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 28th, 2005 25


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


1 LIST OF APPEARANCES (cont'd) 2 3 Kelly Graham ) Malcolm Gilpin, Mark Watt, 4 John Tedball, Cesare 5 DiCesare and Robert Kenneth 6 Scott 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25


1 TABLE OF CONTENTS 2 Page 3 Exhibits 7 4 5 ROBERT KENNETH SCOTT, Resumed 6 Cross-Examination by Ms. Karen Jones 8 7 Re-Examination by Ms. Susan Vella 67 8 9 MICHAEL JAMES SHKRUM, Sworn 10 (Voir dire commenced) 11 Examination-In-Chief by Ms. Katherine Hensel 72 12 (Voir Dire concluded 83 13 Examination-In-Chief by Ms. Katherine Hensel 85 14 Cross-Examination by Mr. Andrew Orkin 162 15 Cross-Examination by Ms. Jackie Esmonde 190 16 Cross-Examination by Ms. Karen Jones 199 17 Cross-Examination by Mr. Al O'Marra 219 18 19 20 21 22 Certificate of Transcript 235 23 24 25


1 EXHIBITS 2 No. Description Page 3 P-378 Curriculum Vitae of Dr. Michael 4 James Shkrum. 84 5 P-379 Expert witness testimony Ontario 6 Dr. Michael James Shkrum. 84 7 P-380 Document Number 1000099 Nov. 8 09/'95 Report of the Centre of 9 Forensic Science re. Anthony 10 O'Brien George. 90 11 P-381 Document Number 1000383 Sept. 12 07/'95 Statement of Dr. G.W. Perkin, 13 Strathroy Medical Clinic, to 14 Det. Bob Martin, London OPP. 227 15 16 17 18 19 20 21 22 23 24 25


1 --- Upon commencing at 9:02 a.m. 2 3 THE REGISTRAR: This Public Inquiry is 4 now in session, the Honourable Mr. Justice Linden 5 presiding. Please be seated. 6 MS. SUSAN VELLA: Good morning, 7 Commissioner, we'll continue with the cross-examination. 8 I believe Ms. Tuck-Jackson was next. 9 COMMISSIONER SIDNEY LINDEN: Good 10 morning, everybody. 11 MS. ANDREA TUCK-JACKSON: I have no 12 questions on reflection. 13 COMMISSIONER SIDNEY LINDEN: Ms. 14 Jones...? 15 16 ROBERT KENNETH SCOTT, Resumed 17 18 MS. KAREN JONES: Good morning, Mr. 19 Commissioner. 20 COMMISSIONER SIDNEY LINDEN: Good 21 morning. 22 23 CROSS-EXAMINATION BY MS. KAREN JONES: 24 Q: Good morning, Mr. Scott. 25 A: Good morning, ma'am.


1 Q: My name's Karen Jones and I'm one of 2 the lawyers who represents the Ontario Provincial Police 3 Association and I had some questions for you about your 4 evidence yesterday. 5 A: Certainly. 6 Q: I wondered, first of all, if -- if we 7 could clarify a few things. Do you recall at all what 8 your unit number would have been in terms of the 9 ambulance that you were in? 10 A: I believe it was a single vehicle; it 11 would have been 1196 or 1505. Again, it was -- those are 12 the only two (2) ambulances I remember from ten (10) 13 years back. 14 Q: Okay. Okay. Could we put up -- 15 Okay. Sorry, it's okay. 16 And, we heard yesterday, I think, that the 17 first time you were ever interviewed about this matter 18 was on February 13th, 2003? 19 A: That's correct. 20 Q: Okay. 21 A: From a detective from Peel Region, I 22 believe it was. 23 Q: Okay. And so, it had been eight (8) 24 years at that point in time? 25 A: Approximately, yes.


1 Q: Yes, since the incident occurred? 2 And, can you tell us a little bit about the circumstances 3 of the interview when you met with the detective? Had 4 you been called beforehand? Had you had a chance to turn 5 your mind to what went on? 6 A: I don't believe I was given a lot of 7 warning, maybe a week's time to expect someone. I really 8 can't recall at this time. I -- I'm sure it wasn't a 9 long period of time. 10 Q: Okay. And, I think that you've told 11 us that you didn't have any notes of what happened on the 12 night of September 6th, 1995? 13 A: That's correct. 14 Q: So, you didn't have anything to 15 refresh your memory with or to go back and check anything 16 against? 17 A: That's correct. 18 Q: Okay. And, I take it from what you 19 said yesterday that what happened on the night of 20 September 6th, 1995 happened very quickly? 21 A: Oh, definitely. 22 Q: Yeah, and a lot of things were going 23 on? 24 A: Yes. 25 Q: And, that during the period of time


1 that you were participating in events, you would have 2 been really focussed on, for the most part, Mr. Dudley 3 George? That would have -- where your attention would 4 have been; is that fair? 5 A: Exactly. From the beginning I was 6 focussed in the cardiac patient and then after the fact 7 on Mr. Dudley George. 8 Q: Right. And, I take it that when you 9 spoke with the detective on February 13th, 2003, that you 10 wanted to be accurate when you spoke to him? 11 A: Oh, definitely. 12 Q: And tell him all of the details that 13 you could recall? 14 A: As much as I could recall. 15 Q: Okay. And I think you also told Mr. 16 Worme yesterday that you had reviewed both that statement 17 and the statement that had been done by the Commission 18 staff -- 19 A: Correct. 20 Q: -- before you came here? And that, 21 in your view, the statement that you had given February 22 13th, 2003, was more reflective of what happened? 23 A: 2003, correct. 24 Q: Yeah. And when you went through that 25 statement, did you find anything in it that was -- stood


1 out to you as an error, was inaccurate? 2 A: Not really. A couple of typos -- 3 Q: Okay. 4 A: -- that's about it. 5 Q: Okay. 6 7 (BRIEF PAUSE) 8 9 Q: And I take it that you would agree 10 that your memory about what happened would have been best 11 at or about the time? 12 A: I'm sorry. Can you repeat that, 13 please. 14 Q: Your memory of -- your recollection, 15 your ability to describe accurately what happened would 16 have been best closer to September the 6th, 1995? 17 A: Correct. 18 Q: Yeah. So, it's unfortunate that the 19 first time that you had an opportunity to give your 20 version of events was some years later? 21 A: Very unfortunate, yes. 22 Q: Yeah. Yeah. And over the course of 23 time details pass, things become unclear, you can get 24 confused about things? 25 A: I could remember a majority of what


1 happened that night, but any fine, minute details, I'm 2 sure I would have forgotten or I would need to be 3 refreshed. 4 Q: Okay. Okay. And -- and I wanted to 5 ask you that because when I listened to your evidence 6 yesterday it sounded very specific and very detailed, and 7 I just wanted to go through that with you and see if -- 8 if your -- if you gave evidence about what you could 9 actually recall -- 10 A: Okay. 11 Q: -- at the time. Okay. 12 And you told us, and -- and there -- there 13 are some inconsistencies between what you said yesterday 14 and what your interview summary said from February of 15 2003, and that, of course, isn't unusual. 16 A: Hmm hmm. 17 Q: That you may like to have a chance to 18 turn your mind to that and -- 19 A: Sure. 20 Q: -- and see if we can address that. 21 You had told us yesterday that your -- 22 this started for you in that you were transporting a 23 cardiac call, an elderly man you were transporting from 24 Glencoe to Strathroy? 25 A: Yes.


1 Q: Yeah. And you have a clear 2 recollection of that? 3 A: How old this person was, no. None of 4 the minute details but, again, it was a -- a male -- 5 Q: Okay. 6 A: -- and I believe it was a cardiac 7 call. 8 Q: Okay. 9 A: That's about it. 10 Q: Okay. Because -- and I -- do you 11 have your February statement before you, your 2003 12 statement? 13 A: I do. 14 Q: Okay. Because if you turn on page 4 15 of that statement -- and, sorry, Mr. Commissioner, for 16 the assistance of Counsel it is Document Number 5000186. 17 COMMISSIONER SIDNEY LINDEN: I have 184. 18 MS. KAREN JONES: 184? I'm sorry. 19 COMMISSIONER SIDNEY LINDEN: That's what 20 I have in my copy. 21 MS. KAREN JONES: Okay. 22 COMMISSIONER SIDNEY LINDEN: Is it the 23 same one? It's a statement? 24 MS. KAREN JONES: No. 25 COMMISSIONER SIDNEY LINDEN: I'm sorry.


