dealing with before 23 knowing whether or not we need extra physicians in the 24 hospital. 25 Q: All right. And so the level of


1 information that you had received indirectly was not 2 sufficient for you to make that assessment prior to the 3 arrival of the first patient? 4 A: Correct. 5 Q: Who was on staff at the emergency 6 department that night, prior to the arrival of the first 7 patient I'm speaking. 8 A: Are you asking about nursing staff? 9 A: Nursing, physicians, doctors -- 10 sorry, surgeons. 11 A: I was the only physician there in the 12 emergency department and I don't recall all the names of 13 the nurses other than what I've read here. 14 Q: Do you recall approximately how many 15 nurses were there? 16 A: Well, there'd normally be two (2) or 17 -- two (2) regular staff and there would have been 18 probably three (3) or four (4) brought from the floor; I 19 would expect around six (6) nursing staff and a nursing 20 supervisor. 21 Q: Thank you. Were you given any 22 details with respect to the -- the severity of the 23 injuries prior to the arrival of the patients? 24 A: No, I don't -- I didn't have any 25 specific communication from the ambulance, no.


1 Q: Is that information that you would 2 normally expect to receive? 3 A: Yeah, very often they will patch 4 through, ten (10) minutes or so before arrival, just what 5 the condition of the patient is. 6 Q: And that's so that you can make 7 better or quicker preparations for the specific -- 8 A: Yeah, that's certainly helpful, yeah. 9 Q: All right. And just before we get to 10 the patient arrival, can you describe very -- in very 11 general terms, the layout of the emergency room at the 12 hospital? 13 A: Well, it's a relatively small 14 emergency room. There's no great distances involved from 15 the entrance which is at the side of the hospital, quite 16 well delineated or signposted, and then glass sliding 17 doors and within fifty (50) of that is the main emergency 18 room. 19 We have one (1) big, what we call trauma 20 room, which is where we were wanting to receive, there's 21 lots of space to move around the patients, and then 22 several cubicles around the outside of that. 23 But seriously injured patients are usually 24 brought into the trauma room first -- 25 Q: All right.


1 A: -- and that would take a minute at 2 the most, from coming through the doors to get to that 3 unit. 4 Q: And would you advise as to what -- 5 what equipment is in the, or was in the emergency room 6 that night? 7 A: I'm not sure where to begin in 8 describing equipment. There would be suction available, 9 there would be oxygen available, there were intravenouses 10 set up ready to go. There would be surgical equipment if 11 necessary, suture trays, intubation equipment, 12 cardioversion equipment for cardiac arrest and whatever 13 medications are necessary and usually used in emergency 14 situation -- situation. 15 Q: Okay. And, how many beds do you have 16 in the trauma room? 17 A: Well, they're moving beds; there's 18 usually only one (1). But, there's one (1) operating 19 room table and then otherwise stretchers are brought in 20 as needed, depending on the -- it's -- it's not usual for 21 us to have more than one (1) person in that room. 22 Q: Fair enough. 23 A: But, it's -- it's a big room, there's 24 lots of space. We would bring in other stretchers if 25 there's more than one (1) patient.


1 Q: And did you eventually receive any 2 Ipperwash related injured persons that evening? 3 A: Yes, there were three (3) injured 4 that came. 5 Q: Three (3) in total. Can you advise 6 me, just in the general sense, who they were and -- and 7 in what order of arrival they came? 8 A: Yeah, the first to arrive was Nick 9 Cottrelle, who came in by ambulance. The second to 10 arrive was Cecil Bernard George who came in by ambulance. 11 And the third to arrive was Dudley George who came in by 12 car. 13 Q: Now, you've mentioned three (3) 14 individuals. You indicated earlier that you had advice 15 that two (2) were coming in; do you know which two (2) -- 16 which -- which one (1) was the unexpected person? 17 A: Unexpected? Yeah, Cecil Bernard 18 George. 19 Q: All right. And, do you know what -- 20 what type of ambulance he arrived in? 21 A: It was a St. John's Ambulance. 22 Q: All right. 23 A: I'm -- I'm told subsequently; I'm not 24 sure that I noticed at the time. 25 Q: Thank you. Did you see any police


1 officers in the hospital prior to the arrival of Nicholus 2 Cottrelle? 3 A: That's a difficult one to answer; 4 I've tried to get a clear memory of that and I -- and 5 there's no documentation anywhere to help me. 6 I do -- I have a memory of walking through 7 the corridors -- empty corridors -- and seeing several 8 policemen what flak jackets on and asking one (1) of the 9 what was going on and being told that they were securing 10 the hospital because they were concerned about people 11 from Ipperwash coming to the hospital and being 12 disruptive. 13 And I just can't remember whether that was 14 whilst I was waiting for patients to come in or whether 15 it was well after all the activity and I was around 3:00 16 or four o'clock in the morning when the patients had all 17 been looked after. 18 Q: And, when you say that flak -- that 19 they were in Flak jackets, can you describe what -- what 20 they were wearing in more detail? 21 A: I just remember some firm looking 22 upper body garment. 23 Q: All right. Thank you. And, you 24 indicated the first patient to arrive was Nicholus 25 Cottrelle. Can you advise us to approximately what time


1 he arrived into the Emergency Department? 2 A: I don't look at times myself. In 3 looking at the documentation he was on the Emergency Room 4 admission -- Emergency Room note said to have arrived at 5 12:00 -- 0:04. 6 Q: All right. And I wonder if you might 7 look at Tab 32 of your brief, an Inquiry Document Number 8 1000043. And if you would go to the third page in that 9 document, it's also identified for the record as Front 10 Number 00000271; it's an emergency and outpatient record. 11 A: I'm -- I'm miles behind you on this, 12 can you tell me the tab number again? 13 Q: Excuse me. 14 15 (BRIEF PAUSE) 16 17 Q: In our Counsel brief it's Tab 32 but 18 the record is Inquiry Document Number 100043, and it's 19 the hospital record of Nicholus Cottrelle. And I was 20 looking at the third page in. 21 A: Can you direct me to it again? 22 Q: The third page in. 23 A: No. The -- the tab number? 24 Q: Oh, I'm sorry. Tab 32. 25 A: My Tab 32 is not that.


1 Q: It -- it may be in front of you as a 2 -- an additional -- Dr. Marr, to -- to your left maybe 3 there. 4 A: Okay. Right at the back, all Nick 5 Cottrelle's is here, yeah. Okay. 6 Which part of this? 7 Q: The third page in. 8 A: Okay. 9 Q: The correct number; the last three 10 (3) numbers is two seven one (271). 11 A: Okay, yeah. 12 Q: And we have it on the screen for the 13 benefit of Counsel as well. Do you -- do you recognize 14 this document? 15 A: Yes. That's my signature. 16 Q: All right. And this is a document 17 that was -- was prepared contemp -- contemporaneously 18 with the events recorded? 19 A: Yes. 20 Q: And is it part of the hospital 21 procedure to have this document filled out and filed? 22 A: Yes. I would have -- I would have 23 signed that though, you know, yeah, within -- before -- 24 at the time of admission to the hospital, so around two 25 or three o'clock in the morning.


1 Q: All right. And when you say, 2 Admission to the hospital at around two or three o'clock 3 in the morning -- or I think it was 2:05 a.m., that would 4 refer to admission of Nick Cottrelle as in-patient? 5 A: Yeah. That's right. Yeah. 6 Q: As opposed to his admission into the 7 Emergency Department? 8 A: Yeah. That time at the top, the 0:04 9 is when he arrived in the emergency room. And the actual 10 admission process doesn't happen until later, when 11 they're stabilized and assessed. 12 Q: All right. And do you know who would 13 have inserted that time in the top left corner of 00:04 14 hundred hours or what -- what personnel would do that? 15 A: You know, I don't know because I 16 would think that normally that would be -- a patient 17 presents to admitting and the secretary or the admitting 18 clerk would document that. But, clearly when someone's 19 brought in by ambulance, it doesn't happen that way; they 20 come straight to the trauma unit. 21 Q: Right. 22 A: And then I think often the secretary 23 follows them in and tries to get the documentation, in 24 the midst of all that's going on, to fill out the forms. 25 But, I -- and I don't know why it would be handwritten


1 over, whatever, the original typing had said. 2 Q: All right. Thank you. Now, have you 3 had the chance to look at the -- the documents under this 4 tab? 5 A: Yes. 6 Q: And can you identify the documents? 7 Are they part of the hospital chart? 8 A: Yes. Yes. 9 Q: All right. For Nicholus Cottrelle? 10 A: Yes. 11 Q: I'd like to make this the next 12 exhibit, please. 13 THE REGISTRAR: Exhibit P-356, Your 14 Honour. 15 COMMISSIONER SIDNEY LINDEN: 356. 16 17 --- EXHIBIT NO. P-356: Document 1000043 Strathroy 18 Middlesex General Hospital 19 Emergency Record of Nicolas 20 Cottrelle September 07/'95 21 22 CONTINUED BY MS. SUSAN VELLA: 23 Q: All right. And does it record -- 24 recollect -- does it recollect with -- at least this 25 12:04, midnight, after midnight, about the time that you


1 believe -- 2 A: Yes. 3 Q: -- Nick Cottrelle came in? 4 A: Yeah. 5 Q: And you said it was about ten (10) 6 minutes after receiving the call? 7 A: Yeah. 8 Q: Thank you. All right. And would you 9 now go to page 34, towards the end of this document, 10 third page from the end; it's Front Number 0000302 for 11 Counsel who's following it. This is an Ambulance Call 12 Report that appears to have been prepared and filed by 13 the ambulance attendants who brought Nick Cottrelle into 14 -- sorry -- to the hospital. 15 Have you seen this document before? 16 A: Well, I saw it last night because -- 17 Q: Right. 18 A: -- you gave it to me, but I haven't 19 paid it much attention before. 20 Q: All right. To your knowledge, is 21 this a document that you would have reviewed at the time 22 that you were assessing and treating -- 23 A: No. 24 Q: -- Mr. Cottrelle? 25 A: I wouldn't have had access to it


1 then. I can't recall if it's on the hospital chart, I 2 think it's probably is, but it's the sort of thing that 3 gets filed afterwards. And only when you review the 4 chart at some later incident would you come across this. 5 Q: Thank you. Now, if you look at -- I 6 take it from that statement that you wouldn't refer to 7 this as part of your assessment or treatment of the -- 8 the patient in the normal course? 9 A: No, I don't know when it's even 10 written up. 11 Q: All right. 12 A: But, what I -- I would -- I would be 13 aware of the content in that the ambulance attendant who 14 wrote it would have been present with the patient and 15 would have summarized it to me as he did. 16 Q: Okay. And I was going to get to 17 that. Let's first of all, go to the second page of this 18 report. You'll see that the ambulance attendants have 19 indicated down in the bottom right corner the arrival 20 time, from their perspective, is 00:06, so, six (6) 21 minutes after midnight September the 7th? 22 A: I don't -- 23 Q: The bottom right corner. Perhaps if 24 you look on the screen there, I believe the marker is at 25 it.


1 A: Okay. Okay. 2 Q: All right. 3 A: Okay. I see, yeah. 4 Q: So, about a two (2) minute 5 discrepancy? 6 A: Hmm hmm. 7 Q: Do you have any explanation for the - 8 - the -- the slight discrepancy? 9 A: Well, do they clock it as they draw 10 up the Emergency Room and we clock it when the patient 11 arrives in the room? 12 Q: Well, the other -- the initial time-- 13 A: That would be two (2) minutes. 14 Q: -- was at four (4) minutes after 15 midnight and this was six (6) minutes after midnight. 16 A: Oh, sorry, I'm thinking it was -- 17 Q: No, not at all. 18 A: Okay. Well, I think that, you know, 19 the hospital clocks are notorious for being different in 20 different parts of the hospital. The -- within the one 21 room they'll be the same all the time, obviously, but if 22 it can vary within the hospital, I'm sure that the 23 ambulance might be two (2) or three (3) minutes on a 24 different clock than we are. 25 Q: All right.


1 A: And, so it's hard to expect that 2 degree of accuracy from a different -- one clock to 3 another clock. 4 Q: All right. In any event, that 5 discrepancy doesn't give you cause for concern? 6 A: I don't think we can be accurate 7 within two (2) or three (3) minutes of that sort of 8 thing. 9 Q: Thank you. Thank you. Now, will you 10 got to the first page of this document, it's Front Number 11 -- and I'll just say the last three (3) numbers; 269. 12 A: Yeah. 13 Q: This is the summary sheet for 14 Nicholus Cottrelle. 15 A: My 269 is my History and Physical. 16 Q: I'm looking at Front Number 269, 17 perhaps you could... 18 19 (BRIEF PAUSE) 20 21 Q: I'm looking at 269, perhaps you could 22 go to that document? 23 24 (BRIEF PAUSE) 25


1 Q: Oh, I see, you're looking at page 268 2 on the right-hand side; is that... 3 A: Are you asking me? 4 Q: Yes, I am. I just want to make sure 5 we're on the same document; it's entitled, Summary Sheet. 6 There's two (2) numbers on it, that's probably what's 7 causing confusion. 8 A: 268 is the front summary sheet. 9 Q: The front... 10 A: The first sheet in the -- in this... 11 COMMISSIONER SIDNEY LINDEN: Yes. 12 13 CONTINUED BY MS. SUSAN VELLA 14 Q: Yes. And what's it entitle -- is it 15 entitled, Summary Sheet, or is the document that's on the 16 screen there? 17 A: Yes. 18 Q: Thank you. Okay. That's page number 19 268. The Front Number's -- 20 A: Yes. 21 Q: -- on the left and the page number's 22 -- sorry there's different numbers on this, that's why 23 there's some confusion. 24 A: I thought you asked me to look at 25 269?


1 Q: Front Number 269. 2 A: Front Number 269. 3 Q: But, I think you have the right paper 4 -- page in any event. 5 A: Okay. Yeah, that page is here. 6 Yeah. 7 Q: Okay. I'm going to be looking at the 8 number on the left -- top left corner as opposed to the 9 top right corner. 10 A: Oh, okay, I can't -- now I can see 11 it. 12 COMMISSIONER SIDNEY LINDEN: There's a 13 little font number. It's confusing, yes. 14 THE WITNESS: Okay. I had to take that 15 off to see it. Yeah, okay. 16 17 CONTINUED BY MS. SUSAN VELLA: 18 Q: Thank you. And I'm only doing that 19 because it's easier for the record, Doctor. 20 A: Okay. So, they're different. I see 21 now, okay. All right. 22 Q: And, this indicates that the time of 23 admission -- the date of admission was September the 7th, 24 1995 and a time of 2:05 a.m. and, again, that refers to 25 the time that he was admitted as an in-patient to the


1 hospital; is that right? 2 A: Correct. 3 Q: Thank you. Did you see Mr. Cottrelle 4 being transported in the trauma room? 5 6 (BRIEF PAUSE) 7 8 A: I don't have a memory of that. I 9 would think I -- I would have been in the trauma room at 10 that point or pretty soon after. It might have been he 11 was there with the ambulance and I was there within 12 seconds of that. I'm not sure that I was there as he was 13 wheeled in. 14 Q: Fair enough, and, was -- was he 15 accompanied by the ambulance attendants? 16 A: Yes. 17 Q: And, was he accompanied by any OPP 18 officer that you remember? 19 A: I don't recall. 20 Q: All right. Would it be normal 21 procedure for an OPP officer or police officer to come 22 into the trauma room with an injured person? 23 A: I -- I don't think I can answer that. 24 It's not very often that the police come in. 25 Q: All right.


1 A: I -- what -- my only experience with 2 police being around the emergency room would be, yeah, I 3 suppose there's been a few times when they've come in and 4 someone's been under some sort of custody and so they 5 would stay close by their side and there's been some 6 times when a patient's being belligerent or dangerous in 7 some way, and they'd be there for controlling the 8 patient, and so we do police staying with the patient at 9 times, yes. 10 Q: All right -- 11 A: I don't recall whether he did -- 12 Q: Okay. Fair enough. 13 A: -- right by the side or was outside 14 in the corridor. 15 Q: Fair enough. It's been ten (10) 16 years, so that's -- it's understandable and -- 17 A: Yeah. 18 Q: -- I appreciate your telling us to 19 the best of your recollection. 20 What, if anything, were you told with 21 respect to Mr. Cottrelle's patient history and -- and 22 injuries at the time he was brought into the trauma room 23 by the ambulance attendants? 24 A: The ambulance attendants said that 25 they thought Nicholus might have been shot, that they


1 thought he had a gunshot would in his right side, but 2 they said that he'd been fully alert on transport and 3 that his blood pressure had been stable and his pulse had 4 been stable. 5 Q: And -- and giving -- what -- what 6 preliminary conclusions, if any, were you able to -- to 7 form on the basis of that information? 8 A: At the time of arrival -- at the time 9 -- during transport and at the time of arrival, he was 10 haemodynamically stable and that was confirmed by the 11 initial assessment; that his vital signs were within 12 normal range. 13 Q: And perhaps you call tell us, then 14 what -- what did you do on your preliminary assessment of 15 Mr. Cottrelle? 16 A: Well, first we asked him what had 17 happened to him and what his symptoms were at the time 18 and he said that -- well, if you want to know precisely, 19 I should look at the chart. 20 21 (BRIEF PAUSE) 22 23 A: I'm looking at the history and 24 physical exam which is your number 270. 25 Q: Thank you. That's at Exhibit P-356,


1 and it's Front Number 270 or page 269. 2 A: Yeah. 3 Q: Yes? 4 A: And he was -- I said he was 5 apparently standing by or sitting in a car, so he was a 6 bit vague and unclear about where he actually was. 7 He heard a gunshot wound -- gunshot sound 8 and he felt pain in his right side. 9 He then described actually, not documented 10 there, but pain on his other side as well and at the 11 time, then, of arrival he was complaining still of pain 12 in those two (2) locations. 13 He was not at all short of breath. He was 14 not lightheaded or faint and he had no other complaints. 15 Q: All right. And what did you do next? 16 A: As I say, we checked his blood 17 pressure and his pulse and his respiratory rate and they 18 were all within the normal limits. 19 He certainly was alert and fully oriented 20 and we had a quick look at the areas that he said he had 21 his pain and noted the -- on the chest wall, on the right 22 posterior axillary line, one (1) centimetre diameter 23 round wound that was a little bit tender around it, but 24 not extremely so, and then on the opposite side an 25 abrasion, a linear abrasion four (4) inches long that was


1 a shallow abrasion, more in the axillary line this side 2 here. 3 Q: All right. This is on -- on his back 4 area is it, both of these wounds? 5 A: One was more on his side; the one on 6 the left. The one on the right was a little bit more 7 towards the back. 8 Q: All right. 9 A: His heart sounded normal and his air 10 entry was good. There was no evidence of any difficulty 11 with air entry into the chest or any fluid in the chest. 12 So, the preliminary assessment was not 13 really consistent with a gunshot wound in that one would 14 have expected if a bullet had gone through that location 15 that he would be internally bleeding, be in some 16 respiratory distress, have an unstable vascular system, 17 which he did not. 18 Q: All right. And the wound that -- 19 that present -- that you looked at as a possibility of 20 being a bullet wound, which side of the body was that on? 21 A: It was on the right posterior chest. 22 Q: All right. And can you just describe 23 that -- that wound a little bit more? Was it -- what 24 shape was it? 25 A: Round, 1 centimetre diameter.


1 Q: All right. Thank you. 2 And as a result, what, if any, steps did 3 you take? 4 A: We arranged for an intravenous line 5 to be started in case he were to become unstable and set 6 up some x-rays to see if we could -- of his chest -- and 7 I'm not sure what else. 8 Q: Were you actually able to commence 9 intravenous at this time? 10 A: I'm just looking at the x-rays that 11 we ordered; the abdomen and the chest. 12 Q: Yes. 13 A: Yeah. I ordered it; I don't know 14 quite when it got started. The nurse would -- would 15 perform the starting of the IV and -- 16 Q: All right. 17 A: -- I'm not sure what time it was 18 started. 19 Q: And, can you just tell us what -- 20 what the purpose of -- of commencing IV was? 21 A: It was still uncertain as to whether 22 it would be -- it had been strongly suggested by the 23 ambulance attendants that he had a gunshot wound and, if 24 that were the case, we might see him collapse imminently, 25 although everything was looking good at the time, and


1 wanted to get an intravenous started in case that were to 2 happen. 3 Q: And, is the purpose of an intravenous 4 to -- to increase fluid flow in the body? 5 A: Yeah. He didn't need it at the time, 6 but if -- if he had such an injury and he were to start 7 bleeding internally, if he had, for some reason been able 8 to tampenade or internal pressure that had stopped it 9 bleeding temporarily and then suddenly it let go and -- 10 and started to bleed, then you would want to be able to 11 resuscitate with lots of fluid and probably blood as 12 well, and if you wait for that to happen, it's harder to 13 get an IV started because the whole peripheral vascular 14 system break down -- shuts down. 15 We didn't know how he'd been traumatized, 16 essentially still; it was just an initial assessment. We 17 needed x-rays to confirm his condition and if there was 18 any question, we needed to resuscitate assuming there 19 could be problems. 20 Q: All right. Now, was it apparent -- 21 did Mr. Cottrelle appear to you to be a minor? 22 A: I don't remember actually really 23 acknowledging his age at the time. 24 Q: All right. Fair enough. 25 A: He didn't look really young. I


1 didn't think about it. 2 Q: And, what did you do next, if 3 anything? 4 A: Well, I think it was not very long 5 into that assessment that Cecil George was brought in. 6 Q: All right. 7 A: And, I know I would have spent more 8 time with Nicholus, although we'd got things moving with 9 him and we'd established that he was stable, but I got 10 clearly called away to Cecil Bernard George. 11 Q: Approximately how long had you spent 12 assessing and treating Nick Cottrelle when Mr. Cecil 13 Bernard George entered the trauma room? 14 A: I would have thought it was about 15 three (3) to five (5) minutes. 16 Q: Three (3) to five (5) minutes. All 17 right. And, at this time, are you still the sole 18 physician in the Emergency Department? 19 A: Yes. 20 Q: And, do you have independent 21 recollection of the sequence of the patients arriving, 22 that is, Nick Cottrelle first and Cecil Bernard George 23 second? 24 A: I remember it that way. 25 Q: All right. Thank you.


1 All right. And, did -- sorry. All right. 2 Now, what was Mr. Cecil Bernard George's presenting 3 problems when he entered the trauma room? 4 5 (BRIEF PAUSE) 6 7 A: Cecil George was brought in by 8 ambulance attendants who said that he had been unstable 9 enroute with a thready pulse and fluctuating level of 10 consciousness; at times he wasn't responding to them. 11 On examination, he -- his level of 12 consciousness was impaired. He kept his eyes closed. He 13 did open his eyes on verbal request. He gave single word 14 answers to questions but he was fluctuating in and out of 15 a stupor state. 16 His main complaints were of pain in his 17 back, his forearm, his shoulder and his abdomen. His 18 blood pressure and pulse and respirations were normal, 19 but he did have impaired level of consciousness. 20 Do you want me to go on to describe his 21 injuries? 22 Q: Perhaps before you do that, perhaps 23 I'll just ask you to explain a few of the terms that 24 you've used. 25 A: Okay.


1 Q: You said that the ambulance 2 attendants advised you that he had had a "thready pulse"; 3 what does that mean? 4 5 (BRIEF PAUSE) 6 7 A: A pulse that was difficult to palpate 8 clearly. 9 Q: So difficult to ascertain the pulse? 10 A: Yes. 11 Q: All right. And when you say he was 12 in a stuporous state, what does that mean? 13 A: That it's somewhere between being 14 awake and being unconscious. They're pretty ill-defined 15 terms, actually, but sort of slow to respond, looking as 16 though he's falling asleep, single word answers that are 17 not always appropriate. Sometimes there was some 18 spontaneous speech that was not following on a question. 19 Q: All right. So, not responsive in 20 that respect? 21 A: Hmm hmm. 22 Q: Okay. All right. And as a result of 23 receiving this information, did you form any clinical 24 impressions at the time? 25 A: Well, that -- that behaviour was


1 consistent with having -- having sustained a concussion. 2 Q: As a result of receiving that inform 3 -- forming that clinic impression, did you commence any 4 treatment? 5 A: Well, concussion was one of his 6 problems and his other soft tissue injuries were his 7 other, and then again because of the suggestion of 8 unstable or absent pulse enroute or thready pulse 9 enroute, we were concerned about internal bleeding. 10 Q: Okay. 11 A: And with respect to the concussion, 12 he was monitored and followed then, for the course in the 13 emergency room and subsequently, to see what direction 14 that went and he did become clearer over the course of 15 the emergency room stay. 16 I would say that he was quite alert and 17 coherent by the time he left the emergency room. 18 Q: All right. 19 A: So, fortunately, that's the direction 20 that his sensorium went, as opposed to becoming more 21 comatose or deeper -- more deeply unconscious. 22 Q: All right. And are you aware -- were 23 you aware at the time that he was transported by St. 24 John's Ambulance people? 25 A: No, it was an ambulance to me.


1 Q: All right. It was a what? 2 A: It was an ambulance. I didn't note - 3 - distinguish between a St. John's or different type of 4 ambulance. 5 Q: Okay. And I wonder if, Mr. 6 Registrar, you'd put before the Witness Exhibit P-342 7 which is an ambulance unit patient report that was 8 prepared by the attendant Karen Bakker. 9 10 (BRIEF PAUSE) 11 12 A: Thank you. 13 Q: And is this a document that you -- 14 you would have received or reviewed during Cecil Bernard 15 George's stay? 16 A: No, I hadn't seen it until you showed 17 it to me yesterday. 18 Q: All right. And to your knowledge, 19 are St. John's Ambulance reports required to be filed 20 with the hospital? 21 A: I know this wasn't on the hospital 22 chart. 23 Q: All right. And how is it that you 24 know that? 25 A: Because I looked at the hospital


1 chart more recently. But, I didn't know that these 2 didn't get filed, but there was an -- the ambulance 3 report for Nick Cottrelle was on the chart when I looked, 4 so I thought -- I -- I looked for one for Cecil Bernard 5 and there wasn't one. 6 Q: All right. Thank you. And did you 7 record your -- your preliminary findings in -- in history 8 and physical examination sheet per Cecil Bernard George? 9 A: Yes. 10 Q: Would you look at Tab 1, Inquiry 11 Document Number 1005045, and it's Front Number 0057737, 12 entitled History and Physical Examination -- 13 A: Got it. 14 Q: -- Bernard George. 15 A: Hmm hmm. 16 Q: You have that in front of you? 17 A: Yeah. 18 Q: And do you recognize that document? 19 A: Yes. 20 Q: And it's -- 21 A: It's missing the last page. 22 Q: I see that. I was going to ask you 23 about that. 24 A: I've got my own copy of it here 25 though.


1 Q: Do you have the second page? 2 A: Yeah. 3 Q: Is that a document that you prepared? 4 A: Yes. 5 Q: Or at least dictated? 6 A: Yes. 7 Q: And is it consistent with your 8 observations of that evening? 9 A: Yes. It's the best record of it. 10 Q: Thank you. I'd like to make that the 11 next exhibit, please. 12 COMMISSIONER SIDNEY LINDEN: Have you got 13 a copy of the second page? 14 MS. SUSAN VELLA: I don't have the 15 second page of -- 16 COMMISSIONER SIDNEY LINDEN: Perhaps you 17 should make a copy of it. 18 MS. SUSAN VELLA: All right. 19 20 (BRIEF PAUSE) 21 22 THE WITNESS: That's the first page. 23 24 CONTINUED BY MS. SUSAN VELLA: 25 Q: All right. Yes. And now on the


1 screen -- 2 A: That's the second page, yeah. 3 Q: -- is the second page. For some 4 reason it's not in my brief but there it is. 5 Is that your signature? 6 A: Yes. 7 Q: Thank you very much. And -- 8 THE REGISTRAR: That's Exhibit Number P- 9 357, Your Honour. 10 COMMISSIONER SIDNEY LINDEN: 357. 11 12 --- EXHIBIT NO. P-357: Document 1005045 Strathroy 13 Middlesex General Hospital 14 history and physical 15 examination of Bernard George 16 September 07/'95 17 18 COMMISSIONER SIDNEY LINDEN: Have you got 19 a copy of it? 20 THE REGISTRAR: I don't have the second 21 page. 22 COMMISSIONER SIDNEY LINDEN: No. Okay. 23 MS. SUSAN VELLA: Well, we'll certainly 24 arrange to get that to you. 25


1 CONTINUED BY MS. SUSAN VELLA: 2 Q: All right. Going back to Exhibit P- 3 342 then, the report filled out by Karen Bakker. 4 5 (BRIEF PAUSE) 6 7 Q: It's on the screen now. Would you 8 kindly look at the -- the bottom section entitled, Vital 9 Signs. And we note that it appears that there were four 10 (4) -- four (4) attempts to take the pulse and 11 respiration by this attendant. 12 I wonder if you could advise with respect 13 to whether or not the pulse readings of seventy (70), 14 zero (0), sixty-two (62) and seventy-eight (78), whether 15 those are consistent with -- with what you saw in terms 16 of the patient's condition in the trauma room some 17 minutes later? 18 A: As I say, when we assessed his pulse 19 and blood pressure, he was stable. There was no evidence 20 of significant internal bleeding at the time that we 21 assessed him and -- and, from hindsight, he continued to 22 be stable and didn't have any significant internal 23 injuries. 24 So, it would be hard to understand how 25 there could be a real finding of no pulse and no


1 respirations in the middle of transport. 2 Q: All right. And indeed, you noted in 3 your report at P-357 that his pulse was eighty (80) and 4 reasonably strong -- 5 A: Hmm hmm. 6 Q: -- and that his blood pressure was 7 one thirty (130) over seventy (70). 8 A: Hmm hmm. 9 Q: And does that further support your -- 10 your conclusions? 11 A: Yes. Those are normal blood 12 pressures and pulse. 13 Q: Now, based on your experience as an 14 emergency physician and medical doctor, is it possible 15 for a patient to very temporarily loose his pulse and 16 respiratory functions and then regain same without 17 medical intervention? 18 A: I would say it's not possible. 19 Q: And based on your treatment and 20 assessment of Cecil Bernard George of that evening, or 21 the early hours of September the 7th, do you have an 22 opinion as to whether or not it was likely that he did 23 very temporarily lose his pulse and respiratory functions 24 without -- and regain same without medical intervention? 25 A: I think it's very unlikely.


1 Q: Thank you. Now, you'll note in Ms. 2 Bakker's report that it was her clinical observation that 3 Mr. George's -- Cecil Bernard George's pupils were 4 temporarily non-reactive to light stimulus; is that also 5 consistent with your assessment and observations of Mr. 6 George in the trauma room? 7 A: His reflexes were normally reactive 8 by the time that we saw him. It takes several minutes of 9 poor blood flow to the brain to change those corneal -- 10 those pupillary reflexes, so again, I think it would be 11 unlikely that that was a real finding enroute, given his 12 stability by the time we saw him. 13 Q: Okay. They also reported that he had 14 lapsed in and out of consciousness. Now, is that, based 15 on your assessment and treatment of Mr. George in the 16 trauma room, is that finding consistent or likely -- 17 A: Oh yeah, no, I think -- 18 Q: -- with what you saw? 19 A: -- that's quite consistent, yeah. 20 Q: All right. 21 A: That he would be unresponsive at 22 times during transport, and more so at the early stages 23 of the transport, but he was still lapsing in and out of 24 consciousness a bit in the emergency room. 25 Q: And finally, with --


1 A: In the early minutes there. 2 Q: I'm sorry? 3 A: In the early period of time; the -- 4 the first twenty (20) minutes there, I would say. 5 Q: All right. In the trauma room? 6 A: Hmm hmm. 7 Q: And finally, she reported that he was 8 not oriented as the time and place enroute. Again, based 9 on your assessment and treatment of Mr. George in the 10 trauma room is that consistent or inconsistent with your 11 findings? 12 A: Yeah, he wasn't fully oriented and he 13 was confused at times and -- for the first half-hour/hour 14 in the emergency room. 15 Q: All right. And were you provided any 16 information with respect to what the circumstances giving 17 rise to his injuries were? 18 A: During the whole course of -- 19 Q: No, sorry, we'll still in the trauma 20 room -- 21 A: Hmm hmm. 22 Q: -- during the initial assessment. 23 A: I don't believe the ambulance 24 attendants gave us any information as to how he'd come by 25 his injuries.


1 When I looked through the different 2 testimony at different times as to how I understood Mr. 3 George had been injured, what did I say -- on the history 4 and physical exam which we were looking at before. 5 Q: Exhibit P-357. 6 A: What I said was: 7 "In piecing together a history provided 8 the patient -- by the patient during 9 his stay in the emergency room and also 10 described by the family who later 11 arrived on the scene, it appears he was 12 in a fight with the police and received 13 blunt trauma to various parts of his 14 body." 15 So that was -- this is dictating this sort 16 of at the end of the time in the emergency room when all 17 different bits of information had come to me. 18 Q: All right. 19 A: What I can't fully be clear on in my 20 mind, and when I went back through the different 21 interviews I've given, I'm not sure whether in the 22 emergency room Mr. George actually said he'd been beaten 23 by the police himself. 24 Q: All right. And -- and you can't -- 25 A: He did say he'd been hit and that


1 there were no -- he hadn't been shot. But I'm not sure 2 that he actually said who had beaten him at that time in 3 the Emergency room -- 4 Q: Fair enough. 5 A: -- himself. 6 Q: Were there any, that you can recall, 7 did any police officer accompany him into the trauma 8 room? 9 A: I don't recall. 10 Q: Do you recall receiving any 11 information from any police officers relating to the 12 origin of his injury -- of Cecil Bernard's injuries? 13 A: No. 14 Q: Did you start treatment, then, based 15 on your preliminary assessment? 16 A: Yes, we again started intravenous 17 lines and arranged for some blood work and some x-rays. 18 Q: All right. Did you have to stabilize 19 his neck or back? 20 A: Yes, we wanted to check those by x- 21 ray before allowing him to move. But, he didn't have any 22 pain over his neck but nevertheless, we stabilized him 23 until he had x-rays to clear his spine. 24 Q: All right. And were you able to 25 complete your -- your assessment of Mr. Cecil Bernard


1 George at that time, that is at the initial -- 2 A: It was -- 3 Q: -- stage? 4 A: -- a preliminary assessment, 5 sufficient to know that his vitals were stable, that he 6 was rousable. We had -- I had concerns about his 7 abdomen, because he had tenderness there and the story of 8 him being unstable enroute, I did worry about him having 9 internal bleeding and -- and we were waiting to see the 10 results of investigations, but I think I was with him 11 only, again, about three (3) or four (4) minutes before I 12 was called away to Dudley George. 13 Q: All right. 14 15 (BRIEF PAUSE) 16 17 Q: All right. So, you indicated that 18 the next, then, another -- a third patient arrived about 19 three (3) to four (4) minutes into your assessment, 20 preliminary assessment of Cecil Bernard George? 21 A: Yes. 22 Q: And, you now know that person to have 23 been Anthony O'Brien Dudley George? 24 A: Yes. 25 Q: Was Mr. Dudley George brought into


1 the trauma room? 2 A: Yes. 3 Q: And, I should ask you, what became of 4 Cecil Bernard George when you -- once you turned your 5 attention to Dudley George? 6 A: I believe he -- he stayed in the same 7 trauma room. As I moved on to other patients, the nurses 8 would have stayed with the -- Nick Cottrelle, originally, 9 and then Cecil George and would have continued to assess 10 and carry out some of the orders that would initiate it. 11 Q: All right. 12 A: He would have been attended to still, 13 but not by me. 14 Q: All right. And the same with -- with 15 Nicholus Cottrelle? 16 A: Yes. 17 Q: And, so at this time do you have 18 three (3) patients, to the best of your knowledge, in the 19 trauma room? 20 A: I know Cecil George was there. I 21 don't know what happened to Nick Cottrelle. I think I 22 read that he had been moved out to provide more space and 23 he was less -- at that point we thought less seriously 24 injured, but I'm -- I'm not sure of that. 25 Q: So, as I understand it, then, within


1 about -- within less than ten (10)_minutes you were 2 presented with a potential gunshot wound patient in the 3 form of Nicholus Cottrelle, a severely injured head 4 trauma patient in the form of Cecil Bernard George and 5 then a gunshot chest wound in the form of Dudley George; 6 is that right? 7 A: Yes. 8 Q: And, at this time, are you still the 9 only physician in the department? 10 A: Yes. 11 Q: All right. Can you tell me, then, 12 did you see Dudley George enter the -- the trauma room? 13 A: No. 14 Q: All right. Were you aware -- 15 informed as to how Dudley George arrived at the hospital? 16 A: I -- I know now, but I don't know 17 that I was told at the time. 18 Q: All right. 19 A: Well, no, I -- I think I would have 20 been. Yes, I did know, because, I mean, what happened 21 was that he was there in the trauma room and the nurse 22 called me over. 23 I didn't see him come in because I was 24 attending to Cecil George and then she was able to tell 25 me that he'd arrived by car and that we didn't have any


1 other information really about how he'd been on -- in -- 2 in transport to the hospital. 3 Q: All right. And did you have any 4 information as to how long he had been in the hospital 5 parking lot prior to being -- 6 A: No. 7 Q: -- transported into the trauma room? 8 A: No. 9 Q: And, you had no information with 10 respect to the circumstances giving rise of his -- to his 11 injuries or the nature of his injuries other than the 12 gunshot wound? 13 A: No. 14 Q: Is that correct? 15 A: Yes, that's correct. 16 Q: Okay. And, did any police officers 17 accompany Dudley George into the trauma room? 18 A: I don't remember. 19 Q: Can you describe the -- Mr. George's 20 presenting condition? 21 A: He had no signs of life. 22 Q: Meaning? 23 A: He had no pulse. On auscultating his 24 heart there were no heart sounds. He had no air 25 movement; no air entry into his chest, no movement of his


1 chest. His pupils were fixed and dilated, his corneal 2 reflexes were absent. 3 Q: All right. 4 A: When we put on the telemetry to see 5 if there was any electrical cardiac activity, it was a 6 flat line. 7 Q: Can you just explain what that -- 8 what that -- what telemetry is and -- and what the 'flat 9 line' means? 10 A: Telemetry is we put electrodes on the 11 chest to record the electrical activity of the heart and 12 normally you'll see contractions happening regularly and 13 even if you can't feel a pulse, if a person's alive 14 you'll see some cardiac activity. 15 It might be that it's not -- that there's 16 been blood loss or internal injury sufficient that you 17 can't feel a pulse and the blood pressure's really low 18 and -- and -- but you'll still see electrical activity in 19 the heart. There was a flat line, there was no 20 electrical activity. 21 Q: And how -- how quickly did you attach 22 this apparatus to Dudley George? 23 A: Seconds. 24 Q: All right. 25 A: I actually have the time of the


1 telemetry that showed the flat line. 2 Q: All right. Can you tell us what 3 document that is? 4 A: I don't think you have it; it was 5 part of the hospital chart. 6 7 (BRIEF PAUSE) 8 9 A: It was 00:15. 10 Q: 00:15 on September the 7th, 1995, 11 that that recording is made? 12 A: Hmm hmm. 13 Q: And is it fair -- is that -- how 14 reliable is the time in that recording? 15 A: Well, it seems consistent with the 16 timing of other records that we have for him. There were 17 tracings at 00:15 and 00:19 was the last tracing, and 18 then we said that we declared -- pronounced him dead at 19 00:20. 20 Q: All right. I wonder if we can make 21 the document that you've just referred to the -- the next 22 exhibit. 23 A: I don't have -- I don't have it. 24 Q: Oh, you don't have it? 25 A: No. It's -- it's telemetry strips on


1 the chart -- 2 Q: Okay. 3 A: -- that have times electronically 4 recorded at the same time; I -- I thought you might have 5 it as a copy of the chart, but... 6 Q: All right. We'll have a look for 7 that. I didn't come across it, that doesn't mean we 8 don't have it. But you -- you recall seeing that -- that 9 report and you're advising what the contents were and 10 what they mean? 11 A: Yeah. 12 Q: Thank you. And did you conduct any 13 other preliminary assessment? 14 You've described that he had no signs and 15 you've explained what that means; did you conduct any 16 other examination or assessment at -- at the time? 17 A: Well, we looked for signs of injury 18 and the main wound was the wound just above the clavicle 19 on the left, which was -- I'm just looking at how it was 20 described: 21 "One (1) centimetre round wound in the 22 left clavicle area." 23 I'm reading from the history and physical 24 from the hospital chart. 25 Q: Yes. This is Inquiry Document Number


1 20 -- sorry, 5000244, Front Number 2939. It's entitled, 2 History and Physical Examination for Anthony George. 3 It's on the screen now. 4 All right. And this is a document that 5 you signed and -- and that you dictated? 6 A: Yes. 7 Q: And dictated on September the 7th, 8 1995? 9 A: Yeah. 10 Q: I'd like to make that the next 11 exhibit, please. 12 THE REGISTRAR: P-358, Your Honour. 13 COMMISSIONER SIDNEY LINDEN: P-358. 14 15 --- EXHIBIT NO. P-358: Document 5000244 Strathroy 16 Middlesex General Hospital 17 history and physical 18 examination of Anthony George 19 September 07/'95 20 21 COMMISSIONER SIDNEY LINDEN: What tab 22 number? What tab number? 23 MS. SUSAN VELLA: It's Tab number 7. 24 25 CONTINUED BY MS. SUSAN VELLA:


1 Q: All right. And this is part of the 2 hospital chart with respect -- 3 A: Yes. 4 Q: -- to Anthony George? 5 A: Yes. 6 Q: Okay. And did you find any other 7 visible injuries or wounds on his body during your 8 preliminary assessment? 9 A: Well, we -- I looked quite carefully 10 for any sign of an exit wound from this bullet and the -- 11 from the gunshot wound in the upper chest, and we didn't 12 see any on his back or front. 13 So, there was no other sign of trauma, I 14 would say, from his waist up. I'm not -- I'm not sure 15 that we examined his legs in detail. 16 Q: And why would that be? 17 A: Because he appeared to be dead and we 18 were focussing on resuscitation effort initially. And 19 subsequent to that, when that resuscitation was not 20 successful, it didn't seem to be all that essential to 21 see if there were other minor wounds as well and there 22 were two (2) other patients still to be looked after. 23 Q: All right. Now, did you -- did you 24 see any signs of bleeding on Dudley George? 25 A: You know, I don't recall a lot of --


1 of blood either from this wound up here or on his clothes 2 and his lower extremities. Certainly if there had been 3 spurting blood or great quantities of blood, we would 4 have closer for more injury in those areas. 5 Q: Hmm hmm. And you indicated that the 6 treatment that you provided was resuscitation? 7 A: You're saying resuscitation efforts 8 were commenced; is that what you're referring -- 9 Q: Yeah. 10 A: -- to? Yeah. Yes. We started 11 intravenous lines to try and provide fluid, made sure he 12 -- the basics of resuscitation are airway, breathing, 13 circulation. 14 Make sure -- try and -- and get the airway 15 open and oxygen flowing to the lungs, try and get 16 circulation going by supporting the circulation given 17 that likeliest cause of his demise or injury was blood 18 loss and doing that did not -- was not successful in 19 providing any signs of life or any encouragement to 20 continue the effort. 21 Q: All right. And just so I understand, 22 the purpose of -- of the intravenous, is to -- is that to 23 circulate fluid through the heart to try to get it to -- 24 to resume pumping? 25 A: From the nature of his injuries, it


1 was likely that his condition was caused by blood loss 2 and so to try and replace that fluid to allow his heart 3 to start to pump again, you have perfuse the heart first 4 and then you have to try and get the heart to act as a 5 pump again, to provide circulation to the rest of the 6 body, but it was not likely to be successful given the 7 condition in which he arrived. 8 Q: All right. Fair enough. Do you 9 recall how long you continued these efforts, this medical 10 intervention? 11 A: Well we had them all underway and in 12 place within a few minutes of his being there and we 13 continued with the cardiac compression -- I had mentioned 14 cardiac compressions as well, and -- and airway control 15 and artificial respiration for several minutes and that 16 didn't achieve any response. 17 It didn't produce any electrical activity 18 at all in the heart, and the first sign of some degree of 19 activity would be the electrical activity. 20 Even if we hadn't been able to get a pulse 21 or the blood pressure, at least if we'd seen some 22 electrical activity, we would have had a hope that we 23 could continue with the resuscitation efforts, but there 24 was -- there was nothing. 25 Q: All right. And as a result, you --


1 you -- you terminated these resuscitation efforts and 2 pronounced him -- 3 A: Yes. 4 Q: -- dead, at 12:20 a.m. on September 5 the 7th? 6 A: That's correct. 7 Q: All right. Can you describe for us 8 what -- what injury Dudley George ultimately died from? 9 A: You gave me the post mortem report 10 yesterday. 11 Q: Yes. 12 A: I had actually had a review of it 13 prior to that as well -- 14 Q: And just for the record, if I might, 15 that's Inquiry Document 1002016 and it's at the last tab, 16 probably, of your documents there. 17 It's a report of post mortem examination 18 with respect to Anthony O'Brien George. 19 Is that the document you're -- 20 A: Yeah. 21 Q: -- referring to? All right. 22 A: Yes. 23 Q: Yes. Carry on. 24 A: Now, I'm not a pathologist and I'm 25 not a coroner, so I'm not really familiar with


1 determining causes of death in that same fashion, that 2 there's role. 3 Q: All right. Just -- 4 A: I -- I certainly can read that post 5 mortem report with interest and concern to know -- 6 Q: All right. 7 A: -- what did happen to him. 8 Q: Let's -- let's put it this way. At 9 the time that you conducted your assessment, and 10 performed medical treatment, had you detected -- you said 11 that he had a loss of blood, do you know where the loss 12 of blood was coming from? 13 A: It didn't seem to be external, so it 14 would -- I assumed it was internal bleeding. 15 Q: All right. And what conclusions, if 16 any, did you draw from that? 17 A: Conclusions... 18 Q: With respect to the -- the gunshot 19 wound, the loss of bleeding -- 20 A: That it had caused some puncture of a 21 major blood vessel in the thorax that had -- he'd bled 22 out from. 23 Q: All right. Thank you. 24 A: And the postmortem -- that's what the 25 postmortem shows, that there was a .5 centimetre tear in


1 two (2) pulmonary arteries on that side of his chest. 2 Q: Okay. 3 A: And, that he had massive -- they 4 described haemothorax on the left side of the chest. 5 Q: And, so as a consequence, he -- he 6 basically bled to death internally? 7 A: Yes. Yes. 8 Q: Now, in -- in retrospect, in knowing 9 what you do with respect to the nature of -- of that 10 injury and the -- the effect of it, was there any medical 11 intervention which might have saved Dudley George; that 12 is, I guess, stopped the internal bleeding that caused 13 him to bleed to death? 14 A: I don't have a lot of experience with 15 gunshot wounds or with this nature of trauma. It would 16 seem that it would have been a very difficult injury to 17 treat, though, even within minutes of -- of injury if 18 you've got a pulmonary artery that's got a .5 centimetre 19 hole in it. 20 It's not -- there's not way of stopping 21 that, really, by any sort of external measures and it 22 would be very hard to keep up with the blood loss with 23 intravenous support, even if you could have gotten an 24 intravenous started within minutes of it happening. 25 You'd have to get to the source of the


1 bleeding to get ahead of the problem and the only way of 2 getting to the source of the bleeding would be to do a 3 thoracotomy, to open the chest and get in there with 4 instruments to occlude the rent in the pulmonary artery. 5 And I'm -- I would think that in places 6 where gunshot victims are arriving at a major trauma 7 centre within minutes of receiving their wound, that 8 would be a possible thing to do, but there's not many 9 places that have that sort of facility in the world. And 10 all those ifs have to be true, too, that you get there 11 quickly and that everybody's on standby and ready to go. 12 It's very tricky dramatic stuff to be able 13 to try and follow that and it's not got really high 14 success rates, either. 15 Q: All right. So, just so that I 16 understand -- 17 A: But, that would be what you'd have to 18 do. 19 Q: What I'm understanding is that within 20 minutes of the injury, of the puncturing of the artery, 21 there would have had to have been invasive surgery to 22 essentially close up that hole in the -- in the artery 23 and allow the blood not to be -- not to be leaking out? 24 Is that a -- a fair way to put it? 25 A: That's a fair way to put it. In


1 terms of the minutes, it's hard for me to say how long; I 2 don't know how quickly you would lose blood from that. 3 Q: Okay, fair enough. 4 A: But, there's nothing to stop the 5 flow, you know, there's no natural clotting forming; 6 there's no natural tampenade that can happen in other 7 injuries in other parts of the body. There's nothing to 8 stop the bleeding, so it would just inexorably go on. 9 Q: All right. And, you say the blood 10 went into the thorax; where's the thorax? 11 A: It's the chest cavity. 12 Q: Thank you. And, you indicated that 13 that, in your -- in your view, even the starting of 14 intravenous and the insertion I guess, of blood into the 15 body likely wouldn't have been sufficient to make up for 16 the rapidity of the -- the blood loss? 17 A: I think it would be difficult to -- 18 yeah, to keep up with that blood loss. 19 Q: All right. 20 A: It would have been the thing you 21 would try to do, but I don't think that would have been 22 sufficient. I think you'd also have to get to the source 23 of the bleeding. 24 Q: And, to you knowledge, did the -- the 25 paramedics with whom you had contact, did they have the


1 ability to -- to -- to undertake that type of intravenous 2 procedure? 3 A: I don't think so. I don't think the 4 paramedics in our area have those advanced support skills 5 and that was '95 as well, but I'm not sure of that, you'd 6 have to inquire. 7 Q: Thank you. And did your hospital 8 have the -- the requisite trauma facility or capability 9 that you've referred to for this type of cardiovascular 10 surgery? 11 A: I'd have to say I doubt that that's 12 ever been done in our Emergency Room in the thirty (30) 13 years -- in the last thirty (30) years, so it would be an 14 extremely rare event. Could it have been? 15 I don't know, I think you would have to 16 ask Dr. Saettler whether it could have been done; she 17 would have been the one to do it. And whether she 18 would have been able to adapt other instruments that are 19 there for a different purpose to be able to do the job, I 20 don't know. 21 Q: All right. And -- 22 A: We do -- I mean, physicians do things 23 in urgent situations, in desperate situations that they 24 really feel they have to do, even if they're not very 25 well prepared and with minimal facilities and can usually


1 adapt things. 2 But, again, when you're not in a 3 sophisticated centre and the whole process has only a 4 very low risk -- low chance of being successful, you're 5 reducing your chances even further when you're doing it 6 in the sort of circumstances you're describing. 7 Q: All right. And Dr. -- did Dr. 8 Saettler join you at some point in the emergency room 9 and -- 10 A: Yeah, I think she -- 11 Q: -- do you recall -- 12 A: Yeah. 13 Q: Do you recall when? 14 A: She came pretty soon after Dudley 15 George arrived. 16 Q: And was she assisting you, then -- 17 A: Yeah. 18 Q: -- with the assessment and treatment 19 of Dudley George? 20 A: Yes. She was more or less there 21 within seconds of his being there. 22 Q: And we will hear from her later, but 23 I understand that she's a general surgeon. 24 A: Yes. 25 Q: Now we have heard testimony from an


1 individual named J.T. Cousins who was the young man who 2 accompanied Dudley George in the back of the car enroute 3 to the hospital, and applied pressure over Dudley 4 George's wound area. 5 And he testified that he -- he believed 6 that Dudley George's heart was still beating when they 7 arrived in the hospital parking lot. 8 And based on your examination and 9 treatment of Dudley George, is it likely that Dudley 10 George's heart was still functioning when he first 11 arrived in the parking lot? 12 A: As I don't know when he arrived in 13 the parking lot, could I answer it by saying I think it's 14 unlikely that his heart was beating five (5) to ten (10) 15 minutes previously. 16 Q: Okay. 17 A: I would think that his heart had 18 stopped beating effectively around five (5) to ten (10) 19 minutes before I saw him. 20 Q: And what is the basis of your 21 conclusion? 22 A: He had the fixed dilated pupils that 23 were unreactive and it takes around five (5) to ten (10) 24 minutes of severe loss of blood flow to the brain for 25 that to happen. And even more so, more like ten (10)


1 minutes or a bit over for the heart's electrical activity 2 to completely stop in a death that's by blood loss -- 3 Q: All right. 4 A: -- where the heart isn't primarily 5 injured itself, but is just failing because of the blood 6 loss. 7 Q: So, as I understand it, your last 8 part of the answer has to do with the time between the 9 stopping of the beating, the physical beating of -- 10 detectable beating of a heart, and the full loss of 11 electrical activity would be about ten (10) minutes? 12 A: Yes. 13 Q: And when it's due to an injury that's 14 not a heart injury, but a blood loss injury as it was in 15 this case? 16 A: Yes. 17 Q: All right. And your estimate -- 18 well, let's put it this way, so unless Dudley George was 19 in the parking lot at least ten (10) minutes earlier, it 20 is -- it is not likely that his heart was still beating? 21 A: Yes. 22 Q: All right. Now, looking back at the 23 time of your initial assessment of Dudley George, were 24 you missing any information which hampered your initial 25 assessment of him?


1 A: We didn't have any information as to 2 how -- what his condition had been like in transport to 3 us. People who are that severely injured are usually 4 brought in by ambulance attendants and you can then have 5 a report from them as to what vitals they've observed 6 enroute. 7 And there was nobody at first, to give us 8 information and as I think we've documented, I asked a 9 nurse to go and try and find out what we could about how 10 he'd been transported and what had been observed about 11 him in transport and that information wasn't available to 12 us. 13 But, we did everything that we could, 14 giving him the -- on the assumption that, perhaps, he had 15 only just collapsed and that there might be some chance 16 of resuscitating him. So, all the measures that we took 17 were on the assumption that there could be an opportunity 18 here that we could bring him -- bring him back. 19 But, if we'd had more information that had 20 quite -- by somebody qualified to make the observation 21 that he'd had not vital signs for twenty (20) minutes 22 enroute, it would be usual not to initiate a 23 resuscitation event in that -- with that history and that 24 happens all the time in the emergency room if we know 25 that someone's been dead for twenty (20) minutes, it's


1 not appropriate to put them through the indignity of a 2 resuscitative effort. 3 Q: All right. And, can you advise me, 4 based on your -- your -- your experience as an emergency 5 physician, over what -- what's the maximum period of -- 6 of time over which there are no vitals would you -- or, 7 sorry, a minimum time, for -- for lack of -- loss of 8 vitals that you would make the decision that 9 resuscitation efforts are not practical and not 10 dignified? 11 You indicated twenty (20) minutes? 12 A: That's a difficult question, really, 13 because it depends a little bit on -- on -- on how much 14 you can depend on the observer, known other illnesses and 15 chances of resuscitative effort, known wishes of the 16 patient. I -- I would -- I would look at a number like 17 twenty (20) -- perhaps twenty (20) minutes if we knew for 18 sure there'd been no vitals. 19 Q: All right. Thank you. 20 A: But, that's very, very generous, I'm 21 sure. The chance of resuscitation after much shorter 22 periods are almost zero. 23 Q: And, I wondering whether you can give 24 us any advice with respect to that or -- of if that's 25 something that's beyond your area of expertise?


1 A: I -- I'd prefer to defer to an expert 2 for giving you a precise number on that. 3 Q: Thank you. And, furthermore, had you 4 been provided with the information that suggested to you 5 conclusively that resuscitation efforts were not viable 6 or dignified, you would have then had an opportunity to 7 go back to the other two (2) patients who, as I 8 understand, were still in need of further assessment and 9 treatment; is that right? 10 A: I don't think that we were 11 influenced, that -- that we felt pressured to not provide 12 more sustained care to Mr. George. I don't think we cut 13 short attention to him on account of the other patients 14 present at all. 15 Q: No, that - that wasn't my suggestion. 16 My suggestion was that, had you received the information 17 that was missing concerning how long he was without 18 vitals, in order to have made a decision not to 19 resuscitate, that it wasn't appropriate to resuscitate, 20 then of course, that would have freed you up to return 21 your attention back to Mr. Cottrelle and Mr. Cecil 22 Bernard George sooner than you did? 23 A: Yes, it would. 24 COMMISSIONER SIDNEY LINDEN: Can we take 25 a morning break here?


1 MS. SUSAN VELLA: Yes, certainly. 2 COMMISSIONER SIDNEY LINDEN: Would that 3 be -- 4 MS. SUSAN VELLA: Certainly, thank you. 5 COMMISSIONER SIDNEY LINDEN: Let's take a 6 morning break. 7 THE REGISTRAR: This Inquiry will recess 8 for fifteen (15) minutes. 9 10 --- Upon recessing at 10:29 a.m. 11 --- Upon resuming at 10:48 a.m. 12 13 THE REGISTRAR: This Inquiry is now 14 resumed, please be seated. 15 16 17 CONTINUED BY MS. SUSAN VELLA: 18 Q: Thank you, Commissioner. 19 Now, once you pronounced Mr. George 20 deceased, what became of the body? 21 A: I'm not able to tell you much about 22 that. I think it's well documented, but I don't have any 23 memory of it, myself. 24 Q: All right. Is it fair to say, that 25 you released the body to medical personnel?


1 A: Yes. 2 Q: And, that it was removed from the 3 trauma room? 4 A: Yes. 5 Q: All right. And, after you released 6 the body, did you examine it ever again? 7 A: No. 8 Q: Now, we have heard testimony from Mr. 9 Sam George, the brother of the deceased, Dudley George, 10 that he was informed by a funeral director that there was 11 a second gunshot wound in his brother's leg. 12 Did you see any other gunshot wound other 13 than the one you've described, obviously, on your 14 examination of Dudley George? 15 A: No. 16 Q: Is that something that you would have 17 expected to locate during your initial examination of 18 this patient? 19 A: I can be confident that there wasn't 20 a gunshot wound on his torso other than the one that 21 we've described. And I -- I'm not sure I can be 22 confident that there was not on his lower extremities. 23 Q: All right. I'd like you to return to 24 the postmortem report, Inquiry Document 1002016. I 25 believe it's the last document in that pile that you have


1 there. 2 First of all, I believe you indicated that 3 you had occasion to review this report prior to the 4 Commission providing a copy to you? 5 A: Yes. 6 Q: And what was the occasion upon which 7 you -- you reviewed the report? 8 A: I -- it's a very unfortunate incident 9 when someone that you've been involved in -- in looking 10 after medically dies, and it's important to learn what 11 you can about what could or could not have been done to 12 help that person. So, it's natural and I think 13 appropriate to want to know what the outcome was and any 14 further information from the autopsy. 15 And so I requested -- I requested of the 16 coroner that I should learn what he had died from 17 exactly. 18 Q: All right. Thank you. 19 A: And I was allowed to look at the -- 20 the coroner's report to that end. 21 Q: Okay. And were there any conclusions 22 or opinions expressed in that report that surprised you 23 in the sense of being inconsistent with your own clinical 24 observations and -- and diagnosis? 25 A: No.


1 Q: I'd like you to turn, please, to the 2 -- I believe it's the second -- it's either the last page 3 or the second last page, it's -- it's a body diagram with 4 respect to Anthony O'Brien George. 5 A: Right. 6 7 (BRIEF PAUSE) 8 9 Q: I'll just wait for a moment for the 10 diagram to go onto the -- there it is -- onto the screen 11 so everyone can follow. 12 And I should ask you first, do you know 13 who conducted the -- the postmortem? 14 A: I understand it was Dr. Shkrum. 15 Q: Okay. Do you know Shkrum from -- 16 A: No. 17 Q: -- past experience? Okay. 18 This appears to be a -- a diagram prepared 19 by the -- the coroner in relation to various marks that 20 he saw on the body of the Late Dudley George. 21 22 (BRIEF PAUSE) 23 24 Q: I'm just being reminded that, of 25 course, it was the pathologist who prepared this report,


1 not the coroner, just to be clear. 2 A: Okay. 3 Q: In any event, this appears to be a 4 diagram of the various markings, if I can put it that 5 way, that he detected on -- on Dudley George's body. 6 And I wonder, in going through it, first 7 of all, can you -- do you have the -- the red laser there 8 in front of you? It's a dark pen in front of you, by 9 your water glass, and you press the button. Hopefully it 10 works. 11 A: I haven't used one of these before, 12 so which button? 13 Q: Can you just assist her? 14 15 (BRIEF PAUSE) 16 17 A: Great. 18 Q: There you go. Thank you very much. 19 I wonder if you could point on the diagram, please, the - 20 - the entry point of the gunshot wound -- or the bullet. 21 All right. And you're pointing to the top 22 right -- it would have been the left shoulder area of 23 Dudley George? The clavicle? 24 A: Hmm hmm. 25 Q: And I'm not understanding where the


1 clavicle is; perhaps you can be a little bit more precise 2 as to what the clavicle is? 3 A: Well the clavicle is the collar bone. 4 Q: Okay. 5 A: Here, the horizontal bone here. 6 Q: Thank you. 7 A: And so the gunshot wound was just -- 8 I think it was just above the clavicle. 9 Q: All right. 10 All right. So, approaching the collar 11 bone as opposed to the chest itself, the heart, I should 12 say? 13 A: Yes. 14 Q: All right. And is that consistent 15 with your recollection of where the entry point for the 16 bullet was? 17 A: Yes. 18 Q: All right. 19 A: He's got it square over the clavicle 20 there on that picture. I thought it was just a little 21 bit above the clavicle into the hollow here -- 22 Q: All right. Just above -- 23 A: -- but very close to it. 24 Q: Okay. Thank you. And I should ask 25 you, did you detect any exit --


1 A: No, we didn't. 2 Q: -- wound? All right. 3 A: And we did look. 4 Q: Thank you. Now, you'll note that 5 there are three (3) markings, it would appear at least, 6 on -- on the legs and starting with the front view first, 7 can you describe what -- what those marking appear to 8 represent, if you're able to? 9 A: I'm not sure I'm comfortable 10 interpreting his -- 11 Q: All right. 12 A: -- diagram. 13 Q: All right. Let me ask you this, 14 then: Did you detect any of those markings on your 15 examination of Dudley George? 16 A: I don't -- I don't recall. 17 Q: Right. Fair enough. Do you recall 18 reviewing any conclusion by the pathologist as to whether 19 or not there was a second bullet wound? 20 A: My impression in reading the 21 pathology report was that they described an abrasion on 22 the right shin. I note that there was an x-ray of the 23 right leg and there was no bullet. 24 Q: Was an abras -- and what is an 25 abrasion then?


1 A: An abrasion is a surface, superficial 2 scratch. I think it had a linear component to it, the 3 way it was described somewhere in the pathology. 4 Q: All right. So, a superficial flesh 5 wound, is that -- 6 A: Yes. 7 Q: Fair enough. I wonder if we could 8 make the pathologist's report, then, the next exhibit 9 please? 10 THE REGISTRAR: Exhibit P-359, your 11 Honour. 12 COMMISSIONER SIDNEY LINDEN: P-359. 13 14 --- EXHIBIT NO. P-359: Document 1002016 report of 15 post mortem examination of 16 Anthony O'Brien George at 17 Victoria Hospital, London 18 September 08/'95 19 20 CONTINUED BY MS. SUSAN VELLA: 21 Q: And perhaps you would go to the last 22 page of that exhibit. This is a report from the 23 department of radiology, Victoria Hospital. 24 Again, did you have an opportunity to 25 review this in the course of --


1 A: No -- 2 Q: -- reviewing the -- 3 A: -- no, I didn't. I didn't see this 4 until yesterday's package. 5 Q: All right. Based on your examination 6 and treatment of -- of Dudley George, is there anything 7 inconsistent in that report with what you observed when 8 you assessed him? 9 10 (BRIEF PAUSE) 11 12 A: No, that's consistent with what we 13 deduced had happened. 14 Q: Thank you. And perhaps you could 15 just express, then, in lay-person's terms what you 16 deduced happened that night. 17 A: That the bullet lacerated large 18 vessels within the chest cavity that bled into the left 19 side of the chest and resulted in a death from blood 20 loss. 21 Q: Thank you. 22 23 (BRIEF PAUSE) 24 25 Q: Now, having the benefit of hindsight,


1 and the knowledge that you have now with respect to the 2 circumstances of -- of Dudley George's death, is there 3 anything that you would have done differently that night 4 which might have resuscitated Dudley George? 5 A: No, unfortunately. 6 Q: All right. And to be clear, when you 7 first examined him, there were no vital signs present? 8 A: No. 9 Q: Correct? 10 A: Correct. 11 Q: Yeah. 12 13 (BRIEF PAUSE) 14 15 Q: And given the nature and -- and 16 severity of his injuries as you assessed them, and the 17 fact that he had lost his vital signs and signs of any 18 electrical activity in his heart, are you able to give us 19 an estimated range of the time that his heart ceased 20 functioning? 21 A: I would, as I think I said before, I 22 would think that he had been dead for ten (10) to fifteen 23 (15) minutes at least, and that's minimum, and it could 24 have been much longer. 25 Q: Thank you.


1 (BRIEF PAUSE) 2 3 Q: Now, just before we leave this 4 subject, My Friend Mr. O'Marra was kind enough to alert 5 me to the existence of telemetry strips, if I'm saying 6 that right, with respect to Dudley George's cardiac 7 activity. 8 A: Telemetry. 9 Q: Telemetry, thank you. 10 Anyways, if we could go to Inquiry Number 11 -- Document Number 5000245, and perhaps you could look at 12 the screen, doctor -- 245. 13 250? Oh, I'm sorry, 250. 14 15 (BRIEF PAUSE) 16 17 Q: Now, I wonder if you're able to 18 identify this document? 19 A: Can I -- I can't really see it from 20 this angle. 21 Q: Certainly. 22 A: Is there a time up there? I can't 23 see that. 24 Q: The -- sorry, is there a...? 25 A: Are those numbers times? Is there a


1 -- I can't read it. I mean, yes, that looks like a 2 telemetry, that does too. I can't see times on them -- 3 Q: No. We can -- 4 A: -- present on every strip, so it 5 depends which part you're taking a picture of. 6 Q: Okay. Fair enough. And, 7 unfortunately, there isn't -- we can't find times -- 8 A: 19:09, there is one time there. 9 Q: That, I think, is a fax. 10 A: No. That 19:09 is a time. 11 Q: What's the time? 12 A: Nineteen (19) minutes and nine (9) 13 seconds after midnight. 14 Q: After the commencement of the 15 process, is that what that -- 16 A: Yeah, that's the time. That's the -- 17 the clock time -- 00:20 is when he was -- 18 Q: Okay. Right. So, in other words, 19 this is -- this can't be Dudley George's record. 20 A: No, it is. What are you commenting 21 on? 22 Q: The 19:09; understanding what time 23 that represents. 24 COMMISSIONER SIDNEY LINDEN: Twenty (20) 25 minutes after midnight.


1 THE WITNESS: Twenty (20) minutes after 2 midnight. 3 4 CONTINUED BY MS. SUSAN VELLA: 5 Q: 00:19:19? 6 A: Yeah. 7 Q: Thank you very much. Okay. And so 8 that -- that was the state of the electrical activity as 9 of that time; is that right? 10 A: Well, yeah, but what you -- what 11 you're not -- what you're confused -- what is confusing 12 about this is that this is -- this looks like electrical 13 activity and it's the effect of the cardiac compressions 14 that produces that tracing. 15 Q: All right. 16 A: What you need to look at is the 17 telemetry when there's no cardiac compressions being 18 performed. 19 Q: Okay. 20 A: And that's what we showed earlier -- 21 Q: All right. 22 A: -- which was the flat line. 23 Q: Okay. Fair enough. And so where 24 this -- this document, for example, there appear to be a 25 -- a more -- is that considered to be a flat line with --


1 with the one (1) peak -- 2 A: Yes. 3 Q: -- in the middle? 4 A: That -- that would have been one (1) 5 compression there. 6 Q: And that's a compression? 7 A: And this will be the flat line there. 8 Q: Okay. Thank you very much. 9 A: And whenever we stopped compressions 10 -- these represent compressions -- there was a flat line. 11 Q: Okay. All right. And, 12 unfortunately, as -- as you've noted, the times, by and 13 large, do not seem visible on these, so we can't tell 14 exactly what time each section is -- was taken? 15 A: Hmm hmm. 16 17 (BRIEF PAUSE) 18 19 Q: Okay. Thank you. I'd this to be the 20 next exhibit, please. 21 THE REGISTRAR: Is there a tab number for 22 that? 360 -- P-360. 23 COMMISSIONER SIDNEY LINDEN: 360. 24 25 --- EXHIBIT NO. P-360: Document 5000250


1 CONTINUED BY MS. SUSAN VELLA: 2 Q: All right. Thank you. What did you 3 do after you released the body of the late Dudley George? 4 A: I went back to do ongoing assessments 5 of Cecil George and Nick Cottrelle. 6 Q: All right. And do you recall who you 7 -- you turned to next? 8 A: I think it was probably Cecil George, 9 because my impression was that he was -- I was more 10 concerned about his stability. 11 And my impression is that Dr. Saettler had 12 gone to see Dr. Cottrelle -- Mr. Cottrelle, so I think we 13 -- one of us went to one, and one to the other and I'm 14 sure it was -- I went to Cecil George and she went to 15 Cottrelle. 16 Q: Okay, fair enough. Had Mr. Cecil 17 Bernard George's condition and presentation changed at 18 all in the interim? 19 A: I'm not sure of the exact timing, but 20 certainly in the course as being in the emergency room, 21 he became more alert, more consistently with open eyes, 22 more consistently responding to questions. 23 Whether that was in the first twenty (20) 24 minutes or a little longer, I'm not sure. 25 Q: Fair enough. And did you come -- did


1 you form any further clinical impressions based on your 2 continuation of the examination of Mr. Cecil Bernard 3 George in the trauma room? 4 A: He had a stable course in the trauma 5 room. His sensorium improved, so his level of 6 consciousness improved, so it became less concerned about 7 the nature of his head injury, although we were still 8 concerned enough to want to monitor him neurologically 9 for the next twenty-four (24) hours in case there was any 10 further deterioration. 11 With respect to his trauma to his body, 12 the x-rays showed that his neck was not fractured. He 13 didn't have any fractures in his limbs. 14 The abdomen didn't show any suggestion of 15 internal injury. His blood pressure and pulse remained 16 stable, suggesting there was no internal bleeding or 17 blood loss. 18 And so our initial impressions were 19 accurate and confirmed by the course that he followed in 20 the emergency room. 21 Q: All right. And I wonder if you would 22 go to Tab 2 of your binder, Inquiry Document Number 23 1005237. 24 25 (BRIEF PAUSE)


1 Q: It appears to be the -- a report from 2 diagnostic imaging department in relation to Cecil 3 Bernard George. 4 Does this reflect the results of the x- 5 rays that you had ordered on him? 6 A: Yes. 7 Q: And perhaps you can just -- does this 8 confirm or could -- what you just said? 9 A: Yes. 10 Q: All right. I'd like to make this the 11 next exhibit, please. 12 THE REGISTRAR: P-361, your Honour. 13 COMMISSIONER SIDNEY LINDEN: 361. 14 15 --- EXHIBIT NO. P-361: Document 1005237 Strathroy 16 Middlesex General Hospital, 17 Department of Diagnostic 18 Imaging Report of Mr. Cecil 19 Bernard George September 20 07/'95 21 22 CONTINUED BY MS. SUSAN VELLA: 23 Q: All right. And just going back to 24 Tab 1 of your brief, Exhibit P-357 you have described 25 what the results of the physical examination were.


1 Just wondering, were these results -- 2 results after the completion of your assessment in the 3 trauma room or were they results that were formed -- 4 conclusions that were formed later on? 5 6 (BRIEF PAUSE) 7 8 A: Well, the second page of that, that 9 again is not present here, does describe the course in 10 the Emergency room, so it was not the very initial 11 assessment, but it would have been the assessment more or 12 less at the time that he left the Emergency room and went 13 to the floor. 14 Q: All right. Thank you. 15 A: And as I say, there's no evidence at 16 the moment of any internal bleeding or of significant 17 neurological trauma, but he's going to be admitted to be 18 observed for the same. 19 You just took me through those x-rays. In 20 fact, the ones you referred to, I think, were done the 21 next day or it was that same day, but later in the day. 22 Q: Okay. Fair enough. 23 A: The second page, the portable C-spine 24 and portable chest were done in the emergency room. 25 Q: Thank you. So, did you have any


1 further conversations with Mr. Cecil Bernard George with 2 respect to what he alleged to be the origin of his 3 injuries? 4 5 (BRIEF PAUSE) 6 7 A: In the emergency room, in the course 8 of his stay there, he made it clear that he'd been 9 beaten. I don't know whether he told me that it was by 10 the police at that time. 11 And he said that he hadn't been shot, to 12 his knowledge. 13 Q: All right. 14 A: As, I think, has been documented 15 elsewhere, some relatives came to the Emergency Room and 16 described more clearly that he had been beaten by police. 17 Q: Now, this was -- this was what they 18 reported to you, do you have any -- did you have any 19 independent basis as to whether or not those allegations 20 were true? 21 A: Oh, gosh, no. No, I was in the 22 Emergency Room looking after patients, I'm just saying 23 what we were told by those relatives. 24 Q: And were -- did you form an opinion 25 as to what the cause, likely cause, of the types of


1 injuries that you observed and diagnosed would be from? 2 A: Well, not particularly at the time in 3 the Emergency Room, but when I reassessed Mr. George that 4 -- later that day, but in particular the following day, 5 by the 8th, he had developed quite a lot of bruising and 6 it was extensive in many different areas and so the -- it 7 was more apparent at that point that he had sustained 8 several injuries. 9 Q: And what type of force, if I can put 10 it, would be required to -- to cause those kinds of 11 injuries? 12 A: He looked like he had been hit quite 13 hard many times with a blunt object and one that had a 14 linear shape to it, judging by some of the larger bruises 15 on the flatter surfaces of his body. 16 Q: All right. A linear shape? All 17 right, and could you determine what the likely -- what 18 other objects or -- or what other objects would likely 19 have contributed to some of the injuries that you 20 witnessed aside from a -- a blunt linear object? 21 A: Other objects? I'm having trouble 22 with that question. 23 Q: All right. 24 A: Can you... 25 Q: Is it fair to say that the injuries


1 that you saw were likely caused by blunt force trauma? 2 A: Yes. 3 Q: And, in layman's terms, that means 4 being hit with something or by something? 5 A: Yes, and a couple of spots the 6 bruising was quite distinctive in its appearance and, as 7 I say, in a sort of linear fashion. 8 Q: Did you have occasion to document in 9 the form of a diagram, those injuries? 10 A: Yes. 11 Q: And I'd like to refer Counsel and the 12 Commissioner to a document that we handed out this 13 morning, it's a two (2) page document dated September 8, 14 1995 9:00 a.m., both exhibits, the shapes of body -- of a 15 body; the front view and the back view. 16 And is this the -- do you recognize this 17 document? 18 A: Yes. 19 Q: And I should say it's on the screen 20 now. Did you prepare this document? 21 A: Yes. 22 Q: When did you prepare it? 23 A: Nine o'clock on September the 8th, 24 1995. 25 Q: And, that's 9:00 a.m.?


1 A: 9:00 a.m. 2 Q: Is that prior to the discharge of 3 Cecil Bernard George? 4 A: Yes. 5 Q: And what was the -- was the basis of 6 your preparing this document your -- your visual 7 observations of Cecil Bernard George on the 8th? 8 A: Yes, and -- and examination. 9 Q: Sorry? 10 A: And examination. 11 Q: Yes, okay. And I wonder if you could 12 take us through this. Well, firstly, let me ask you 13 this. Why did you prepare this document? 14 A: When the bruising had developed and 15 it was obvious that there were many different areas of 16 bruising and particularly seeing that they were -- looked 17 as though they were by long sticks, perpetrated by long 18 sticks on his back. 19 And as the history had become available 20 through many -- the different sources that there was the 21 suggestion that he had been beaten, I thought it was 22 important to -- to document the extent of his injuries, 23 not so much from the point of view of his medical 24 recovery, but from a legal point of view. 25 Q: All right.