1 MS. KAREN JONES: You'll see -- 2 COMMISSIONER SIDNEY LINDEN: What -- 3 MS. KAREN JONES: I'm sorry, Mr. 4 Commissioner. 5 COMMISSIONER SIDNEY LINDEN: Maybe I'm 6 looking at the wrong one. 7 186; you're right, Ms. Jones. I'm sorry. 8 9 CONTINUED BY MS. KAREN JONES: 10 Q: And you'll see at that time you were 11 asked -- at the top of the page you'll see that you were 12 asked a question about: 13 "What was the nature of that call and 14 what were you doing at the hospital 15 when you noticed something unusual 16 occurring?" 17 And your answer at that time was that 18 under the call: 19 "I don't know the nature of the call. 20 However, we were transporting the 21 person -- patient to Strathroy 22 Hospital." 23 And I took from looking at that that you 24 didn't have a recollection at the time of the kind of 25 patient or the age of patient or the details of the


1 patient. 2 A: At that time, maybe. As well as I 3 may -- may not have realized if this person was in 4 cardiac arrest or this person was stable and we were just 5 transporting. But, I do remember it was a male patient 6 and I do recall it was cardiac of nature. 7 Was this person VSA? No, because I don't 8 believe it was a panic in the back of the ambulance when 9 I was dealing with this patient going to Strathroy so, it 10 may not have even been a Code 4, it could have been a 11 Code 3; not lights and siren, but urgent to get to 12 Strathroy. 13 Q: Okay. So, some of the details that 14 you gave us yesterday about it being a Code 4, you're not 15 sure about? 16 A: Again, ten (10) years ago... 17 Q: You -- you don't know that, those 18 details? 19 A: 100 percent? No. 20 Q: Okay. And, you told that part way to 21 Strathroy you received information from your partner that 22 you'd be staying at -- at the hospital after the call? 23 A: Correct. 24 Q: And, I take it at that point in time, 25 or maybe I'm incorrect, you were on standby?


1 A: They would have put us on a Code 8 2 after the call that we finished. 3 Q: Okay. 4 A: The standby call. 5 Q: Okay. And, at that point in time, at 6 that time, would you have been committed to the standby? 7 A: Definitely, yes. We would have had 8 to stay there until we were cleared by Dispatch. 9 Q: Okay. So, there wouldn't be any 10 further details that you'd have to confirm with the 11 dispatcher, that was the call that confirmed you to be a 12 Code 8? 13 A: Once we got to the hospital -- 14 Q: Yeah. 15 A: -- it would have been Mark Weiss -- 16 no, actually, it would have been myself since I was doing 17 the attending. I would call Wallaceburg Dispatch -- 18 Q: Okay. 19 A: -- and confirm the Code 8 number and 20 get times and what have you that we arrive; what time 21 they expect us to leave and what have you. 22 Q: Okay. And, you told us when you 23 arrived at the hospital that you saw a number of officers 24 in the vicinity? 25 A: Yes.


1 Q: Yeah. Do you have -- can you help us 2 with about -- now about how many offers -- officers you 3 might have seen? 4 A: Again, I can't give an exact detail. 5 Officers are dressed in dark colours. 6 Q: Sure. 7 A: I do remember two (2) cruisers to my 8 left and an exact number, I can't give; five (5) -- six 9 (6) officers, maybe. 10 Q: Okay. And, you told us that police 11 were dressed in their usual full uniform and some had 12 Stetsons on? 13 A: I do remember I -- I believe there 14 was a lady officer, blonde hair with a Stetson. 15 Q: Okay. 16 A: Probably about 5'5" maybe, 5'4". 17 Q: Okay. 18 A: Again, minute details, I -- I was 19 concentrating on my patient and getting him to Strathroy 20 Hospital, I wasn't really looking at what was going 21 around to be honest. 22 Q: Sure. Okay. And, I -- I wanted to 23 ask you that, because I understand and I anticipate that 24 we can -- we will hear that the OPP didn't start wearing 25 Stetsons until 1997.


1 A: Okay. 2 Q: So, your evidence yesterday about 3 seeing officers or -- officer or officers in a Stetson 4 doesn't seem to coincide with -- 5 A: I can live with that. 6 Q: -- what happened. 7 A: I just -- again, minute detail. 8 Q: Okay. But again, this is one -- one 9 of the things that -- that I wanted to make sure we 10 understood about your evidence because it seemed 11 yesterday that you were quite descriptive and quite clear 12 about details. 13 A: Okay. Well, I gave a false 14 impression then. I'm not 100 percent sure. 15 Q: Okay. Well, let -- let's go through, 16 then, about what you're clear about. 17 You talked about, then, taking your 18 patient into the hospital and dropping the patient off in 19 the trauma area? 20 A: Yes. 21 Q: Yeah. And, can you -- is that -- is 22 that trauma area the same area where Dudley George was 23 taken later? 24 A: I can't recall. There is two (2) 25 areas that you can bring patients into --


1 Q: Okay. 2 A: -- into Strathroy, if I remember 3 correctly. There is -- and they're both to the left. Go 4 past the waiting room to the left and the nurses will 5 direct you what room to go to. 6 At the time, we might have even brought 7 him up to the floor; we might have brought him up to the 8 Trauma Unit, got him stabilized and assisted to bring him 9 up to the floor, but I can't recall that. Odds are we 10 just brought him to the Trauma Unit, the cardiac patient. 11 Q: Okay. And -- and, I take it from 12 your answer that you can't specifically recall what you 13 did with the patient? 14 A: No. 15 Q: Or where he went or where you took 16 him? 17 A: No, it's out of my hands after we 18 bring him in. 19 Q: Okay. And, I take it then, you also 20 couldn't recall whether there was anybody else in the 21 room you dropped the patient off at the time? 22 A: Oh, definitely no. 23 Q: No, no. 24 A: I don't recall that at all. 25 Q: Okay. And, in terms of -- of just


1 looking at some times, I wondered if we could get Inquiry 2 Document Number 1002002 up on the screen. 3 And, this is what the Commission has 4 obtained are the reports from the Central Ambulance 5 Communication Centre in Wallaceburg. 6 A: Okay. 7 Q: And you told us yesterday that at 8 some point in time, you would have passed from London 9 through the -- through to the Wallaceburg dispatch and I 10 think you've gave -- given us your number, so what I 11 wanted to do is see if we can find you on this and look 12 at some times. 13 THE REGISTRAR: P-345. 14 MS. KAREN JONES: I'm sorry? 15 THE REGISTRAR: P-345. 16 MS. KAREN JONES: And it's P-345. Thank 17 you very much. 18 19 (BRIEF PAUSE) 20 21 CONTINUED BY MS. KAREN JONES: 22 Q: Okay. And if we just scroll down the 23 document a little bit, under -- the middle half of it, 24 we'll see a line that reads -- column that's "CCAC 25 London" and it says: "Glencoe 1169," I take it that's


1 you? 2 A: That would be -- 3 Q: And -- 4 A: -- correct. 5 Q: -- it's a Code 8, which is the 6 standby code? 7 A: Yes. 8 Q: And the time is given there at 00:03, 9 that is three (3) minutes after midnight? 10 A: Correct. 11 Q: Okay. And you've told us a little 12 bit earlier, I think you told us today that you made the 13 call to dispatch, and I think yesterday you told us your 14 partner did; and you can't recall -- 15 A: No. 16 Q: -- one way or the other? 17 A: No. Usually it's the person who is 18 attending who would make the call to dispatch, because 19 you're sitting at the desk, finishing your forms, and 20 that's where the phone -- the phones are -- 21 Q: Sure. 22 A: -- directly to dispatch. 23 Q: Sure. But, in any event, you did get 24 a confirmation and -- and we can look at this. And -- 25 and just to be fair to you, I -- I understand that


1 there's some issue from time to time about times in 2 different documents and discrepancies in times, but at 3 least, according to this, it looks like at about three 4 minutes after midnight you got the final confirmation -- 5 A: Okay. 6 Q: -- about the 8. Okay? 7 A: It doesn't look like I was on standby 8 either by the looks of it -- or on standby -- the call -- 9 Q: The Code 8? 10 A: Looking at the times here as well, it 11 looks like I probably would have been on regular duty as 12 well and this would not have been a standby or a call- 13 back call. Because I work until one o'clock, and from 14 1:00 until 7:00 I would have got called out. So, this 15 obviously wasn't a call-back call either, just to 16 clarify. 17 Q: Well, tell me what we're looking at 18 then, because now -- 19 A: Well, looking at the times there -- 20 Q: -- I'm confused. 21 A: -- if -- 22 Q: Okay. 23 A: -- time committed was 00:03 -- 24 Q: Yeah. 25 A: -- I originally stated that the