1 A: I anticipated that at some point I 2 might be questioned about them and there were so many 3 that I wanted to be able to be accurate in my description 4 of them. 5 Q: All right. And at this point in 6 time, September the 8th, 1995, had you concluded that it 7 was likely that these injuries were caused by a beating 8 of some sort? 9 A: They seemed very consistent with 10 that. 11 Q: All right. And perhaps, was this -- 12 did you file this with the hospital chart? 13 A: I did not. As you can see, it's on a 14 history sheet of the hospital and that's his name plate 15 there on the right upper corner. 16 Perhaps I should have left it on the 17 chart; it was clearly in my mind something that would be 18 of -- of -- might be of legal importance rather than 19 medical care importance and I made a bit of distinction 20 in my mind on that, but it probably would have been 21 appropriate to leave it on the hospital chart. 22 Q: And have you made any changes or 23 alterations of any kind to this document since you 24 prepared it? 25 A: No, I haven't, no.


1 Q: All right. Would you, with the aid 2 of this document, then, describe the visible injuries 3 which you observed on Cecil Bernard George in the morning 4 of September the 8th of 1995? Perhaps you would use your 5 laser pointer? 6 A: It's going to be difficult for me, I 7 don't have glasses here, I can't -- 8 Q: All right, well -- 9 A: -- I'll try. 10 Q: I -- I could -- maybe I can assist, 11 Doctor, you certainly have coordinated each location with 12 a number. I think for the record that that would be 13 sufficient. 14 A: Okay. If you can see -- where -- 15 where is "1" up there? 16 Q: And we're starting with the front 17 view, yes. 18 A: Is that "1" up there? 19 Q: Yes. 20 A: Well, if I don't have to point, I can 21 -- and you can see it, would somebody else like to point 22 to the numbers -- 23 Q: Sure, I could -- 24 A: -- if you want them pointed at? 25 COMMISSIONER SIDNEY LINDEN: Perhaps


1 Katherine could do it. 2 MS. KATHERINE HENSEL: Yeah, I'll 3 certainly do that. 4 5 CONTINUED BY MS. SUSAN VELLA: 6 Q: And perhaps you'd just describe for 7 the record -- 8 A: I've got the numbers on the diagram 9 and I've got descriptions by the side, so -- 10 Q: Would you also describe for the 11 record, the general location of the injury as well? 12 A: Right, yeah. The -- number 1 was 13 over and above his right eyebrow. There was an abrasion 14 down here and he was tender there, yeah. 15 Number 2 was mid-forehead position; a 16 little off to the left there was a faint bruise there and 17 he was tender. 18 Number 3 was over his left eyebrow; there 19 was swelling, bruising, and tenderness. 20 Number 4 over his cheekbone and axilla, he 21 was tender over the prominence of the cheekbone, although 22 there was no bruising or swelling visible there. 23 Q: And, I'm sorry, what side -- which 24 cheekbone was that? 25 A: Right.


1 Q: Sorry? 2 A: Right. 3 Q: Thank you. 4 A: Number 4 -- Number 5, on the bridge 5 of his nose, it was bruised, he was tender; it was not 6 swollen. 7 Number 6 is his upper lip; it was -- on 8 the left side of his upper lip was swollen, had been 9 sutured, bruised around there. He was also tender in his 10 gum underlying that lip. 11 Q: And, do you recall, Doctor, how many 12 stitches were administered to his upper lip? 13 A: No, Doctor Saettler sutured that 14 laceration; she would be able to tell you. 15 Q: Thank you. 16 A: Number 7, right neck. The 17 sternocleidomastoid, which is this muscle here, was 18 tender; there was no bruising. 19 Q: All right, and just for the record, 20 you pointed to a -- a muscle that is -- can you just 21 describe that muscle? 22 A: The right side of the neck here -- 23 Q: All right. 24 A: -- going from the ear to the 25 clavicle.


1 Q: Thank you. 2 A: Number 8 on the right upper chest, it 3 was red diffusely and tender in an area two (2) inches by 4 four (4) inches. 5 On the -- number 9 -- on his anterior 6 shoulder, he was very tender there without any visible 7 bruising. 8 Q: Now is that the right shoulder? 9 A: Right shoulder. 10 Q: Thank you. 11 A: Number 10, right lateral thigh, he 12 was tender without any visible changes there. 13 Q: When you say, "the right lateral 14 thigh," is that just above the knee? 15 A: Just above the knee, yeah. 16 Q: Thank you. 17 A: Number 11 on the same leg, below the 18 knee and more medially, yeah, he was tender there with 19 abrasions -- two (2) small abrasions. 20 Q: Now, just -- abrasions are what, 21 Doctor? 22 A: A break in the skin. 23 Q: Thank you. 24 A: Just a superficial break in the skin, 25 not sufficient to require suturing.


1 Number 12, left medial thigh he was 2 tender, with an abrasion over the area. 3 Q: And a medial thigh, did you say? 4 A: Yeah, that's again just above the 5 knee on the inside of the leg. 6 Q: Thank you. 7 A: Number 13 was over the shin on the 8 left, where he was tender and had an abrasion. 9 And Number 14 was the abdomen, just below 10 the belly button. He was tender, there was no bruising. 11 Q: Or abrasions? 12 A: Or abrasion. 13 Q: And can you give us a sense as to the 14 -- the span of the area in the abdomen that appeared to 15 be tender? 16 A: Well, the -- that was the area that 17 was shaded. 18 Q: In the centre? 19 A: Yeah. 20 Q: All right, and that -- that concludes 21 the visible injuries that you observed on the front -- 22 A: Yes. 23 Q: -- of Mr. George's body? Okay, let's 24 proceed then to the next page, and the back view. 25 Perhaps you can review those injuries with us.


1 A: Number 1 was on his left hand. He 2 was tender on the little finger side, the ulna border 3 with an abrasion close to the wrist and some mild amount 4 of swelling. 5 Number 2, going up to the head, at the 6 base of the skull, he had a laceration that we had -- I 7 had put two (2) metal sutures in, a two (2) inch 8 laceration horizontal across the back of his head. 9 Q: And doctor, just pausing on this 10 injury. Why -- why -- what would give rise to using 11 metal sutures on this particular injury? 12 A: They're easy and quick and effective 13 to apply to scalp lacerations and they control the -- any 14 blood -- bleeding from it very quickly. 15 Q: All right, thank you. 16 17 (BRIEF PAUSE) 18 19 Q: Yes, Number 3? 20 A: Number 3, on the back of his head, 21 higher up there, I described it as a half inch haematoma 22 or bruise with a burst abrasion that was quite tender. 23 Was -- the skin gets macerated and -- and 24 broken, but not clean edges, so you wouldn't be able to 25 suture that together.


1 Number 4, over the -- just below the 2 laceration at the back of his neck but a little bit lower 3 down over the protuberance there at the back of the head, 4 he was mildly tender over there. 5 Number 5 was over the back of his left 6 shoulder. Number 5, yeah -- we had a -- a linear bruise 7 with an abrasion in that sort of distribution that was 8 shaded there. 9 I think you're looking at -- yeah, okay, 10 that's Number 5, yeah, in that -- in that direction, 11 yeah. 12 Number 6 was higher up above there, where 13 there was diffuse bruising and tenderness in the areas 14 that are shaded. 15 Number 7, on the other shoulder, there was 16 a linear bruise and tenderness in that sort of dimension. 17 That "X" marked a tattoo that was in that location. 18 Q: And perhaps I should just ask you, 19 you've used the term a few times, a "linear bruise". 20 What -- what -- what are you -- what -- give us a 21 description of a linear bruise. 22 A: Had -- had length to it. 23 Q: Yes. As opposed to? 24 A: As opposed to a round bruise that's 25 going out in all directions.


1 Q: All right, and what, if anything can 2 you conclude from the fact that he had some linear 3 bruises in terms of the likely cause of injury? 4 A: The linear bruises seemed to be 5 consistent with the history of his being beaten with a 6 baton. 7 Q: A police baton? 8 A: Yes. 9 Q: So, a long object -- 10 A: Yes. 11 Q: -- in other words? All right. 12 A: There would -- there were, perhaps, 13 the three (3) particularly on his back, that clearly 14 looked -- Number 8, especially, which doesn't show up 15 very well there actually, where there were two (2) 16 parallel lines of bruising of about -- I measured it at 17 being fifteen (15) centimetres long, parallel lines that 18 were a centimetre apart. 19 Q: And when you say, Two (2) inches 20 lateral, Two (2) red lines, what are you referring to 21 there? 22 A: Well, number 8 I described as mid- 23 back nine (9) inch tramlines, two (2) linear parallel red 24 areas, tender throughout, and two (2) inches lateral to 25 them. So the tenderness was two (2) inches lateral to


1 the actual red lines or bruising that was developing. 2 And there was a central clearing area between the two (2) 3 red lines, there was a centimetre apart. 4 Q: Thank you. And you say this is not 5 measured but it was an estimate; is that right? 6 A: Where did I say that? 7 Q: In the paragraph beside the diagram 8 fifteen (15) centimetres, under number 8. 9 A: Oh, okay. Yeah, that's right. 10 Q: All right. 11 A: Thank you. 12 Q: Number 9? 13 A: In the mid-axillary line there was a 14 dark bruise, that's just under the arm but on the 15 ribcage, with central clearing that was very tender. 16 Number 10, down on his thigh, right thigh, 17 outer aspect, just below the hip, tender, there was no 18 bruising. 19 The right knee, number 11, behind the 20 right knee, again on the inside surface; abrasion, 21 swelling, bruising and tender. 22 Number 12, right upper arm, at the back; 23 bruising and tender. 24 Number 13, just a little below that, above 25 the elbow, on the right arm at the back; bruising,


1 swelling, tender, a linear pattern horizontally. 2 Q: All right. And what, if anything, 3 did you conclude with the fact that -- your observation 4 that this was a -- a linear pattern horizontally? 5 A: Again, it looked -- it looked as 6 though it had been perpetrated by a -- an object that had 7 length to it. 8 Q: Okay. 9 A: And number 14, on the right -- right 10 forearm and wrist, he was tender diffusely over the 11 distal forearm, from halfway down towards the wrist, 12 abrasion marks and -- and tenderness. The wrist itself 13 was stiff, with painful range of motion. 14 Q: Now, when you use the term -- you 15 used the term a few times, "diffuse", as in the context 16 of diffused bruising or tender diffusely, can you just 17 describe what -- what that meant? 18 A: In a widespread area. 19 Q: All right. And is that -- have you 20 now reviewed all of the visible injuries that you could 21 see on that particular day? 22 A: Yes. 23 Q: Commissioner, I'd like to make this 24 the next exhibit, please. 25 THE REGISTRAR: P-362, Your Honour.


1 --- EXHIBIT NO. P-362: Front and back view of Cecil 2 Bernard George September 3 08/'95 9:00 a.m. document 4 injuries by Dr. Alison Marr 5 6 CONTINUED BY MS. SUSAN VELLA: 7 Q: Now, as I understand your evidence, 8 as of April the 8th in the morning there were a total of 9 -- I'm sorry, September the 8th -- 10 A: September the 8th. 11 Q: -- excuse me, 1995, in the morning, 12 there was a total of twenty-eight (28) visible markings 13 on -- on Mr. Cecil Bernard George's body; is that fair? 14 A: Well, we've actually described 15 twenty-eight (28) areas of either tenderness or bruising. 16 Q: All right. 17 A: Some of them, I think I commented, 18 there wasn't a bruise but there was tenderness. 19 Q: Fair enough. And were all of these 20 injuries consistent with some form of blunt-force trauma? 21 A: Yes. 22 Q: And is it fair to say that not all of 23 these injuries were visible as of the -- the night that 24 he was admitted into the trauma room? 25 A: Yes. And that would be the nature of


1 -- of the injury, that it would take a little while for 2 the bruising to develop. 3 Q: All right. And that -- that's with 4 respect to bruising in particular, not the abrasions 5 though? 6 A: Yeah. No, the abrasions would have 7 been visible. 8 Q: Hmm hmm. On -- 9 A: And the lacerations clearly were 10 documented, yeah. 11 Q: Now, of these injuries, which caused 12 you the most concern the night that he was in the trauma 13 room, when you initially assessed him? 14 A: Well, the -- the injuries around the 15 head. We knew of the laceration on the lip and the 16 injuries on the back of the head were likely the cause of 17 his impaired consciousness and just the degree to which 18 his head trauma was uncertain at the initial 19 presentation. 20 But it, as we've said, continued to 21 improve, rather than deteriorate. That was one (1) area 22 of concern. 23 The abdominal tenderness and together with 24 the history of the uncertain vitals en route, led us to 25 be concerned about internal bleeding, but it turned out


1 not to be the case. 2 The right forearm was -- he was certainly 3 complaining of his -- of the pain there. One (1) of his 4 -- that was one (1) of his major areas of complaint and 5 we were concerned about whether that could be actual 6 fracture, but it wasn't. 7 Q: Now, do you recall when it was that 8 Cecil Bernard George was discharged from the hospital? 9 A: I believe it was later the day of the 10 September the 8th. 11 Q: And perhaps you would -- excuse me, 12 perhaps you would look at Inquiry Document Number 13 1005327, that's Tab 3, and it's a summary sheet with 14 respect to Mr. Cecil Bernard George. 15 16 (BRIEF PAUSE) 17 18 Q: And this indicates in the -- on the 19 right-hand side, halfway down, discharge date of 20 September the 8th, 1995 and a discharge time of 16:30 or 21 4:30 in the afternoon. 22 A: Yes. 23 Q: Does that seem accurate to the best 24 of your recollection? 25 A: Yes.


1 Q: I'd like to make this the next 2 exhibit, please. 3 THE REGISTRAR: P-363, your Honour. 4 5 --- EXHIBIT NO. P-363: Document 1005327 Strathroy 6 Middlesex General Hospital, 7 Summary sheet of C. Bernard 8 George September 7,8/'95 9 10 CONTINUED BY MS. SUSAN VELLA: 11 Q: Now you -- did you authorize or 12 approve of his discharge? 13 A: Yes. 14 Q: All right, and what was his 15 condition, in general terms, at the time of the 16 discharge? 17 18 (BRIEF PAUSE) 19 20 A: If I can refer to my progress notes, 21 on September the 8th, he had -- he was now fully alert 22 and had had no neurological sequelae. 23 He did have a mild headache but it was 24 mild and responding well to simple analgesics. 25 He still had pain at the back of his head


1 and his right forearm, and multiple lesser pain elsewhere 2 and stiffness, but those were not injuries that required 3 further hospital attention. 4 Q: All right. And you're referring to 5 your progress notes which you hand -- hand wrote at the 6 time -- 7 A: Yes. 8 Q: -- of the events? All right. And 9 that was part of the hospital chart? 10 A: Yes. 11 Q: I'd like to make that document the 12 next exhibit, please. 13 THE REGISTRAR: P-364. 14 COMMISSIONER SIDNEY LINDEN: 364. 15 THE REGISTRAR: What was the document 16 number again, please? 17 MS. SUSAN VELLA: I don't have the 18 Inquiry document number, but I have the document. We'll 19 get you that later, thank you. 20 21 --- EXHIBIT NO. P-364: Progress notes made by Dr. 22 Alison Marr re Cecil Bernard 23 George 24 25 CONTINUED BY MS. SUSAN VELLA:


1 Q: All right, now you have since become 2 aware that -- that Cecil Bernard George was transported 3 by the St. John's Ambulance organization; is that fair? 4 A: Yes. 5 Q: All right, and I think you indicated 6 at -- at the time, you did not know that he had been 7 transported by St. John's Ambulance personnel? 8 A: Yes. 9 Q: In retrospect, does the fact that 10 this individual was transported by St. John's Ambulance 11 personnel, in a St. John's vehicle, cause you any 12 concern? 13 14 (BRIEF PAUSE) 15 16 A: I'm not actually that familiar with 17 what the St. John's -- the difference is between the St. 18 John's ambulance and a regular ambulance is. 19 Q: All right, we've heard evidence that 20 the St. John's Ambulance attendants were not paramedics, 21 that -- that one was a practical nursing student and that 22 the unit was a second-hand, if you will, Ministry of 23 Health ambulance unit that was not currently certified, 24 if you will, or -- or licensed under the Ministry of 25 Health regulations.


1 We've also heard that neither of the -- 2 the driver nor the attendant had the Class F license, 3 which is the license for -- authorizing transport of 4 injured persons. 5 So with that knowledge, do you have any 6 concern that this individual was handed over to them to 7 be transported to the hospital, given what were the state 8 of his injuries, the possible -- and the possible 9 injuries that he had? 10 A: I think I can answer it, perhaps, 11 this way, that certainly in the first hour of his time in 12 the Emergency Room we were quite concerned about his 13 well-being. And those same features of his history and 14 examination would have been apparent, presumably at that 15 time that he was picked up or -- or a decision was made 16 as to how he should be transported by anyone assessing 17 him at that time. 18 And it would have been prudent to 19 transport him in a fashion that would have been able to 20 provide some support should he have needed it en route. 21 Q: All right. And were his injuries, 22 then, at the time of transport based on, of course, your 23 assessment of Cecil Bernard George in the trauma room, 24 were they potentially life-threatening? 25 A: They were -- they were potentially


1 life-threatening. As his course evolved in the Emergency 2 Room, it turned out that he didn't require major 3 resuscitative efforts and I don't think he -- his course 4 was adversely affected by coming through the St. John's 5 Ambulance, but it was fortunate that was the case. 6 And as he appeared to us when we saw him, 7 I didn't know what direction his condition was going to 8 go. So at the scene, when he was presumably more 9 symptomatic even, an hour earlier, it would have been 10 prudent to give him the benefit of the doubt of being 11 assisted by qualified by medical personnel. 12 Q: All right. Would you have expected a 13 trained Level 1 paramedic doing a competent -- paramedic 14 doing a competent initial assessment to have taken 15 certain precautions, which were not done, in this case, 16 on transport? 17 A: I think it's routine if there's known 18 head trauma to be concerned about trauma to the neck and 19 to stabilize the neck, which is what I think you're 20 referring to. As it turned out, he didn't have a neck 21 injury and it didn't have an impact on his course. 22 Q: All right. And, would you have 23 further expected a -- a trained Level 1 paramedic doing a 24 competent initial assessment to have ascertained that the 25 injuries were, at least, potentially life-threatening?


1 A: Yes. 2 Q: And based on what? 3 A: Based on, in particular, his head 4 injury, that there was evidence that he'd been 5 unconscious at the scene and clearly had visible evidence 6 of blows to the head. 7 Q: Okay. 8 A: That would be the major alert feature 9 of the history, I would say. 10 Q: And, what about that particular 11 injury with Cecil Bernard George could have been -- made 12 it potentially life-threatening? 13 A: Well, he could have become more 14 obtundant, more unconscious in the ambulance and could 15 have stopped breathing as a result of his head injury and 16 would have needed the attendance of someone capable of 17 giving him artificial respiration. 18 Q: And typically, is any type of 19 equipment assist -- used to assist in that process? 20 A: That would be present in a well- 21 equipped ambulance. 22 Q: Yes, and what -- what kind of 23 equipment, though? 24 A: An ambu. bag and mask. 25 Q: A mask?


1 A: A mask and bag, too. 2 Q: All right. And with respect -- 3 A: To apply positive pressure 4 ventilation. 5 Q: And, with respect to the -- the vital 6 sign issue, the -- the inability of Ms. Bakker-Stephens 7 to ascertain a pulse temporarily, was there any -- is 8 there any equipment that would normally be on an 9 ambulance that would assist in detecting a pulse? 10 A: I would have thought that an equipped 11 ambulance would have been able to apply leads, as we had 12 described -- telemetry leads, as we've described before 13 for Dudley George and -- and confirm there was cardiac 14 activity, and would have been able to do a blood pressure 15 as well and might have auscultated the heart to hear that 16 there was an apical beat, even if a peripheral pulse was 17 difficult to find. 18 19 (BRIEF PAUSE) 20 21 Q: Now, during the course of Cecil 22 Bernard George's stay at the hospital, did you have 23 occasion to characterize him as not forthcoming? 24 A: Did I, did you say? 25 Q: Yeah.


1 A: I did use that word, as you know, and 2 in particular I think in the statement 7th of September. 3 So it was the same -- it was the day of admission. 4 Q: Yeah. Can you -- can you advise what 5 it was you -- you meant when you said that he was not 6 forthcoming? 7 A: My experience of Mr. Cottrelle and 8 Mr. George were that in -- in all the time that I had 9 with them, they were quiet, courteous, respectful, not 10 volunteering any information or any spontaneous 11 conversation that they initiated. 12 If I asked questions, I was given a 13 minimal simple response to that question. 14 Q: Hmm hmm. 15 A: No amplifications, no outbursts of 16 affect in any way. 17 Q: And -- 18 A: And that's what I meant by not 19 forthcoming, information was not spilling out of them 20 easily. 21 Q: All right. And given what -- what 22 you understood to be the circumstances leading to them 23 being in the hospital, there had been a confrontation of 24 some sort at least with the police, did that lack of 25 affect and lack of forthcomingness, if you will, did that


1 surprise you? 2 A: It wasn't anything I'd ever 3 experienced before in interacting with people who have 4 been injured or presented to the emergency room. I -- I 5 was puzzled by it at the time. 6 It's been suggested to me that it was 7 related to police presence and concern about not making 8 any statements or be overheard by the police. That 9 didn't actually occur to me at the time but it does make 10 some sense. 11 Q: Let me ask you, during -- were you 12 provided with any opportunities to speak to these 13 patients when a police officer was not within earshot? 14 A: I really wasn't paying that attention 15 at anytime but when I think back, probably not, because 16 there were police around every corner. 17 Q: And even when those patients were 18 admitted to their own rooms as -- as in-patients, were 19 there still police present? 20 A: I do remember actually with Cecil -- 21 Cecil George that, on the 8th for sure, when I went up to 22 his room a policeman was outside and I went in and closed 23 the door, and I was in the room by myself with him. 24 Q: Okay. So, you did have some 25 opportunity to have --


1 A: Yeah. 2 Q: -- a discussion with him. And what 3 about with respect of -- of Mr. Cottrelle? 4 A: I don't remember. I -- I don't have 5 a distinct memory of whether or not I was alone with him. 6 Q: Now, just before we leave our 7 discussion with respect to Cecil Bernard George, I 8 understand that it's your evidence that notwithstanding 9 the lack of -- of prudent measures which might have been 10 taken with respect to Cecil Bernard George on transport 11 and the fact that he was transported by non-paramedics, 12 in -- in a non-Ministry of Health ambulance, that did not 13 affect or hamper his alternate condition and you were 14 able to treat it? 15 A: I would agree with that statement. 16 Q: Thank you. All right, I'd like to 17 return now to your treatment of Nick Cottrelle. And I 18 think your evidence earlier was that it's your 19 recollection that while you turned your attention to 20 Cecil Bernard George, it was likely Dr. Saettler who 21 attended to Nicholus Cottrelle in the trauma room; is 22 that right? 23 A: Yes. 24 Q: All right. 25 A: Initially, after we moved on to look


1 after those two (2), yes. 2 Q: All right. And did you, at some 3 point later on, in the trauma room, turn your attention 4 to Nick Cottrelle as well? 5 A: I recall that Dr. Saettler and I 6 conferred again around his -- her findings and my 7 findings and discussed them. 8 I think I did go back to again listen to 9 his chest and reviewed the x-rays together with her. 10 Q: All right. And just so I understand, 11 were his x-rays actually the results available to you 12 prior to him leaving the trauma room? 13 A: Yes, they would have been because 14 they were portable films that were done that morning. 15 Q: I'm sorry? They were -- 16 A: Yes, they would have been. They were 17 portable films; they were done in the emergency room. 18 Q: Okay. And perhaps we'll just refer 19 to Exhibit P-356, and that's your -- or my Tab 32, but 20 it's Inquiry document 100043. 21 I believe it these -- this -- this is the 22 hospital chart of Nicholus Cottrelle; is that right? 23 A: Hmm hmm. 24 Q: Yes? 25 A: Yes, yes.


1 (BRIEF PAUSE) 2 3 Q: All right. And if you look at -- at 4 the font number -- Front Number 0000279, we're on the 5 right side, it's page 278, there's a document from the 6 department of diagnostic imaging. 7 A: Yes. 8 Q: And it's dated September 7th, 1995 9 and it appears to be, well, two (2) pages in total, 10 though the second page is an ultrasound? 11 A: Yes. 12 Q: All right. And the first page, is 13 that consistent with -- with your recollection of the 14 results of the x-ray? 15 16 (BRIEF PAUSE) 17 18 A: Yes, I recollect that that evening we 19 didn't pay a lot of attention to that tiny triangular 20 metal density. We were looking for a bullet and we may - 21 - I think Dr. Saettler refers to having seen that there, 22 but it wasn't of a lot of medical significance; it was 23 superficial and tiny. 24 But we were very reassured to find from 25 these films that there was no evidence of a gunshot


1 wound. 2 Q: All right. And that was located in 3 the portable supine abdomen. Can you just tell me where 4 that is on the body. Describe the location. 5 A: Well, it's actually over the ninth 6 and tenth ribs that that triangular -- 7 Q: Right -- 8 A: -- density is -- supine abdomen is 9 somebody lying down and take a picture of the abdomen, 10 but you'll catch a little bit of ribs as well in that 11 picture, and that's where they saw that metal density. 12 Q: Okay. Thank you very much. And do I 13 understand this -- the result with respect to the chest 14 x-ray was that there was no radio opaque material, in 15 particular no metal present? 16 A: Yes. 17 Q: All right. And just tell me what 18 radio opaque material refers to. 19 A: Things only show up in x-ray if 20 they're radio opaque and a bullet would be very radio 21 opaque, it would be really, really dense. 22 Q: Okay. And on the second page it 23 refers to an ultrasound, and what was the result of that 24 ultrasound; an abdominal ultrasound? 25 A: Yeah. It was a normal report.


1 Q: All right. 2 A: I think that was ordered particularly 3 to check that the liver was not damaged. 4 Q: And did you have occasion to receive 5 any further history about this patient, concerning the 6 origin of his injuries, aside from what you've told us 7 the -- he told you, himself? 8 A: No, I noticed that on the progress 9 note, I think because when we first saw those films, we 10 didn't make very much of that metallic density -- 11 metallic fragments there that was described. 12 And the next morning, as often the case, 13 you -- I went to review the films with the radiologist 14 and he described them as in the report here, because 15 that's his report, the radiologist's report and -- 16 Q: Yes, that we just looked at. 17 A: -- so I went back to talk to Nicholus 18 and get a more clear history of what he'd experienced and 19 that's under the progress notes that you have in the 20 chart. 21 Q: All right. And I believe they're on 22 the screen as well. And that's to be found at Front 23 Number 0000274? 24 A: Yes. 25 Q: Is that right? And is that the


1 extent of your progress notes with respect to Nicholus 2 Cottrelle? 3 A: Yes. And "Re: mechanism of injury," 4 that was just an update, having talked to him again given 5 those findings on x-ray. 6 Q: All right. 7 8 (BRIEF PAUSE) 9 10 Q: Now, we're attempting to put up on 11 the screen for you... 12 13 (BRIEF PAUSE) 14 15 Q: All right. Thank you. On the screen 16 now are -- is a photograph, and this has been previously 17 entered into evidence as Exhibit P-126. 18 And perhaps you could just look at the 19 screen and advise whether or not you can identify this 20 particular injury? 21 A: I think that's a picture of the -- 22 what I described as -- in the history and physical, your 23 270, a one (1) centimetre diameter round wound. You 24 can't see from there where it is but it was on the 25 posterior auxiliary line on the right.


1 Q: On the back -- 2 A: On the back. 3 Q: -- area? 4 A: And -- 5 Q: And how close to the spine was that? 6 A: A long way away. Posterior auxiliary 7 line is just -- this is the auxiliary line here. 8 Q: All right. So you're indicating more 9 or less below the shoulder blade -- 10 A: Yes. 11 Q: -- in terms of the line? 12 A: Yes. 13 Q: All right. And just for the record, 14 we're looking at the photograph of the injury of Nicholas 15 Cottrelle identified as MAG-52. 16 And still staying within the same exhibit 17 -- and I should ask you first of all, was this the -- the 18 wound that gave you cause to be concerned that that was a 19 bullet wound? 20 A: Yes. Yeah. 21 Q: All right. 22 A: It's actually a little bit further 23 around than under the shoulder. This is the axillary 24 line here, and the posterior one is just as it joins the 25 back.


1 Q: Okay. 2 A: So it's about there. 3 Q: I'm going to show you maybe a 4 different vantage -- 5 A: Picture, okay. 6 7 (BRIEF PAUSE) 8 9 Q: It's hard to see on that screen but 10 that's MAG-51, still part of P-126. 11 12 (BRIEF PAUSE) 13 14 Q: And is that the approximate location 15 that -- 16 A: Yeah, that -- that would be it, yeah. 17 Q: All right. So it does -- it shows 18 it's below the shoulder blade, towards the side of the 19 body, as you've indicated, and it's just above his bent 20 elbow, if we're to take that photograph -- 21 A: Okay. 22 Q: -- on the back; is that fair? 23 A: Yeah. 24 Q: Thank you. All right. We can next 25 go to MAG number 49.


1 (BRIEF PAUSE) 2 3 Q: Okay, that will do. That will do. 4 This is MAG-50; do you recognize that injury? 5 A: Yes. That was the abrasion on the 6 other side of his chest wall, more in the flank region. 7 Q: All right. And could you try to see 8 if you can get this one. And, finally, I'll show you one 9 (1) further photograph from Exhibit P-126, and it's 10 number 15.7(A). And perhaps you can turn that around for 11 me. 12 13 (BRIEF PAUSE) 14 15 Q: Okay, if you can't do it, that's it. 16 Thank you. And that appears to be a close-up of the 17 abrasion; is that fair? 18 A: Yes. 19 Q: All right. And it shows the 20 approximate distance -- or length I should say, of that 21 abrasion in terms of centimetres by a ruler underneath 22 it? 23 A: Hmm hmm. 24 Q: Thank you. All right. Now, did you 25 provide any ongoing -- well, let me ask you this, why did


1 you recommend admission or why did you admit this patient 2 as an in-patient later on that morning on September the 3 7th? 4 5 (BRIEF PAUSE) 6 7 A: I think there was just enough 8 uncertainty around the situation. We didn't feel 9 comfortable not observing him for twelve (12) hours. It 10 was 3:00 or four o'clock in the morning as well. We'd 11 been given the history that he'd had a gunshot wound and 12 we were quite confident by now that he hadn't, but still 13 it was a sort of uncomfortable situation. 14 The x-rays are reviewed the next day, we 15 had repeat blood work the next day to make sure there was 16 no drop in haemoglobin from any internal bleeding; that 17 was the plan. 18 Q: All right. And, if you look at the 19 first page of P-356 or Tab 32, this is the hospital 20 chart, it indicates that the admission time was, in fact, 21 at 2:05? 22 A: Yeah. 23 Q: a.m.? 24 A: Yeah. 25 Q: All right. I wonder if you would go


1 next to Front Number 0000275. In the following four (4) 2 pages there appear to be laboratory reports with respect 3 to Nicholas Cottrelle. 4 Now, are these tests that you ordered? 5 A: Well, I see Dr. Saettler's on 274. 6 Q: Yes, and also on the last page as 7 well. 8 A: I suspect that she ordered them, 9 actually. 10 Q: Okay. Do you recall discussing these 11 results with her, or at least learning of what -- what 12 these test results were? 13 A: We did confer the next day around his 14 care, yes. 15 Q: And what -- what did you conclude 16 with respect to his condition the next day based on these 17 reports and the general observations? 18 A: That he was stable, that there was no 19 evidence of any internal injury and with review of the 20 films that that was not a penetrating injury. 21 Q: I wonder if you would, next, go to 22 Front Number 0000281, a little bit further on in this 23 document, it's entitled, Doctor's Order Sheet. 24 A: Right, yeah. Yeah, so you can see 25 there that the orders, actually, for this blood work was


1 by Dr. Saettler. 2 Q: All right, thank you. I noticed that 3 your signature appears from time to time here as well? 4 A: On that order sheet? 5 Q: Yes. 6 A: Yes. 7 Q: And, what were the specific orders 8 that -- that you provided with respect to the treatment 9 of this patient? 10 A: I think those would have been, well, 11 the IV would have been ordered in the first few minutes 12 of his being in the Emergency Room. Sometimes you don't 13 write the orders at the time, you just say them verbally 14 in the kafuffle of what's going on because by the time I 15 wrote them I was also saying, Repeat a CBC in the 16 morning, so I must have been thinking of the next day and 17 be ready for him to be leaving the Emergency Room by 18 then, so I may not have written anything up until then. 19 Q: All right. 20 A: And that with the vitals, q2h was his 21 -- to be checked over night, over the rest of the day 22 until next day. 23 Q: And I noticed halfway through the 24 page under Number 3, just -- and it's September 7, 1995 25 at 0300, there's a comment:


1 "Consult Dr. Langdon. Notified but 2 would -- will not see." 3 I'm just wondering whether you have any 4 information about what this comment references? 5 A: I think what that reflects is that 6 Dr. Saettler, who was the general surgeon, had said on 7 one of the charts and when she'd written her history, 8 that she wasn't going to be available, yes. 9 Your number 273, she'd said at the end of 10 her admission history: 11 "Recommend assessment by surgeon in the 12 a.m. I am unavailable for ongoing 13 follow up of this patient." 14 Q: Okay. 15 A: As she will tell you, she was about 16 to go on holiday and given her recommendation, I put in 17 that consult to the surgeon who was going to be available 18 the next day. 19 As it turned out, fortunately, the 20 patients were quite stable from a surgical point of view, 21 and also Dr. Saettler did come back and did -- I don't 22 know if she delayed her departure or she was around 23 longer than she thought she was going to be, but she did 24 review them the next day with me. 25 And I think given that circumstance that


1 she was available, Dr. Langdon (phonetic) chose not to 2 get involved in the matter. 3 Q: All right. And then as a result of - 4 - of the test results and your ongoing conclusion there 5 was no internal bleeding and no evidence of any gun 6 wound, or at least any fragments in the body; did you 7 make a decision to discharge this patient? 8 A: Yes. 9 Q: And if we go back to page 1 of this 10 document, it's recording a discharge date of September 11 the 7th, 1995. Or is that -- that the 7th? 12 A: Yeah, it was the same day. 13 Q: And the time I'm having difficulty 14 reading on my -- on my document; do you recall the 15 approximate time of the discharge? 16 A: No. 17 Q: All right, but in any event it was on 18 September the -- 19 A: It might -- I mean it would have to 20 be a little later on because there was an ultrasound of 21 the abdomen that wasn't actually ordered until 10:28 that 22 day. 23 So maybe that says 16:35. 24 Q: Okay. We know from your chart, your 25 progress notes, that he was certainly there at 14:00


1 hours. Is that -- 2 A: And actually, the discharge was noted 3 by the nurse at 14:05. 4 Q: All right. Thank you very much. And 5 what was his condition at discharge? 6 A: He -- he was well. He had some pain 7 in both sides of his chest from those two (2) areas and 8 some tenderness just close to those wounds, but not very 9 extensive. 10 Q: And was any follow up treat 11 recommended to him? 12 A: As I wrote on that treatment order, 13 he needed dressing changes on those wound areas daily. 14 There weren't, I don't think, any specific other 15 directions for followup care. 16 Q: Do you recall whether you 17 communicated that advice to either Nicholas or his 18 parents? 19 A: I don't recall, I'm sorry. 20 Q: All right, is it -- would it be your 21 practice to advise in these circumstances the -- the 22 parents of a -- of a minor or -- 23 A: It would normally be, but I don't 24 recall speaking with those -- with any relatives on the 25 day of discharge.


1 Q: All right. 2 A: I -- I recall there being police in 3 attendance and some requests from the police to be able 4 to discharge him, which I had no difficulty with at that 5 point, but there was certainly a -- my understanding was 6 he was going to be in the custody of the police as he 7 left the hospital, and they were the ones I was aware of 8 accompanying him, not family. 9 Q: All right. Did that cause you any 10 concern, given that he was under eighteen (18)? 11 A: I don't recall ever being really 12 focussed on his age. 13 Q: All right. Did you have any -- did 14 you have any understanding as to under what circumstances 15 he was going to be detained by the police or in police 16 custody? 17 A: No, I didn't know. 18 Q: Okay. Were you advised by any police 19 officer that he was under arrest? 20 A: I believe I was. 21 Q: You believe you were? 22 A: Oh, I was aware of that. 23 Q: Okay. Now, after he was discharged, 24 did anything come to your attention, medically speaking, 25 that -- that caused you to wish you had a further


1 communication with Nick Cottrelle? 2 A: Yes, what happened with that x-ray 3 was that when I went to look at the films with the 4 radiologist, he didn't mention what he'd seen in terms of 5 the metal densities -- possible metal densities. He just 6 -- I said to him, You know, has this fellow been shot? 7 Is there any evidence of any internal injury; this is the 8 circumstance. 9 And, he looked at the films and said, No, 10 it's okay, there's no sign of any gunshot wound or 11 anything else and he didn't verbally mention to me this 12 other stuff here. 13 Q: The metal fragment? 14 A: Metal density fragments. So, I 15 didn't see that until it was printed up, which was the 16 next day and now the patient's gone. I wasn't concerned 17 about implications for his health so much as this is 18 clearly now a legal issue and that there might be 19 questions around that and that I should follow it up. 20 Q: And -- and how many metal fragments 21 did you see on the x-ray? 22 A: Well, they just described one (1) 23 tiny triangular possibly metal density. 24 Q: All right. And, would this not be 25 something that you would convey to the patient


1 irrespective of there being a -- a legal situation 2 developing? 3 A: Yeah, it could have some consequences 4 in terms of infection if there's a foreign body still 5 there, so that was -- that was part of the concern to let 6 him know that because I hadn't given him that information 7 at this point. 8 Q: And what steps did you take to 9 communicate or to attempt to communicate this information 10 to Mr. Cottrelle? 11 A: I believe at first there was some 12 attempts at phoning. We had a phone number, I think, 13 from the -- did we have a phone number? No phone 14 number on there. I -- I recall that I attempted to 15 phone, but I don't know where I would have had a phone 16 number when I'm just looking at that now, but what I 17 ultimately did was wrote a letter. 18 Q: All right. Now, let me just ask you 19 before you -- you get to that, that you were aware that 20 he was in police custody at the time; did you make any 21 attempts to communicate with the police? 22 A: Hmm hmm. 23 24 (BRIEF PAUSE) 25


1 A: At some point I talked with police 2 and I'm not sure when. 3 Q: All right. You indicated that -- 4 that you ultimately wrote a letter to Mr. Cottrelle? 5 A: Hmm hmm. 6 Q: I wonder if you would go to Tab 19, 7 Inquiry Document Number 1005660, it's a covering letter 8 addressed to Mr. J. Kennedy, Investigator, Special 9 Investigations Unit. 10 11 (BRIEF PAUSE) 12 13 Q: And, there's an enclosure as well. 14 Now -- 15 A: What was the tab number again? 16 Q: I'm sorry, Tab 19 and the letter's 17 dated January 23, 1996. 18 Now, do you recall writing this covering 19 letter to Mr. Kennedy? 20 A: I signed it; it looks vaguely 21 familiar. I don't really have a recollection of it, but 22 yes, I wrote that. 23 Q: All right. Do you recall being 24 interviewed by members of the SIU, including Mr. Kennedy? 25 A: Yes.