1 cardiac call was a call-back, call-back hours being from 2 1:00 in the morning until 7:00 in the morning -- 3 Q: Right. 4 A: -- so this obviously looks like we 5 originally got the cardiac call when we were actually 6 onsite at the ambulance station; that clarifies any times 7 as well. Because originally in my statement I said there 8 was a call-back call for the cardiac patient, meaning 9 from 1:00 until 7:00. 10 Q: Okay. Now, again, I'm confused. 11 Does -- when -- if you look at that then, if we go 12 through the sequence of events, you've told us that you 13 had picked up the patient, who you now recall as a 14 cardiac patient? 15 A: Yes. And by the sounds of it -- or 16 by looking at this document here, I originally thought 17 the patient was after one o'clock. 18 Q: Okay. 19 A: It looks like that patient would have 20 been before one o'clock, actually before twelve o'clock 21 obviously now. 22 Q: Sure. 23 A: So, just to clarify that as well. 24 Q: Sure. So the timing is different 25 than what you had recalled yesterday --


1 A: Yeah. 2 Q: -- when you look at that? 3 A: Yeah. 4 Q: So you would have -- you would have 5 picked up the cardiac patient, taken him, based on what 6 you say now, to Strathroy? 7 A: Strathroy. 8 Q: And when you got to Strathroy you 9 would have got the -- you would have confirmed with 10 dispatch the Code 8? 11 A: Exactly. 12 Q: Okay. So, at or about three (3) 13 minutes after midnight you're in the Strathroy Hospital, 14 right, your patient has already been dealt with, and 15 you've had time to be on the phone to dispatch and 16 receive confirmation? 17 A: Well, there could be about a ten (10) 18 minute discrepancy there as well for the fact that -- 19 Q: Sure. 20 A: -- dispatch may have given us the 21 Code 8 as we arrived at the hospital three (3) minutes 22 after. Or after we got the patient settled into the 23 hospital, got over to the phone and then made the call to 24 dispatch; we may have gotten the confirmation for code 8 25 at that time.


1 So they can either give us a Code 8 when 2 we arrive and mark the time or they can give us a Code 8 3 after we give them a call, and they give us that Code 8. 4 Q: Right. 5 A: So, it could be ten (10) minutes of 6 discrepancy there, no more than that I'm sure. 7 Q: Okay. So you could -- you could -- 8 what you're saying, as I understand it then, is that you 9 could have got that direction from dispatch as you first 10 drove in to the hospital or after you've already 11 delivered your patient and you're then -- then -- and 12 then you're done that call? 13 A: Yeah, normal procedure. That -- that 14 would be the time that we called -- 15 Q: Right. 16 A: -- normal procedure. 17 Q: And I take it you can't recall? 18 A: No. I'm sorry, I can't. 19 Q: No. Okay. And you then talked a 20 little bit about the things that you do after you drop 21 off your patient, and I understood from what you said 22 that you would or you or Mark would have taken the old 23 linen off a stretcher and put new linen on a stretcher? 24 A: Yes. 25 Q: That's what one person would have


1 done. 2 A: Yes. 3 Q: And another person would have done 4 the paperwork? 5 A: Correct. 6 Q: Okay. And can you help us understand 7 where in the emergency area of the hospital would you be 8 stripping the linen off the stretcher and putting fresh 9 on; is it right in the Emergency department? 10 A: It's right in the hallway. As soon 11 as you come through the sliding doors of Emerg. -- 12 Q: Hmm hmm. 13 A: -- you advance maybe ten (10) to 14 twelve (12) feet and you turn left, you go into Emerg. 15 If you keep going straight you're in the main hallway. 16 Q: Okay. 17 A: Usually we make the stretcher up 18 right in the main hallway. 19 Q: Okay. So if you were, and I take it 20 today you can't recall if you were the one who did the 21 stretcher or you were the one that did the paperwork? 22 A: No, I can't recall. A lot of time we 23 make it up together. We make the stretcher up together 24 or whoever's available first makes the stretcher up; 25 that way, we're ready to go.


1 Q: You don't know. 2 A: I don't know, no. 3 Q: Sure. But if -- if -- regardless, 4 the -- the making up of the stretcher takes place in the 5 Emergency department very close to the door -- 6 A: Yes. 7 Q: -- as a matter of course. 8 A: Yeah. 9 Q: And in terms of the paperwork, where 10 would you do the paperwork; would you do that in the 11 Emergency department? 12 A: Two (2) different areas you can do 13 the -- 14 Q: Okay. 15 A: -- paperwork. One (1) is, again as 16 you turn left -- 17 Q: Right. 18 A: -- from the main hallway to get into 19 Emerg., the trauma area, there's also a side room that 20 the nurses use and they allow us to do the paperwork in 21 there -- 22 Q: Okay. 23 A: -- or when you come through the front 24 door you can turn right, and there's an administrative 25 office in there. I'm not sure if we were using the


1 administrative office at that time or not. 2 Q: Okay. But in any event, if someone 3 was doing paperwork, they again would be in the Emergency 4 department and close to the door; is that right? 5 A: If you turn to the left, you're close 6 to -- 7 Q: Sure. 8 A: -- Emerg., but again, you're in a 9 separate room. 10 Q: Right. 11 A: Either way you're in a separate room. 12 Q: Sure. And I take it from any of 13 those areas, given that the Emergency department's a 14 pretty small area, you would be able to see and hear 15 what's going on in the department? 16 Would you be aware of what's going on? 17 A: No. 18 Q: No? 19 A: You wouldn't. 20 Q: Not at all? 21 A: Well, if there's a large commotion -- 22 Q: Okay. 23 A: -- you could probably hear something, 24 but just normal goings-on in the hospital, you wouldn't 25 really raise your suspicion for any reason why you'd get


1 up out of your chair. 2 Q: Okay. And do you recall if at any 3 period in time between the time that you were in the 4 Emergency department and the time when Mr. George 5 arrived, whether any other patients came into the 6 Emergency department? 7 A: No, it's not really something that 8 I'm paying attention to, to be honest. 9 Q: Okay. And similarly I take it, then, 10 you wouldn't have noticed if any other First Nations 11 persons came in in that time? 12 A: No. 13 Q: No? 14 A: I wouldn't have noticed or noted. 15 Q: And then you've told us, I think 16 yesterday, that when you were in the Emergency department 17 you didn't see any police at all inside. 18 A: Not that I can recall. 19 Q: Okay. And then you told us you heard 20 a commotion outside? 21 A: I think heard, sensed the commotion 22 going on outside as well, because again, I'm milling 23 around the Emergency department after my paperwork and 24 what have you is done and -- 25 Q: I'm sorry, your what?


1 A: I'm just, sort of, milling around the 2 Emergency department just looking for something to do or 3 finding a magazine to read when we're on standby for the 4 fact of, again, we don't know what's going on and -- 5 Q: Okay. 6 A: -- I would have been in the Emerg. I 7 may have saw a visual, someone moving across outside and 8 -- or -- 9 Q: And again, this -- you're speaking in 10 terms of "may" and "could have" and "might have". 11 A: Exactly. 12 Q: So, this is you filling in the 13 blanks, but you have no recollection; is that right? 14 A: No definite recollection. 15 Q: Okay. 16 A: Correct. 17 Q: So, at some point in time, you hear 18 something, you say and you go outside and you told us 19 yesterday that you saw a white car driving towards the 20 Emergency department. 21 A: Correct, as I'm -- as I'm exiting 22 Emerg. to go outside and the car's pulling in. 23 Q: Right. 24 A: Before the car came to a complete 25 stop, I backed out -- backed into Emerg. again.


1 Q: Right, and you told us that I think 2 you saw sparks flying from the front driver's side tire 3 area. 4 A: Yes. 5 Q: Is that right? 6 A: Yes. 7 Q: And what did that mean to you? What 8 -- what did you see? 9 A: It just meant someone was coming in 10 really, really fast. 11 Q: Okay. 12 A: They blew a tire. I didn't really 13 correlate that anything that was going on. 14 Q: Okay. And in -- you're clear about 15 where you saw the sparks coming from, or is that again 16 something that you're not clear about? 17 A: Well, my best recollection again is 18 it coming from the front driver's side. 19 Q: Okay. Because I -- again, I 20 anticipate that we'll hear evidence that the flat tire 21 was on the rear and I take it that doesn't particularly 22 change your recollection -- 23 A: No, I mean, if -- if the sparks were 24 coming -- originating from the left, they could have been 25 flying over the right and again, I'm not getting a


1 prolonged stare at this vehicle, I'm glancing out -- 2 Q: Sure. 3 A: -- and going back in. 4 Q: And going back in. Okay. And, I 5 think you told us also, yesterday, that the only police 6 cars that you saw were in the parking lot? 7 A: Correct. And that's to the left of 8 the Emerg. 9 Q: Right. And, over the course of the 10 time that you were in the Emergency department or going 11 out or going back in again, did you ever see police cars 12 in or around the pad of the Emergency department itself? 13 A: I can't give you a 100 percent answer 14 on that, no. 15 Q: You -- you don't recall? 16 A: No. 17 Q: Okay. And then -- I'm sorry? Okay. 18 And, we talked a little bit earlier about 19 time, about -- we -- we saw that the time that you were 20 committed according to this document is three (3) minutes 21 after 12:00 and that is the Central Ambulance 22 Communication Centre? 23 A: Hmm hmm. 24 Q: And, you've told us that it could 25 have been ten (10) minutes -- I -- ten (10) minutes


1 either way? 2 A: Give or take ten (10) minutes, yes. 3 Q: Yes. 4 A: Although, I -- I don't think it would 5 be ten (10) minutes after, it might be ten (10) minutes 6 before. 7 Q: Okay. And, do have any idea at all 8 about how long you would have been in the Emergency 9 department before you heard the commotion outside? 10 A: No. 11 Q: Okay. 12 A: I probably would -- I would have had 13 enough time to finish my paper work, which usually takes 14 ten (10) to fifteen (15) minutes -- 15 Q: Okay. 16 A: -- to finalize the accident report -- 17 ACR report. 18 Q: Okay. And again, you're saying, 19 "would have" and, are you filling in the blanks, or do 20 you recall? 21 A: Well no, I mean that's just a -- a 22 universal answer I would give to fill out an ACR report; 23 it would be ten (10) to fifteen (15) minutes. 24 Q: Right. And, I take it -- 25 A: That's what it normally would take


1 me. 2 Q: Okay. And, you said that you backed 3 into the Emergency Room for about ten (10) to twenty (20) 4 seconds and -- and you've described that there were wide 5 sliding doors? 6 A: Yes. 7 Q: And, I take it -- can you see through 8 the doors? Is there glass on the doors? 9 A: Yes. 10 Q: So, you could see what was going on 11 outside? 12 A: If I were to look out, sure. 13 Q: Okay. And, were you looking out to 14 see what was going on? 15 A: I'm sure I was, but again, if I -- I 16 can't -- it's not 100 percent, but I believe the car 17 stopped just before the Emergency door, so if I was 18 standing in Emerg in the hallway looking straight out, I 19 don't believe I would actually see the car. 20 Q: Okay. 21 A: It might have stopped just before the 22 Emerg. doors. 23 Q: You don't know? 24 A: No, I -- I can't give a hundred -- a 25 definite answer.


1 Q: Okay. And, you said that you then 2 came out and you saw a Native woman up against the wall 3 to your left with the legs prone and arms in the air? 4 A: Yes. 5 Q: Okay. Now, I just wanted to ask you, 6 up until this point in time, had you received any 7 information that you can recall about -- from anyone 8 about concerns about what might be coming to the hospital 9 -- any concerns that staff might have had, any concerns 10 that police might have had? 11 A: None. 12 Q: None? 13 A: No. 14 Q: Okay. And, that's -- Okay. 15 And, you told us yesterday that when you 16 went out and you saw the woman standing up against the 17 wall, you thought that she was the only person? 18 A: Correct. Up to that point I assumed 19 that she was the driver. 20 Q: Okay. And, I -- I wanted to ask you 21 about that because -- did you -- do you recall looking 22 around to see what was going on or was your attention 23 really focussed on her? 24 A: When I originally went out, I guess 25 that's where the commotion was --


1 Q: Right. 2 A: -- so, obviously I'm looking to my 3 left. 4 Q: Right. 5 A: I didn't see anybody else that really 6 caught my attention. 7 Q: Okay. And, you said -- I think you 8 told her that there were -- told us there were two (2) or 9 three (3) officers detaining her? 10 A: To my best recollection, there was 11 two (2) to three (3) officers; at least two (2) officers 12 detaining against the wall and I believe there was 13 another officer, if not two (2), standing back observing. 14 Q: Okay. And, were they just standing 15 there? 16 A: Just standing there, correct. 17 Q: Not doing anything? 18 A: No, they were just standing there. 19 Q: Okay. And, were they close to the -- 20 they were in the ramp area; is that right? 21 A: In the ramp area to the east of the 22 Emerg. 23 Q: Okay. So, when you come out the 24 doors, to the left? 25 A: To the left, correct


1 Q: Okay. And, did you see any police 2 cars at or around the white car? 3 A: Again, I -- I wasn't scanning the 4 area per se. 5 Q: Okay. 6 A: I didn't have time. I wasn't 7 thinking of scanning the area for any other vehicles or-- 8 Q: Sure. 9 A: -- persons. 10 Q: Sure. And we've already heard some 11 evidence from the woman that you saw, Ms. George -- 12 A: Hmm hmm. 13 Q: -- and I anticipate that we'll hear 14 more evidence, that at the time that she was outside in 15 the ramp area there were two (2) other people that were 16 there. 17 And she gave the Commission evidence that 18 Mr. Pierre George was close enough to her that she could 19 see him when she was being arrested by the officers. And 20 I anticipate we'll also hear evidence that the third 21 person in the car was at the ramp area too. 22 And do you recall seeing that at all? 23 A: I didn't see any other commotion, 24 other than Ms. George up against the wall. 25 Q: Okay. And I take it you're not


1 saying that didn't happen. I -- I take it you're saying 2 that you were really focussed on Ms. George because 3 that's where your attention was drawn? 4 A: That's where my attention was 5 focussed on, correct. 6 Q: Okay. And you then said that you 7 heard the woman yelling, and then you looked in the back 8 of the car? 9 A: Yes. 10 Q: Do you recall -- do you recall the 11 sequence of events there? 12 A: Again, you're asking me to put a 13 puzzle together that happened ten (10) years ago. I'm 14 trying to recollect. There's so much going on-- 15 Q: I am asking. And the reason I'm 16 doing that, again, is because your evidence yesterday was 17 very, very detailed and very, very specific. And it 18 wasn't clear to me at all from listening to you if you 19 were saying what you recalled or you were filling in the 20 blanks. 21 And I'm not asking you to fill in the 22 blanks. I'm -- 23 A: Okay. 24 Q: -- trying to see if we can establish 25 what you can recall.


1 A: Okay. 2 Q: Okay. And so do you -- do you recall 3 what happened then, after you heard the woman say, My 4 brother, my brother or words to that effect? 5 A: At that point, the vehicle obviously 6 had come to a full stop. At that point I would have 7 looked inside the vehicle, again out of curiosities sake. 8 Well, if she was yelling, My brother. My 9 brother, and -- and the officers had her detained against 10 the wall at that point, I believe I -- I walked back into 11 the Emerg. again and then I walked back out again to look 12 into the vehicle. 13 Q: Okay. Now, can you help us 14 understand, when you hear her say that, why would you 15 have walked into the Emergency department and why would 16 you have walked back out? 17 A: Again, no one's giving me direction-- 18 Q: Sure. 19 A: -- to stay, to go -- 20 Q: Sure. 21 A: -- to get away from the vehicle, to 22 assist. 23 Q: Sure. But, first of all, why did -- 24 hearing that, why -- why did you go into the Emergency 25 department?


1 A: Again, I'm not a police officer; this 2 is obviously a police -- 3 Q: Sure. 4 A: -- scene, not a paramedic scene. 5 Q: Sure. 6 A: I have no authority there. 7 Q: Sure. And so you would stay out of 8 the way? 9 A: Oh, definitely. 10 Q: Right. 11 A: If they're going to ask for my 12 assistance, they'll ask for my assistance. 13 Q: Sure. And other than that your view 14 was, and I take it you would have know, is that you 15 should keep clear? 16 A: Definitely. It's my opinion. 17 There's obviously something major that's going on and, 18 not being a police officer, it's still common sense to 19 stay away from the area. 20 Q: Sure. And yet I take it you then go 21 back out? 22 A: I then went back out. 23 Q: Okay. And what did you do when you 24 went back out? 25 A: Scan the vehicle; look inside at the


1 front seat; look inside at the back seat; noted Mr. 2 George in the back seat; again, waiting for direction, 3 what do to. 4 At that point, look around, no one's 5 giving me direction, I open the back of the car up, 6 eventually did a VSA, ABC's, airway, breathing, 7 circulation, did a -- I can do that in about five (5) 8 seconds just by doing a visual scan. 9 Eventually, I more likely would have taken 10 a carotid pulse as well. That's what -- 11 Q: Okay. If -- again, if you slow down 12 a little bit and we take this step by step it might work 13 out a little bit better. 14 A: Well, just stop me when you want me 15 to stop. 16 Q: No, I -- I will. Don't worry about 17 that. You've talked about looking in the back of the car 18 and then you open the car door? 19 A: Yes. 20 Q: And I think that you told us 21 yesterday that you didn't have any particular concerns 22 about doing that, concerns -- 23 A: No. There was -- 24 Q: -- for your safety? 25 A: -- really nothing that grabbed my


1 attention that's going to make me stop. I didn't notice 2 anything unusual for my safety. 3 Q: Okay. And you've told us that you 4 took from the commotion and the number of police in the 5 circumstances that something was going on? 6 A: Yes. 7 Q: And that you knew you should stay out 8 of the way? 9 A: Yes. 10 Q: Right. And in your statement that 11 you gave on February of 2003, and if you want to check on 12 page 6 of it, you talked then about being concerned about 13 weapons: 14 "Because at that point I believe I knew 15 shots had been fired somewhere." 16 So, that you did a chi -- quick visual 17 scan and you didn't see any weapons, and is that 18 something that you recall now or you don't recall? 19 A: I don't recall now, no. 20 Q: Okay. 21 A: I'm sure I may have heard -- 22 overheard conversations or what have you, why I said 23 that. 24 Q: But again, you're filling in blanks. 25 A: Filling in blanks, exactly.