1 Q: Okay. And, if you look at the next 2 page, it appears to be a -- a computer-generated record 3 of a letter addressed to Mr. Cottrelle -- 4 A: Yes. 5 Q: -- dated September 22, 1995 and you 6 have an address there of R.R. Number 2, Forest, Ontario? 7 A: Yes. 8 Q: Is that a -- a true copy of the 9 contents of the letter that you sent to Mr. Cottrelle? 10 A: Yes, I've got the original letter 11 there and it is. 12 Q: All right. And was it sent on or 13 around September 22nd, 1995? 14 A: Yes. 15 Q: All right. I'd like to make this 16 document, that is the letter to the SIU and the enclosed 17 attachment the next exhibit. 18 THE REGISTRAR: P-365, Your Honour. 19 COMMISSIONER SIDNEY LINDEN: P-365. 20 21 --- EXHIBIT NO. P-365: Document 1005660 January 22 23,'96 computer record of 23 letter to Mr. Cottrelle from 24 Dr. Alison Marr sent to 25 investigator J. Kennedy SIU


1 2 CONTINUED BY MS. SUSAN VELLA: 3 Q: And, Dr. Marr, you have a duplicate 4 copy of the actual letter that you sent to Mr. Cottrelle? 5 A: Yes. 6 Q: I'd like to make that the next 7 exhibit as well. 8 THE REGISTRAR: P-366. 9 COMMISSIONER SIDNEY LINDEN: P-366. 10 11 --- EXHIBIT NO. P-366: Duplicate copy of a letter 12 sent to Nicholas Cottrelle by 13 Dr. Alison Marr September 14 22/'95 15 16 CONTINUED BY MS. SUSAN VELLA: 17 Q: And, did you receive any response 18 from Mr. Cottrelle or anyone on his behalf with respect 19 to this information? 20 A: No, I didn't get any direct response 21 from that, but I know at some point whether it was the 22 SIU or earlier, I don't recall, said that it had been 23 taken care of, that they had taken him -- I understood 24 that they had taken him to someone who would do a 25 forensic exam of what that material was.


1 Q: The SIU would or the OPP? 2 A: Yeah, I don't know. 3 Q: All right. 4 A: I -- I don't know. 5 Q: All right. Do you recall being 6 interviewed by Acting Sergeant Michael Harwood of the 7 Ontario Provincial Police on or about -- on September the 8 20th, 1995, in relation to these events? 9 A: Yes, that's -- the names -- 1995, 10 yes, okay, 20th of September, yeah. 11 Q: And if you look at Tab 13, which is 12 Inquiry Document Number 1005645, that appears to be the 13 transcript of the interview that you provided to him? 14 A: Yeah. There's two (2) records of it, 15 two (2) versions of it, yeah. 16 Q: Yes, I appreciate there are two (2) - 17 - two (2) transcripts. And I believe that one (1) isn't 18 complete, the one -- the prior page. Or this one isn't 19 complete I should say. 20 A: Hmm hmm. 21 Q: However, at the end of this document 22 you'll see there's an amendment to interview, it appears 23 to be signed by you, and it's dated November 23, 1995; so 24 the -- the last page at Tab 13. 25 A: Oh yes.


1 Q: Perhaps you take a moment to -- to 2 review that and see if that refreshes your memory at all 3 with respect to the circumstances of your attempts to 4 contact Mr. Cottrelle and the -- the result. 5 6 (BRIEF PAUSE) 7 8 A: Yes, that's -- that seems accurate. 9 Q: All right. So does that refresh your 10 memory then, and did you in fact make two (2) phone calls 11 to him and a letter -- and then write the letter? 12 A: Yeah. And this letter does mention 13 the phone number that I was using. 14 Q: Okay. 15 A: Yeah. So I did have a phone number; 16 I don't know where it came from. 17 Q: Thank you. And does it refresh your 18 memory at all with respect to who told you that your 19 concerns about there being further X-rays had been taken 20 attend -- care of? 21 A: No, it doesn't. And if it's 22 November, that's some time after that, and it sounded as 23 though I still didn't know what had happened to it by 24 then. 25 Q: Okay.


1 (BRIEF PAUSE) 2 3 A: It -- it does mention the discussion 4 with Dr. Saettler about the nature of the finding on the 5 X-ray and the possibility it might -- it might even be an 6 artifact rather than anything real. 7 And I -- I'm still puzzled by it in that 8 when we went through the diagrams of the round wound that 9 was at the back and these lesions were -- this fragment 10 was at the front on the abdomen it seems, but -- 11 Q: And, therefore, did you detect the 12 point of entry with respect to these fragments when you 13 examined him? 14 A: No. No, though I don't -- don't 15 recall there being anything at the front that would have 16 corresponded to these findings in the -- there's 17 something embedded there. 18 I think initially when we saw this we were 19 thinking, Was there something that went through that 20 first wound but just superficially, was it sort of a 21 penetrating fragment of metal that caused the entry wound 22 and just went a little bit into the skin, not deep, not 23 causing serious injury, but somewhere around that site. 24 But, as I look at it now, those fragments 25 are described as being at the front of the abdomen, which


1 is quite remote from that wound, so I don't know what 2 they represented. 3 Q: All right. And based on your 4 examination and assessment of Mr. Cottrelle, would you 5 have expected to have seen some visible -- 6 A: Yes. 7 Q: -- entry point with respect to those 8 metal fragments, had they occurred on September the 6th 9 or 7th of 1995? 10 A: Yes. It's odd that there's no 11 correlate on the surface of any surface injury. 12 Q: Thank you. 13 14 (BRIEF PAUSE) 15 16 Q: And Dr. Marr, in retrospect, is there 17 anything which you think you could have done differently 18 with respect to any of these patients. 19 We've covered Dudley George, of course, 20 but the other two (2) patients on September the 7th, 21 1995, in terms of the care -- their care and treatment? 22 A: The simple answer to that is no, I 23 don't think that the medical care of the injured patients 24 themselves could or should have been any different. 25 Q: All right. And was there anything


1 generally that you would have done different over the 2 course of that evening, in responding to this situation? 3 A: The situation was quite strained and 4 quite different from what one normally encounters. I 5 think that when I look back at the interactions, it's -- 6 and you've highlighted a couple of times, it's -- it's 7 remarkable, perhaps, that I didn't have any formal 8 interaction with any of the relatives or accompanying 9 friends or important people of the injured, either Dudley 10 George or the other two. 11 And I think that was because of the nature 12 of the busyness of the evening, and other people took 13 those roles. 14 Normally, though, as the attending 15 physician, you would have some interaction with family 16 members and attend to their needs and give them some 17 communication around the health and welfare of the 18 injured parties and I don't recall having any involvement 19 in that regard. 20 Q: Okay. And you've indicated the 21 reason for that was because of the -- the busyness of 22 attending to the three (3) patients in the sequence and 23 events -- 24 A: And also I think the access to the 25 patient -- to the other parties and that the police were


1 controlling movement around the department. 2 Q: All right. Now, had you received 3 specific advance notice, as you said you would often do, 4 by ten (10) minutes or so that -- that you were about to 5 receive two (2) potential gunshot wound victims, 6 including a gunshot wound to the chest area, and a victim 7 with severe head trauma, is there anything that you would 8 -- any steps you would have taken differently, than you 9 did that night, to prepare for that event? 10 A: Well, I think if we'd had word from 11 two (2) ambulances that they had patients with unstable 12 vital signs, I might have called before arrival for 13 anther physician to be present. 14 But as it turned out, we had two (2) 15 physicians present and I think we were not overwhelmed 16 with the work that we needed to do -- 17 Q: All right. 18 A: -- or compromised in any way. 19 Q: And in retrospect, had you engaged a 20 further physician, would that have freed up your time to 21 speak with the relatives or did that cross your mind? 22 A: It might have done. 23 Q: All right. 24 25 (BRIEF PAUSE)


1 Q: Do you have any recommendations, 2 doctor, for the Commission regarding how the medical or 3 emergency response system might be improved to deal with 4 similar situations as you faced, in the early hours of 5 September the 7th, 1995, should you be presented with 6 those circumstances again? 7 A: Well, that's a big one. It's -- I'm 8 not sure I've got enough of an overview of the situation 9 to -- to make a comment. 10 To try and focus just on the medical 11 component, I would -- it's obviously important that -- 12 that excellent care be available at the site of injury as 13 soon as possible, and that can be really important in 14 terms of outcome from injury. 15 So paramedics or even advanced paramedics 16 at such a scene, if you're really thinking there may be 17 injuries, would be really important. 18 Ongoing information from those ambulances 19 carried an injured to the destinations they're going to, 20 to give them as accurate information as possible of what 21 they're expecting. 22 Dispersal of those ambulances if there's 23 more than appropriately two (2) different destinations if 24 they're going to overwhelm any one facility. 25 But that's really all I can say that's


1 sort of medically relevant. 2 Q: Thank you very much, doctor. As 3 well, as I understand it had there been advanced 4 paramedic training at the site, by which you mean by 5 Ipperwash Park, that would have been -- that would be a 6 helpful -- a helpful thing to happen. 7 Is that what you mean? 8 A: Yes, in that if there is serious 9 injury, the soonest you can get proper resuscitation 10 started, the better. 11 Q: Hmm hmm. And, had there been 12 communication capabilities on the part of the St. John's 13 Ambulance system with the hospital, that would be 14 advisable? 15 A: It's always good to know what's 16 coming and to have adequate warning of that, yes. 17 Q: And, finally -- 18 A: I don't know -- 19 Q: -- having appropriate paramedics and 20 appropriate ambulance units available to carry the -- the 21 injured, obviously, would be important? 22 A: Yes, but I'm not sure how you can be 23 prepared for such a thing when you don't know that such 24 an event is going to occur? 25 Q: All right.


1 A: But that's not a medical issue. 2 Q: Dr. Marr, thank you very much for 3 your testimony. Commissioner, that concludes the 4 examination-in-chief, perhaps before lunch we can canvass 5 parties with respect to cross-examination estimates. 6 COMMISSIONER SIDNEY LINDEN: Does anybody 7 have any questions for this Witness? Give us an idea. 8 THE WITNESS: I might be here for a 9 while. 10 COMMISSIONER SIDNEY LINDEN: Yes...? How 11 long...? 12 MR. ANDREW ORKIN: Fifteen (15) minutes. 13 COMMISSIONER SIDNEY LINDEN: How long? 14 MR. ANDREW ORKIN: Fifteen (15) minutes. 15 And, Mr. Rosenthal...? 16 MR. PETER ROSENTHAL: Approximately forty 17 (40) minutes. 18 COMMISSIONER SIDNEY LINDEN: And, Mr. 19 Ross...? 20 MR. ANTHONY ROSS: No more than ten (10). 21 COMMISSIONER SIDNEY LINDEN: And, Mr. 22 George...? 23 MR. JONATHAN GEORGE: Ten (10) minutes. 24 COMMISSIONER SIDNEY LINDEN: And, Ms. 25 Tuck-Jackson...?


1 MS. ANDREA TUCK-JACKSON: Five (5) 2 minutes. 3 COMMISSIONER SIDNEY LINDEN: And, Ms. 4 Jones...? 5 MS. KAREN JONES: About an hour. 6 COMMISSIONER SIDNEY LINDEN: About an 7 hour? 8 MS. KAREN JONES: Yes. 9 COMMISSIONER SIDNEY LINDEN: And, Mr. 10 O'Marra...? 11 MR. AL O'MARRA: Ten (10) to fifteen (15) 12 minutes, sir. 13 COMMISSIONER SIDNEY LINDEN: That's fine. 14 We'll break for lunch. And I'm just thinking about Dr. 15 Saettler, she's on standby. I guess we'll just leave it 16 at that. 17 MS. SUSAN VELLA: Perhaps we can consult 18 over the lunch. 19 COMMISSIONER SIDNEY LINDEN: We'll 20 adjourn now for lunch for an hour and a quarter and we'll 21 begin cross-examination right after lunch. 22 THE REGISTRAR: This Inquiry stands 23 adjourned until 1:35. 24 25 --- Upon recessing at 12:21 p.m.


1 --- Upon commencing at 1:37 p.m. 2 3 THE REGISTRAR: This Inquiry is now 4 resumed, please be seated. 5 COMMISSIONER SIDNEY LINDEN: Good 6 afternoon. 7 Mr. Orkin...? 8 MR. ANDREW ORKIN: Thank you, 9 Commissioner. 10 11 (BRIEF PAUSE) 12 13 CROSS-EXAMINATION BY MR. ANDREW ORKIN: 14 Q: Good afternoon, Dr. Marr. 15 A: Good afternoon. 16 Q: My name's Andrew Orkin, I'm Co- 17 Counsel to the Dudley George Estate and the Sam George 18 group of family members; siblings of Dudley George's. 19 As you probably saw from the go-around I'm 20 only going to be fifteen (15) minutes or less, so I think 21 out of all of the questioners, this -- this might be 22 quite painless. 23 I have asked Commission Counsel if she can 24 put a slide on the screen that you saw earlier, which was 25 one (1) of the injuries that was suffered by Nick


1 Cottrelle. 2 3 (BRIEF PAUSE) 4 5 Q: I'm sorry, Susan. 6 7 (BRIEF PAUSE) 8 9 Q: Dr. Marr, I wonder if you could 10 remind us, please, of the positioning of that wound on 11 Mr. Cottrelle's body, of -- where it was located? 12 A: I believe that was on his left side 13 around here -- 14 Q: And, you referred to -- 15 A: -- of the costal margin. 16 Q: Thank you. 17 A: The rib cage. 18 Q: You referred to that as a -- as an 19 abrasion or a -- 20 A: Yes. 21 Q: And it's -- would you agree that it's 22 an abrasion that's lateral in character, that is -- is -- 23 A: Yes. It has some length to it. 24 Q: Do you have any ideas as to how an 25 injury like that might have been caused, or did Mr.


1 Cottrelle -- I'll pause there. 2 A: What Mr. Cottrelle described was 3 feeling pain in his right side followed soon after by 4 pain in his left side. So, that's all I know of the 5 mechanism and he did hear glass shattering somewhere 6 around the same time; he heard gunshots somewhere around 7 the same time. 8 Q: Would that wound possibly have been 9 caused by a bullet graze? 10 A: I wouldn't have the expertise to say 11 that. 12 Q: No. Thank you. 13 14 (BRIEF PAUSE) 15 16 A: I wouldn't have the expertise to 17 recognize whether that was a bullet wound graze. 18 Q: Could you help -- help me identify 19 the document we've just referred to. 20 MS. SUSAN VELLA: Yes, it's Exhibit P- 21 126 and we've identified it as Document 15.7(A) -- 22 MR. ANDREW ORKIN: Document 15.7(A) of 23 Exhibit P-126. 24 25 CONTINUED BY MR. ANDREW ORKIN:


1 Q: Dr. Marr, you went at some length and 2 we're grateful for this, through the two (2) diagrams 3 that you drew of the injuries that you identified as 4 having been suffered by Cecil Bernard George, which 5 diagrams were drawn on the early morning of September the 6 8th, 1995. 7 You indicated, did you not, this morning, 8 that that was a time at which those injuries had become 9 quite apparent; bruising was clear and so forth? 10 A: Yes. 11 Q: And a number of these injuries appear 12 to have a, as you referred to it, I believe, an elongated 13 or lateral lengthy character; is that correct? 14 A: Yes. 15 Q: Were those, where you said this 16 morning, those injuries appeared to you to have been 17 caused a blunt, linear object or perpetrated by long 18 sticks, when Ms. Vella was questioning you. 19 Were you indicating to us, in general 20 terms, that these elongated injuries were consistent with 21 blunt -- blunt instrument or blunt object trauma? 22 A: Yes. 23 Q: Approximately -- and you might want 24 to refer to -- to the diagrams again, approximately how 25 many of the overall number of injuries that you detailed,


1 approximately how many of those might have had that 2 character? 3 A: One (1) -- one (1) on the front and 4 four (4) on the back had a linear distribution to the 5 bruising and the injury to the tissue. 6 I would add that you'd only expect to see 7 that linear pattern on a broad, flat surface of the body 8 which those injuries were on. 9 The other injuries that didn't have a 10 linear pattern tended to be on prominences where such an 11 instrument wouldn't have come into a linear contact with 12 the body, as in blow there, you're not going to see a 13 linear pattern, because the contact point would not be 14 linear. 15 Q: So, the injuries that were not marked 16 on your diagram as having an elongated character, were 17 not so marked -- this is a double negative, forgive me, 18 were marked in the way they were not because they were 19 possibly not caused by an elongated object, but because 20 they way they manifested on Mr. George's body would not 21 have been apparent? 22 In other words, having -- as you indicated 23 physically, having been borne by a smaller part of the 24 surface of his body. 25 A: Yes, I would agree with that


1 statement. 2 3 (BRIEF PAUSE) 4 5 Q: To read for a moment, from a report 6 that you addressed to Mr. Jeffrey House, barrister and 7 solicitor, which was dated December the 3rd, 1997 and I 8 believe was put before you today. It -- 9 A: Yes, I have that. 10 Q: -- was a report that you sent to Mr. 11 House, the copy I have is unsigned, but this is your 12 document -- 13 A: Yes. 14 Q: -- is it not? 15 A: Yes. 16 Q: There's no Inquiry document number as 17 yet. On page 3 of that document in -- in the paragraph 18 at the bottom -- 19 A: Hmm hmm. 20 Q: -- I'll give you a chance to locate 21 it -- 22 A: Yes. 23 Q: -- in the third and fourth line, you 24 indicate -- you indicate the phrase, 25 "Mostly not associated with a break in


1 the skin surface, consistent with 2 trauma from a blunt object, which made 3 only a small area of contact with the 4 body." 5 Are these the kind of blows that you were 6 talking about a moment ago? Areas of bruising over 7 curved surfaces, i.e., limbs and skull? 8 A: Yes, those would be over smaller body 9 parts, where the contact would have been a smaller area. 10 Q: Then lower down, you indicate: 11 "These linear lesions are also 12 consistent with trauma from a blunt 13 object, one of which is narrow and 14 long." 15 And those are numbered 5, 7 and 13 on back 16 view and Number 8 on front view? 17 A: Yes. 18 Q: I'd like to read you from the 19 transcript of April the 20th at these hearings in which 20 My Friend, Mr. Roland, objected to a question I asked in 21 which he said: 22 "My Friend used the term 'blunt 23 instrument'. I don't think there's 24 going to be evidence coming from any 25 experts about blunt instrument, so I'm


1 not sure that's really entirely 2 accurate. There certainly was trauma 3 from some force, but the suggestion 4 that it was a blunt instrument I don't 5 think is entirely accurate." 6 Dr. Marr, in light of what you've just 7 told us this morning, would you agree that the use of the 8 term 'blunt instrument' or 'blunt object', which was the 9 wording you used, is in fact accurate? 10 A: I'm comfortable with the use of the 11 word, and the description. 12 Q: Thank you very much. Thank you, 13 Commissioner. 14 COMMISSIONER SIDNEY LINDEN: Thank you. 15 16 (BRIEF PAUSE) 17 18 MR. ANDREW ORKIN: Commissioner with your 19 indulgence, I've forgotten one (1) question which I would 20 like to proceed to before closing completely, if I can 21 persuade this computer to cooperate. 22 THE REGISTRAR: We'll make the letter, 23 Your Honour, as P-367. 24 COMMISSIONER SIDNEY LINDEN: P-367; the 25 letter from Dr. Marr to Jeff House.


1 THE REGISTRAR: Right. 2 3 --- EXHIBIT NO. P-367: Letter to Jeffry A. House, 4 barrister & Solicitor from 5 Alison J. Marr, M.D. December 6 03/'97 re Cecil Bernard 7 George 8 9 MR. ANDREW ORKIN: Commissioner, we've 10 concluded this isn't going to happen. Thank you. 11 COMMISSIONER SIDNEY LINDEN: Thank you, 12 Mr. Orkin. 13 MR. ANDREW ORKIN: Thank you, Dr. Marr. 14 COMMISSIONER SIDNEY LINDEN: Mr. 15 Rosenthal...? 16 MR. PETER ROSENTHAL: Thank you, Mr. 17 Commissioner. 18 MR. ANDREW ORKIN: Commissioner, might I 19 reserve if I can get the technology back again? 20 COMMISSIONER SIDNEY LINDEN: Yes, 21 depending on how the -- 22 MR. ANDREW ORKIN: Thank you. 23 COMMISSIONER SIDNEY LINDEN: -- time 24 goes -- 25 MR. ANDREW ORKIN: Yeah.


1 COMMISSIONER SIDNEY LINDEN: -- we should 2 have some time to get to Dr. Saettler. 3 4 (BRIEF PAUSE) 5 6 CROSS-EXAMINATION BY MR. PETER ROSENTHAL: 7 Q: Good afternoon, Dr. Marr. 8 A: Hmm hmm. 9 Q: My name is Peter Rosenthal. I'm 10 Counsel on behalf of a group of First Nations People from 11 Stoney Point under the name Aazhoodena and George Family 12 Group. 13 Now, in your experience in working in the 14 emergency room at Strathroy, have police officers 15 sometimes brought individuals in to the emergency room 16 when they weren't accompanied by an ambulance? 17 A: When they were not accompanied by an 18 ambulance? 19 Q: Yeah. Does it ever happen that the 20 person has a more minor injury and a police officer 21 brings them by the emergency room? 22 A: Yes, I would think that has happened 23 on occasion. 24 Q: Yes. And then you told us that, to 25 your previous experience, previous to this rather unusual


1 evening that you've told us about, police had sometimes 2 stayed there with a patient if there was concern that the 3 patient might be belligerent. 4 But, on this evening it was different from 5 all other evenings in your experience, and you told us 6 that the police told you that they were securing the 7 hospital because they expected a disruption by some First 8 Nations People or something to that effect; is that 9 correct? 10 A: I said something to that effect. 11 Q: Okay. Can you try to take your mind 12 back and assist us as to what they actually told you, as 13 best as you can recollect; we all recognize that it's 14 many years later and it's difficult to -- 15 A: Yeah. Well, I -- I'd just reiterate 16 what I said, I think, earlier today, that I have a memory 17 of having encountered police officers in the hallway and 18 without any other person -- any relatives and no -- no 19 relatives around at that time, no other First Nations 20 People around at that time, in which I asked what they 21 were doing, and they gave me the understanding that they 22 were securing or protecting the hospital in case there 23 was an arrival of a number of people from the Ipperwash 24 event who might interrupt function at the hospital. 25 They were not talking about injured -- or


1 patients -- 2 Q: Yes. 3 A: -- but other interested parties, and 4 reassured me that everything was fine and that they would 5 keep the place under control. 6 But, I can't remember whether that was 7 whilst we were waiting for the first injured patient to 8 arrive or whether it was more like three o'clock in the 9 morning, after we had finished attending to the injured 10 patients. 11 Q: And there were in fact a number of 12 officers around the hospital in that -- that time period 13 and continuing for the next couple of days; is that -- 14 A: Oh, there were indeed after that. I 15 -- I'm clear about that, yeah. 16 Q: And, the hospital had a quite 17 different atmosphere from the usual with the number of 18 officers standing in the hall? 19 A: Yes. 20 Q: And, that would have created a kind 21 of tension in the hospital I would have thought, would it 22 not? 23 A: Yes, it did. Everybody was very 24 civil and respectful and we went about our business 25 trying to do things as we would normally do them.


1 Q: Now, ambulance people and police 2 officers, other people who have occasion to bring people 3 to the Emergency Room know or at least should know that 4 it's important to try to give the receiving people some 5 history as to how the person got the injuries or whatever 6 as they attend; is that correct? 7 A: Yes. 8 Q: And, in this case, we've had evidence 9 that with respect to Mr. Cecil Bernard George, that a 10 police medic turned him over to the St. John's Ambulance 11 people, but didn't give them any information as to how 12 the injuries were caused and therefore they had nothing 13 that they could transmit to you. I'm just telling you 14 this for background -- 15 A: Okay. 16 Q: -- to the question I'm leading up to. 17 And, with respect to Dudley George, we've had evidence 18 that what happened was -- 19 COMMISSIONER SIDNEY LINDEN: Just a 20 minute Mr. Rosenthal. I'm sorry, I thought Jones was... 21 MR. PETER ROSENTHAL: Sorry? 22 COMMISSIONER SIDNEY LINDEN: I didn't 23 mean to interrupt you, I thought Ms. Jones was going to 24 make a statement, but she's not. Carry on. She stood up 25 and I thought she was coming to the podium, but she's


1 not. Carry on. 2 3 CONTINUED BY MR. PETER ROSENTHAL: 4 Q: Thank you. With respect to Dudley 5 George, we had evidence that what happened was there was 6 a car that arrived in the -- outside the Emergency Room 7 driven by his brother Pierre George and accompanied by 8 his sister Carolyn George, but then upon their arrival, 9 they were placed under arrest by the -- by police 10 officers, charged with attempted murder and taken away. 11 The charges turned out to have no content; they were 12 released the next day. 13 But, that's -- that's the answer as to why 14 there wasn't anybody there when you sent -- you sent a 15 nurse to try to check. I -- I knew I would spark a rise 16 at some point, sir, it was just premature. 17 COMMISSIONER SIDNEY LINDEN: I think 18 you're giving evidence. 19 Yes, Ms. Tuck-Jackson...? 20 MS. ANDREA TUCK-JACKSON: With great 21 respect, Mr. Commissioner, we haven't and, indeed, I 22 intend to explore this area with Dr. Marr, we haven't had 23 any evidence yet as to when Carolyn George and Pierre 24 George were actually removed from the hospital property 25 and that is a live issue.


1 2 CONTINUED BY MR. PETER ROSENTHAL: 3 Q: We -- we have had evidence, perhaps, 4 I'll make sure that we -- I get it correct and consistent 5 with my Friend's objection, Dr. Marr. 6 We've had evidence that upon their arrival 7 at the premises outside, they were immediately, more or 8 less, grabbed by police officers and held. As to when 9 they were removed from the parking lot, I agree with My 10 Friend, we don't have precise evidence on that. 11 In any event, they were not free -- I 12 believe in some of the documents you indicate that you 13 wondered why family members didn't come in with Mr. 14 Dudley George as -- as you would normally expect and the 15 reason that those two (2) people didn't is that they were 16 apprehended by police officers. So, that's just 17 background. 18 MS. SUSAN VELLA: Well, yeah, I don't 19 know who's giving the evidence at this point, whether 20 it's Mr. Rosenthal or the Witness. 21 COMMISSIONER SIDNEY LINDEN: Right. 22 MS. SUSAN VELLA: Perhaps we can get to a 23 question and -- and -- 24 COMMISSIONER SIDNEY LINDEN: Right. 25 MS. SUSAN VELLA: -- then the Witness can


1 answer it. 2 COMMISSIONER SIDNEY LINDEN: Is that the 3 question now? You've already given the background. 4 MR. PETER ROSENTHAL: Mr. Commissioner, 5 that's an entirely improper objection, in my respectful 6 submission. I indicated I was giving background for a 7 question and I am doing so. 8 COMMISSIONER SIDNEY LINDEN: You've done 9 the background now, you've come to the question? 10 MR. PETER ROSENTHAL: Yes, sir. 11 COMMISSIONER SIDNEY LINDEN: That's fine. 12 13 CONTINUED BY MR. PETER ROSENTHAL: 14 Q: And, the question now is, Dr. Marr -- 15 I want to give additional background, let's do one (1) 16 more sentence that the only person of the three (3) 17 injured that you got information about soon upon -- after 18 his arrival was Mr. Cottrelle and that you got from him 19 because he was not so seriously injured that he couldn't 20 give it to you, right? 21 A: About his own injuries? 22 Q: About his own injuries, yes. 23 A: Yes. 24 Q: And, in fact, we had evidence that in 25 that case, his mother had attempted to join him enroute


1 to hospital, but was precluded from doing so. 2 Now, given that information, there is a 3 question and the question is: Would you agree that given 4 the importance of emergency personnel knowing how 5 injuries were caused, it would be useful if this 6 Commission would make some kind of recommendation that 7 police officers be instructed about that importance so 8 that if they are to arrest someone, they would make sure 9 the information gets transmitted? 10 If they are to not allow someone to go in 11 one ambulance, they take them in another way and so on so 12 that they would realize the importance that would ensure 13 that that information gets to the emergency room. 14 A: I would agree with that statement. 15 Q: Thank you. 16 17 (BRIEF PAUSE) 18 19 Q: Now, with respect to Mr. Cottrelle, 20 we -- we have heard evidence at this Inquiry that he was, 21 in fact, in a school bus at the time that he was shot at, 22 and there was a shattering of glass and a hearing of 23 bullets by him. 24 Now, is it possible that when he was 25 talking to you that he said the word vehicle rather than


1 car, and that you naturally just sort of translated it to 2 car in your mind? 3 A: It's possible. I'd have to look at 4 exactly what I wrote. Did I write consistently car -- 5 Q: Well, I believe you -- 6 A: -- every place. 7 Q: -- wrote car, but -- 8 A: Hmm hmm. 9 Q: -- I'm suggesting it might have been 10 that you, hearing "vehicle" would have assumed car and 11 might have used that slightly different word. 12 A: I did say car again when I discussed 13 it again with him on the -- that morning, later on, on 14 the floor in his hospital room and he said -- I said car 15 again, so that would just -- 16 Q: Yes. 17 A: -- support it being car was the word 18 he used. 19 Q: So you think it was probably car that 20 he used there, or -- but is it possible that you 21 translated it from "vehicle"? 22 A: It's possible, I -- yeah. 23 Q: Now you told us that there was a 24 request from police officers to discharge him at some 25 point; is that correct?


1 A: Hmm hmm. 2 Q: Did I understand you correct? Can 3 you describe that more fully? 4 I didn't understand -- I think that's all 5 you said, that there was such a request, but what do you 6 recall the circumstances, and could you tell us what 7 happened? 8 A: I just recall that it was 9 communicated to me that he was under arrest and that they 10 were wanting to take him wherever they were needing to 11 take him as soon as he was medically cleared to go. 12 And he was medically clear to go and so I 13 had no reason, really, to hold him -- 14 Q: Yes. 15 A: -- given that. Whether I would have, 16 without that pressure, necessarily have been rushing him 17 out of hospital that day, I -- there was really no reason 18 to keep him, but that was -- that was sort of why we were 19 acting as quickly as we were. 20 Q: Yes, but what I wished to ask you 21 about for that, is did you think it was, first, unusual 22 and, secondly, perhaps, improper for the police to put 23 any pressure on you, whether or not you would have 24 reacted to it or not, but for a police officer to suggest 25 to a doctor you should discharge someone from hospital,


1 might seem to be improper. 2 What's your view? 3 A: I don't think it was really pressure. 4 It was probably my just feeling the situation was a 5 little tense that I'm even describing it that way. 6 I'm sure if I'd had concerns medically 7 about him not being stable to go, I wouldn't have had any 8 difficulty saying, No, he's not ready to be discharged. 9 Q: Oh, yes, no I'm certain that's so. I 10 -- that wasn't the thrust of my question. The thrust 11 was, nonetheless, in spite -- in spite of that would you 12 think it's improper for an officer to say to a doctor, 13 This patient should be discharged? 14 A: I don't think he said this patient 15 should be discharged. I think he said as soon as he can 16 be discharged, we'd like to take him. 17 Q: I see, okay, thank you. 18 19 (BRIEF PAUSE) 20 21 Q: Now, with respect to Dudley George, 22 you've told us that the nature of the injuries were such 23 that it was very unlikely you would have been able to do 24 much for him in any event, apparently, correct? 25 A: Hmm hmm.


1 Q: But had -- had his -- had he arrived 2 in a better condition, what you would have done would 3 have been to stabilize him as best you could, and then 4 send him on to the London Trauma Unit, probably, if his 5 wounds had been similar but somewhat less serious? 6 A: If we could stabilize him sufficient 7 for him to be safe to transport, that's ideal. But if we 8 couldn't -- 9 Q: And that -- 10 A: -- if we couldn't establish adequate 11 circulation we might have had to choose to do something 12 else there at the site. 13 Q: And as you indicated earlier in 14 questions, that you might have had to improvise and the 15 surgeon there might have had to do as well as she could 16 have, given the -- 17 A: Yes, he might not have been -- 18 Q: -- circumstances? 19 A: -- safe to transport. We might have 20 had to have acted if we... 21 Q: You told us also that the wounds to 22 Dudley George, the -- the break in the arteries being so 23 large, he would have bled very quickly and intravenous 24 wouldn't have been able to replenish that fluid as 25 quickly as he would be bleeding; is that correct?


1 A: That would be my estimate, but I 2 can't be sure of that. 3 Q: Yes. But even if that is the case, 4 would it not be true that if he were receiving 5 intravenous fluids at the same time as he was bleeding 6 out rather quickly, at least it might prolong his life a 7 bit and might -- the total loss, the net loss would be 8 the difference between what was going in and what was 9 going out, and he might have survived a bit longer and 10 perhaps been able to be dealt with; is that fair to say? 11 A: That's possible. And really, to be 12 able to have a reasonable prediction of that, you'd need 13 to know how quickly he did collapse after the injury. 14 And if he was still talking twenty (20), thirty (30) 15 minutes after it, then if an IV had been started -- or 16 still alert, an IV had been started right at the time of 17 the injury, perhaps it could have kept up with his loss. 18 But if in fact he collapsed and -- and was 19 in dire condition within a few minutes of the gunshot 20 wound, then that was a very, very fast loss of blood and 21 it might -- nothing might have been able to keep up 22 intravenous with that loss. 23 Q: Yes. 24 A: But I -- I still don't know when that 25 happened.