1 Q: You have no recollection today -- 2 A: Exactly. 3 Q: -- of that? 4 And at the time, I take it when you spoke 5 to the detective, your recollection was different? 6 A: Yes. 7 Q: Yeah. And you've told us that you 8 saw someone in the backseat of the car and I think you 9 told us that they were lying down? 10 A: Yes. 11 Q: And their head was towards the 12 driver's side of the car? 13 A: Yes. 14 Q: Okay. And do you recall if the 15 person was lying on their back or on their side? 16 A: It would have been lying on their 17 side with their back against the back seat. 18 Q: Okay. And again, given what you know 19 about the circumstances and knowing your -- your views 20 that you should keep out of the way, did you say anything 21 to the police about, I'm going in the car or, I -- you 22 know, is it okay if I do this or can someone help me or 23 can I assist you? 24 A: At no given time. 25 Q: Pardon me?


1 A: No, I didn't. I was waiting for 2 direction from the police. I wasn't going to give them 3 direction, I was waiting for them to give me direction. 4 Q: Okay. And you weren't going to check 5 with them until you did something? 6 A: Yeah, well, that was my intention, 7 but obviously I did go in without asking -- 8 Q: Sure. 9 A: -- without given direction. 10 Q: Okay. And you told us yesterday that 11 when you looked in the back seat and then -- and looked 12 closer, that the person in the back seat had no shirt on? 13 A: Yes. 14 Q: Yes? And you told us yesterday that 15 the person had blue jeans on? 16 A: I'm sorry? 17 Q: Had blue jeans on? 18 A: Yes, to the best of my recollection, 19 yes. 20 Q: Yeah. Okay, and are you clear about 21 that recollection? 22 A: Well, the more times you ask me I can 23 always put doubt in my mind, but my best recollection is 24 there is -- blue jeans and no shirt. 25 Q: Okay. And again, I -- I'm asking


1 that, because we have heard evidence and we will hear 2 more that Mr. George had a shirt on and we'll also hear 3 evidence, I anticipate, that he had grey pants on; he 4 didn't have blue jeans on. So, I take it if that's 5 correct, your recollection is inaccurate. 6 A: Again, a lot going on. I wasn't 7 doing a wardrobe check at that time. 8 Q: Absolutely. It's just that you come 9 here and you say things that are very specific and so, 10 again, I'm trying to find out what you actually recall 11 and what you -- what you're filling in or might be 12 unclear that you filled in. 13 A: I'll try my best. 14 Q: Okay. And then you told us you 15 looked inside and then you stepped back from the car? 16 A: Yes. 17 Q: Okay. And do you recall how long you 18 stepped back from the car for? 19 A: A matter of seconds, I assume. 20 Q: Okay. But, you don't recall? 21 A: No. 22 Q: No. Okay. And then you told us that 23 you went forward again and you opened up the back door of 24 the car? 25 A: Yes.


1 Q: Okay. And which door did you open? 2 Was it on the passenger side or the driver's side? 3 A: It would have been on the passenger 4 side, the rear door. 5 Q: Okay. And you said, again, you 6 stepped back. 7 A: Stepped back again, waiting for the 8 fact of someone must see me making a movement towards the 9 car and someone must see the door open now. Someone's 10 going to stop me eventually. Nothing happened. 11 Q: And you say someone's going to stop 12 you eventually. What did you anticipate would happen? 13 A: I was just waiting for someone to 14 say, well, no, don't go in there. 15 Q: Okay. 16 A: This is a police matter, not a 17 paramedic matter. 18 Q: Okay. 19 A: It's not my authority to go in the 20 back of the vehicle and it wasn't my authority to back in 21 the vehicle. 22 Q: Sure, and so help me out with this, 23 then, why were you doing it? 24 A: I'm a paramedic. 25 Q: Okay.


1 A: There's a person in need of help, 2 obviously. 3 Q: Okay. And I take it if -- if you had 4 concerns about the person and you wanted to, you could 5 have gotten some assistance from inside -- 6 A: Hmm hmm. 7 Q: -- as well, from the staff that were 8 inside. 9 A: I could have. 10 Q: Sure. 11 A: Yeah. 12 Q: And you also could have said 13 something to the police? 14 A: I could very well have, yes. 15 Q: And you didn't? 16 A: Well, they could have asked me a 17 question as well. 18 Q: They -- 19 A: They could -- I was actually waiting 20 for direction from the police. Again, I'm not being 21 flippant with you by any means. I was just waiting for 22 someone to give me direction. 23 Q: Okay. And then you've talked about 24 doing the ABCs -- sorry. 25 And, at that point in time when you step


1 back from the car, did you go back into the Emergency 2 department or did you come out? 3 A: I can't recall 100 percent. 4 Q: Okay. And, you've told us, then, 5 that you did the ABC's; airway, breathing and 6 circulation. And, I think you told us yesterday it took 7 you about five (5) seconds to do that? 8 A: I can do that in about five (5) 9 seconds. 10 Q: Okay. So, I just wanted to go back 11 to that because you've told us about you're on the 12 passenger side of the car? 13 A: Yes. 14 Q: And, the head of the person in the 15 back of the car is at the driver's side? 16 A: Yes. 17 Q: And, they're on their side? 18 A: I'm sorry? 19 Q: They're on their side you've told us? 20 A: Yes. 21 Q: Okay. And, the first part of the 22 ABC's is 'airway?' 23 A: Airway. 24 Q: Okay. And, can you tell us how would 25 -- and, did you do a visual check? Did you just look at


1 the person or did you check their airway? 2 A: It's a -- a visual check for the 3 ABC's. In a trauma situation like that you look to see 4 if they have vomit in the mouth that's going to be 5 blocking the airway. 6 You're looking if there's going -- any 7 obstructions at all. I didn't see anything protruding 8 from the person's mouth, anything like that and anything 9 that would have caught my attention. 10 Then the breathing; is the chest rising; 11 is the abdominal rising to show that there's air being 12 pushed. I didn't see that and 'C' for circulation. Is 13 there blood on the -- on the floorboards? Is there blood 14 in the body? Is there blood anywhere else? I didn't see 15 that and I didn't see any mass trauma on the body. 16 Q: Okay. And, when you say that you 17 didn't see any breathing, I -- I take it that the normal 18 respiratory rate is somewhere between twelve (12) and 19 sixteen (16)? 20 A: Twelve (12) and sixteen (16). 21 Q: Sure. And, so over a five (5) second 22 period a person -- and -- and that would be a breath, in 23 essence, every five (5) or -- sorry, four (4) to six (6) 24 seconds? 25 A: Correct.


1 Q: Right. So, if you don't see a chest 2 rise or you don't see abdominal movement in that period 3 of time, that may not be abnormal, right? 4 A: It may not be. 5 Q: Sure. And, I take it also if someone 6 is breathing very shallowly, it may be very difficult to 7 see if their chest is rising? 8 A: Very much so. 9 Q: Sure. And, you've told us that you 10 saw no blood at all? 11 A: I do remember seeing just a little 12 bit on the chest, on the clavicle, but nothing's that 13 going to get my attention and make me stop and put gloves 14 on, per se. Nothing's going to make me stop and just 15 observed a bit longer. Nothing really caught my 16 attention. 17 Q: Okay. So, the person's lying on 18 their side you've told us? 19 A: Hmm hmm. 20 Q: And, where -- you say now that you 21 saw some blood or do you not recall? 22 A: I guess just more -- more redness in 23 the chest area. Again, I -- I -- 24 Q: You don't recall? 25 A: I don't recall 100 percent.


1 Q: No, okay. And, you told us, then, 2 that you took a carotid pulse? 3 A: Yes. 4 Q: And, that there was no pulse? 5 A: No pulse. 6 Q: Okay. And, I take in order to take 7 the carotid pulse you would have had to somehow get to 8 the person's head area? 9 A: Lean in. 10 Q: So, you leaned your body into the car 11 over top of the person? 12 A: Yes. 13 Q: And, do you recall doing that? 14 A: Yes. 15 Q: Okay. And again, to take you back to 16 February 2003 when you were asked by the detective 17 whether or not you took vital signs you had no 18 recollection of taking a pulse? 19 A: Yeah, that's what my notes say. 20 Q: Right. And, you do have a 21 recollection today? 22 A: I do. 23 Q: Okay. 24 A: Yes. 25 Q: And then, you told us that you got


1 back out of the car? 2 A: Yes. 3 Q: And, you went to the Emergency 4 department? 5 A: To retrieve the stretcher, I believe. 6 Q: Sorry, can you help us with what 7 you're looking at now? 8 A: I'm just looking at the notes and 9 trying to follow with you here. 10 Q: Okay. 11 A: I figure you're going to the next 12 page. 13 Q: Well, actually I'm -- I'm trying to - 14 - I'm taking you back to what you said yesterday. 15 A: Okay, yes. I -- I would have went 16 back into the Emerg. at that time, I believe, and got my 17 stretcher. 18 Q: Okay. And, at that point in time, 19 did you say anything to the police? 20 A: No. 21 Q: Did you say anything to any staff in 22 the hospital? 23 A: I don't believe I saw any staff at 24 that time. 25 Q: There was no staff there?


1 A: Again, I -- I don't believe I saw any 2 staff. Again, it could have been tunnel vision where I 3 was just concentration going directly to my stretcher and 4 bringing the stretcher out. 5 Q: Okay. And then, you told us that you 6 went out and you put your stretcher alongside the car? 7 A: Yes. 8 Q: Yeah. And at that point in time did 9 you try to move the person in the back seat by yourself? 10 A: I think I may have. 11 Q: Okay. And you said yesterday that 12 Mr. George -- I think your language was, "was a large 13 boy"? 14 A: He would have been very large, 15 probably about -- I'm estimating now, again, I didn't -- 16 I only was with him maybe ten (10) minutes for the whole 17 procedure -- but maybe two-forty (240), two-twenty (220). 18 Q: Okay. 19 A: That's -- that's a large individual 20 for me to lift. 21 Q: Okay. And did you have any idea 22 about how tall he might have been when you were dealing 23 with him? 24 A: No. I -- I'm sure he was more than 25 five (5) foot, not any more than seven (7) foot, so I


1 imagine in the six (6) foot range. 2 Q: Around six (6) feet tall? 3 A: Again, laying down. 4 Q: Okay. And when you say he weighed 5 somewhere between two twenty (220) and two forty (240), 6 is that -- I -- I take it that in the course of what you 7 do you're used to lifting people quite regularly? 8 A: Yes. 9 Q: And do you consider yourself pretty 10 accurate in terms of estimating weight? 11 A: I wouldn't get a job at the fair per 12 se estimating weight but -- 13 Q: No. 14 A: -- again, this person was laying in 15 the back seat -- 16 Q: Sure. 17 A: -- I -- again, things were happening 18 fast. 19 Q: Sure. 20 A: I'm just giving you an estimation 21 from what I can remember, in my own memory. 22 Q: Right. 23 A: I do remember Mr. George being a 24 large individual. 25 Q: Okay. And then you tell us that you


1 yell, I can't do this on your own? 2 A: Yes. I remember getting up, saying: 3 "Guys, I can't do this on my own." 4 Q: Okay. And you told us, I think, that 5 Mark Weiss comes in response to your yell; that's what 6 you recall? 7 A: Yes. 8 Q: Okay. And your recollection, as I 9 understand it, is that no police officers assisted? 10 A: There may have been police officers 11 there. Again, there was a lot of uniforms around and a 12 lot of people around. Looking at other statements here, 13 I believe there was another paramedic who assisted as 14 well from Forest or Watford. I can't even remember 15 seeing the other paramedic. 16 Q: Okay. So, again, you were so 17 focussed on the person that you didn't really see what 18 was going on or who was there or what was happening -- 19 A: Yes. That's -- 20 Q: -- is that fair enough? 21 A: -- very correct. 22 Q: Okay. And then you told us that you 23 and Mark Weiss took Mr. George into the Emergency 24 department? 25 A: Correct.


1 Q: Took him to the trauma room? 2 A: Yes. 3 Q: Okay. And then you told us yesterday 4 that you lifted him by a sheet onto a bed? 5 A: That would have been the normal 6 procedure. 7 Q: Okay. And is that something that you 8 recall doing or is that something that you're filling in? 9 A: I can't recall doing that but that's 10 the only way we more likely would have gotten him over. 11 99.9 percent of the times we lift someone over it's with 12 a sheet lift. 13 Q: Okay. I guess my question to you is: 14 Do you actually recall moving Mr. George from a stretcher 15 to -- 16 A: No. 17 Q: -- a bed? 18 A: I'm not going to say 100 percent, no. 19 Q: You don't recall that. So, again, 20 that was something that might have happened but you don't 21 know; is that -- 22 A: Yes. 23 Q: Okay. And then you told us that you 24 helped in the resuscitation efforts with bagging Mr. 25 George, and that, I take it, meant using a Ambu. bag to


1 press air into his lungs? 2 A: Yes. 3 Q: Okay. And do you have a clear 4 recollection of that? 5 A: I remember not doing the whole 6 procedure because I do remember a nurse taking over at 7 that point. It was starting to get crowded in the room. 8 A nurse is going to be able to do the bagging as well as 9 assist further on other medical procedures, so at that 10 point, I believe, I did just step aside. 11 Q: Okay. You do recall bagging him 12 though? 13 A: I do. 14 Q: And you recall bagging him the trauma 15 room? 16 A: I do recall bagging, yes. 17 Q: Again, in February of 2003, when you 18 spoke to the detective, you told the detective that you 19 had moved Mr. George from a stretcher to a hospital bed 20 and after that point in time you had no contact with him. 21 Do you -- do you recall that? 22 A: I recall giving the statement. I 23 don't recall giving that comment but obviously I did from 24 the fact it's in the notes here, I'm... 25 Q: Yeah. Yeah.


1 A: Okay. 2 Q: And does that assist you at all today 3 in terms of what happened or does it help -- in terms of 4 your recollection, could that again be something that 5 you're filling in? 6 A: It could very well. 7 Q: Something that you're filling in? 8 A: Filling in, exactly. 9 Q: Okay. And you told us yesterday that 10 there was one (1) other person in the room? 11 A: Yes. 12 Q: And is that something that you 13 recall? 14 A: That's something I definitely recall. 15 Q: Okay. 16 A: When they were filling that in there 17 was a young male native up against the -- on a hospital 18 bed. 19 Q: Okay. 20 A: In the same room that we came in. 21 Q: Okay. And was there any other 22 patients in that room. 23 A: I can only recall seeing that one (1) 24 person. 25 Q: Okay.


1 A: For the fact of as soon as we came 2 in, that's who I noted. 3 Q: Right. And so is -- is it possible 4 that there was someone else in the room; another patient 5 in the room or not? 6 A: Again, 100 percent no. I don't 7 believe the room's that big and again, hospital 8 procedure. I was surprised -- actually that's why I 9 remember this person, for the fact of why is there 10 someone in here already when we're bringing another 11 trauma patient in. 12 Normally, the room's clear at that point. 13 Only for the persons who should be in there. 14 Q: Right. And I take it if there had 15 been two (2) people in there, it might have been even 16 more -- that again would have been something that would 17 be very unusual for you? You might have noted that. 18 A: Yes. 19 Q: Yeah. 20 A: Yeah. 21 Q: And you don't have any recollection 22 of that? 23 A: No, and for the fact when we first 24 came into the trauma room, I can only recall seeing two 25 (2) beds in there, one (1) that this other young male was


1 laying on and the other bed that Mr. George would have 2 been put on. 3 There may have been beds to the right. I 4 can't recall seeing anybody on those beds, or I can't 5 even recall seeing any beds to be honest, so... 6 Q: Pardon me? 7 A: There may have been beds to the right 8 when you first come into the trauma room -- 9 Q: Okay. 10 A: -- or there may have been persons in 11 there. I didn't note. 12 Q: Okay. 13 A: For the fact of my vision is just 14 going straight to the secondary bed. 15 Q: Okay. And your recollection is that 16 there was a bed in the room that was empty? 17 A: Yes, there was two (2) beds in there, 18 one (1) that there was a young male native laying on and 19 there was another bed that Mr. George was going on. 20 Q: Okay. And that's something that 21 you're clear about? 22 A: Def -- I'm clear about that. 23 Q: Okay. Because I anticipate that 24 we'll -- we've already heard evidence about the number of 25 beds in that room and we will be, I anticipate, hearing