1 Q: Yes. Now, I believe you told us that 2 at the time, and even now, in this area there are no 3 paramedics who are -- have the training and capacity to 4 themselves begin intravenous's at the site of the injury; 5 is that correct -- at the time they first encountered the 6 patient? 7 A: Well, at the time, in '95, I don't 8 believe there were any paramedics that routinely brought 9 patients to our hospital that had that advanced training. 10 I don't know what the case is now. 11 Q: I see. 12 A: And I don't know what the case is of 13 ambulances that might have their base outside of 14 Strathroy. I understand that one of the ambulances was 15 from Sarnia, and I don't know if they had advanced 16 paramedics. 17 Q: Would you agree that it would be 18 appropriate in an area like this to have that potential 19 at least to call on, especially if one knows that there's 20 likely to be a confrontation where there might be serious 21 injuries, to have the potential to call on paramedics who 22 have that kind of training and that kind of equipment? 23 A: I think that would be ideal. If 24 you're looking potential for serious injuries, you want 25 someone who's highly trained as possible at the site. I


1 don't know if they were available in -- in Southwestern 2 Ontario at that time. 3 Q: Or at this time even? 4 A: Or at this time. 5 Q: But they are -- 6 A: There are some in London, I think, 7 for sure. 8 Q: But they are available in some parts 9 of Ontario? 10 A: Hmm hmm. In Toronto, yeah. 11 Q: And that can make the difference in 12 the case of a seriously injured person of the nature of 13 Dudley George's injuries, although perhaps not exactly 14 the same, in life or death if a person is able to get 15 enough fluids right at the beginning in order to remain 16 somewhat stable; isn't that fair? 17 A: Yes. Trauma and appropriate 18 resuscitation in the field is very important to outcome. 19 Q: And then, if paramedics had been able 20 to stabilize Dudley George in that way, would they maybe 21 have considered going directly to the trauma centre at 22 London Hospital, to -- so that he -- his arteries could 23 be repaired? 24 A: I don't know. It would make some 25 sense if they were confident that they really had been


1 able to do all those things. Generally, you'd have to 2 ask ambulance routine authorities as to what they direct 3 them, because they're very strongly controlled by what 4 their directives are. 5 And, usually, they're to go to the nearest 6 hospital to make sure you've had a full resuscitation 7 before you risk the extra journey. But it might be 8 different for advanced paramedics, I don't know. 9 Q: Okay. Now, with respect to Mr. Cecil 10 Bernard George, you -- you've told us about the linear 11 fashion of some of the injuries, the -- the ones that are 12 -- that don't have the linear character, you told us, 13 could lack that character because of the part of the body 14 that they're on, which wouldn't allow for a -- a long 15 bruise. 16 But, also, could it be the case that if 17 someone is hit with a stick, for example, or a baton, 18 that if just the end of the baton, for example, ends up 19 hitting the person, it wouldn't have a linear character 20 but it could still be a blow caused by the baton -- 21 A: Hmm hmm. 22 Q: -- isn't it fair? 23 A: Hmm hmm. Yes. 24 Q: So it's only -- the linear character 25 is only when a long object comes into contact with the


1 body along the object for some distance; right? 2 A: Yes. You need -- yes. 3 Q: And, also, could some of the injuries 4 that you noted on Cecil Bernard George have been caused 5 by kicks? 6 A: Yes. 7 Q: And not the linear ones probably but 8 some of the others could have been caused by a kick with 9 a boot? 10 A: Yes, that would be another blunt 11 object. 12 Q: Now, each of the areas that you 13 marked on, I believe, it's Exhibit 362 now in the 14 diagram, would represent a -- a separate application of 15 blunt force; is that correct, they're each discreet in 16 that sense? 17 A: Yes. 18 Q: So, counting the number of spots that 19 you've marked there comes to fourteen (14) on the front 20 and fourteen (14) on the back, so that would be -- would 21 mean that Mr. George received at least twenty-eight (28) 22 different applications of force; is that fair? 23 A: Yes. 24 Q: And, he could have received more. 25 There could have been areas that were tender that you


1 didn't note; isn't that correct? 2 A: Yeah, I was going to say with 3 hesitation there that those are the ones that I noted 4 and -- 5 Q: Yeah. 6 A: -- I -- I did ask him to direct me to 7 where he was tender, so he cooperated to show me those 8 areas, but we -- we may have missed some in going over 9 that area. 10 Q: And also this was a day-and-a-half 11 afterwards, so some of the original injuries might have 12 healed enough to where he wouldn't point them out and you 13 wouldn't notice them in a day-and-a-half; is that fair? 14 A: It's possible if they're of more 15 minor in nature. 16 Q: Yes. So, it's a reasonable 17 conclusion from your evidence that Mr. George suffered at 18 least twenty-eight (28) different traumas by blunt force? 19 A: Yes. 20 Q: Now, I'm getting to the question that 21 the St. John's Ambulance driver and the notation of zero 22 pulse and zero breathing at one point. 23 I believe that you indicated in your 24 testimony with Ms. Vella that it was very unlikely that 25 his heart had actually stopped, but it is -- it is true,


1 is it not, that a human heart can stop and then 2 spontaneously start again within a few seconds or 3 minutes; is that fair? 4 A: I -- I can't -- I'm having trouble 5 thinking of any circumstances when that might happen. 6 Q: You're not aware of that ever 7 happening that people are even on a heart monitor, for 8 example, and their heart doesn't beat for ten (10) or 9 fifteen (15) seconds -- it might be called, bradycardia 10 if it starts again, rather than stopping; isn't that 11 fair? 12 A: I -- well, I suppose if you're 13 thinking of a primarily cardiac condition that they could 14 be in arrhythmia that could resolve spontaneously without 15 any intervention and for the time that the arrhythmia was 16 occurring, there may not be a pulse -- 17 Q: Yes. 18 A: -- or respiratory effort. 19 Q: Yes. 20 A: There probably would be some 21 respiratory effort at first, but then that might cease 22 too. 23 Q: And, that could be -- 24 A: For a short period of time. 25 Q: -- like, ten (10) -- fifteen (15)


1 seconds, say? 2 A: Hmm hmm. 3 Q: So, in that sense, whether you call 4 it, "stopping" maybe you wouldn't call it stopping of the 5 heart, but it could be say a ten (10) -- fifteen (15) 6 second interval where the heart doesn't beat and then 7 beats again? 8 A: Yes, but that would be in the context 9 of an injury or a cardiac condition rather than a 10 traumatic injury or a low blood volume injury. 11 Q: Yes, but -- 12 A: So, it would not be likely in this 13 circumstance unless he had another condition with his 14 heart that has not been identified during this 15 hospitalization. 16 Q: Now, we had testimony from the St. 17 John's Ambulance woman who recorded those readings and 18 she told us that at about the same time she also noted 19 that he wasn't breathing, as indicated on the chart, but 20 you also noted that his pupils did not react to light at 21 approximately the same time and that he didn't seem to 22 react to stimulus, either, in spite of the fact that he'd 23 been very strongly reacting, wincing, with respect to, 24 especially the stomach earlier -- because of tenderness 25 in the stomach and that he was unconscious.


1 So, could all of that be correlated with 2 at least a very slow, a very weak pulse? 3 A: I think it's unlikely that his 4 cardiovascular system declined for a period of time, that 5 profoundly, to cause him to stop breathing and to have no 6 pulse and then to spontaneously recover within a few 7 minutes. 8 Q: The next reading that she gave for 9 the pulse after that period was sixty-two (62) as opposed 10 to the earlier in the more standard '70's and the later 11 in '78. 12 Would that suggest a possible slowing 13 down, at least, of the heart during that period or? 14 A: That's not remarkably different from 15 the average -- 16 Q: No. 17 A: -- to make you -- bradycardia or slow 18 heart rate, you'd measuring the sort of 40's or low 50's, 19 or 60's not unusual. And again, it's difficult to 20 palpate in the ambulance. The accuracy of the number 21 maybe under question. 22 It would have been interesting to know 23 whether you could hear any heart sounds when she felt she 24 couldn't feel a pulse. 25 Q: Yes.


1 A: there's a big difference between not 2 being able to palpate a pulse and not being able to hear 3 any heart activity at all. 4 Q: Yes. Thank you very much, Dr. Marr. 5 Thank you, Mr. Commissioner. 6 COMMISSIONER SIDNEY LINDEN: Thank you, 7 Mr. Rosenthal. 8 I think Mr. Ross is up next...? 9 10 (BRIEF PAUSE) 11 12 CROSS-EXAMINATION BY MR. ANTHONY ROSS: 13 Q: Good afternoon, Dr. Marr. 14 A: Good afternoon. 15 Q: My name is Anthony Ross and I 16 represent the Aazhoodena group who are resident at what 17 used to be the Ipperwash Camp and among the client base 18 was Nicholus Cottrelle. And I will be asking just a few 19 questions, in that most of what I wanted to address, have 20 been addressed by Counsel. 21 In his evidence, Mr. Cottrelle indicated 22 to us that when he arrived at the Strathroy Hospital he 23 was treated in the emergency room first. 24 Is that the general practice for somebody 25 with his type of injury?


1 A: Yes. 2 Q: Yes. He tells us later that he was 3 taken upstairs to what he referred to as his own room. 4 A: Yes. 5 Q: And he tells us further that there 6 were two (2) police officers in the room and one (1) 7 standing outside of the room. 8 Were you aware that they had these police 9 officers around him at that time? 10 A: I remember encountering police 11 officers outside the room of each patient, Mr. Cottrelle 12 and Mr. George. I don't remember that there was a police 13 officer in the room when I went in. 14 Q: I see. Now, he says further that he 15 was tired, but he tried to stay awake because he was 16 afraid of what the police officers were going to do him. 17 And he goes on to tell us that at one stage between sleep 18 and wake, he found that there was police officers rubbing 19 cotton gauze on his hands. 20 Do you -- did you know of any police 21 intervention to try to get any -- any evidence from -- 22 from -- 23 A: No. 24 Q: -- your -- your patient? 25 Did the police ask your permission to deal


1 with your patient? 2 A: No. 3 Q: Would you agree with me that it would 4 be substantially irregular for the police to attend the 5 hospital and, without seeking the permission of the 6 doctor in charge, to interfere with the patient? 7 A: To interfere with the patient, that 8 could affect his medical condition, yes. 9 Q: The evidence was from Mr. Cottrelle 10 that the police advised him that they were trying to find 11 gunshot residue on his -- 12 A: Hmm hmm. 13 Q: -- hands. 14 A: Hmm hmm. 15 Q: Did the police indicate to you that 16 they were going to be trying to extract evidence -- any 17 gunshot residue from Mr. Cottrelle's hands? 18 A: I don't remember being asked 19 permission for anything like that to happen. 20 21 (BRIEF PAUSE) 22 23 Q: Mr. Cottrelle further indicated that 24 when -- that he was accompanied to the Strathroy Hospital 25 by a Constable Boon.


1 Do you recall Constable Boone giving you 2 any information on Mr. Cottrelle's condition? 3 A: No. 4 5 (BRIEF PAUSE) 6 7 Q: And Mr. Cottrelle, I understand, was 8 hospitalized around midnight on the 6th of September and 9 discharged approximately 3:00 p.m. on the 7th? 10 A: Yes. 11 12 (BRIEF PAUSE) 13 14 Q: Yes, around 3:00 in the afternoon of 15 the 7th? 16 A: Yes. 17 Q: And my understanding is that around 18 the time of his discharge, the police had already -- had 19 taken away his clothing and he had to be discharged in a 20 hospital gown; was this your recollection? 21 A: No, I don't know that. 22 Q: You didn't know about that, okay. 23 Thank you very much, Dr. Marr, those are my questions. 24 COMMISSIONER SIDNEY LINDEN: Thank you 25 very much.


1 Mr. Orkin, have you got your equipment 2 working? Do you want to get your one (1) question in 3 before we go to Mr. George? 4 MR. ANDREW ORKIN: Thank you, 5 Commissioner. 6 COMMISSIONER SIDNEY LINDEN: It is still 7 one (1) question, is it? 8 MR. ANDREW ORKIN: It is still one 9 question (1) question. 10 THE WITNESS: A computerized question. 11 12 (BRIEF PAUSE) 13 14 CONTINUED CROSS-EXAMINATION BY MR. ANDREW ORKIN: 15 Q: Dr. Marr, on October the 20th, here 16 at the Ipperwash Inquiry David George, who is one of the 17 Occupiers at the Ipperwash Park testified about what he 18 saw in regard to the injuries sustained and the beating 19 that he described that Mr. Cecil Bernard George received. 20 In light of your testimony about the 21 injuries that Mr. George received, what I'd like to do is 22 read you a brief extract from the transcript of the 23 Inquiry. At page 113 of the transcript -- page -- 24 starting at the bottom of page 112, Mr. David George was 25 asked:


1 "Okay. And so Mr. Cecil Bernard George 2 was caught by the police and what then 3 happened? 4 Answer: They just started clubbing 5 the hell out of him. 6 Question: When you say, "they started 7 clubbing the hell out of him,"... 8 Answer: I seen him go down on his -- 9 Question: Who are you referring to 10 as, "they?" 11 I seen him go down on his back, they 12 just run right over him and he kind of 13 -- he was still looking at them and he 14 was trying to talk -- talk to them 15 right at the moment they run over, and 16 he went down on his back like this and 17 he had his hands up like that because 18 they were -- they just run him right 19 over. 20 I think they might have -- two (2) of 21 them might have clubbed him on -- on 22 the head and he fell backwards and he 23 was trying to use his arms to cover 24 himself and he landed right on his back 25 and his legs came up and he tried make


1 himself into a ball because they just 2 surrounded him, like, right as soon as 3 they run him over. 4 There were some guys behind him that 5 kind of filled the gap where those 6 officers were that first encountered 7 him and they started beating the hell 8 right out of him, like, they were 9 clubbing him all different angles. 10 They surrounded him. He was -- there 11 was a full circle right around him and 12 there was people -- I could see people 13 trying to jump over the cops trying to 14 get in a shot. 15 Question: And, how many police 16 officers did you observe around Mr. 17 Cecil Bernard George? 18 Answer: I'd say there was at least -- 19 at least ten (10) cops on him. 20 And then what happened? 21 Answer: They just -- they -- they 22 beat the hell out of him. They were -- 23 they were -- he was on the ground; they 24 were clubbing him, clubbing him up, 25 kicking him and those cops, they just -


1 - they come up to the fence again and 2 we ran back in and we were watching 3 them. 4 After we came back in, those cops came 5 back up and they didn't come right up 6 to the fence that time, they came just 7 short of the fence and they stayed 8 there while Slippery's getting beat up 9 and we seen them. Some cops had him by 10 the hair and they were dragging by his 11 hair. 12 I think two (2) -- two (2) cops there, 13 they were fighting over his hair and 14 who got to drag him and his hair was 15 all stretched out; they were dragging 16 him every which way. 17 There was guys beating him by his coat 18 and there were still people beating him 19 while they were dragging him across the 20 ground. And he was trying to cover 21 himself, but he was just getting beat 22 and beat and beat and beat and then 23 pretty soon, he was just limp and they 24 were still dragging him by his hair." 25 Dr. Marr, without asking you to comment on


1 any of the specifics and the blow-by-blow account of Mr. 2 David George as a witness to this occurrence involving 3 Cecil Bernard George, would the injuries that you so 4 carefully diagrammed and documented be consistent with 5 this description of what happened to Cecil -- Cecil 6 Bernard George? 7 A: I can say yes in a -- 8 Q: In general terms 9 A: -- in a general way. 10 Q: In general terms. 11 A: I can't -- I can't -- the dragging by 12 the hair, I -- I can't comment on that, that there's any 13 sort of support for that in terms of head injury. He had 14 a lot of injuries on the front of his head as well as on 15 his back and you're describing blows around the head, 16 there. 17 He had injuries on the front of his legs. 18 You described him being on his back with his legs drawn 19 up, trying to protect himself, and those were the 20 surfaces that did have bruises, the fronts of his legs. 21 And the -- presumably the arm here to 22 protect himself; that right arm had a lot of bruises on 23 it. But he also had bruises on his back, the biggest 24 bruises were on his upper back. And that description 25 didn't really include a clear opportunity to receive


1 blows there, because it sounded like he was on his back 2 some -- most of the time, there, in that description. 3 Q: That's very helpful. Thank you very 4 much. Thank you, Commissioner. 5 COMMISSIONER SIDNEY LINDEN: Thank you. 6 Mr. George...? 7 8 (BRIEF PAUSE) 9 10 CROSS-EXAMINATION BY MR. JONATHON GEORGE: 11 Q: Good afternoon, Dr. Marr. My name is 12 Jonathon George and I represent the Kettle and Stony 13 Point First Nation and several individuals, including 14 Cecil Bernard George. And it does appear previous 15 Counsel has -- has covered most of the areas I wished to, 16 so I'll be very brief. 17 With respect to your -- with the respect 18 to the description you at one time gave with respect to 19 Cecil Bernard George that he was not forthcoming, I take 20 it it would be inaccurate for anyone to ascribe to that 21 any negative connotations? 22 A: Yes. It was not mentioned in any way 23 negative. 24 Q: Simply an observation of yours, and 25 it had to do with him being quiet and reticent?


1 A: Quiet and reticent in a situation 2 that was chaotic, and I would have expected some 3 pronouncements of anger and -- 4 Q: Sure. 5 A: -- emotion at the experiences that 6 they had had, they were not wanting to talk about them. 7 Q: Regardless of the chaotic 8 circumstances, that kind of observation, reaction of a 9 patient wouldn't be unusual with someone with a closed 10 head injury, especially in those initial stages? 11 A: But it did continue throughout his 12 stay. 13 Q: Okay. Thank you. Now, I -- I don't 14 want to repeat Mr. Orkin's question, okay, I'm going to 15 try not to be repetitive, but I do want to ask you, 16 forgetting about any previous witness's description of 17 what happened to Mr. Cecil Bernard George, and I listened 18 to your assessment of his injuries very carefully, would 19 you agree with my characterization that based on that 20 assessment of his injuries only, that that is consistent 21 with someone who had suffered a persistent beating? 22 And what I mean by that is that the 23 injuries were sustained by actions which were clearly 24 prolonged -- clearly prolonged or -- and/or at the hands 25 of several individuals; would you agree with that?


1 A: Yes. 2 Q: Okay. Also, Dr. Marr, you indicated 3 earlier in your testimony that the kinds of injuries 4 sustained by Mr. Cecil Bernard George could become life 5 threatening. 6 And you didn't expand on that much further 7 but I take it you meant that if these kinds of injuries 8 were not monitored or treated in a timely fashion, it 9 would lead to other things, like perhaps excessive 10 swelling of the brain, loss of breathing and the 11 requirement for resuscitation; do I got that correct? 12 A: Yes. I think that his greatest risk 13 with the injuries that he had were of -- of a most -- of 14 a severe concussion and a sequelae there, bleeding or 15 swelling of the brain. 16 Q: And Ms. Vella, I believe she, twice 17 today when asking your questions, referred to Mr. Cecil 18 Bernard George's injuries as being, quote/unquote, severe 19 head trauma? 20 A: Yes. 21 Q: Did I take it from your answers you 22 agreed with her suggestion? 23 A: Yes. 24 Q: Okay. And would you agree with me, 25 doctor, that based on what you've told us and based on


1 the circumstances and his injuries, it's actually quite 2 remarkable he wasn't more seriously injured than he was? 3 A: I don't know that I can comment on 4 that. 5 Q: Okay. You -- you didn't find it 6 unusual, given that he had severe head trauma and that he 7 had been struck at least twenty -- twenty-eight (28) 8 times, you didn't find it unusual that there were no 9 fractures or broken bones or things of that nature? 10 11 (BRIEF PAUSE) 12 13 A: I wouldn't have been surprised if 14 we'd found a -- a fracture on his forearm from the 15 severity of the findings there. And -- but other sites, 16 I -- I can't really comment on. 17 And he certainly had blunt trauma to the 18 head and could have developed intracerebral bleeding or 19 swelling that could have had more serious consequences, 20 but he didn't and it wasn't due to any interventions that 21 we provided. There weren't any appropriate 22 interventions; it was a question of observing and waiting 23 to see and then acting if those things happened. 24 Q: Right. I -- I guess I kind of put 25 the question awkwardly. I guess a better way to put it


1 would have been, if he were to have suffered a fracture 2 to the skull, for instance, that wouldn't have surprised 3 you, given the other things you know right now? 4 A: It wouldn't have surprised me. 5 Q: Now, finally Doctor, would you agree 6 with me that it -- it would be completely inappropriate 7 for anyone, including anyone in this room or the public 8 for that matter, to engage in any minimization of Mr. 9 Bernard George's injuries by virtue of your assessment 10 that it's unlikely his pulse stopped or it's unlikely his 11 vital signs were lost at some point in time? 12 A: I -- I don't think my -- 13 Q: And, I'm -- I'm not suggesting you're 14 doing that, I'm just -- would you agree with me -- 15 A: No, my -- my comment that -- that I 16 think it's unlikely that he had no pulse or apnea for any 17 period of time doesn't detract from the fact that I think 18 he was potentially quite seriously injured; he did have a 19 major head injury. 20 Q: Okay. 21 A: And, he might well have had other 22 interabdominal injuries at the first assessment and, 23 indeed, for the first half hour of our assessment we were 24 concerned that might be the case. It would have been 25 very hard for anyone else to have ruled that out at the


1 scene. 2 Q: Okay. Thank you very much, Doctor. 3 COMMISSIONER SIDNEY LINDEN: Thank you 4 very much. 5 Andrea Tuck-Jackson is up. 6 MS. ANDREA TUCK-JACKSON: Good afternoon, 7 Commissioner. 8 COMMISSIONER SIDNEY LINDEN: Good 9 afternoon. 10 11 (BRIEF PAUSE) 12 13 CROSS-EXAMINATION BY MS. ANDREA TUCK-JACKSON: 14 Q: Good afternoon, Dr. Marr. My name is 15 Andrea Tuck- Jackson and I'm going to ask you some 16 questions on behalf of the OPP. 17 And, I'd like to begin, if I can, 18 following up on the last time you heard from me in 19 relation to my objection to Mr. Rosenthal's question. 20 And, I'd ask you if you could, please, to 21 turn to the document at Tab 12 of your materials. For 22 the purposes of the record, that is Document 5000227. 23 And I understand, Dr. Marr, that this is a 24 transcript of an audio taped interview that took place on 25 September the 20th, 1995; is that correct?


1 A: Yes. 2 Q: Okay. And if you turn to page 17, 3 I'd be grateful. 4 5 (BRIEF PAUSE) 6 7 Q: And, in particular, I'm interested in 8 the exchange that you had with Officer Harwood toward the 9 end of that page. And, you'll recall in your evidence 10 today you talked about the fact that you had requested 11 one of the nurses to try and speak with the individuals 12 who brought or accompanied Dudley George to the hospital. 13 And I'm interested in a passage. Officer 14 Harwood indicates to you: 15 "Okay. And you stated earlier that you 16 were never able to locate the persons 17 who had brought Anthony Dudley George 18 in to obtain further information." 19 And, your answer, as it has been recorded 20 here is: 21 "Yes, I didn't look myself." 22 And, pausing there for a moment, I trust, 23 Dr. Marr, that it's self-evident, I'm sure, your hands 24 were full, you -- you weren't in a position to make those 25 inquiries?


1 A: Correct. 2 Q: Right. Okay. 3 "But I had asked a nurse to go and do 4 that." 5 And, again, pausing for a moment and I 6 appreciate it's been a very long time, do you recall 7 which nurse you tasked with that? 8 A: No. 9 Q: Okay. It's the next piece that I 10 find of interest. 11 "I don't know how much time and effort 12 she put into looking for them, because 13 there was a lot of other things going 14 on at once, but certainly I would have 15 liked to have had a history to the -- 16 to the [I'm sure that says] preceding 17 half hour." 18 Now, backing up for a moment, your 19 observation that there was certainly a lot of other 20 things going on at once, I trust you'd agree with me that 21 events were moving fast and furiously in that ER that 22 night? 23 A: Yes. 24 Q: All right. And I trust you can't 25 assist us as to how much time that particular nurse was


1 able to dedicate to trying to find the individuals in 2 question? 3 A: I think there's something that she 4 testifies to somewhere in here, but I can't put my finger 5 on it easily. 6 Q: Okay. Having regard to what you've 7 told us today, it would appear that not a great deal 8 turns on what information you could have obtained in 9 terms of starting other procedures or doing other 10 treatments. 11 But I am, nonetheless, interested in 12 knowing what efforts were made to speak with both Carolyn 13 George and Pierre George, whom we know were the 14 individuals who were brought -- who brought in their 15 brother to the hospital. 16 And you've agreed with us that you 17 pronounced Mr. George dead at 12:20 in the morning? 18 A: Yes. 19 Q: Okay. I anticipate that we're going 20 to hear from the officers who were responsible for the 21 arrest of Carolyn George and Pierre George that they did 22 not remove them from the hospital parking lot until some 23 time on or after 12:20 a.m. 24 So, it certainly would appear that they 25 were still on the premises, at least in the parking lot


1 area. And again, I don't pose the question in any 2 critical way, but again I ask, were you aware of the 3 extent of the efforts that were made by the nurse to try 4 and speak with them? 5 A: No. I don't know, I don't remember 6 having any -- I don't remember the details of the 7 feedback from the nurse, except to the effect that they 8 hadn't been able to find anyone who knew anything, any 9 information. 10 And the information was no so important 11 after we had gone through the full resuscitation efforts. 12 So finding them after -- twenty (20) minutes after 12:00 13 at which point we had decided there was no effort that 14 was being effective, would not really have been 15 information that I'd have been spending a lot of time on 16 at that point. I -- 17 Q: I appreciate that entirely. 18 Obviously, I'm interested in -- 19 A: We needed it in the first five (5) 20 minutes. 21 Q: Of course. 22 A: Although, as you have said, it really 23 made no difference to the resuscitation effort, the 24 absence of the information, because we did everything we 25 possibly could to try and resuscitate him.


1 Q: And that's entirely fair. I wanted 2 also to -- to question you briefly about the contact that 3 you were able to have, both with Cecil Bernard George and 4 Nicholas Cottrelle and their respective family members. 5 And we've heard, for example, from up to 6 this point, four (4), I think, four (4) different 7 ambulance -- no, excuse me, three (3) different ambulance 8 attendants who've testified that, apart from -- from some 9 time that's necessary to secure or clear a scene to 10 ensure safety and security of all people involved, that 11 at no time were they of the view that the police, in any 12 way, impeded their ability to treat patients that they 13 were attending. 14 And to that end, I wanted to -- to ask you 15 some questions. 16 So, for example, I trust you would agree 17 that no police officer impeded your ability to 18 communicate with Cecil Bernard George? 19 A: There was certainly no direct 20 interference. I wonder, on retrospect, whether some of 21 the reticence to say very much was because they thought 22 the police were within earshot. 23 Q: I understand that. Leaving that 24 aside for a moment, however, no police officer, in any 25 way, actively impeded or obstructed you --


1 A: Oh, absolutely not, no. 2 Q: Neither in your communication with 3 your patient or your treatment of your patient? 4 A: No. 5 Q: And you've already told us, Dr. Marr, 6 that you were able to speak with some relatives of Cecil 7 Bernard George, once they had arrived? 8 A: Yes. 9 Q: And so I trust also that the police 10 in no way impeded or obstructed your ability to 11 communicate with those relatives? 12 A: No, they were allowed access into the 13 trauma room. 14 Q: Thank you, they were allowed access 15 to the trauma room. 16 And also with respect to Nicholas 17 Cottrelle, again, I trust that no police officer impeded 18 your ability to communicate with Nicholas Cottrelle? 19 A: No, they did not. 20 Q: Or did anything to impede your 21 ability to treat him. 22 A: They did not impede my ability to 23 treat him. 24 Q: All right. Now also I understand 25 that Nicholus Cottrelle's mother was in attendance at the


1 hospital that day or that night, excuse me? 2 A: I -- I don't recall meeting or 3 talking with her. 4 Q: All right. 5 A: I think there may be some indirect 6 evidence that I did, but I don't recall it or I couldn't 7 identify her or remember any of the conversation. 8 Q: All right. But certainly, as best as 9 you can tell us, the fact that you did not speak with her 10 wasn't as a result of any action by the police? 11 A: No. 12 Q: Dr. Marr, thank you for your time. 13 COMMISSIONER SIDNEY LINDEN: Thank you, 14 Ms. Tuck-Jackson. 15 Ms. Jones...? 16 17 (BRIEF PAUSE) 18 19 CROSS-EXAMINATION BY MS. KAREN JONES: 20 Q: Mr. Commissioner. 21 Good afternoon, Dr. Marr. 22 A: Hello. 23 Q: I'm Karen Jones, one of the lawyers 24 for the Ontario Provincial Police Association. I just 25 wanted to follow up briefly on the questions that you


1 were just asked. 2 I take it if you had been of the view at 3 the time that the police were somehow impeding your 4 ability to speak to your patients or their ability to 5 speak to you, that you wouldn't have hesitated to ask the 6 police to leave? 7 A: Yes, that would have been 8 appropriate. 9 Q: Sure. And I take it that never 10 happened, you never -- 11 A: No. 12 Q: -- had that concern at the time at 13 all? 14 A: I -- I had the sense -- I had the 15 feeling or the belief at the time that we were -- I was 16 obtaining enough answers to the questions I was asking to 17 be able to provide the appropriate medical care. I 18 wasn't getting extra information around the events that - 19 - the drama that went with it, but I was -- 20 Q: Right. 21 A: -- getting enough answer to know the 22 mechanism of injury, which is really what I was concerned 23 about. 24 Q: Right. Now, I wanted to take you 25 back a little bit, Dr. Marr, and just ask you a few more


1 questions about the Strathroy Hospital and what you do 2 there and how you do it. You had started off this 3 morning talking to Ms. Vella a little bit about the 4 services provided at Strathroy and how often you worked 5 there, and that kind of a thing. 6 And I take it from your answers that 7 Strathroy Hospital is a fairly small community hospital? 8 A: Yes. 9 Q: And that you provide basic services 10 there but for specialized services people need to go to 11 other facilities? 12 A: We have pretty comprehensive services 13 for a Level 1 hospital -- 14 Q: Yes. 15 A: -- which is a community hospital; we 16 do have surgery and anaesthesia -- 17 Q: Yes. 18 A: -- and intensive care. Hmm hmm. 19 Q: Okay. And you talked a little bit 20 about stabilization of patients before they get 21 transported, and I just wanted to make sure we were all 22 clear on what stabilization means. 23 And I understand that it would mean that 24 the patient would have a patent airway, either because 25 they could maintain their own -- their own airway or they


1 had some kind of assistance in maintaining the airway? 2 A: That would be one of the 3 prerequisites. 4 Q: Sure. And that they would either be 5 breathing sufficiently on their own or they would be 6 getting some assistance either with oxygen or with some 7 kind of other device, so that you could ensure that they 8 were getting enough air in and out of their lungs? 9 A: That would be part of stabilization. 10 Q: Right. And I take it, generally, if 11 someone was being transported and you wanted to ensure 12 that their circulatory system was maintained, that they 13 would have an IV? 14 A: Hmm hmm. Yes. 15 Q: And that intravenous could be for a 16 variety of reasons, one would be to give them fluid if 17 they needed fluid? 18 A: Yes. 19 Q: And one would be to give them 20 medication if they needed medication intravenously? 21 A: That would be reasonable. 22 Q: Right. And also would be so that 23 they could receive blood products if they needed blood 24 products? 25 A: Yes.


1 Q: And sometimes, I take it from what 2 you said, that you would have an IV inserted as a 3 precaution? 4 A: Yes. 5 Q: Not because you need it at the time 6 but because you might need it down the road? 7 A: Yes. 8 Q: Okay. And as part of stabilization 9 you could also put on, for example, pressure dressings or 10 a splint or immobilize limbs or areas that needed that 11 kind of treatment? 12 A: These are the type of things you 13 might do in trauma. 14 Q: Yes. 15 A: Hmm hmm. 16 Q: Okay. And we've heard a little bit - 17 - are there other things that I missed in terms of 18 stabilization? 19 A: No, I think you've hit the main 20 points. 21 Q: Okay. And, I just wanted to take you 22 back to some questions that Mr. Rosenthal asked you 23 about, giving someone who was bleeding IV fluid. And, I 24 take it for the most part, when someone refers to "IV 25 fluids" that someone would get would be -- get -- would


1 get in a hospital or in an ambulance if they were 2 bleeding, you'd be talking about normal saline or some 3 kind of fluid like that? 4 A: Yes. 5 Q: And do you agree with me that if 6 someone is bleeding quite a bit, that at some point in 7 time, it's not sufficient to replace blood loss with a 8 fluid like normal saline, but you have to replace it with 9 blood or a blood product? 10 A: Yes. 11 Q: Okay. We heard some evidence, Dr. 12 Marr, from the ambulance attendants about what a baseline 13 assessment for an ambulance attendant would be and they 14 talked, for example, about going through the ABC's; 15 airway, breathing, circulation, looking at vital signs, 16 maybe doing a neurological check if need be and then 17 going on to a secondary assessment, seeing if there are 18 any other injuries. 19 And, I take it that as an Emergency Room 20 physician, that when someone comes into the Emergency 21 Department, you perform, essentially, that same protocol 22 on them in perhaps a more sophisticated way or using more 23 sophisticated equipment, but that's the basic process 24 that you and others use in trauma situations? 25 A: That's fair enough.


1 Q: Yeah. 2 3 (BRIEF PAUSE) 4 5 Q: And, I wanted, Dr. Marr, to take you 6 to Nick Cottrelle and just ask you some questions about 7 that. Again, Mr. Rosenthal had asked you about what Mr. 8 Cottrelle told you in terms of the circumstances under 9 which he was injured and you've told us that you 10 documented on more than one (1) occasion in his chart 11 that he was in a car. 12 I take it that Mr. Cottrelle never said to 13 you that he was standing and got shot in the back and 14 then walked to a car? 15 A: Well, on the original history, I said 16 he was apparently standing by or sitting in the car. 17 Q: Okay. 18 A: I don't know whether he told me two 19 (2) versions or he was unsure about which it was. 20 Q: Okay. And, then later on, I take it 21 you -- 22 A: The next -- 23 Q: -- the next time you talked to him 24 about it -- 25 A: -- time I talked to him, I said -- he


1 says he was in his car when a riot broke out. 2 Q: Right. And, I take it, Dr. Marr, 3 that when you first assessed Nick Cottrelle in the 4 Emergency Department, you've told us he was the first of 5 the patients to come in that night, that you were 6 satisfied in the fairly brief time that you had with him, 7 before you moved on to other patients, that he was in 8 stable condition? 9 A: Yes. 10 Q: And, I take it that you had had a 11 sufficient opportunity to assess that? 12 A: Yes, it was brief. 13 Q: Yeah. 14 A: But he was fortunately quite clear in 15 his description of his symptoms as well, which was 16 helpful. 17 Q: Yes. And that any interventions you 18 felt you needed to do, you had had an opportunity to do 19 at that time? 20 A: Yes, we'd ordered the intravenous and 21 some blood work -- 22 Q: Right, and you had given the orders-- 23 A: -- and some x-rays. 24 Q: -- that you needed to give? 25 A: Yes.


1 Q: Okay. And you talked a little bit 2 earlier about the resources available at the hospital, 3 the medical resources available at the hospital. 4 You've told us that there was another 5 doctor in the hospital and you could call other doctors 6 if need be? 7 A: Yes. 8 Q: And, I take it as a doctor, your 9 often in the position where there are multiple demands on 10 your time? 11 A: Yes. 12 Q: And, I take it that you, therefore, 13 have expertise and experience in determining what you can 14 do and when you need to do it? 15 A: You do need to triage and put 16 priority on which -- 17 Q: Right. 18 A: -- actions you take when. 19 Q: Right, and I take, if there was any 20 time that night that you felt like you were unable to 21 care for the patients in the Emergency department, that 22 you would have called for more assistance? 23 A: Well, yes, and that would have been 24 quite quickly available. 25 Q: Sure, and you didn't have the need to


1 do that? 2 A: No, the -- fortunately the nature of 3 Mr. Cottrelle and -- 4 Q: Right. 5 A: -- Mr. George's injuries were that 6 they were stable and they didn't need to go -- 7 Q: Right. 8 A: -- urgently to surgery or other 9 interventions. 10 Q: Right. 11 A: Unfortunately, Mr. George -- there 12 was nothing further that we could do. 13 Q: Yes. Now, Dr. Marr, I wanted to ask 14 you a little bit with -- about Nick Cottrelle and this 15 material that might or might not have been seen on x-ray, 16 because I'm not exactly sure about the sequence of events 17 and what it was or what it wasn't. 18 And I don't know if it's of assistance to 19 you to look at Mr. Cottrelle's record and specifically, 20 the -- your progress notes and the x-ray report, because 21 if it is, you should -- please feel free to do that. 22 23 (BRIEF PAUSE) 24 25 Q: And you told us, first of all just to


1 make sure about the sequence of events, that the x-ray of 2 Mr. Cottrelle's chest and abdomen had been taken fairly 3 soon after he got to the emergency department? 4 A: That's my recollection, yes. 5 Q: Yes. And that you had spoken to the 6 radiologist about the findings. 7 A: Later. 8 Q: Later, because you were concerned 9 about whether or not there would be any indication of a 10 bullet present? 11 A: Yes. 12 Q: And you had been told no. 13 A: When I spoke with the radiologist 14 that was -- he said there was no evidence of a 15 significant penetrating wound or any damage to the heart 16 or lungs or abdomen. 17 Q: Right. And that was consistent with 18 what your physical assessment had been as well? 19 A: Yes. 20 Q: Okay. Because I noted in your 21 progress notes and that's Inquiry Document 100043, on 22 September the 7th, that you say the wounds were more 23 consistent with shattered glass than a bullet. 24 A: Yes, I think the sequence of events 25 when I see it there, is that I went up to see him again


1 that morning. It would have been around eight or nine 2 o'clock -- 3 Q: Yes. 4 A: -- and listened to his story again. 5 Q: Yes. 6 A: And -- and he described the shattered 7 glass and I felt from his story that the wounds more -- 8 were more consistent with having some glass causing those 9 two (2) -- 10 Q: Right. 11 A: -- abrasions on both sides of his 12 body. And I said, review x-rays, at the end of that 13 first note so I hadn't looked at the x-rays again at that 14 point. 15 Q: Right -- 16 A: And -- 17 Q: -- and then if we look further down 18 on your progress note -- 19 A: Yeah. 20 Q: -- of September the 7th, it looks 21 like at 14:00 hours -- 22 A: I had by then talked to the 23 radiologist, yes. 24 Q: Right. And so the ultrasound was 25 reviewed and the x-ray was reviewed?


1 A: And the x-ray was reviewed verbally 2 with the radiologist at that point. 3 Q: Right. 4 A: And perhaps, because I was 5 particularly asking him about is there any serious injury 6 here and his answer was no -- 7 Q: Right. 8 A: -- we didn't notice or talk about the 9 tiny triangular possibly metal density that was 10 eventually reported on that portable supine of the 11 abdomen. 12 Q: Yes, and it appears from -- and we'll 13 ask Dr. Saettler about this as well, but it appears from 14 her consultation report that as -- and it may well be in 15 the chart in front of you as well, I'm not sure. 16 It's Inquiry document, again, number 17 100043. But she has a note dated September 8th, 1995 18 where there's a review of the x-ray and she notes: 19 "Query small density posterior to 20 twelfth thoracic vertebrae, probably 21 not foreign body secondary to gunshot, 22 but needs to be checked with 23 radiologist in a.m." 24 A: Yes, so it does seem from that, that 25 she had made comment on it, whereas I had not.


1 Q: Okay. 2 A: I actually, this morning too, had not 3 properly interpreted that. 4 Q: Yes. I was just going to ask you -- 5 A: Supine abdomen -- 6 Q: -- I was going to ask about that -- 7 A: -- whether -- 8 Q: -- because I had thought you might 9 want to go back and have another look at that and 10 possibly -- 11 A: Yeah. Now I -- now I see that supine 12 abdomen again. 13 Q: Yes. 14 A: We can't tell from that one (1) view, 15 the radiologist writes as if it's in the anterior. 16 Q: That's right. 17 A: I read it that way, but you couldn't 18 tell whether it was anterior or posterior actually. 19 Q: That's right. 20 A: There might have been other views. 21 Q: I'm sorry, I didn't mean to interrupt 22 you but I was going to ask you that, because it wouldn't 23 have appeared that you could tell if it was anterior or 24 posterior? 25 A: You're absolutely right, yeah.


1 Q: And I take it from your -- your views 2 of the matter at the time and your discussions with Dr. 3 Saettler, that you were assuming that it was posterior, 4 that it was -- 5 A: Around the site of the entry wound -- 6 Q: -- around the site -- 7 A: -- of the wound that we saw. Hmm 8 hmm. 9 Q: That's right. And so I take it once 10 you had that discussion, that you were then of the view 11 that you should alert Mr. Cottrelle -- 12 A: Hmm hmm. Yes. 13 Q: -- to the possibility that there was 14 some small object in that area? 15 A: Yes. Although I think, as Dr. 16 Saettler says, it was likely of -- of no medical 17 consequence to him. 18 Q: Yes. Yeah. And you've told us about 19 the efforts that you made to contact Mr. Cottrelle about 20 that. 21 And then there was some questions to you 22 about, I believe, speaking with the SIU about that; do 23 you recall that? 24 A: Questions this morning? 25 Q: Yes.