1 evidence from the nurse in the room who said that there 2 wasn't a bed in that room for Mr. George, that he stayed 3 on the stretcher. 4 A: Okay. 5 Q: Does that change your view at all or 6 make -- 7 A: No. 8 Q: -- you think about what you're 9 filling in and what you're actually recalling? 10 A: No. 11 Q: No? 12 A: No. 13 Q: Okay. And you talked about the 14 resuscitation going on for a period of time and when it 15 was done, you said that you might have made an incident 16 report? 17 A: May have made an incident report, 18 yes. 19 Q: Okay. But, you said that you did not 20 complete an accident -- a call report. 21 A: Yes. 22 Q: Okay. 23 A: Again, I'm not a 100 percent sure if 24 we did or we didn't. 25 Q: Okay. Because in --


1 A: It should be on record if we did. 2 Q: Okay. Because in February you had 3 told the -- of 2003 you had told the detective that you 4 did do that. 5 A: Okay. 6 Q: And I take it that when we go through 7 the sequence and the chronology that, in part because it 8 was a long time ago and in part because a lot of things 9 were happening, and in part because you were very 10 focussed, that time would have been compressed. 11 It would be hard to get a sense of time? 12 A: Oh definite -- and that's what I'm 13 experiencing now. It's -- it's when you ask me a 14 question regards to time, again I apologize. I'm not 15 trying to be flippant but it's hard to -- 16 Q: Yeah. 17 A: -- remember the time and the events. 18 Q: No. And that some things that seem 19 like they were clear in your mind, may not in fact be so? 20 A: Could very well be for the -- 21 Q: Sure. 22 A: -- timeframe as well as reading other 23 statements and -- 24 Q: Sure 25 A: -- what have you.


1 Q: And other things. And I anticipate 2 that we -- sorry, let me just go back here a little bit. 3 4 (BRIEF PAUSE) 5 6 Q: We've already heard evidence from Mr. 7 Watt, an ambulance attendant, on April 25th of -- in this 8 proceeding, and what he told us is that he was also in 9 that area, that is on or around the ramp -- 10 A: Hmm hmm. 11 Q: -- when the white car drove in and he 12 also heard someone yelling and he says that at that point 13 in time a stretcher came out very quickly from the 14 Strathroy Hospital's Emergency department and he and 15 other people very quickly got Mr. George onto the 16 stretcher and into the Emergency department. 17 And I take it that given the passage of 18 time and given the circumstances that it's possible that 19 the sequence of events, that is, the car coming in, the 20 stretcher coming out and Mr. George being put on it could 21 have happened quite quickly? 22 A: Oh, definitely so. 23 Q: Yeah. And, that it's not -- it's -- 24 it's certainly -- Mr. Watt was quite clear that he was 25 there assisting without any prompting from anyone. And,


1 I take it that that would be possible as well? 2 A: Yes, very much so. 3 Q: Sure. And, I anticipate that we will 4 also hear from an OPP officer, Constable Boon who will 5 say he was also in that area at the time and when the car 6 came in, there was also some yelling; he heard that. And 7 very quickly a stretcher came out and he also assisted in 8 getting Mr. George onto the stretcher and into the 9 Emergency department. 10 And, I take it, that would be possible, 11 too? 12 A: Oh, very much so. I -- again, Mr. 13 George was a heavy individual, so obviously myself and 14 Mr. Weiss, if we struggled we could have gotten him onto 15 the stretcher, again, being -- coming from the back of 16 the car on to the stretcher, so obviously we would have 17 had help from others as well. 18 Q: Sure. Sure. And, it's not 19 inconsistent with your recollection that the stretcher 20 would have come out and there would have been people 21 assisting to get him on very quickly? 22 A: Oh, definitely. 23 Q: Yeah. And, in fact, I -- I -- and 24 the other -- the other -- the other portion of evidence 25 that I anticipate that we'll hear was that at the time


1 that the white car was on the ramp and people were being 2 arrested was that there were many police officers in the 3 area and I understand that we'll -- or anticipate that 4 we'll hear evidence that those officers and the people 5 who were arrested stayed in that area for some time? 6 A: Okay. 7 Q: And, I take it that that's possible, 8 too? 9 A: Sure. And -- and again, it was -- 10 there's lights out there, but I can't -- I'm not scanning 11 there, eh, per se, so very -- very possible there was 12 others. 13 Q: You may have been focussed and you 14 may not have looked around and you may not have seen what 15 was going on? 16 A: Yeah, very true. 17 Q: Yeah, okay. And, those are my 18 questions. Thank you very much. 19 COMMISSIONER SIDNEY LINDEN: Thank you, 20 Ms. Jones. 21 Mr. O'Marra, do you have any questions? 22 MR. AL O'MARRA: No, thank you. 23 COMMISSIONER SIDNEY LINDEN: No 24 questions? Is there any re-examination, Ms. Vella or Ms. 25 Hensel? I notice Mr. Worme's not here.


1 2 RE-DIRECT EXAMINATION BY MS. SUSAN VELLA: 3 Q: Thank you, Commissioner. I just have 4 a few questions for you, Mr. Scott. 5 Did the events of the early hours of 6 September the 7th, 1995 make an impression upon you? 7 A: From the beginning of the call, not 8 really for the fact I really didn't know what was going 9 on and wasn't filled in as to what was going on. After 10 the fact, yes. 11 Q: All right. Is it fair to say that 12 you don't recall clearly the events from that night which 13 were peripheral to your main concern, which was hearing 14 the white car come into the parking lot, the Carolyn 15 George arrest commotion and then finding and transporting 16 Dudley George? 17 A: Yes, that was -- that was my main 18 concentration. I wasn't paying as much attention to the 19 police procedure as I was for the medical procedure. 20 Q: Or the events surrounding those 21 events? 22 A: Yes, yes. 23 Q: And similarly, you were not looking 24 at any clock or watch while these events were occurring? 25 A: Yes.


1 Q: And so, your impression of time, the 2 time consumed by these events, it's really a peripheral 3 event? 4 A: Exactly. It -- it probably takes me 5 longer to explain the event than the event actually 6 happen. 7 Q: Is it fair to say that when you have 8 revised you estimate of the time consumed from when you 9 first hear the car come into the parking lot to the time 10 that you transport Dudley George into the trauma unit is 11 based on what you now know to be the standard time for 12 police officers to clear a car of suspects? 13 A: Yes. 14 Q: So, you've revised your time estimate 15 from what you gave in 2003 based on your after-acquired 16 information? 17 A: Yes. 18 Q: I suggest to you, Mr. Scott, that the 19 time period which would have been consumed during the -- 20 all the events that you describe having undertaken on 21 that evening from the time of hearing the car coming to 22 the parking lot to the time that you physically entered 23 the trauma unit with Mr. George is more -- was more 24 accurately reflected in your 2003 statement, when you 25 didn't have the after acquired information upon which you


1 now rely. 2 Do you agree? 3 A: I'm thinking of the time I have in my 4 mind now is probably more accurate to be honest. 5 Q: All right. Did you continue to do a 6 visual examination while you were transporting Dudley 7 George into the trauma unit on the stretcher? 8 A: I can't recall. 9 Q: All right. Are you clear today that 10 you were the first person to go to the white car in which 11 Dudley George was located? 12 A: Yes. And there may have been persons 13 around, that just in my peripheral I didn't see them. 14 Q: And that when you first approached 15 the car to discover Dudley George, you were alone? 16 A: Yes. 17 Q: And the item which most clearly 18 stands out in your memory today, is you bewilderment that 19 no one at least, initially, seemed to notice that there 20 was a apparently severely injured man in the back of that 21 car? 22 A: I think what stands out in my mind 23 more so is that no one was giving me direction. Again, 24 I'm standing up, I'm six (6) foot tall, I mean, hopefully 25 someone could see me. I'm waiting for someone to give me


1 direction as to proceed further or to stop what I'm 2 doing. 3 Q: So, it was your bewilderment which -- 4 which really is the strongest impression that -- that you 5 have from that evening? 6 A: Yes. 7 Q: Thank you. Those are my questions. 8 I want to thank you very much, Mr. Scott, for coming and 9 giving your testimony to the Commission. 10 COMMISSIONER SIDNEY LINDEN: Thank you 11 very much for giving us your testimony. 12 THE WITNESS: Thank you, sir. 13 COMMISSIONER SIDNEY LINDEN: Thank you 14 very much. 15 16 (WITNESS STANDS DOWN) 17 18 COMMISSIONER SIDNEY LINDEN: Would you 19 like to start this witness now? I think we should, I'd 20 like to break around -- 21 MS. KATHERINE HENSEL: 10:30? 22 COMMISSIONER SIDNEY LINDEN: -- somewhere 23 between a quarter after; sometime there. 24 MS. KATHERINE HENSEL: All right. 25 COMMISSIONER SIDNEY LINDEN: I think we