1 A: Yes. 2 Q: Okay. And do you recall whether or 3 not you did speak to the SIU specifically about the issue 4 of whether there was an object in Mr. Cottrelle's back? 5 A: I -- I think I did discuss it with 6 them. 7 Q: Okay. And there's two (2) things 8 that I can take you to that might help you, Dr. Marr; I 9 know it's a long time ago and it's hard to recall. 10 And the first thing that I would take you 11 to is a document that is called, "Anticipated evidence 12 of" -- woops, sorry, that's the wrong one, that's not 13 going to help. 14 15 (BRIEF PAUSE) 16 17 Q: It's Inquiry Document Number 1002484 18 and it is an interview with the SIU dated January 22, 19 1996. And for the assistance, you'll find that in your - 20 - in your book at Tab 18. And I don't know if you need a 21 chance to look at that, Dr. Marr, before I take you to 22 it. 23 I can tell you if you look at -- starting 24 at page 2, going partway down to the bottom, you'll see 25 that there's the start of the discussion about the X-


1 rays. 2 3 (BRIEF PAUSE) 4 5 A: Hmm hmm. Okay. That does bring back 6 a memory that -- trying to find where Mr. Cottrelle would 7 be. I called the policeman in charge of the 8 investigation and he said that he'd been discharged. So 9 that maybe he gave me the phone number too because I 10 can't see where else I would have got it from. 11 Q: Hmm hmm. Okay. And Dr. Marr, I 12 wanted to see if we could understand a little bit better 13 the nature of your concerns about this object. 14 I take it at this point in time you 15 weren't clear if there actually was something in Mr. 16 Cottrelle's back or whether it was artifact on the x-ray? 17 A: That's right. 18 Q: Okay. And, again, perhaps you could 19 help us by telling us what "artifact" means? 20 A: Oh, that it could have been something 21 on the hospital bed as it was being x-rayed that 22 would have appeared to be as part of -- of his film, but, 23 in fact, was just something sitting on the -- getting in 24 the way of the film at some point. 25 Q: Okay.


1 A: Or, I suppose it could be a technical 2 problem with the film, too, but more likely something in 3 clothing or bed drapes that had appeared as a radio- 4 opaque object. 5 Q: Okay. And, can you explain to us a 6 little bit about the nature of your concern if Mr. 7 Cottrelle did have some sort of a tiny object by -- 8 superficially by the wound? 9 A: There would be some risk of infection 10 from a foreign -- the presence of a foreign body. It 11 might be uncomfortable still and he might benefit in 12 terms of comfort from it being removed by exploration. I 13 just felt that the -- I hadn't really addressed the 14 presence of those fragments with him at the time of his 15 discharge. 16 If I'd been able to tell him about it or 17 even at the time of discharge and say to him, You know, 18 this is what might happen; keep an eye on it. If it does 19 happen, you ought to have some follow-up. Then I 20 would have probably been quite satisfied with that 21 approach, but I hadn't had a chance to share that 22 information with him. 23 Q: Okay. And in the document that you 24 were just looking at, the transcript of the SIU 25 interview, it says partway down the page:


1 "However, it occurred to me at the time 2 that this may well have some medical 3 legal consequences." 4 And, could you explain to us what your 5 concern was about the medical legal consequences? 6 A: There may be two (2) -- two (2) 7 aspects of that; one (1) is the very thing that's 8 happening now that there was a finding that I really 9 didn't fully follow through and I just -- 10 Q: Sure. 11 A: -- felt that I should. I would be 12 asked about it, perhaps, at some future date and I 13 wouldn't be able to account for it. 14 Secondly, just more from a forensic point 15 of view, I thought there might be an issue around whether 16 he had been shot or whether it was metal or whether it 17 was glass and that it would be part of the evidence of 18 any inquiry into the matter. 19 Q: Okay. 20 21 (BRIEF PAUSE) 22 23 Q: I then wanted to ask you some 24 questions about Mr. Cecil Bernard George. And I think 25 you had told us earlier this morning that when you spoke


1 to the ambulance attendant that she had expressed some -- 2 or told you that there had been some -- that there was a 3 report of a thready pulse along the route. 4 Did the ambulance attendant ever say to 5 you that at any point in time there was no pulse? 6 A: My memory was that it was thready and 7 they weren't sure that -- they thought he'd lost him at 8 some time, I think they said, but I don't remember them 9 saying absolutely no pulse or no respirations, although I 10 see that's how it's charted on the report. 11 Q: But that's not something that she 12 communicated to you? 13 A: They did say they thought they'd lost 14 him at some point, which would suggest that they couldn't 15 find any -- 16 Q: Okay. 17 A: -- signs of life. 18 Q: Okay. And we spent some time, Dr. 19 Marr, looking at your diagram and I'm sorry I don't have 20 the exhibit number, but the front view and the rear view 21 diagrams that you did, it's P-363. 22 And, I take it when you made this chart, 23 Dr. Marr, that you wanted to note down anything that was 24 reported to you -- 25 A: Yes.


1 Q: -- in terms of any tenderness or any 2 pain -- 3 A: Yes. 4 Q: -- so that was sort of the threshold 5 criteria for noting something. 6 And I take it that if there was something 7 significant about any of the things you saw, for example, 8 the bruises or the abrasions, that you wanted to document 9 that in your notes on this chart as well? 10 A: Yes, I believe I did. 11 Q: Okay. And when I was going through 12 the notes that you've made along with the chart, I've 13 noted -- it appears that there are a few areas where you 14 made some comment, either that bruising was diffuse, 15 which you've told us was -- would be broadly spread, or 16 you made some comment or notation about the size of an 17 abrasion or a cut. 18 And I take that if either the size of the 19 bruise or the size or the appearance of an abrasion or a 20 cut seemed more significant, that that was something that 21 you would want to document very carefully? 22 A: I think I tried to document all of 23 them carefully. 24 Q: Okay. For example, did it -- did you 25 think of or did it seem worth your while when you were


1 doing this chart, to take any measurements of things like 2 the size of bruise or the size of abrasion? 3 A: I did not take any measurements. I 4 estimated the measurements as I said there. 5 Q: Sure. And I take it that you 6 estimated the measurements of bruises or, for example, 7 the lacerations that seemed like they were significant? 8 A: Yes. 9 Q: Yeah. 10 A: And the shadings sort of represented 11 the area on the body that was affected and anatomically 12 we can get an idea of size from that. The drawing's to- 13 scale, sort of. 14 15 (BRIEF PAUSE) 16 17 Q: So, are -- do -- were you very 18 careful when you made these markings that they would 19 represent size as well as location or were they more 20 particularized for location? 21 A: They would be proportional to the 22 site of injury. 23 Q: Okay. 24 A: But drawn freehand, so as accurate as 25 that would be.


1 Q: Sure. So it would be a rough -- 2 A: Yeah. 3 Q: Yeah. And I think you've clarified 4 or been -- been clear that Mr. Cecil Bernard George had 5 no broken bones? 6 A: Correct. 7 Q: And he had no internal injuries? 8 A: Correct. 9 Q: And I've noted from some of your 10 previous -- sorry, just to be clear. There's nothing in 11 your diagram or nothing in your evidence that indicates 12 that there was any injury at all in his genital area, his 13 crotch, his inner thighs? 14 A: I think I stated somewhere that for 15 the purpose of this exam on September the 8th, he was 16 dressed in boxer shorts and I did not ask him to remove 17 them. 18 Q: Okay. 19 A: So, I'm not aware of any bruising he 20 may have had in that area. 21 Q: Okay. Do you remember, doctor, 22 giving evidence at -- Mr. Cottrelle's trial? 23 A: Yes, I did do that. I'm not sure 24 exactly what I said there, but it's in -- 25 Q: Well, let me --


1 A: -- there -- 2 Q: -- give you some assistance here if I 3 can, and see if I can't refresh your memory a bit. 4 5 (BRIEF PAUSE) 6 7 Q: In your Tab 20, and it's Inquiry 8 Document Number 3000847, there's a transcript of your 9 evidence in-chief at Mr. Cottrelle's trial. 10 11 (BRIEF PAUSE) 12 13 A: What was the number again, please? 14 Q: It is your Tab number 20. 15 A: But the number in the font -- the 16 front? 17 Q: It should be 0055811. 18 19 (BRIEF PAUSE) 20 21 Q: And if you turn to -- I'm sorry, Dr. 22 Marr, have you found that document in your binder? 23 A: No. 24 25 (BRIEF PAUSE)


1 Q: Sorry, Dr. Marr, I know it's hard 2 when you go back and forth between different documents. 3 COMMISSIONER SIDNEY LINDEN: I've got the 4 transcript, Ms. Jones, but I don't have the page either. 5 What page? 6 MS. KAREN JONES: At page 65. 7 COMMISSIONER SIDNEY LINDEN: 65? 8 9 (BRIEF PAUSE) 10 11 COMMISSIONER SIDNEY LINDEN: -- Ms. 12 Jones, page 65 of 75? 13 MS. KAREN JONES: Page 65. It's page 65 14 of -- sorry, if you look at the top, where it says the 15 number of 75, it's page 68 of 75. 16 17 (BRIEF PAUSE) 18 19 THE WITNESS: Where are you? 20 21 CONTINUED BY MS. KAREN JONES: 22 Q: I'm on -- if you look at the top 23 right-hand corner of the document pages, you'll see, it 24 says page 68 of 75. 25 A: 68 of 75?


1 Q: Yes. 2 A: Okay. 3 Q: And under the pagination for the 4 document itself it says "65". So there's -- there's two 5 (2) different places that these documents are numbered. 6 A: We only go to 66 here. 7 COMMISSIONER SIDNEY LINDEN: Mine too. 8 They only go up as high as 66 in this. Are you still in 9 the evidence in-chief or are in the cross-exam? The 10 evidence in-chief ends at page 65. 11 MS. KAREN JONES: Oh, I'm sorry, in -- in 12 the document I have is included both the evidence in- 13 chief and the cross-examination. And the evidence in- 14 chief ends at 66 of 75 and it carries on -- 15 COMMISSIONER SIDNEY LINDEN: That's as 16 far as -- 17 MS. KAREN JONES: -- with the cross- 18 examination. 19 COMMISSIONER SIDNEY LINDEN: -- as our 20 copy goes -- 21 MS. KAREN JONES: Okay. That's -- that's 22 my mistake. 23 COMMISSIONER SIDNEY LINDEN: -- up to the 24 end of the evidence in-chief. 25 MS. KAREN JONES: I'm sorry about that.


1 (BRIEF PAUSE) 2 3 CONTINUED BY MS. KAREN JONES: 4 Q: It -- it may be, Dr. Marr, I bet, the 5 whole of this wasn't included in your volume. 6 A: Okay. 7 Q: And it may be that we can put it on 8 the screen or what I can do is read to you the passage, 9 both a little bit before and some afterwards so that you 10 get some context. 11 A: Okay. We can try that. 12 Q: Okay. This is page 65, yeah. And if 13 we look down closer to the bottom of the page, and just 14 to help orient you a little bit, at this stage you were 15 being asked questions about the diagram, Dr. Marr, and 16 you'll see that there is a question, almost at the 17 bottom, that says: 18 "All right. As I look at the diagram, 19 I see no injury noted to the crotch 20 area, penis, testicles or inner thigh? 21 Answer: "No awareness of any problem 22 there, no." 23 And then question: 24 If there had been, you would have know 25 about it?


1 And the answer is: "Yes." 2 Does that assist you at all? 3 A: What was the -- when was this? What 4 was the date of this -- of that year? 5 Q: The date of this transcript is March 6 the 27th, 1998. 7 A: '98? 8 Q: Yeah. 9 10 (BRIEF PAUSE) 11 12 A: I'm just looking to see what evidence 13 more contemporaneously was that I didn't examine his -- 14 Q: Okay. 15 A: -- genital area but... 16 17 (BRIEF PAUSE) 18 19 A: Yeah, the only evidence I have was 20 the letter, December '97, in which I stated that when I 21 was describing the injuries, I said with Mr. George's 22 verbal consent I drew a diagram of the injuries from the 23 front and back perspective with the exception of the 24 genital area which was not examined. 25 That was the letter to Mr. House --


1 Q: Okay. 2 A: -- that we discussed earlier. 3 Q: Okay. 4 A: That was December '97 when I wrote 5 that and I do feel I have a memory of doing that exam. 6 You know, it was a lengthy procedure and I remember 7 feeling that it would be perhaps a little embarrassing 8 for both of us to go through this lengthy procedure with 9 no clothes on at all, and -- 10 Q: Sure. 11 A: -- and we -- we didn't examine that 12 area for that reason. 13 Q: Sure. 14 A: So, I think that's an accurate 15 memory. I don't know why I reported differently there. 16 Q: Sure. But I take it, Dr. Marr, if 17 you were looking at Mr. Cecil -- Cecil Bernard George for 18 some period of time, looking at his front and looking at 19 his back and top and bottom and that kind of thing, that 20 he wouldn't have had to have been naked for that entire 21 time? 22 A: No, he wouldn't, but I know that's 23 sort of what was going through my mind at the time, and 24 it was also going through my mind at the time this wasn't 25 really a fully medically necessary process we were going


1 through, it -- 2 Q: Sure. 3 A: -- was, perhaps for other reasons as 4 we've already discussed, that the broaching of his 5 dignity was not appropriate when the role was slightly 6 different. 7 But -- so I don't think I did -- 8 Q: Okay. 9 A: -- examine on that day -- 10 Q: Okay. 11 A: -- that area. 12 Q: But, I take it from you've told us 13 earlier that you asked him very carefully about any area 14 where he had any pain or any tenderness at all? 15 A: Yeah, I did ask him to indicate to me 16 where -- where his areas -- 17 Q: Sure. 18 A: -- of pain were and he -- I don't 19 recall him bringing attention to that area, or I might 20 have then discussed with him examining the area to be 21 able to document it. 22 Q: Sure, because you wanted to be very 23 careful to document anywhere that -- that there was any 24 pain or any tenderness, even if there was no physical 25 finding other than that?


1 You were being quite conscientious and 2 careful in this document, I take it? 3 A: I was, but I was also -- 4 COMMISSIONER SIDNEY LINDEN: You're 5 rising, Mr. Orkin...? 6 MR. ANDREW ORKIN: Commissioner, I'm 7 puzzled by this line of questioning. We're attempting, 8 it seems, to find a contradiction and when I read and re- 9 read the text on the screen, I can't find one. 10 We're talking about subjective awareness - 11 - could we have the slide on the -- thank you. 12 13 (BRIEF PAUSE) 14 15 16 MR. ANDREW ORKIN: We're talking in the 17 second last answer: 18 "No awareness of any problem there? 19 No. 20 If there had been, you would have known 21 about it? 22 Yes." 23 As many times as -- as My Friend questions 24 on these points relating to the other matters she's 25 raising, I'm still unable to find that contradiction.


1 So, perhaps she can clarify this for us -- 2 COMMISSIONER SIDNEY LINDEN: She's not 3 finished questioning -- 4 MR. ANDREW ORKIN: -- but I've listened 5 to it for the last five (5) or so minutes and I'm getting 6 lesions scratching my own head. 7 COMMISSIONER SIDNEY LINDEN: Well, I'll 8 let Ms. Jones continue and see where she's going. She's 9 not finished yet, I take it, or you are finished with 10 this area, I don't know. 11 MS. KAREN JONES: I actually was, Mr. 12 Commissioner. 13 COMMISSIONER SIDNEY LINDEN: All right. 14 Then let's -- 15 MS. KAREN JONES: Yeah, I thought I'd 16 taken Dr. Marr to the passage. She'd had a chance to 17 refer to another document, she had gone back, she had 18 talked about the document whether or not that reflect -- 19 the document that you looked at, 363, is the injuries or 20 not. 21 COMMISSIONER SIDNEY LINDEN: Yes, that's 22 fine, carry on. 23 MS. KAREN JONES: Thank you. 24 25 CONTINUED BY MS. KAREN JONES:


1 Q: And Dr. Marr, you were asked a number 2 of questions in which Mr. Cecil Bernard's George's 3 injuries were described as, for example, life 4 threatening -- 5 COMMISSIONER SIDNEY LINDEN: Just before 6 you continue, Ms. Jones? 7 MS. KAREN JONES: I'm sorry. 8 COMMISSIONER SIDNEY LINDEN: You're 9 moving on -- 10 MS. KAREN JONES: yes. 11 COMMISSIONER SIDNEY LINDEN: -- from this 12 area? 13 MS. KAREN JONES: Yes. 14 COMMISSIONER SIDNEY LINDEN: Could we 15 take a break now? 16 MS. KAREN JONES: Surely. 17 COMMISSIONER SIDNEY LINDEN: You're going 18 to be continuing for some time -- 19 MS. KAREN JONES: Surely. 20 COMMISSIONER SIDNEY LINDEN: -- and I -- 21 MS. KAREN JONES: Yeah. 22 COMMISSIONER SIDNEY LINDEN: -- think we 23 could use a break now. 24 MS. KAREN JONES: Yeah. 25 COMMISSIONER SIDNEY LINDEN: Thank you


1 very much. 2 THE REGISTRAR: This Inquiry will recess 3 for fifteen (15) minutes. 4 5 --- Upon recessing at 3:17 p.m. 6 --- Upon resuming at 3:33 p.m. 7 8 THE REGISTRAR: This Inquiry is now 9 resumed. Please be seated. 10 11 CONTINUED BY MS. KAREN JONES: 12 Q: Dr. Marr, before the break I had 13 started wanting to ask you questions about the use of 14 language, life-threatening, and, as I understood it, your 15 evidence this morning and throughout the day has been 16 from the time that you first saw Mr. Cecil Bernard George 17 that his vital signs were stable throughout? 18 A: With the exception of his level of 19 consciousness. 20 Q: Right. And, you had told us that 21 when he first came to the Emergency Department there were 22 two (2) things that you had concerns about, one (1) was 23 his decreased level of consciousness and one (1) was his 24 complaints of abdominal pain? 25 A: Yes, they were the two (2)


1 priorities. 2 Q: Right, and those were two (2) things 3 that you would want to keep a close eye on as I 4 understand it, because if, in fact, he did have internal 5 injuries in his -- in his abdominal area, that could be a 6 serious problem? 7 A: Yes. 8 Q: And, if in fact, his level of 9 consciousness decreased so that he became more stuporous 10 or more confused or even comatose, that would be 11 something that would indicate that there was a serious 12 medical problem? 13 A: Yes. 14 Q: And as I understand from your 15 evidence, neither of those things happened? 16 A: That's correct. 17 Q: His level of consciousness increased 18 and he never -- and you did some investigation, including 19 the ultrasound of his abdomen, and he had no internal 20 injuries? 21 A: Yes. 22 Q: So, I take it when he first came to 23 the Emergency Department, although he appeared stable, 24 but for his decreased level of consciousness he was in 25 stable condition at that time?


1 A: Yes. 2 Q: And, his situation improved? 3 A: Yes. 4 Q: And, so in terms of him having life- 5 threatening injuries, in fact he didn't have any life- 6 threatening injuries? 7 It was something you would want to keep an 8 eye out for and you were always cognizant of the 9 possibility of, but in fact, he didn't have that? 10 A: That's correct. 11 Q: Okay. And, similarly, Ms. Vella put 12 to you this morning that Mr. Cecil Bernard George was 13 severely injured. 14 A: That he had a severe head injury -- 15 is that not the term? 16 Q: Okay. It was actually, 'severely 17 injured.' And, I wanted to ask you about the severe head 18 injury. 19 Is there an objective criteria or a 20 generally accepted way of classifying head injuries? 21 A: Yes. 22 Q: Okay. 23 A: You might refer to -- head injuries 24 are classified in may different ways, but a common way to 25 classify it would be by a Glasgow Coma Scale --


1 Q: Yes? 2 A: -- which describes basically the 3 response -- visual response, talking and motor activity-- 4 Q: Yes. 5 A: -- and it's a way of trying to 6 objectify the description of severity of head injury. 7 Q: Right. And, as I understand, the 8 Glasgow Coma Scale is scored out of fifteen (15)? 9 A: Yes. 10 Q: And, five (5) relates to level of 11 consciousness, whether someone's awake, alert and 12 oriented; that kind of thing? 13 A: Fifteen (15) would be -- the highest 14 score is good. 15 Q: Right. 16 A: Fifteen out of fifteen (15/15) is 17 perfectly alert and oriented and -- 18 Q: Right. 19 A: -- normal sensorium. 20 Q: Right. So, the pupils would be equal 21 and reactive; some would -- would be awake; they would be 22 oriented times three (3), that kind of thing? 23 A: Yeah. Actually, pupil assessment 24 isn't part of -- 25 Q: Okay.


1 A: -- the Glasgow Coma Scale. 2 Q: Okay. Maybe just so it's very clear 3 for everyone, how then, out of a score of fifteen (15), 4 are the points allocated? 5 A: Can I refer to the scale that I 6 actually have here? 7 Q: You surely can. And I believe that 8 in the ICU records -- 9 A: Yes. 10 Q: -- for Mr. Cecil Bernard George and 11 perhaps -- 12 A: I don't have those, I don't think. 13 Q: I'm sorry? 14 A: I don't think I have those, but -- 15 Q: Oh. 16 A: -- unless -- are they in here? 17 18 (BRIEF PAUSE) 19 20 Q: I'm not sure, Doctor, exactly what 21 you have in your book because my book is put together a 22 little bit differently. Do you -- do you have the chart 23 for Cecil Bernard George in your book? 24 A: I don't believe so. 25 Q: Okay.


1 (BRIEF PAUSE) 2 3 Q: Maybe what we can do, Dr. Marr, is 4 the entire document should be in -- on the computer. So 5 perhaps we can put one of the -- the neurological vital 6 sign flow sheets from the emergen -- from the ICU up on-- 7 A: Yes, if you wish. 8 Q: -- and -- and use it for -- for a 9 sort of a visual cue to walk through. 10 A: I don't know that it -- it displays 11 the Glasgow Coma Scale. 12 Q: Okay. Perhaps we can give it a try 13 and -- and you can let us -- 14 A: Okay. 15 Q: -- know if that's accurate. If we 16 look at Document Number 100047 and page 343 of that 17 document. 18 19 (BRIEF PAUSE) 20 21 Q: And, Dr. Marr, this is a little 22 awkward to turn around and I appreciate that, but what we 23 have up on the screen is an excerpt from Mr. Cecil 24 Bernard George's medical record and it's called the, 25 Neurological Vital Sign Flow Sheet, and it's dated the


1 7th day of the 9th month 1995. 2 And you'll see along the left-hand side of 3 the document, there is an area for LOC, which is level of 4 consciousness, and it sets out four (4) different 5 categories; -- 6 A: Yeah. 7 Q: -- alert, drowsy, stuporous or 8 comatose. And going down the page, it sets out the 9 pupils, talking about the left pupil, the right size and 10 their reaction. And I take it that means reaction to 11 light, that is whether they dilate -- 12 A: Yeah. 13 Q: -- and constrict in response to the 14 light level? And -- 15 A: Just down below is the Glasgow Coma 16 Scale. 17 Q: Okay. So if we go down we see, "Eyes 18 open." And there's a portion that says, "Spontaneously 19 to speech, to pain," and "none" and then, "Best verbal 20 response: Orientated, confused, inappropriate words, 21 incomprehensible sounds" and "none," and then, "Best 22 motor response." 23 And I take it that those -- 24 A: Hmm hmm. 25 Q: -- three (3) categories, eyes open --


1 A: Those top three (3) categories are 2 the three (3) categories that -- that are scored for a 3 Glasgow Coma Scale. 4 Q: Okay. 5 A: So the eyes open, he was in 6 emergency, on arrival he was opening his eyes at loud 7 verbal command, which is -- 8 Q: So speech. 9 A: -- equivalent to speech, so -- 10 Q: Okay. 11 A: -- he was -- they were charting him 12 as still only doing that in the ICU. I think that 13 fluctuated because -- 14 Q: Yes. 15 A: -- it would have said that he was 16 actually more spontaneously opening his eyes by the time 17 he left the emergency room. But he was in and out of 18 that, still, for the first few hours of being -- 19 Q: Okay. 20 A: -- in ICU there. 21 Q: Okay. 22 A: And so, so I -- 23 Q: And, sorry, just to be clear, if 24 someone is opening their eyes spontaneously, I see 25 there's four (4) boxes in that category, that would get


1 them a four (4) on the Glasgow Coma scale? 2 A: Yes. 3 Q: And if they had -- 4 A: Full score. 5 Q: -- had none, they would get a zero. 6 A: Yeah, so I took one (1) off for 7 that -- 8 Q: Okay. 9 A: For the responding only to speech -- 10 Q: Okay. 11 A: -- with the eyes initially. 12 Q: Okay. 13 A: And then his best verbal response, I 14 said he was confused, disoriented, which is just one (1) 15 off -- 16 Q: Okay. 17 A: -- there. And then he was -- 18 Q: And so on -- 19 A: -- soon -- 20 Q: I'm sorry, on the scale then, out of 21 the best -- 22 A: Yeah, four (4). 23 Q: -- verbal response is got -- 24 A: Four (4) out of five (5). 25 Q: He's got four (4) out of five (5) and


1 then the best motor response? 2 A: The best motor response, he was 3 pushing away noxious stimuli which is -- localizes pain-- 4 Q: Okay. 5 A: -- according to that. So he had a 6 score of twelve (12) out of fifteen (15) on arrival in 7 the emergency room. 8 Q: Okay. 9 A: And -- 10 Q: And you've told us that on terms of - 11 - of a way of categorizing head -- head injuries, that 12 one way that you can do that is using the Glasgow Coma 13 scale, and by the numbers or the scores that someone gets 14 when you assess them according to the Glasgow Coma scale. 15 And can you -- and -- and so, again, in 16 terms of the category, when you say a "severe head 17 injury," what -- what does that mean? 18 A: Well, the Glasgow Coma Scale is 19 intended to be an objective measure of severity of head 20 injury. It certainly has some fallibility and -- 21 Q: Yes. 22 A: -- inaccuracies and subjectivity to 23 it -- 24 Q: Yes. 25 A: -- but using the scale as we've


1 described it there and as illustrated there, a range of 2 three (3) to twelve (12) is considered a major head 3 injury. Thirteen (13) to fifteen (15) is considered 4 minor. 5 Q: Okay, and -- 6 A: So he just was in the major category 7 with a score of twelve (12). 8 Q: Okay, and I take it that the Glasgow 9 Coma scale sort of represents a snapshot in time -- 10 A: Oh, yeah. 11 Q: -- that it represents what someone is 12 -- what their number is -- what -- what their score is at 13 a particular time? 14 A: That's right and it's useful to 15 follow it in terms of clinical progression. 16 Q: Yes. 17 A: And had he had a Glasgow Coma scale 18 half an hour earlier en route in the ambulance, he might 19 have scored less. 20 Q: Yes. 21 A: And certainly when he wasn't opening 22 his eyes with stimulus, as the attendants described, he 23 would have had a lower score. 24 Q: Yes. 25 A: But at the time that I saw him, he


1 was a twelve (12) out of fifteen (15). 2 Q: Okay. And you've told us that by the 3 end of the period of time that Mr. Cecil Bernard George 4 was in the emergency department, that he was more awake 5 and that he was more lucid, and I take it in that period 6 of time he was in the emergency department then, his 7 Glasgow Coma scale would have gone, for example, from a 8 twelve (12) to a higher number? 9 A: Yeah, I -- he might -- I thought he 10 was a fifteen (15) as he left the emergency room, but 11 that's actually not the observations here because they're 12 still taking a few points off at times. 13 But he quickly did become a consistent 14 fifteen (15) which is probably quite normal in the 15 progression -- 16 Q: Yes. 17 A: -- fluctuating progression of his 18 condition. 19 Q: Yes. So by the end of the period of 20 time that Mr. Cecil Bernard George was in the emergency 21 department, if you were scoring him at a fifteen (15) on 22 the Glasgow Coma scale, you no longer then would have 23 assessed him as having a severe head injury; is that 24 right? 25 A: I don't know if you can say that. I


1 think that if -- 2 Q: Okay. 3 A: -- he ever scored that sort of 4 severity that was a valid observation that -- 5 Q: Oh -- 6 A: -- the circumstances had been 7 sufficient to cause that loss of function. 8 Q: Yes. 9 A: It was obviously a good prognosis 10 that he was recovering from that, but he had been there-- 11 Q: Yes. 12 A: And certainly he had some post- 13 concussive symptomotology for some period of time, and 14 that's not a good sign in terms of potential long term 15 effects of brain injury. 16 Q: Okay, now -- 17 A: We're talking here of being safe and 18 recovering from his -- 19 Q: Sure. 20 A: -- injury and not going into a deep 21 comatose state with an inter-cerebral bleed. We're not 22 saying much about prognosis and the chance that he might 23 have some ongoing deficient as a result of the injuries. 24 Q: Sure. And I take it that between the 25 period of time that Mr. Cecil Bernard George left the


1 emergency department with the Glasgow Coma scale of 2 fifteen (15) and the time that you discharged him from 3 the hospital, two (2) days later, I take it that you 4 would have been satisfied that he didn't have any of 5 those possible conditions that you've just discussed; 6 that he didn't have an inter-cranial bleed -- 7 A: Yes, I -- I -- 8 Q: -- that he didn't have brain damage, 9 for example? 10 A: I couldn't -- I couldn't rule out 11 some subtle brain damage, I could say that he was not 12 likely to go the course of further acute deterioration. 13 The longer term recovery and -- and assessment of mental 14 function would -- would be necessary to be able to assess 15 whether he made a complete 100 percent recovery. 16 Q: Right. 17 A: Which I did not have a chance to do. 18 Q: Right. But I take it -- 19 A: It might not be appropriate to do it 20 until several weeks later. 21 Q: Sure, but I take it that you wouldn't 22 have discharged him if you had any concern that there was 23 a possibility that he had some kind of an acute brain 24 injury that could cause his condition to deteriorate? 25 A: Oh, yes, I didn't anticipate he would


1 -- he would deteriorate, but I -- 2 Q: Right. 3 A: -- I can't say that he had no brain 4 injury, he may well have had a subtle brain injury that 5 was sequela still -- 6 Q: Right. 7 A: -- but not life-threatening ones. 8 Q: Sure. He might and he might not 9 have? 10 A: As anybody whose had a significant 11 concussion. 12 Q: Right. 13 A: And, it's difficult sometimes to know 14 until many weeks have passed. 15 Q: Sure. And lastly, Dr. Marr, I just 16 wanted to ask you a few questions about Mr. Anthony 17 George and you've told us that when he came into the 18 Emergency Department that you followed the normal 19 protocol or the normal processes for assessing someone. 20 You checked for his airway and his 21 breathing and circulation and I understand from your 22 description that at that point in time there were no 23 visible signs of life at all. 24 A: Correct. 25 Q: Okay. And, I understand from looking


1 at the records that in order to protect his airway and to 2 help give him oxygen that you intubated him at that time? 3 A: Correct. 4 Q: And, just -- perhaps you can just 5 tell us what "intubation" means. We've been using that 6 language a lot and I'm not sure it's been well described. 7 A: Intubation means inserting a rigid 8 tube -- that's a curved tube -- through the airway, 9 through the larynx and into the trachea. There's 10 actually a cuff on it that you inflate as well to keep it 11 in position and to make it air tight and then you can 12 attach a positive pressure ventilation bag to that tube 13 and then oxygenate the lungs with control of that airway. 14 Q: And, that bag is also called the 15 Laerdal Bag or an Ambu. Bag? 16 A: Ambu. bag let's call it, yeah. 17 Q: Different people use -- 18 A: Yeah. 19 Q: And, what that allows you to do 20 essentially is to force, under some controlled 21 conditions, air into the lungs? 22 A: Correct. 23 Q: And then, in terms of circulation, 24 you've talked a little bit about chest compressions and I 25 take it that one -- you or someone there was doing CPR on


1 Mr. George, so pressing down on his chest regularly? 2 A: Yes. 3 Q: And the purpose of that would be to 4 compress the heart and to, in fact, sort of squeeze blood 5 out of it so that there's some circulating blood? 6 A: Correct. 7 Q: Okay. And, you've also told us and 8 we saw earlier when we saw the telemetry strip or the 9 electrocardiogram strip, that those chest compressions, 10 that is that squeezing down on someone's chest can cause 11 some variations in the line? 12 A: Correct. 13 Q: And I take it that that's another 14 example of artifact -- 15 A: That is an artifact. 16 Q: -- that you can sometimes see because 17 it doesn't truly represent electrical activity at all in 18 the heart? 19 A: That's right. 20 Q: Okay. And you've also talked about 21 starting IV's and that was to give him fluid? 22 A: Yes. 23 Q: And that would -- so that there would 24 be more circulating volume in his blood system? 25 A: Yes.


1 Q: Okay. And, one (1) of the things I 2 understand that would sometimes happen in a resuscitation 3 like that, is that you might consider giving cardiotonic 4 drugs like adrenalin or epinephrine? 5 A: Yes. 6 Q: And, those are drugs that would 7 stimulate the heart and help it to start beating? 8 A: Yes. 9 Q: And, I take it that you didn't do it 10 in this case because there was essentially nothing to 11 stimulate or start? 12 A: I think that would be a fair 13 description of the situation. 14 Q: And also, on some occasions one would 15 defibrillate the heart and that would mean applying 16 electrical current to it to try get it starting to beat 17 again? 18 A: Hmm hmm. 19 Q: And I take it that you wouldn't have 20 done that in this case because, again, in essence, there 21 was nothing that would start that beating in your view? 22 A: That's correct. And indeed, as -- as 23 you may know, you -- you can't defibrillate asystole. 24 Q: Right. 25 A: You don't, it's not indicated.


1 Q: And asystole meaning -- 2 A: Asystole, when there is no flat -- 3 when there is a flat line and no electrical activity. 4 Defibrillation is useful when there is a fibrillatory 5 pattern -- 6 Q: Some electrical activity. 7 A: Some electrical activity. 8 Q: Even if it's chaotic electrical 9 activity? 10 A: Exactly, yeah. 11 Q: Okay. And you've talked a little bit 12 about after Mr. George was intubated, listening to his 13 chest and not hearing any air entry on his left side? 14 A: Yes. 15 Q: And I take it that there could have 16 been a few different reasons for that, and you gave us 17 two (2), one was that a pneumothorax and one was a 18 haemothorax. 19 And just to be clear about what that 20 language means, a pneumothorax I take it would mean air 21 in the chest cavity that would compress the lung so it 22 couldn't inflate with air? 23 A: Yes. 24 Q: And a haemothorax similarly would be 25 blood in the chest cavity that would collapse the lung so


1 it wouldn't fill with air? 2 A: Yes. 3 Q: And I take it in some circumstances 4 you might consider putting in a chest tube to either take 5 away the air or the blood, and you didn't do that in this 6 case again because Mr. George was dead? 7 A: Yes. 8 Q: Okay. And you were asked a little 9 bit about the location of the bullet wound. And there 10 was some language used, and we may hear it down the road 11 as well, about the injury being in the clavicular or 12 supra-clavicular area. 13 And I take it that that refers to the 14 collar bone? 15 A: Yes. 16 Q: Which is the bone that joins the 17 shoulder to the sternum in the centre of the chest? 18 A: Yes. 19 Q: Yes. And you can feel that if you 20 press along the top of your shoulder? 21 A: Yes. 22 Q: And I take it from your description 23 that the bullet hole was above the clavicle, in your 24 recollection? 25 A: Yeah, that's -- that's my memory of


1 it. 2 Q: Okay. And so, in fact, it would be 3 quite close to the neck area; is that right? 4 A: I remember it being about in the 5 middle of the clavicle. 6 Q: Okay. 7 A: Not -- not so close that -- I would 8 say about there. 9 Q: Okay. So near or at the top of the 10 shoulder as opposed to further -- lower down on the 11 chest? 12 A: Yes. 13 Q: So if you looked at Mr. Dudley 14 George's chest, there would have been no injury in his 15 chest area itself? 16 A: Yes, you might not see it if you're 17 looking in that -- 18 Q: Right. 19 A: -- straight on. 20 Q: Right. 21 22 (BRIEF PAUSE) 23 24 MS. KAREN JONES: Mr. Commissioner, I'm 25 sorry, if I just take one (1) second, I can look at my


1 notes and make sure that I'm all sorted out. 2 COMMISSIONER SIDNEY LINDEN: Thank you. 3 MS. KAREN JONES: I'm sorry to keep you 4 waiting. 5 COMMISSIONER SIDNEY LINDEN: You're 6 almost exactly at an hour, so you've done just fine. 7 MS. KAREN JONES: Well, I presume it has 8 to be close -- 9 COMMISSIONER SIDNEY LINDEN: You've done 10 just fine. 11 MS. KAREN JONES: Okay. And I think 12 those are all my questions. Thank you very much. 13 THE WITNESS: Thank you. 14 COMMISSIONER SIDNEY LINDEN: Thank you 15 very much, Ms. Jones. Mr. O'Marra...? 16 17 (BRIEF PAUSE) 18 19 CROSS-EXAMINATION BY MR. AL O'MARRA: 20 Q: Thank you, Commissioner. Good 21 afternoon, Dr. Marr. My name is -- 22 A: Hmm hmm. 23 Q: -- Al O'Marra and I appear on behalf 24 of the Chief Coroner. I have three (3) areas that I'd 25 like to ask you questions on, and I hope to be no more


1 than about five (5) with -- with each. 2 For sure, as -- as you know, doctor, the 3 purpose of, in part, of an Inquiry is of course to ensure 4 that the record accurately reflects the events. As one 5 (1) Counsel said, that if not -- evidence not be 6 minimized, the circumstances not be minimized and -- and 7 not be overstated as -- as well. 8 It also assists in dispelling unfounded 9 rumours and I'd -- I'd like to firstly thank you for your 10 evidence today because I think you've assisted in -- in 11 great part in achieving that around one (1) aspect. 12 You may have been somewhat surprised to 13 have evidence -- or questions asked of you about Mr. 14 Cecil Bernard George and -- and whether his heart had 15 stopped and started up spontaneously, but I should advise 16 that during the course of the Inquiry it was reported 17 publicly that George suffered twenty-eight (28) blunt 18 force trauma wounds to his face. 19 Now, you've -- you've clarified that, it 20 was twenty-eight (28) blunt force trauma wounds to his 21 body, front and back, head-to-toe, in fact; also that to 22 the chest and groin and his heart stopped temporarily 23 after the beating. 24 I take it from all that you've said and 25 your involvement with Mr. Cecil Bernard George, you saw


1 no evidence of his heart having stopped temporarily? 2 A: That's correct. 3 Q: There was, however, concerns based on 4 his presentation that he was seriously injured because of 5 head injuries; a concern about a closed head injury and 6 possible breathing -- bleeding? 7 A: Correct. 8 Q: Which would have had significant 9 repercussions -- 10 A: Yes. 11 Q: -- if that, in fact, had happened? 12 A: Yes. 13 Q: What kind of repercussions might 14 there have been had he that kind of bleed? 15 A: Well, if it had continued -- if he 16 had a bleed that was continuing he might have certainly 17 become more comatose and required surgery to stem that 18 bleeding or relieve the pressure. 19 Q: Okay. And, by way of dealing with 20 that, at least in terms of the initial presentation with 21 Mr. George, I take it it was to observe and to see how he 22 progressed? 23 A: And, we felt that was a safe route to 24 go given he was already recovering his level of 25 consciousness in the time period in the Emergency Room


1 during assessment. 2 Q: And, you admitted him for a further 3 period of observation to be assured that -- that there 4 was no -- or at least there is a -- 5 A: No -- no latent neurological 6 deterioration, yes. 7 Q: Thank you. And -- and, the -- the 8 second major area of concern was because of his 9 complaints of abdomen pain and tenderness, that he was 10 perhaps bleeding internally? 11 A: Yes. 12 Q: And, in terms of dealing with that, 13 again a process of -- of dealing with it would be 14 observation. You also indicated that you had set up IV 15 or ordered setting up of IV? 16 A: Yes. 17 Q: Okay. Now, was that -- was that 18 actually administered at any point or just set up? 19 A: Oh, I'm sure he had an IV running -- 20 Q: Running. 21 A: -- but just at maintenance level, not 22 fast level of fluid infusion. 23 Q: Okay. So, that it would be in -- in 24 situ if -- if there was a deterioration -- 25 A: If it was needed.


1 Q: -- then it could be infused -- 2 A: Yes. 3 Q: -- more fast -- or fast -- faster? 4 A: Yes. 5 Q: Okay. And then, based on the 6 period of -- of observation, you were satisfied in terms 7 of those two (2) areas where there could have been 8 bleeding that that, in fact, was not occurring? 9 A: Yes. 10 Q: But that's not to say that he didn't 11 have multiple soft tissue injuries as you've diagrammed 12 and -- and referred to -- 13 A: Yes. 14 Q: -- in -- in your chart? And, it's 15 consistent, I take it, with him having received a 16 significant and serious beating? 17 A: Yes. 18 Q: And -- and, no doubt a very painful 19 beating? He complained of -- of that? 20 A: Yes, he certainly was complaining of 21 pain. 22 Q: And -- and, as well, just so it's 23 clear, while they were life-threatening injuries, or at 24 least, concerns about life-threatening injuries, as a 25 result of his hospitalization and treatment, they were


1 not life-threatening injuries? 2 A: That would be correct. 3 Q: Now, the -- the second area relates 4 to Mr. Anthony "Dudley" George and you've indicated that 5 you had the opportunity to see Dr. Michael Shkrum's 6 postmortem examination? 7 A: Yes. 8 Q: And, it indicated that, I take it 9 consistent with -- with your concerns that there were 10 significant lacerations to major vessels as a result of 11 the -- the bullet -- 12 A: Yeah. 13 Q: -- and significant blood loss? And - 14 - and, I take it as well, based on -- on the types of 15 injuries, a rapid blood loss? 16 A: Yes. 17 Q: In his report as well, we'll hear 18 from Dr. Shkrum, he's scheduled to appear on -- on 19 Thursday -- 20 A: Hmm hmm. 21 Q: -- but I just wanted to ask you about 22 a reference to Dr. Shkrum having found 1,000 cc's of 23 blood liquid in the -- in the chest or the thoracic 24 cavity. 25 Can you just comment on that volume of --


1 of blood in terms of the mass volume of blood that 2 individuals would have? 3 4 (BRIEF PAUSE) 5 6 A: It's -- in some ways doesn't seem to 7 be a huge amount to have led to his death from 8 hypovolemia, but I don't know how accurate that 9 measurement is and -- 10 Q: Right. 11 A: -- I think he'd have to comment on 12 that. 13 Q: Okay, thank you. 14 A: But I think he is -- the thrust of 15 his report was that that was the cause. It was a 16 hypovolemic death. 17 Q: Sanguation (phonetic), yeah. 18 In terms of your observations of Mr. 19 George he has, as you testified, no vital signs; no 20 pulse, no heart sounds, no respiratory effort being 21 displayed. 22 I noticed in some of the many, I guess, 23 interviews as -- as well as reports, that there is 24 reference to him being quite cool to the touch in his 25 extremities; is that --


1 A: Yes. 2 Q: And that his pupils were fixed and 3 dilated and -- and non-reactive? 4 A: Yes. 5 Q: Okay. And as well, you've talked 6 about the ECG strips and no electrical heart activity. 7 Based on all of your observations and 8 involvement with Mr. George, is it your view that on his 9 presentation in the trauma when you -- you first saw him, 10 that he was dead on arrival? 11 A: Yes. 12 Q: You've also indicated that based on 13 all of your observations, that the range and time in 14 which his heart would have stopped, I take it prior to 15 discerning whether there's any electrical activity, and 16 consistent with the fixed and dilated, non-reactive 17 pupils, anywhere from five (5) to fifteen (15) minutes 18 and perhaps longer, before his arrival to the hospital? 19 A: Yes. 20 Q: One other observation, I anticipate 21 that we will hear from a nurse that she made 22 observation's of Mr. George's skin tone to be mottling; 23 you understand that -- that term, doctor? 24 A: Yes. 25 Q: What does that indicate?


1 A: Lack of circulation to that part of 2 the body. 3 Q: Okay. So, the mottling to the 4 extremities as well as down the back of the neck and the 5 back, and a indication of pooling of blood? 6 A: Yes, I think the Coroner might 7 comment on that in terms of what it might indicate as 8 to -- 9 Q: All right. 10 A: -- time of death, but I'm not 11 familiar enough with it to give you a time. 12 Q: Right. But just -- I just wanted to 13 know whether you made those observations in terms of skin 14 tone and the mottling and -- and -- and down the back of 15 the neck and -- 16 A: And -- 17 Q: -- the back? 18 A: I didn't document them, so I can't 19 say I have clear memory of that. 20 Q: All right. Thank you, doctor. Those 21 -- oh, just -- the third area, and this deals with the 22 contingency plan. 23 You had indicated that you only received 24 notice of incoming patients a very short time before 25 their actual arrival. You've had no personal awareness


1 of the events going on at Ipperwash? 2 A: That's correct. 3 Q: Now, I understand you're -- well, 4 you're not in emergency now, you -- you continue as chief 5 of medicine at the -- 6 A: No, I'm not actually now, no. 7 Q: No? Oh, I'm sorry, I thought -- I 8 understood from your CV, from '95 on that that was 9 your -- 10 A: No, that was -- that was written in 11 '95 and not updated since '95. 12 Q: Oh, all right. My misunderstanding-- 13 A: It's a rotating function, usually, 14 among staff, so. 15 Q: Okay. I just wondered whether in 16 your role as a physician, then, and -- and you still have 17 a relationship with the Strathroy Middlesex -- 18 A: Yes, I still -- 19 Q: -- Hospital? 20 A: -- have privileges there, yes. 21 Q: Okay. Are you aware of emergency 22 planning that involves the hospital as well as municipal 23 services? 24 A: Yeah, we do have a -- I think it's 25 called a disaster plan.


1 Q: Disaster plan. And it works in a 2 co-ordinated fashion to -- to make sure that you can 3 respond and appropriately to a disaster? 4 A: Yes. 5 Q: And is there any reason from your 6 perspective as to why the police should not be involved 7 in that, if they're engaged in sort of public order 8 events where they -- 9 A: Oh, I think -- I think they probably 10 would be. 11 Q: They would be. 12 A: I think it's a community plan that 13 involves police and ambulance as well. 14 Q: Right. And, so that they are engaged 15 in a -- and perhaps you're not familiar with the term, 16 but a -- a public order event such as we had at 17 Ipperwash, that that's something that could be part of 18 that -- that planning process? 19 A: Yes, I don't know whether it is. 20 Q: Okay. Are you engaged in any way in 21 -- in that process with the -- with the hospital and... 22 A: I'm not, no. 23 Q: No. Okay. Thank you, Doctor, those 24 are my questions. 25 COMMISSIONER SIDNEY LINDEN: Thank you


1 very much, Mr. O'Marra. 2 Ms. Vella...? 3 4 RE-EXAMINATION BY MS. SUSAN VELLA: 5 Q: A couple of questions on re- 6 examination for clarification, Doctor. 7 Going back to the x-ray of Nicholus 8 Cottrelle for a moment and the -- the notation that there 9 was a metal density. 10 A: Yes. 11 Q: Now, does mental -- is a metal 12 density only consistent with the existence of a metal 13 object? 14 A: I don't know, the radiologist 15 would have to tell you whether that could have been 16 glass. 17 Q: All right. But, my question was, 18 could -- in -- in the general terms, can glass have a 19 metal density that would be picked up? 20 A: I don't know. 21 Q: Okay. Thank you. In terms of the -- 22 the location of that metal density as indicated in the x- 23 ray report, was the location consistent with a possible - 24 - with a possible entry level being the circular wound 25 that you identified in the photograph?


1 A: Yes, I've -- I've looked at that 2 written report since this morning when I expressed some 3 confusion around the location, but realized that because 4 it was just a single view of the abdomen when it's 5 portable supine, it's taken with the patient lying there 6 and the x-ray machine looks down, they don't know which 7 level that metal density sat at; it could have been at 8 the front or it could have been at the back from one (1) 9 view like that. 10 You'd have to take a different view, in 11 particular a lateral view, to be able to say was it at 12 the front or at the back, because it looks exactly the 13 same on one (1) single view. 14 I was reading it as if he'd been quite 15 clear in the report that it was the front, but we really 16 can't say that from one (1) view. 17 Q: Right. 18 A: So, it could have been at the back. 19 Q: All right. So, you can't rule it in 20 or out? 21 A: No. 22 Q: Is that fair? 23 A: Yes. 24 Q: All right. Thank you. 25 Now, I just want to go back to the -- the


1 diagram or the -- the scoring that Ms. Jones took you to 2 and this is, for the record, the neurological vital sign 3 flow sheet at Inquiry Document 100047 Front Number 4 0000344 and I just want to ensure that we understand how 5 it is -- how this -- how this works, if you will, and how 6 it's scored. 7 And, I was noticing -- just excuse me for 8 a minute -- 9 10 (BRIEF PAUSE) 11 12 Q: Now, I'm noticing that there appear 13 to be different timed entries, which would -- would this 14 represent the time -- the times at which the test was 15 filled out for each column? 16 A: Yeah, they would. Yeah, yeah, it 17 looks like they're quite early on, actually. The -- 18 Q: Okay, and it does look like -- 19 A: -- 00:30:55 -- 20 Q: Yeah, the first one looks like 00:30, 21 and then 00:35, 00:45, 00:50 -- 22 A: Okay. The time -- 23 Q: -- and then the time starts to 24 increase in increments. 25 A: Okay, hmm hmm.


1 Q: And, it looks like it goes to, at the 2 end there; is that 4:30 and 5:30? 3 A: 04:30, 05:30, yeah. 4 Q: All right. And, so I just wanted to 5 know when it was that according to this test, when -- 6 when did it start, I guess, being administered relative 7 to Mr. George? 8 A: It would look from that as though 9 some -- as though the nurse keeping that record was doing 10 it in the Emergency Room. 11 Q: All right. 12 A: I -- I assumed when you first put 13 that up, because I really haven't looked at it closely 14 before, that it was an ICU flow sheet and would have 15 started when he was transferred to ICU, but he -- he 16 didn't go to ICU until later; more like I would have 17 thought, two o'clock. 18 I'm not sure of the time of transfer, but 19 it was certainly -- he was still in the Emergency Room I 20 would have thought at those earlier times, I'm sure. 21 Q: Yes, I believe -- 22 A: So, that was just around -- 23 Q: -- he was admitted around 2:00 in the 24 morning to the -- 25 A: It was that the same as Nicholus


1 Cottrelle was, yeah. 2 Q: All right. And so, 00:30, would that 3 mean essentially 12:30 a.m. September 7th? 4 A: Yes, that would be -- yes, that was 5 when we were going back to look at him. 6 Q: And, that's the -- the first -- 7 A: The second -- 8 Q: -- that's when the test was commenced 9 if -- 10 A: Yeah. 11 Q: -- I can put it that way? All 12 right -- 13 A: That is consistent then with the 14 course that I described, by the time he was around 02:00 15 hundred, he's now getting up into -- there seems to be 16 some significance to where she's putting the ticks on 17 that line, that as she gets further into the box he's 18 more alert. 19 I'm not sure if it's really intended that 20 way. 21 Q: All right. And I suppose we'll 22 have -- 23 A: But it seems that's the trend. 24 Q: -- we'll have to ask the nurse who 25 recorded these for --


1 A: Yes. 2 Q: -- for what the location of the check 3 marks mean. Okay and let me just go down to the part 4 that was the -- is it Glasgow Coma Score. 5 6 (BRIEF PAUSE) 7 8 Q: And I believe now we have the three 9 (3) categories that were used by you to -- to score the 10 Glasgow Coma -- 11 A: Yes. 12 Q: -- test? 13 A: Yes. 14 Q: All right. And just to help us 15 understand, starting with the first column which would 16 have been under the 12:30 a.m. -- 17 A: Yes. 18 Q: -- just interpret that for me, 19 please. 20 A: With respect to the eyes, he was -- 21 he was not opening his eyes spontaneously. He was only 22 responding to verbal stimulus to -- talking to him. 23 And the next, the verbal response, they're 24 describing inappropriate words then, I think I would have 25 scored him as confused under the verbal response, but the


1 nurse documented inappropriate words, a subjective 2 distinction there. 3 Best motor response, localized pain; is 4 that with any sort of painful stimulus he would move the 5 right part of his body to avoid it. 6 But, he wasn't following commands clearly, 7 initially. 8 Q: All right. And just based on those - 9 - that single column, that -- at that time slot -- 10 A: That gives him a Glasgow Coma Scale 11 of twelve (12). 12 Q: That gives a Glasgow Coma -- 13 A: A score of twelve (12). 14 Q: -- Scale of twelve (12), and can you 15 just -- is because it's fifteen (15) minus the three (3) 16 checkmarks? 17 A: Yeah, the -- the eyes open is a total 18 score of -- of -- it's out of four (4). The next, 19 talking is out of five (5) and the motor's out of six 20 (6), so -- which gives you a total potential of fifteen 21 (15). 22 So, if you take one (1) off the eyes 23 score, one (1) off the verbal score, basically we took 24 one (1) of each. 25 Q: Right.


1 A: He was one (1) off the top category 2 for each of those scores which gives him three (3) off 3 the total of fifteen (15), gives him twelve (12). 4 Q: All right. And so using that formula 5 then, as we go along, we can see that -- 6 A: Pretty quickly he's scoring better. 7 8 (BRIEF PAUSE) 9 10 Q: Can you show me where it is he is 11 scoring better? 12 A: Well, eyes; he's in the top score of 13 eyes by the fourth -- by the third column. But, then he 14 goes down again and then he's back up consistently by the 15 one (1), two (2), three (3), four (4), five (5) squares 16 over under eyes, whatever that time is, I can't see. 17 And then he's a top score, he's oriented 18 under verbal response really from the next time it was 19 measured although I don't know if she means by having the 20 tick further down that he wasn't quite fully oriented and 21 only when the tick's right in the box does she consider 22 he's completely oriented. 23 But, certainly by the fifth square, she's 24 got him right properly oriented. And by best motor 25 response, she's got him responding appropriately by the


1 third box. 2 Q: All right. And I take it from your 3 comments that -- that you did not actually administer 4 this test? 5 A: I'm not the one that filled out this 6 chart, no. 7 Q: All right. So, this is a nurse who 8 has filled out, has administered the test; is that fair? 9 A: Yes. 10 Q: All right, and what you're doing 11 right now is you're interpreting the test that she 12 administered for us? 13 A: Yes. 14 Q: And hence, when you say you would 15 have scored some things differently -- 16 A: Yes. 17 Q: -- you're saying had you administered 18 the test -- 19 A: Well, I did. I described to you that 20 I gave him a score of twelve (12) from the observations 21 that I recorded on my initial assessment. And I said his 22 best verbal response was confused, rather than 23 inappropriate words, that's the only difference between 24 my assessment and the nurse's on that first assessment. 25 So, she would have had actually given a


1 total score of eleven (11), I think, rather than twelve 2 (12). 3 Q: Okay. So, just so I'm clear, you did 4 administer this test, but that's not the results that 5 you -- 6 A: No. 7 Q: -- actually recorded. 8 A: No. 9 Q: Thank you. 10 A: In fact, I think you probably won't 11 find on my record any reference to the test, but I'm 12 looking back at the words that I described, and they fit 13 those criteria. 14 Q: Okay. And so these are the clinical 15 observations that you made at the time? 16 A: Yes. 17 Q: And is fair to say that in the course 18 of making your clinical observations you directed your 19 mind to -- to being able to assess the severity of the 20 head trauma under the Glasgow Coma Scale? 21 A: Yes. 22 Q: All right. Thank you. I'd like to 23 make this document the next exhibit, please. 24 COMMISSIONER SIDNEY LINDEN: I was just 25 going to ask you what number is it?


1 THE REGISTRAR: P-368. 2 COMMISSIONER SIDNEY LINDEN: 363? 3 THE REGISTRAR: Eight (8). 4 COMMISSIONER SIDNEY LINDEN: Sorry, 368. 5 6 --- EXHIBIT NO. P-368: Document 1000047 neurological 7 vital sign flow sheet of 8 Cecil Bernard George 9 September 07/'95 starting at 10 00:30 hours 11 12 CONTINUED BY MS. SUSAN VELLA: 13 Q: Now, you also indicated in response 14 to a question from Ms. Jones that he exhibited, Mr. Cecil 15 Bernard George of course, exhibited post-depressive 16 symptomology after -- after he was transported to the 17 ICU; did I hear that correctly? 18 A: Post-concussive syndrome. 19 Q: Perhaps that's what you said. Is 20 that -- 21 A: Yes. 22 Q: All right. And can you provide us 23 with the -- the objective indicators or criteria that you 24 observed which led you to that conclusion? 25 A: Well, he was still, I believe,


1 described a headache and some dizziness. 2 3 (BRIEF PAUSE) 4 5 A: On my progress note of September the 6 8th, which was the day that he was discharged, he -- I 7 described that he had a mild headache and -- but no 8 significant dizziness. So the headache was the only 9 feature I could document as being potentially still a 10 result of the concussion. 11 Q: All right. And I take it that when 12 he left, when he was discharged, you no longer diagnosed 13 him as being in -- in any acute distress, clearly, but 14 that didn't rule out the fact that he had had, on 15 admission, a severe head trauma? 16 A: Well, yes. A severe head injury, as 17 defined by that Glasgow Coma Scale, is someone who has 18 had a significant period of loss of consciousness and 19 those features that we've just gone through. And there 20 are subtle long-term sequelae of those sorts of injuries 21 for some people, certainly not for everybody. Some 22 people make a complete recovery from such a concussion, 23 but they're not trivial injuries. 24 But we were confident at that time that he 25 was not likely to have any significant neurological


1 decline, acutely. Having observed him for the time that 2 we did and following the course that he did, the chance 3 of a rapid decline was very -- was minimal at that point. 4 So it was safe to be discharged, he didn't need further 5 hospital care or observation. 6 Q: And you had no further contact with 7 Mr. Cecil Bernard George in -- in a medical capacity? 8 A: No. 9 Q: Thank you. And when -- when Dudley 10 George was admitted to the trauma unit, did you detect 11 any bloodstain on his shirt? 12 A: I don't remember seeing a lot of 13 blood, externally. 14 Q: All right. 15 A: But I -- I don't have a clear memory 16 of -- of his clothing. 17 Q: Fair enough. Doctor, that completes 18 my re-examination. I wish to thank you on behalf of the 19 Commission for appearing and giving your testimony. We - 20 - we very much appreciate your taking time out of your 21 busy practice to -- to share that evidence with us. 22 A: Thank you. 23 COMMISSIONER SIDNEY LINDEN: Thank you 24 very much, Doctor. 25 THE WITNESS: Thank you.


1 (WITNESS STANDS DOWN) 2 3 COMMISSIONER SIDNEY LINDEN: Ordinarily 4 we might break at 4:30 but I understand that we want to 5 try to get the Evidence In-Chief of Dr. Saettler. 6 MS. SUSAN VELLA: Yes, Commissioner. 7 Our -- our difficulty is that Dr. Saettler has to be in 8 surgery tomorrow afternoon in a different city. So we 9 are committed to having her take the stand, if possible, 10 and complete her evidence her evidence by noon or so 11 tomorrow. 12 COMMISSIONER SIDNEY LINDEN: Or else we 13 would have to break it up. 14 MS. SUSAN VELLA: Or else we would have 15 to break it up. 16 COMMISSIONER SIDNEY LINDEN: We'll try to 17 get her Evidence-In-Chief. Mr. Worme assures me that 18 it's possible to get it in -- 19 MS. SUSAN VELLA: Thank you. 20 COMMISSIONER SIDNEY LINDEN: -- this 21 afternoon. 22 MR. DONALD WORME: I remain optimistic, 23 Commissioner. 24 COMMISSIONER SIDNEY LINDEN: Very much. 25


1 (BRIEF PAUSE) 2 3 COMMISSIONER SIDNEY LINDEN: Thank you 4 very much. 5 6 (BRIEF PAUSE) 7 8 MR. DONALD WORME: Dr. Saettler will 9 swear. 10 DR. ELIZABETH SAETTLER: Do I need to 11 stand? 12 THE REGISTRAR: No, you don't. 13 DR. ELIZABETH SAETTLER: No. 14 15 ELIZABETH SAETTLER, Sworn 16 17 EXAMINATION-IN-CHIEF BY MR. DONALD WORME: 18 Q: Dr. Saettler, thank you for making 19 yourself available to attend here and provide us with 20 your testimony. 21 I want to thank you, as well, for 22 providing us with a copy of your curriculum vitae. I 23 want to perhaps, Commissioner, if I might file this as 24 the first exhibit and you will find that, sir, at Tab 18 25 of the document brief in front of you.


1 THE REGISTRAR: P-369, your Honour. 2 COMMISSIONER SIDNEY LINDEN: 369. 3 4 --- EXHIBIT NO. P-369: Curriculum vitae of Dr. 5 Elizabeth Saettler 6 7 CONTINUED BY MR. DONALD WORME: 8 Q: And if I may, Dr. Saettler, I just 9 want to briefly review your curriculum vitae with you. 10 By way of your undergraduate education, you had studied 11 at the University of Western Ontario, obtaining a 12 Bachelor of Science, I take it, in Physics in 1981? 13 A: No, it was just a straight MD. I did 14 two (2) years of physics prior to medicine, but I don't 15 have an undergraduate degree. 16 Q: And you obtained your MD, then, from 17 the University of Western Ontario in 1985? 18 A: Hmm hmm. 19 Q: Following that, you completed your 20 rotating internship at Dalhousie University in Halifax, 21 completing that in 1986? 22 A: That's correct. 23 Q: You had then completed your general 24 surgical residency at Dalhousie University? 25 A: Also correct, in 1990.


1 Q: 1990. In 1996 to '98 you held a 2 Fellowship in General Surgical Oncology at the University 3 of Calgary? 4 A: That's correct, that was following my 5 time in Strathroy. 6 Q: Okay, and in 1999 you completed a 7 qualitative research methods course at McMaster 8 University in Hamilton? 9 A: Correct. 10 Q: Just with respect to that last 11 credential, is there anything about that, that is 12 particularly relevant to what it is that you would tell 13 us about here? 14 A: I can only sort of explain why I took 15 a single course as a post-graduate education at McMaster 16 which had to do with the fact that my husband was then 17 completing his Master's degree in health research 18 methodology and I was working as a surgical oncologist at 19 -- at the Henderson Hospital in Cancer Care, Ontario, at 20 that time. 21 It was a -- it was a useful course in that 22 it exposes one to more of aspects of the social sciences 23 than I was accustomed to in my medical training. 24 So, it was more focussed on psychology, 25 sociology, that -- literature, than I had previously had


1 experience with. 2 Q: And thank you for that, doctor. 3 Following your surgical residency in Dalhousie, you were 4 then -- took employment as a general surgeon at the 5 Canadian Forces Hospital in Halifax? 6 A: That's correct, hmm hmm. 7 Q: You went directly, I take it, from -- 8 A: More or less. I didn't have a job 9 lined up when I finished my residency training. And at 10 that time, we finished in the summer and sat our exams in 11 November. 12 And that was at the time of the Gulf war 13 and the base in -- at Strathcona was requiring support 14 with general surgeon -- with a general surgery because 15 they had sent men to the Gulf. So they hired me for a 16 temporary position and then they re-hired me when I again 17 was between jobs, later in -- in Ottawa. 18 Q: That would be in -- from January to 19 July of 1992, Doctor? 20 A: That's correct. 21 Q: At -- at National Defence Medical 22 Centre? 23 A: Right. 24 Q: And further to that, from 1992 of 25 July to June of '94 you were a general surgeon at


1 Dartmouth General Hospital, in Dartmouth, Nova Scotia? 2 A: That's true. 3 Q: And at -- not finally, but certainly 4 in the relevant period from July of '94 to June of '96 5 you were the general surgeon at Strathroy Middlesex 6 General Hospital in Strathroy. 7 Q: That's true. I was one of two (2) 8 general surgeons there. 9 Q: And beyond that we can see from your 10 -- from your curriculum vitae that you have gone on to 11 various other positions, typically as a general surgical 12 oncologist; is that -- would that be fair? 13 A: That's correct. And for those who 14 aren't familiar with medical terms, an oncologist deals 15 with cancer. So I almost exclusively do cancer surgery, 16 at this time, and I'm on the Faculty with the Department 17 of Surgery at the University of Manitoba. 18 Q: And certainly in terms of your other 19 certification together with the publications, the 20 presentations that are also present in your curriculum 21 vitae, there is a focus with respect to oncology, and 22 that is your specialty; would that be fair? 23 A: That's true. 24 Q: In terms of your training and 25 experience, doctor, can you tell us what training and


1 experience you may have with respect to specifically 2 emergency-type medicine, trauma medicine, if I may? 3 A: Any general surgery residency 4 includes exposure to trauma in the emergency room. And 5 throughout those four (4) years I would have had 6 experience with multiple aspects of trauma. In order to 7 complete a residency, you must demonstrate that you have 8 appropriate knowledge in the management of trauma cases, 9 as well as the surgical skills needed to deal with 10 trauma. 11 I don't have any additional trauma 12 certification beyond that, nor have I done any additional 13 courses or specialty training in that area. 14 Q: Doctor, we've heard the acronym -- or 15 perhaps some of us have heard the acronym ATLS -- 16 A: Right. Advanced -- 17 Q: -- would you describe that for us? 18 A: Advanced trauma life support. It's - 19 - it's one (1) of a group of courses and certificates 20 that are available to ensure that there is some standard 21 of care for people dealing with trauma. It's meant for 22 anyone, emergency physicians, general -- general 23 practitioners, anyone who wishes, may take it. 24 And -- and many people who deal with 25 emergency room trauma will have taken it at some point.


1 However, it -- it isn't considered mandatory. And to 2 some extent it duplicates or -- the training that one 3 might -- that one is -- that one receives as a general 4 surgeon. 5 So although it is now common for general 6 surgery residents to obtain, during their training, a 7 certificate in ATLS, it wasn't common at the time I 8 finished, in 1990, and I didn't do it, and I have not 9 subsequently done it. 10 Q: Would it be fair to say nonetheless, 11 doctor, that what one would learn within that particular 12 course, ATLS, that through your residency and your 13 experience, that you are generally competent in those 14 areas? 15 A: I think it would be fair. 16 17 (BRIEF PAUSE) 18 19 Q: You have a certificate in general 20 surgery from the Royal College of Physicians and Surgeons 21 of Canada, Doctor? 22 A: That is correct. 23 Q: And -- as well you're a licentiate of 24 the Medical Council of Canada; did I say that properly? 25 A: That's correct.


1 Q: And so that a layperson might 2 understand those designations, would you be good enough 3 to tell us about that? 4 A: The licentiate of the Medical Council 5 actually has been replaced by a -- a different set of 6 letters now but that enables one to practice medicine, at 7 least as I understand it. So every person graduating at 8 that time and practising medicine would have had such a - 9 - a licence. 10 And the fellowship or certification with 11 the Royal College indicates that I successfully met their 12 standards to practice as a general surgeon. I actually 13 have an additional certificate now in general surgical 14 oncology which isn't listed on my CV there, but. 15 Q: All right. But in 1995 you were 16 still licenced -- 17 A: That's correct. 18 Q: -- as a general surgeon? 19 A: Yes. 20 Q: And could you describe briefly for 21 us, if you would, doctor, what it is that a general 22 surgeon might do as opposed to a general practitioner? 23 A: A general surgeon sees elective 24 cases, mainly on referral, that is the general 25 practitioners will refer problems which might require a


1 surgical opinion or surgery to the -- to a general 2 surgeon. We don't do primary care assessments of 3 patients, either in the office or generally in the 4 emergency department. 5 It's our purview to manage, for instance, 6 acute abdominal problems, acute chest problems. Sub- 7 specialty areas of surgery are now usually not included 8 in the general surgeons, so Gynaecology, Urology, those 9 sort of things would not usually be part of a General 10 Surgeon's practise. Am I providing you with the 11 information you want? 12 Q: It'd be fair to say it's fairly -- 13 it's fairly specialized then, is it? 14 A: It's -- it's entirely distinct from - 15 - from general practise, although it's a distinction that 16 general surgeons have had trouble making clear to other 17 people. 18 Q: Thank you, Doctor. Certainly in 19 September of 1994, you were serving as the General 20 Surgeon, I think, as you've confirmed for us? 21 A: Correct 22 Q: At the Strathroy Middle -- Middlesex 23 General Hospital? 24 A: Correct. 25 Q: In 1995, I'm not sure if I made that


1 clear? 2 A: Yes. 3 Q: If I can draw your attention then and 4 take you to September the 6th -- September the 7th of 5 1995, I understand that you weren't on call or on duty on 6 that particular evening, but you were, nonetheless, in 7 your office. 8 And I wonder if you might just take it 9 from there and explain what it is that you were doing and 10 what it is that -- that occurred? 11 A: Okay, my office is on the main floor 12 of the hospital in a room that used to be the old infant 13 nursery. And I had had clinic office there earlier in 14 the week and it was my intention to begin holiday for 15 about ten (10) days on the 7th of September. 16 And in order to complete my consultation 17 notes and get those letters out to the referring 18 physicians, I was in the office typing my letters into -- 19 into the computer at about midnight when these events 20 transpired. 21 Q: So, you were doing catch-up work in 22 order to -- 23 A: Correct. 24 Q: -- in order to allow yourself some 25 semblance of a holiday?


1 A: Right. And, my office, just for your 2 information, is on the -- on the back side of the 3 hospital in relation to the Emergency Room. I entered 4 through a different entrance and I -- as far as I'm aware 5 none of the people involved in these events would have 6 known that I was in the hospital at that time. 7 Q: Okay. You didn't let anybody know 8 that you were going to be at work? 9 A: No. 10 Q: You didn't want to be bothered, I'm 11 sure. 12 A: I was a little embarrassed that I had 13 to be there at midnight typing letters. 14 Q: So, you mentioned midnight, go ahead 15 from there, Doctor, and tell us what it is that -- that 16 happens? 17 A: I heard overhead on the PA system, a 18 code called, and in -- when I'm in hospital at the time 19 of a code I -- I usually make a judgement as to whether I 20 might be needed; that is, if it's daytime and it's in ICU 21 and there's an abundance of people, I don't necessarily 22 respond to -- to a code. 23 But I felt, in this situation, that there 24 would certainly only be one (1) physician in hospital, 25 the emergency physician on-call and I thought that my --


1 that my help might be -- might be needed. 2 Q: Were you aware at that time, Doctor, 3 who the emergency physician on-call would have been? 4 A: No. 5 Q: All right. And when you say, "a 6 code" you might -- you make a determine as to whether or 7 not to respond, we -- we have been provided with 8 testimony of various codes indicating different levels of 9 -- of emergency, if I can put it that way. 10 A: Hmm hmm. My notes indicate that it 11 was a Code blue, which is an -- an arrest or a coronary 12 resuscitation. So, that's what I -- 13 Q: Okay. 14 A: -- felt I was responding to. 15 Q: And, in terms of your response, then, 16 what was it that you did? 17 A: I walked over to the Emergency 18 Department and -- and made known to Dr. Marr that I was 19 there and I would help her as she saw fit with whatever 20 needed to be done. 21 Q: You -- the -- I'm sorry, Doctor. 22 A: With whatever she felt needed to be 23 done first. 24 Q: So, we can take it from that response 25 that you knew at that point, then, the attending or the


1 on-call physician was Dr. Marr? 2 A: Yeah, as I walked into the trauma 3 room I could see that she was in attendance on -- I think 4 with Dudley George at the time and I -- 5 Q: When you say that she was, "in 6 attendance on him" what else can you tell us about that 7 attendance, perhaps other people that might have been 8 around, other activity that's going on? 9 A: Yeah, the -- the trauma room at the 10 Strathroy Hospital is a fairly -- fairly large room and 11 to my recollection all three (3) of the patients were in 12 the room at that time when I arrived. 13 Dr. Marr was there and I'm sure that 14 other, possibly ambulance attendants and nurses were also 15 there, but I -- I don't have a direct recollection of who 16 they were or what they were -- what they were doing at 17 the time. 18 Q: In terms of the resuscitation 19 efforts, do you recall, Doctor, whether or not among 20 these individuals there might have been ambulance 21 attendants? 22 A: I think that's likely, but as I said, 23 I don't have a direct recollection of who or where they 24 were. 25 Q: In terms of the patient then, that


1 was the subject of these efforts, did you learn at any 2 point in time, his status upon -- upon arrival? 3 A: I think the initial -- for the 4 initial few minutes we were involved in placing an airway 5 and sort of assessing whether that was effective and 6 whether there was any cardiac function. And, during that 7 time, Dr. Marr probably gave me a capsule summary. 8 I -- I'm -- can't really recall whether -- 9 whether she was able to say that -- for sure that it was 10 a gunshot injury. I think that probably I did know that, 11 but I don't really recall hearing any more information 12 about -- about what or where this -- where the injury 13 occurred. 14 Q: Okay. I want to talk to you a little 15 bit more about that, but just before we go on there, you 16 mentioned that there were two (2) other patients or three 17 (3) in total in the trauma room? 18 A: Hmm hmm, that's correct. 19 Q: And I take it because attention was 20 focussed, then, on the person you've described as Dudley 21 George, that there was some call made as to why the 22 attention would be focussed there first? 23 A: I believe that Dr. Marr had had a 24 brief -- an opportunity to briefly assess the other two 25 (2) and felt that they were stable, whereas this patient


1 had no vital signs and -- and she made the decision that 2 resuscitation was required there first. 3 Q: And as you participated with her in 4 these efforts, did you determine or make any assessment 5 as to whether or not there were any vital signs that were 6 obvious? 7 A: Well, I would have probably been 8 palpating pulses, at least femoral or carotid pulses for 9 output with CPR. And I -- my notes indicate that I 10 listened to the chest to try and ascertain whether we had 11 an adequate airway and whether the lungs were being 12 ventilated. 13 I -- I'm not sure that I made any 14 assessment myself of the pupillary reflex until later or 15 if I did it at all or relied on Dr. Marr's examination. 16 Q: All right. We are told and we've 17 heard Dr. Marr testify that there was, in fact, a cardiac 18 monitor that was already in place, do you recall that at 19 all? 20 A: I don't have direct recall of it, 21 surprisingly, but I have seen the monitor strips and I -- 22 I -- the -- there was no electrical activity, it was a 23 flat line. 24 Q: And you'll agree with the 25 interpretation of those strips that the -- the blips, if


1 I can put it that way, on the telemetry were -- were from 2 the resuscitation efforts -- 3 A: Yes. 4 Q: -- that were ongoing at the time? 5 A: There are expected changes with 6 cardiac compressions. 7 Q: Okay. Perhaps what I can get you to 8 do, Doctor, is if you might just outline briefly for us 9 what the resuscitation protocol is and whether that was 10 being engaged in as -- as you walked into the room -- 11 A: Hmm hmm. 12 Q: -- and as you continued in the room 13 with this particular patient? 14 A: In the initial -- the protocol for 15 resuscitation involves, as you've heard probably earlier, 16 the ABC's, that is to establish and maintain airway, to 17 ensure that there's breathing or adequate ventilation of 18 the patient. 19 And then the "C" is for circulation, that 20 is to try to ascertain whether there is blood pressure 21 and to -- to provide fluids and cardiac compressions to 22 ensure cardiac output if there is none. 23 Q: All right. Are there successive 24 steps that are taken when the initial steps meet with no 25 positive result?


1 A: Yeah, well, it's hard to say when -- 2 when no -- no positive results are obtained. And at -- 3 at that point, the onus, I think, is on the physician to 4 decide whether -- whether there is a reasonable prospect 5 of -- of obtaining positive results and when that 6 opportunity has passed. 7 But provided that some -- that either that 8 a decision is made to continue with resuscitive efforts, 9 then the next step would be a secondary survey, looking 10 for sites of blood loss and doing any -- anything 11 necessary to improve the status of the patient; that is 12 to apply pressure to bleeding sites or to, in this case, 13 what we considered was placement of a chest tube, to 14 improve ventilation and -- and those things were, in 15 fact, not done in this case. 16 Q: Okay, we'll come to that in a moment. 17 You had occasion, I take it, doctor, to see Dr. Marr's 18 reports? 19 A: Yes. 20 Q: And there's one at Tab 19 which is a 21 history and physical examination. It's signed at the 22 bottom by Dr. Marr. 23 A: Yes. 24 Q: The narrative of that, in short, 25 confirms, I think, what you've told us, that Mr. Dudley


1 George was absent vital signs upon arrival? 2 A: Correct. 3 Q: No palpable pulse? 4 A: Yes. 5 Q: No spontaneous cardiac activity on 6 the monitor, and I take it that is the cardiac monitor 7 that you confirmed for us was in place. 8 A: That's true. 9 Q: And no respiratory activity? 10 A: Correct. 11 Q: Lastly, the pupils were fixed and 12 dilated at that point? 13 A: Right. 14 Q: And all of those indications are 15 positive clinical indications that he was, at that point 16 in time, deceased? 17 A: Yes. In this setting, the complete 18 absence of electrical activity of the heart, as well as 19 the fixed and dilated pupils would indicate that the 20 patient was dead, in fact, and possibly had been for a 21 period of time. 22 Q: And did you make any estimations, 23 doctor, as to what period of time that might have been? 24 A: I think, based on those two (2) 25 findings, that is the flat line on the cardiogram and --


1 and the pupillary -- or lack of pupillary response, one 2 would expect a minimum of ten (10) to fifteen (15) 3 minutes of -- of -- in which the patient had had 4 negligible cardiac output. 5 Q: And no respiratory activity? 6 A: Correct. 7 Q: And collectively those things, is it 8 fair to say that -- that the neurological deficit that 9 would be occasioned by that, for that period of time, 10 would be extensive? 11 A: Significant and probably not 12 reversible. 13 Q: I see. You had mentioned that Dr. 14 Marr had inserted a -- a tube, that is -- 15 A: Yes. 16 Q: -- an endotrachial tube? 17 A: That's correct. 18 Q: Okay. And you mentioned as well, 19 doctor, something about a chest tube. I suppose that's - 20 - that's distinct as intubation -- distinct from 21 intubation? 22 A: Yeah, a chest tube is a -- is 23 inserted through a puncture between the ribs, that is 24 it's a plastic tube that passes between the ribs into the 25 cavity of the chest, the plural cavity, but not into the


1 lung. 2 It allows egress of air or blood or other 3 fluids from the cavity, the chest cavity surrounding the 4 lung. 5 And with the -- in this setting where 6 there was a gunshot injury, one -- one might expect to 7 obtain blood or -- or -- there might -- that there might 8 be air or blood in the chest, which would be released by 9 a -- by a chest tube. 10 Q: All right. And that may have the 11 effect of resuscitating the patient? 12 A: Not likely. It certainly wouldn't 13 have any effect on bleeding, which I -- I suspected was 14 the primary injury in this patient. 15 It is beneficial in improving ventilation 16 of that lung, so that if -- if the lung were collapsed as 17 a consequence of the injury, and a chest tube were 18 inserted, the lung might be re-expanded and improve the 19 oxygenation of the patient, provided that there was blood 20 flow to carry that oxygen to the rest of the body. 21 Q: And Doctor, this is a procedure that 22 you've indicated was not carried out in this -- in this 23 instance. 24 A: That's correct. 25 Q: And in our earlier discussions you


1 had informed me you that you have agonized and perhaps 2 that's too strong a word, I'm not sure that's the word 3 you used, but perhaps puzzled over -- over this for some 4 -- for some years. 5 A: Well, I had -- I had a concern. 6 Although, in retrospect and recognizing the condition of 7 the patient on arrival in Emerg., that is the fixed 8 dilated pupils and the flat line cardiogram, which I, in 9 later years, didn't recall so clearly, I wondered whether 10 there might have been a tension pneumothorax, and that 11 whether placing a chest tube at that time could have had 12 an impact on our ability to resuscitate this patient. 13 A tension pneumothorax is a collection of 14 air that leaks out of the lung and accumulates in the 15 chest under pressure, causing the heart and the central 16 structures of the chest to shift and impairing a return 17 of blood-venus flow to the heart and thereby causing a 18 drop in blood pressure. 19 It's -- it is corrected by insertion of a 20 chest tube. And if that is the underlying -- if that 21 were the underlying problem, one would expect that blood 22 flow would be restored. 23 Q: You've had some discussion with Dr. 24 Marr about employing this particular intervention? 25 A: My notes indicate that I did discuss


1 that specifically. I don't recall that conversation 2 directly, at this time, but that's what my notes say. 3 Q: And we know from -- from your 4 testimony and from Dr. Marr's testimony that that was not 5 employed. And the reason that that was not employed 6 would be? 7 A: Is because we felt that there was, in 8 fact, no prospect that this patient could be successfully 9 resuscitated based on -- on the physical findings, as 10 I've said. 11 Q: How would you describe the -- the 12 injury that you observed with respect to -- to the 13 decedent, Dudley George? 14 A: It was -- I've described it as being 15 a small sort of circular hole in -- just behind or above 16 the clavicle, in what -- what is called the 17 supraclavicular fosse, or the little dip at the base of 18 the neck behind the collarbone. 19 It was small. There wasn't any obvious 20 injury in the tissues around, and I don't recall a lot of 21 blood there. 22 Q: So generally unimpressive? 23 A: It was. 24 Q: Did you detect or did you look for an 25 exit wound, having seen what could potentially be a -- a


1 bullet entry wound? 2 A: There was no evidence of an exit 3 wound with the patient lying on his back, as we were 4 making efforts at resuscitation. After we had terminated 5 efforts at resuscitation, he was turned, in an effort to 6 see whether there was an exit wound on the back, and 7 there was none visible. 8 Q: And as a consequence of not being 9 able to find an exit wound, did you come to any 10 conclusions as to the nature of the injury? 11 A: Well, one might suppose that the 12 bullet had entered and passed downward through the chest, 13 based on the fact that -- that no exit wound was seen. 14 But beyond that, I really didn't form any other opinion, 15 I don't think. 16 Q: And you mentioned that efforts at 17 resuscitation, at some point, ceased? 18 A: Yes. 19 Q: Can you recall for us how long from 20 the time that you came into the room that these efforts 21 were engaged in? 22 A: I certainly can't recall at this time 23 directly. My statements earlier indicated that I thought 24 that the time that the code was called, that is 25 resuscitation was stopped, was 12:20. And at one (1)


1 point, when pushed to give an estimate, I estimated 2 twenty (20) minutes. 3 But looking at the documentation that -- 4 that is on the charts and that you've provide, I think 5 that my estimate was too long. 6 Q: Okay. In any event, the activity at 7 resuscitation or the attempts at resuscitation, I take it 8 there was no restoration of any blood pressure, of any 9 cardiac activity? 10 A: That's correct. 11 Q: Any respiratory activity? 12 A: Nothing. 13 Q: All right. And a pronouncement was 14 made, as you have indicated, at 00:20 hours? 15 A: Correct. 16 Q: Doctor, did you have any information 17 as to how this patient had arrived at the hospital, how 18 long he had been in an unresponsive state? 19 A: No, we had no -- I had no idea of how 20 long he had been unresponsive or his condition during 21 transport. 22 Q: And I -- 23 A: I did -- what I understood about his 24 coming to hospital was that he had not arrived by 25 ambulance but in a -- a car, and that whoever had come


1 with him was not available to give any history; that's 2 all that I knew. 3 Q: And that history, I take it, is 4 important in terms of informing the activity that -- 5 that, as trauma people, you would engage? 6 A: The more information that one has 7 about the duration of the patient's loss of consciousness 8 or loss of vital signs, the more is known about the time 9 of injury, the mechanism of injury, the more likelihood 10 there is of -- of appropriately managing the patient. 11 Q: As a -- as a result of not having 12 this information, Doctor, can you tell us whether the 13 resuscitation efforts that you were assisting in, whether 14 that went on for a longer time than otherwise might 15 occur, a shorter time; can you -- can you tell us? 16 A: It would depend to some extent on the 17 -- on the information that was provided. If -- if there 18 was a reliable history of loss of vital signs, twenty 19 (20) minutes previously and the physical findings were 20 such that we observed, I don't think that any 21 resuscitative efforts would have been appropriate. 22 On the other hand, if there were a 23 reliable history that, you know, there was a response of 24 patient up to five (5) minutes prior to arrival, we might 25 have persisted for longer, despite the physical findings


1 that suggested that that was, in fact, not the case. 2 Q: And were you satisfied, Doctor, that 3 the call that Dr. Marr made at 00:20 hours was the 4 appropriate one? 5 A: Yes, I am. We, in fact, discussed it 6 before -- before terminating our efforts and I'm in 7 agreement with that. 8 Q: Following the -- following Dr. Marr 9 making that call, Dr. Saettler, was there any further 10 examination of the body of the decedent, Dudley George, 11 for other injuries? I think you've indicated already 12 that there was some attempt to seek out an exit wound? 13 A: Other than turning him to observe his 14 back and that the nurses or someone had cut the shirt so 15 that we could observe the back, I don't have any 16 recollection of examining his extremities or legs, any 17 other areas of his body. 18 Q: And that's the question I was going 19 to ask you, whether, in particular, there was any 20 injuries noted to his legs? 21 A: I don't -- I don't recall examining 22 his legs at all. 23 Q: And there's no indication in your 24 notes that you did and -- and made any such findings; do 25 you agree with that?


1 A: Yes, I do. 2 Q: All right. The last question I want 3 to ask you with respect to -- to this patient, Doctor, is 4 at any -- at any point during your attendance at the 5 trauma room, did you see whether this patient, Dudley 6 George, had been left unattended for any length of time 7 prior to the declaration of -- of his passing by Dr. 8 Marr? 9 A: Not that I'm aware of. As far as I 10 recall, we were both in attendance continuously from, 11 well, she first and then after I arrived we both were in 12 attendance on him continuously until he was pronounced 13 dead. 14 Q: Thank you, Doctor. The other two (2) 15 patients in the room, one (1) of -- one (1) of whom you 16 were able to identify subsequently is Cecil Bernard 17 George? 18 A: Yes. 19 Q: Okay. Can you tell us what your 20 involvement would have been insofar as treating Mr. 21 George; at what point in time might you have commenced? 22 A: Hmm hmm. After the resuscitation 23 efforts were finished related to Dudley George I went to 24 assess Cecil George and the notes indicate that that was 25 about 12:20 and as I recall, Dr. Marr also -- we were --


1 at least the initial phases of that assessment we were 2 both present and then subsequently I went on to examine 3 the third patient and -- 4 Q: Okay. 5 A: -- his -- 6 Q: Before -- and before we move to -- to 7 the third patient, would you describe for us please, 8 Doctor, the condition and the injuries of Cecil Bernard 9 George? 10 A: He was -- he was lying on the -- on 11 the transport gurney, the stretcher and -- and was quite 12 restless. He was, at that time, I felt not appropriate - 13 - not entirely responsive, although -- and he tended to 14 lapse into sort of -- into drowsiness when he wasn't 15 being stimulated or -- or spoken to, alternating with 16 restless periods. 17 He was -- he had lacerations and -- around 18 his scalp and bruising, I believe, over his forehead, 19 chest, and arm -- right arm. 20 21 (BRIEF PAUSE) 22 23 Q: And did you make any -- any 24 determinations as to his -- as to whether he was 25 conscious or not?


1 A: He was conscious, but his level of 2 consciousness was not normal. He -- as I said, he was 3 restless and at times lapsing into drowsiness and he was 4 confused. He didn't know where he was and wasn't 5 responding appropriately to questions. 6 So, I felt -- I felt that he had a 7 diminished level of consciousness, or altered sensorium. 8 Q: All right, in terms of the laceration 9 of the scalp that you've told us about, I understand that 10 you had taken some measures to -- to deal with that. 11 A: I think that the actual laceration 12 was more posteriorly. As I recall, there was a lot of 13 blood sort of behind him on the stretcher and I noted 14 that, but I didn't lift his head to -- to examine that at 15 that time. 16 I noted some bruises over his forehead and 17 he had a cut through his lip, through the full thickness 18 of his lip. 19 I believe he had some bruising over the 20 right chest, if I'm remembering correctly and -- and was 21 complaining of pain and had visible swelling and bruising 22 over the forearm and on the right, as well. 23 Q: The right forearm? 24 A: That's correct. 25 Q: That particular injury, just with


1 respect to the right forearm, did you make any 2 determinations as to how those sorts of injuries are 3 occasioned? 4 A: I didn't on my initial assessment, 5 but after I had obtained some information as to the 6 mechanism of his injury, I -- I looked at those injuries 7 as being likely the result of being struck while 8 attempting to protect his head or -- from blows. 9 Q: Okay, the laceration through his 10 upper lip, I -- is that how you described it? 11 A: That's correct. 12 Q: So it was completely through? 13 A: It was right through the muscle and 14 the whole thickness of the lip was -- 15 Q: And did you make -- 16 A: -- split open. 17 Q: -- take some measures to treat that? 18 A: Yeah, I -- I sutured it, 19 approximating the muscle of the lip first, so as not to 20 leave a -- a gap and a defect in his lip after I'd closed 21 the skin. 22 23 (BRIEF PAUSE) 24 25 Q: In terms of Mr. George's level of


1 consciousness, you had come to the conclusion that there 2 was -- he wasn't -- he wasn't okay? 3 A: Right, I felt -- 4 Q: The responses -- 5 A: -- he had a -- 6 Q: -- that -- I'm sorry? 7 A: I felt he had had a significant head 8 injury. 9 Q: Okay, and the responses that he was 10 providing you, you've indicated were inappropriate? 11 A: He was talking, but it seemed he 12 wasn't answering specific questions accurately and I felt 13 that indicated a level of confusion. 14 Q: And as part of your assessment of 15 this patient or any patient, you would ask a series of 16 questions to come to that determination? 17 A: Right. Try to assess whether he knew 18 who and where he was and so on. 19 Q: Did he say anything about how this 20 happened to him? 21 A: He didn't, initially. I'm not -- he 22 -- I think that he -- he said that he had -- he didn't 23 know what had happened or he didn't know how it happened, 24 and he didn't provide any information other than that he 25 had been kicked, he had been kicked in the -- in the


1 abdomen. 2 I think he told me that directly. 3 Q: And you have some notation of that? 4 A: I do. Both my statements indicate 5 that he described being kicked. 6 Q: Okay, and I anticipate we may hear 7 some evidence about other things he might have said to 8 other people, things about seeing stars -- 9 A: That's correct, yes. 10 Q: -- or something like that -- 11 A: He did in the -- I believe that's 12 corroborated in the nurse's notes as well. He told me 13 that he just saw stars, and to me that indicated that he 14 had had a neurologic injury. 15 Q: All right. During the course of your 16 dealing with Cecil Bernard George, did his level of 17 consciousness improve? 18 A: It did. It took about an hour before 19 he -- he was able to answer questions appropriately. 20 Q: And before we turn to the third 21 patient, I'll suggest to you that that third patient was 22 Nicholus Cottrelle. 23 A: That's correct, as I understand it. 24 Q: Do you recall whether or not Nicholus 25 Cottrelle, as he was ins the same room, provided any


1 information relative to Cecil Bernard George? 2 A: I saw -- I saw Nicholus Cottrelle -- 3 I made my assessment of him after he had been moved out 4 of the common area of the trauma room and into an 5 adjoining curtained area. 6 And I believe that it was at that time 7 that he -- he made some -- he gave me information about 8 the mechanism of injury of Cecil George. And I may have 9 asked him that directly, although I don't have a 10 recollection of it. 11 Q: As to whether he volunteered it or -- 12 A: Yes. 13 Q: -- whether you -- you had -- 14 A: As to whether I questioned him in 15 that regard, I might have but I don't remember. 16 Q: And in terms of the mechanism of 17 injury, what was it that you learned from Nicholus 18 Cottrelle? 19 A: He described seeing Mr. George being 20 beaten with sticks by nine (9) policemen. 21 22 (BRIEF PAUSE) 23 24 Q: Aside from what you've described for 25 us, the suturing of the upper lip, what other treatment


1 did you administer to Cecil Bernard George? 2 A: That would constitute the whole 3 treatment. Part of my role in his assessment was to make 4 a judgement about, first of all, whether he was in fact 5 stable from a -- from the point of view of his blood 6 pressure. 7 And because he had sustained injuries to 8 the upper abdomen from kicking and there was a -- a 9 history of possible loss of blood pressure in transport, 10 I -- in my differential diagnosis or in my mind I 11 considered whether he might have some injury to the liver 12 or spleen as a consequence of kicking. 13 Those are injuries which can bleed slowly 14 or intermittently, and so I considered whether he had 15 some -- some internal organ injury related to the kicking 16 in the abdomen. 17 Q: And did you ever resolve that? 18 A: Well, he remained stable. And I 19 think when I left notes on his admitting history I 20 indicated that if he remained stable then it probably 21 wasn't necessary to -- to proceed further, or that one 22 might consider imaging or a CT scan of the abdomen if -- 23 if there was any compromise in his blood pressure, but 24 there wasn't and so, as far as I know, that wasn't done. 25 I did consider all sorts of things in the


1 emergency department before I really knew whether he was 2 stable, and you'll see references to those in my 3 statements. 4 And one of the things I thought about was 5 what was called at that time a peritoneal tap or 6 diagnostic lavage. It wouldn't be done now because 7 almost everywhere has a CAT scan, but it's a means of 8 instilling liquid into the abdomen through a -- a tube 9 and then aspirating that -- sucking out that fluid to see 10 if there's bleeding or -- or any other abnormality that 11 might indicate you had to proceed with surgery. 12 So I did consider that, and that's 13 mentioned in my notes, but I didn't think it was 14 necessary. 15 Q: All right. And you didn't think it 16 was necessary because his sensorium continued to improve? 17 A: It continued to improve and his blood 18 pressure remained stable. 19 Q: All right. You've indicated just at 20 the outset, Doctor, that there were concerns about loss 21 of blood pressure in transport; how did you come about 22 that information? 23 A: As I recall, that information was 24 provided by the -- by an attendant who had been with him 25 during the transport. And I -- as to the words or the


1 exact description, I -- I can't really recall that. 2 Q: All right. One of the things that we 3 were told emergency physicians are often cognizant of is 4 the use of alcohol by patients that are brought in to 5 trauma? 6 A: Particularly if there's some 7 compromise in their level of consciousness. 8 Q: Was this a concern with respect to 9 Cecil Bernard George; and if so, did you do anything to 10 ally that concern? 11 A: Yes. I -- I asked him whether he had 12 been drinking and he said that, No, he had not and he -- 13 that he doesn't drink. And I obtained, as part of his 14 blood work, an alcohol level, and there -- there was no 15 alcohol in his blood. 16 Q: All right. In terms of the injuries, 17 you've already described injuries to the outside of the 18 forearm? 19 A: That's right. 20 Q: Consistent with -- and you'll correct 21 me if I'm wrong -- consistent with defensive-type 22 actions? 23 A: Yeah. There was a whole series of -- 24 sort of a confluent bruise over the ulnar aspect, that is 25 the side -- on the baby finger, the outer aspect of the


1 forearm, which is -- is typical of someone who's raised 2 their arm to ward off a blow. 3 Q: Okay. Did you make any 4 determinations as to whether he might have, what I'm 5 going to call, aggressive type injuries -- 6 A: Yes. 7 Q: -- knuckles, that sort of thing? 8 A: That's correct. I made mention of 9 that in my comments to the SIU or the OPP, was that he 10 didn't have any fractures of the metacarpals, boxer's 11 fractures they're called, which might occur in a fist 12 fight where he was at least an equal participant or a -- 13 had -- had thrown some punches. 14 Q: And given the information that you'd 15 received from Nicholus Cottrelle as well as, I take it, 16 from Cecil Bernard George himself as he continued to 17 become more lucid, did you come to any conclusions as to 18 how he sustained the various injuries? 19 A: I felt that the injuries I observed 20 were consistent that -- with the description given by 21 Nick Cottrelle, and I didn't have any information as to 22 why he obtained those injuries but it appeared to me 23 likely that he had been struck with -- with sticks or 24 truncheons by the police. 25 Q: Okay, and I understand, Doctor, from


1 your various comments in the -- in the documentation that 2 none of the -- pardon me, neither Nicholus or Cecil 3 Bernard George were particularly forthcoming, I think is 4 the words that you had described their demeanour? 5 A: That's correct. I found them to be 6 quiet and I had difficult -- I -- I had to draw out all 7 the information that I needed, rather than having them 8 volunteer any -- any information. 9 Q: And they've been described variously 10 as polite and co-operative and, notwithstanding that, 11 they would not volunteer information? 12 A: I would agree with that description. 13 Q: Okay. And did you come to any 14 conclusions as to why that might be? 15 A: I felt at the time that it -- that 16 they might not have a -- a level of trust that would 17 allow them to -- to -- to volunteer information to me. 18 Q: All right. Did you concern yourself 19 at all that -- that might have been, perhaps, a -- an 20 element of the culture of these particular individuals, 21 that is as aboriginal people, they might not be 22 volunteering? 23 I mean is that the sort of thing that 24 might even cross your mind? 25 A: I haven't a lot of previous


1 experience to -- to draw on, so whenever I encounter a 2 response that isn't as expected, I don't know that it's 3 so much my impression of how aboriginal people might 4 behave, but I did take into account that it just might 5 not be culturally appropriate for them to -- to volunteer 6 information to me. 7 Q: Thank you for that. 8 9 (BRIEF PAUSE) 10 11 COMMISSIONER SIDNEY LINDEN: I don't want 12 to push you too hard, but it's getting late. Do you have 13 much more to go? 14 MR. DONALD WORME: I don't have much more 15 to go, I -- 16 COMMISSIONER SIDNEY LINDEN: Well, let's 17 see if we can -- 18 MR. DONALD WORME: If you don't mind, 19 Commissioner, I think I'd like to press on, if that's all 20 right with the doctor? 21 COMMISSIONER SIDNEY LINDEN: It would be 22 good if we could finish it tonight -- 23 MR. DONALD WORME: Thank you, sir. 24 25 (BRIEF PAUSE)


1 CONTINUED BY MR. DONALD WORME: 2 Q: With respect then, to Cecil Bernard 3 George, Doctor, is there anything that you can then 4 recall for us that you haven't already told us, insofar 5 as your treatment of him or your observations of his 6 demeanour and improving sensorium? 7 A: No, I -- I -- after suturing his 8 laceration and -- and being satisfied that his 9 neurological status was improving and that he was stable, 10 I didn't have any further sort of examination that night 11 and I didn't see him the following day. 12 Q: Okay, and just before we leave that, 13 you had indicated that there had been information passed 14 along by ambulance attendants that had transported Cecil 15 Bernard George, that they were, in fact, quite concerned 16 about his blood pressure and hence the concern that you 17 had. 18 In fact, I suggest to you that it was a 19 quite a bit -- quite a bit of concern that was provided 20 that there was a suggestion that, perhaps, his cardio 21 activity had stopped as well. 22 A: I'm not sure if I was aware of that-- 23 Q: Right. 24 A: -- that his -- that there was a 25 question of cardiac activity, because it certainly would


1 be unusual to have a patient arrive in the Emergency 2 Department with that history and then be stable with a 3 normal pulse. 4 So, I'm not sure if I was aware of that, 5 but I was attuned to the idea that he might have had a 6 transient drop in pressure, partly because of those 7 injuries to his abdomen. 8 Q: Thank you, Doctor. Let's turn, 9 lastly, then to the attention that you had provided to 10 Nicholus Cottrelle? 11 A: Okay. I saw Nicholus Cottrelle last, 12 and his wounds, basically, seemed to consist of a 13 puncture injury in the right flank, that's the back over 14 the kidneys, basically, and a linear sort of cut or 15 abrasion across the left flank. 16 Other than that, and by description of the 17 ambulance attendants he seemed to have been stable and 18 not to have any other significant injuries. 19 Q: You agreed with me earlier, Doctor, 20 that the injury to Dudley George was quite unimpressive. 21 A: That's correct, only a few 22 millimetres; a round hole. 23 Q: Was there any correlation between 24 that and the -- and the outcome of that injury to what 25 you'd observed on Nicholus Cottrelle?


1 A: Well, it was a similar injury in the 2 -- in the skin surface, but the patient had been stable 3 for a period of more -- about forty (40) minutes by the 4 -- in hospital by the time I came to assess him. 5 I wasn't so much concerned that he might 6 have a life-threatening injury, but if he had sustained a 7 bullet wound to the flank or the bullet could conceivably 8 have injured structures in the -- behind the abdomen in 9 the retroperitoneum, that would be the kidney or -- there 10 are some large vessels there, of course the aorta and the 11 vena cava, but his status wasn't consistent with a major 12 vascular injury. 13 Q: And, can you describe the injuries 14 beyond that; I think you've already -- you've already 15 done that to some degree, Doctor, but the -- the injuries 16 of Nicholus Cottrelle? 17 A: I -- I think that I made the 18 assumption that they -- because of his description of the 19 mechanism of injury he told me that he had been in a 20 vehicle, had heard shots and glass shattering and I -- I 21 thought it likely that these were bullet wounds or -- and 22 there was some dark discolouration of the skin around the 23 linear marking on the left, which I -- I wondered whether 24 it was related to a powder burn from a close range 25 firearm -- firearm injury.


1 So, I asked him directly if that was the 2 case, if there -- where the gunshots were and whether 3 there could have been any gunfire from within the vehicle 4 and he said, No, there were no guns within the vehicle, 5 that the gunshots came from without and probably at a 6 distance of ten (10) to fifteen (15) feet. 7 Q: As a result of -- I -- I take it from 8 his responses as you observed them, that he was totally 9 lucid? 10 A: Yes, completely. 11 Q: And conscious? 12 A: And cooperative, yeah. 13 Q: All right. And, did you make any 14 determination as to whether or not you would be prepared 15 to discharge him at that time? 16 A: I -- I wasn't prepared to discharge 17 him at that time. In retrospect, I think it was because 18 of the circumstances of the injury and my uncertainty as 19 to whether there might be some -- still some bullet or 20 other injury related to that. 21 We had done -- we had done an x-ray of the 22 abdomen, which I know you've discussed earlier, showing 23 some sort of a foreign body adjacent to the lower -- 24 about the level of T-10, the lower thoracic spine and 25 that would have been, to me, consistent with the level of


1 his external injuries and I -- I didn't have -- although 2 it didn't look like a bullet, I -- I didn't have a good 3 explanation for that foreign body and I thought it 4 wouldn't be unreasonable and probably safer or prudent to 5 observe him over night. 6 Q: Okay, so if you had to do something, 7 he's right there and you could take -- 8 A: Yeah, it's a small hospital and bed 9 availability was not really an issue and we didn't, of 10 course, have access to a CT scan or things that 11 would have sort of simplified the process and allowed us 12 to rule out significant injuries easily. 13 Q: And, we understand that the patient, 14 Nicholus Cottrelle, was wanting to go home? 15 A: Yes, that's true. 16 Q: And your decision not to release him, 17 did that change his character from cooperative and 18 polite, as you described him earlier? 19 A: Not as far as I recall. 20 Q: All right. You had told us earlier, 21 doctor, that you were preparing to leave for a vacation, 22 as a result of that -- 23 A: I -- I was -- I had plans to leave 24 for Halifax the following day at 3:30 in the afternoon 25 and I planned to be away for about ten (10) days. I did


1 return to the hospital the following morning and my -- my 2 appointment book indicates that I was scheduled to help 3 another surgeon in the operating room with his case 4 throughout the whole of that day. 5 But I see in -- I see in reviewing the 6 nurses' notes that I -- and the order sheets from the 7 hospital that I visited the ward and -- and wrote some 8 orders on Nick Cottrelle, which are incorrectly dated 9 September 8th, but they were written on the morning of 10 September 7th. 11 I can't recall if I examined him, and I 12 didn't make any notation of that. So I'm not sure 13 whether I in fact had an opportunity to reassess him or 14 not. 15 Q: Okay. Doctor, did you have any 16 conversations -- well, let me ask you this: Did you see 17 any police officers around the hospital? 18 A: Yes, there was -- there were a lot of 19 police around the hospital the following morning. And 20 they were, for the most part or -- or all, dressed in -- 21 in body armour, sort of what I would call riot gear or -- 22 Q: All right. 23 A: -- quite -- quite obviously prepared 24 for violence. And -- and there was -- there was a rumour 25 of riot. I heard, and I'm not sure if it was from the


1 nurses or -- or how I heard it, but that -- that there 2 was concern that there might be an attack on the hospital 3 by the Native People, that there was police presence for 4 our protection. 5 Q: I see. I do you know where that -- 6 that rumour or that comment would have emanated from? 7 A: I wish I could say where it was that 8 I heard it, but I -- I don't remember. 9 Q: And how did the presence of these 10 police, attired as they -- they were, as you've described 11 them, how did that affect the mood of the hospital? 12 A: It was -- it was disconcerting and -- 13 and intimidating. 14 Q: Okay. Did you see any family members 15 of any of the patients that you had treated around the 16 hospital? 17 A: I cannot recall having any direct 18 contact with family members. 19 Q: And after completing the various 20 treatments that you've described for us, doctor, what 21 then did you do? 22 A: I returned to my office and finished 23 my notes, and went home about 2:30 in the morning. 24 Q: Okay. And then you've already told 25 us that in fact you would have came in the next morning,


1 you had made certain orders on the -- on the nurses' 2 sheets? 3 A: Hmm hmm. 4 Q: Perhaps I can just, on that note, 5 draw you to Tab number -- draw your attention to Tab 6 number 4, that is already marked as a -- as an exhibit in 7 these proceedings. 8 And I wonder, Mr. Registrar, if you could 9 just confirm for me that that is... 10 11 (BRIEF PAUSE) 12 13 THE REGISTRAR: P-356. 14 MR. DONALD WORME: That is P-356, yes. 15 Thank you. 16 17 CONTINUED BY MR. DONALD WORME: 18 Q: And if I could take you, Dr. 19 Saettler, there is a front number, which is a small 20 number on the upper left-hand corner, 000272? 21 A: I see it. 22 Q: Those are your notes, are they? 23 A: They are; again, incorrectly dated. 24 Q: It bears the date September the 8th? 25 A: Yeah. That's incorrect.


1 Q: Okay. 2 A: It was September 7th. 3 Q: And the nameplate up at the right- 4 hand side is Nicholus Cottrelle? 5 A: Correct. 6 Q: All right. 7 8 (BRIEF PAUSE) 9 10 Q: The last comment on the -- on the 11 very next page of that, it looks as though you are 12 suggesting that the patient would then be further 13 assessed by a surgeon, that you wouldn't be available? 14 A: That's correct. I was -- I was going 15 to be in the operating room and then gone as -- in the 16 early afternoon. I felt that if the patient -- I had 17 hope that, regardless of his status, he could be 18 reassessed by a surgeon. But, as it turned out, he 19 remained stable. 20 And -- and, as I said, if I reassessed him 21 I didn't make any notes, so I -- and I can't recall. And 22 that, since he was stable, I felt that he could be 23 reassessed and managed by Dr. Marr. I made notes for her 24 and recommendations that I felt were adequate to ensure 25 his ongoing care.


1 Q: All right. Thank you for that, Dr. 2 Saettler. The mandate of this Commission is to review 3 these -- review the circumstances of the death of Dudley 4 George and to come up with recommendations as Mr. 5 Commissioner will do, in due course. 6 Is there anything that you could provide 7 by way of comment of opinion that might assist the 8 Commissioner in coming to those recommendations, given 9 your experience of the day, given your observations and 10 your involvement in this, Dr. Saettler? 11 A: It's my opinion that if the police 12 were aware of the level of force and -- that was likely 13 to occur and anticipated injuries of this nature from -- 14 from high-powered weapons, that better arrangements for 15 medical care could have been made. 16 And, to my mind, that would include a 17 higher level of paramedic assistance at the site, the 18 ability to start IV's, intubate onsite or during 19 transport, the ability to do CPR and possibly 20 defibrillate en route. 21 And I don't think it was -- I think that 22 the only prospect of resuscitating patients with injuries 23 of this sort is to transport them quickly and directly to 24 a hospital which has a reasonable capability for vascular 25 surgery or thoracic surgery and that Strathroy Hospital


1 was not equipped to deal with an injury of this nature, 2 even if we had received this patient in a timely fashion. 3 Q: On that note, Dr. Saettler, we know 4 from Dr. Marr's testimony that the injury to Dudley 5 George was a -- and I'll be corrected if I'm wrong, I'm 6 sure, but a five 5 or 0.5 centimetre tear on the 7 pulmonary aorta? 8 A: That's what I understand, I haven't 9 seen that report directly. 10 Q: And, what does that mean in terms of 11 your ability as a surgeon to be able to repair that if, 12 for example, let's say, you were on site? 13 A: Yeah. If -- if -- if, in the course 14 of resuscitation that patient had had their -- they 15 would have required a thoracotomy or an open surgical 16 procedure in the Emergency Department to expose the 17 heart. 18 And a laceration or injury to the heart, 19 the ventricles of the heart, can sometimes be directly 20 sutured in the Emergency Room, but exposure and suturing 21 of the pulmonary artery would be nearly impossible in the 22 Emergency Department. So, it's difficult to gain access 23 to that area and suturing a vessel of that sort is not 24 simple, either. 25 It could be done and possibly with success


1 if -- if a vascular surgeon was available, in my opinion. 2 Q: All right. And are you qualified as 3 a vascular surgeon? 4 A: No, I have no particular training in 5 vascular surgery, nor was it part of my practise at that 6 time. 7 Q: The capacity of the Emergency or 8 Trauma Room of the Strathroy Middlesex General Hospital, 9 of that date, was there such capacity at that point, 10 Doctor, in your opinion? 11 A: No, the usual practise in Strathroy, 12 the -- the surgeons were two (2) general surgeons, myself 13 and another. And the third person on our call roster is 14 a urologist who had extensive capabilities in -- in the 15 areas of obstetrics and, to some extent, in general 16 surgery. 17 But none of us had, well, I can't speak 18 specifically for the second general surgeon, but as far 19 as I'm aware, none of us had any additional experience 20 with thoracic or vascular surgery. 21 And those surgeons were not in hospital 22 on-call. They would have had to be called in. 23 Q: All right. And lastly, Doctor, your 24 observation, your comment was, that the degree of 25 preparedness might have been much higher, perhaps, a


1 greater degree of trauma preparedness, is that... 2 A: Yeah, I reviewed the internet notes 3 from yesterday and there was mention made of -- of the 4 police inquiring about the availability of MAST trousers 5 in the ambulance and -- and similar things. 6 And that, to me, indicates that they had 7 an expectation that there might be serious vascular 8 trauma, as one might expect from gun -- gunshot wounds. 9 And the -- I don't think that there were adequate 10 arrangements to deal with that type of injury. 11 I mean, I don't think that type of injury 12 was appropriate at all. I think that indicates the use 13 of excessive force to me, but I don't think you're 14 looking for my opinion about that. 15 So -- but in terms of the results of that 16 force, I don't think there was adequate preparation from 17 a medical perspective. 18 Q: Thank you, doctor, for your -- your 19 testimony. Those are all my questions, Mr. Commissioner. 20 COMMISSIONER SIDNEY LINDEN: Thank you 21 very much. 22 We'll just do a quick -- 23 MR. DONALD WORME: Please. 24 COMMISSIONER SIDNEY LINDEN: -- 25 canvassing of estimated cross-examination and then we'll


1 adjourn for the day. 2 Who expects to cross-examine the witness? 3 Mr. Orkin, how long do you anticipate you 4 might be? 5 MR. ANDREW ORKIN: Mr. Orkin, twenty 6 (20) -- 7 COMMISSIONER SIDNEY LINDEN: I'm sorry, 8 Mr. Orkin, it's very late. 9 MR. ANDREW ORKIN: Don't apologise. 10 That's correct; twenty (20) minutes. 11 COMMISSIONER SIDNEY LINDEN: It's very 12 late. 13 Mr. Rosenthal...? 14 MR. PETER ROSENTHAL: About fifteen (15) 15 minutes, Your Honour. 16 COMMISSIONER SIDNEY LINDEN: And Mr. 17 Ross...? 18 MR. ANTHONY ROSS: No more than ten (10) 19 minutes. 20 COMMISSIONER SIDNEY LINDEN: And Ms. 21 Tuck-Jackson...? 22 MS. ANDREA TUCK-JACKSON: Five (5) to ten 23 (10) minutes. 24 COMMISSIONER SIDNEY LINDEN: And Ms. 25 Jones...?


1 MS. KAREN JONES: Twenty (20) minutes. 2 COMMISSIONER SIDNEY LINDEN: And Mr. 3 O'Marra...? 4 MR. AL O'MARRA: I reserve ten (10) 5 minutes, sir, just so -- 6 COMMISSIONER SIDNEY LINDEN: That gives 7 you an idea of what we can expect in the morning. We 8 should be able to get you out of here before noon. 9 THE WITNESS: Thank you. 10 COMMISSIONER SIDNEY LINDEN: So, with 11 that, we will adjourn from now until nine o'clock 12 tomorrow morning. 13 MR. DONALD WORME: Thank you, sir. 14 COMMISSIONER SIDNEY LINDEN: It's been a 15 long day; that's two (2) in a row. Thank you very much 16 for your indulgence. 17 18 (WITNESS RETIRES) 19 20 THE REGISTRAR: This public Inquiry is 21 adjourned until tomorrow, Wednesday, April 27th at 9:00 22 a.m. 23 24 --- Upon adjourning at 5:29 p.m. 25


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