1 should start now. 2 MS. KATHERINE HENSEL: All right. The 3 Commission calls as its next witness, Dr. Michael Shkrum. 4 5 (BRIEF PAUSE) 6 7 COMMISSIONER SIDNEY LINDEN: I'm correct, 8 am I, Ms. Hensel, Dr. Shkrum is our only witness for 9 today? 10 MS. KATHERINE HENSEL: That's right. 11 12 (BRIEF PAUSE) 13 14 COMMISSIONER SIDNEY LINDEN: Good 15 morning, Dr. Shkrum. 16 THE REGISTRAR: Good Morning, Doctor. 17 DR. MICHAEL SHKRUM: Good morning. 18 THE REGISTRAR: Do you prefer to swear on 19 the Bible or affirm, sir? 20 DR. MICHAEL SHKRUM: I'll -- I'll swear 21 on the Bible. 22 THE REGISTRAR: Take the Bible in your -- 23 DR. MICHAEL SHKRUM: Would you like me to 24 rise? 25 THE REGISTRAR: That's fine. Could you


1 give us your name in full please. 2 DR. MICHAEL SHKRUM: It's Michael James 3 Shkrum. S-H-K-R-U-M 4 THE REGISTRAR: Thank you, sir. 5 6 MICHAEL JAMES SHKRUM, Sworn 7 8 (VOIR DIRE COMMENCED) 9 10 EXAMINATION-IN-CHIEF BY MS. KATHERINE HENSEL: 11 Q: Good morning, Dr. Shkrum. 12 A: Good morning. 13 Q: I'm going to begin, Doctor, by going 14 through your professional and educational background. 15 Commissioner, if you'd like to turn to Tab 16 13 in the brief in front of you, you'll find it contains 17 Dr. Shkrum's curriculum vitae. 18 COMMISSIONER SIDNEY LINDEN: Thank you. 19 20 (BRIEF PAUSE) 21 22 CONTINUED BY MS. KATHERINE HENSEL: 23 Q: Dr. Shkrum, I understand that you 24 obtained your Bachelor of Science Degree in Biology from 25 the University of Western Ontario in London, Ontario;


1 that degree was conferred in 1978? 2 A: Yes, it was. 3 Q: And you actually completed those 4 studies during the years 1971 to 1974? 5 A: Yes. 6 Q: You received your Doctor of Medicine 7 from the Faculty of Medicine, University of Western 8 Ontario in 1978? 9 A: Yes. 10 Q: You completed a rotating internship 11 in 1978 and 1979 at the Ottawa Civic Hospital? 12 A: Yes, I did. 13 Q: And, from 1979 to 1984 you completed 14 a residency in anatomical pathology at the University of 15 Western Ontario Teaching Hospitals? 16 A: Yes. 17 Q: From 1984 to 1985 you completed a 18 fellowship in forensic pathology and Assistant Chief 19 Medical Examiner at the Office of the Chief Medical 20 Examiner in Chapel Hill, North Carolina, USA? 21 A: Yes. 22 Q: I understand that you are licentia 23 with the Medical Council of Canada since 1978? 24 A: Yes. 25 Q: You're a diplomat -- am I saying that


1 right -- a diplomate -- 2 A: Diplomat, yeah. 3 Q: Thank you, of the National Board of 4 Medical Examiners since 1979? 5 A: Yes. 6 Q: You've had a certification from the 7 Royal College of Physicians and Surgeons of Canada in 8 anatomical pathology since 1983? 9 A: Yes. 10 Q: You're a Diplomat of the American 11 Board of Pathology in anatomical pathology since 1983? 12 A: Yes. 13 Q: And, as well in forensic pathology 14 since 1986 from the same body? 15 A: Yes. So, basically what that means 16 is that I received my certification as a specialist in 17 anatomical pathology in Canada and I also have my 18 specialty examination or certification from the United 19 States in both anatomical and forensic pathology. 20 Q: Okay. And, are those certifications 21 in forensic pathology available in Canada? 22 A: Not at the present time, although 23 recently the Royal College of Physicians and Surgeons of 24 Canada has recognized forensic pathology as a sub- 25 specialty and probably in the next few years there will


1 be more formal certification in that regard. 2 Q: Okay. And, the training that you 3 undertook in North Carolina, in Chapel Hill, was that, at 4 the time, available in Canada? 5 A: There were some fellowship programs 6 available in -- in Canada. Some of them, for example, in 7 Alberta required that you had -- had to go down to the 8 United States to do part of your training there. 9 Q: All right. Thank you. Okay. Just 10 to continue, I understand that you hold medical licenses 11 in both Ontario and North Carolina? 12 A: I -- I held a medical license in 13 North Carolina during my fellowship year in 1984 to 1985. 14 Q: Okay. 15 A: But I currently hold -- hold a 16 general medical license in the Province of Ontario. 17 Q: Okay. In terms of your employment 18 history and clinical appointments, since 1985 you have 19 held the position of Staff Pathologist with the 20 Department of Pathology at the Victoria Hospital in 21 London, Ontario? 22 A: I -- I started at the -- the old 23 Victoria Hospital in London and that -- that hospital as 24 well as two (2) others, the University Hospital and St. 25 Joseph's Hospital have merged. I'm sorry, the --


1 Victoria Hospital has merged with the University Hospital 2 to become London Health Sciences Centre. 3 Q: Okay. And -- and, that is where 4 you're currently serving as a Staff Pathologist? 5 A: Yes. 6 Q: Since 1987, you've been a member of 7 the Consulting Medical Staff with the Department of 8 Pathology at St. Joseph's Healthcare as well? 9 A: Yes. And again, that -- that 10 particular department has merged as one (1) big 11 department. So, the three (3) hospitals, Victoria 12 Hospital and University Hospital and St. Joseph's 13 Healthcare, are now one (1) -- one (1) Department of 14 Pathology based at the former University Hospital. 15 Q: And, since 1986, I understand that 16 you have served in various capacities as a professor or 17 assistant or associate professor with the Department of 18 Pathology, Faculty of Medicine at the University of 19 Western Ontario? 20 A: Yes, I -- I progressed through the 21 academic ranks at the University and I'm -- I'm currently 22 a -- a full professor in the Faculty of Medicine. 23 Q: Okay. And, I understand that you are 24 also currently the medical leader for autopsy services 25 with the Department of Pathology at the London Health


1 Sciences Centre? 2 A: That's correct. 3 Q: Okay. And, you've held that position 4 since 1987? 5 A: No, actually -- 6 Q: Or, 1997, sorry. 7 A: Sorry, 1997. 8 Q: Yeah. And further, you are the 9 Director of the Regional Forensic Pathology Unit in 10 London, Ontario since 2001? 11 A: Yes. 12 Q: Okay. Just to go back to the 13 previous position, can you describe briefly for us, what 14 duties you fulfill as medical leader with the department 15 -- with Autopsy Services? 16 A: This a -- a new position created in 17 1997 with the merger of the hospitals and the departments 18 of pathology. There was certain leadership positions 19 recognized in the department, one (1) of them being the 20 Autopsy Services. 21 I've -- I've listed a -- a number of 22 things that were done since that time regarding the 23 autopsy service, but one of them was the actual 24 architectural planning for an autopsy facility in London. 25 This facility was also to address forensic needs in -- in


1 Southwestern Ontario. So, there was a lot of thought 2 that went into that. 3 We also prepared a -- a proposal to the 4 Ministry of Solicitor General at the time, for 5 establishment of a forensic unit in London, and funding 6 was realized for this unit in 2001. That was the year I 7 was actually appointed the director of that unit. 8 I also participated in the consolidation 9 of the autopsy services in -- from all three (3) 10 hospitals, Victoria Hospital, University Hospital and St. 11 Joe's (phonetic), such that all the -- any autopsy now 12 that's required in the city comes to our one facility; 13 before there used to be three (3) separate facilities. 14 I also participated in the development of 15 a city-wide autopsy authorization form, information 16 pamphlet for families to inform them what the autopsy was 17 about; developed scheduling for -- for pathologists that 18 -- to rotate in the -- in the autopsy service, 19 particularly in the forensic cases. 20 I obviously prepare an annual report that 21 goes to the office of the Chief Coroner reporting on our 22 activities. That's sort of, in a nutshell, what -- what 23 I've done. 24 Q: It sounds like quite a bit. Thank 25 you, Dr. Shkrum.


1 COMMISSIONER SIDNEY LINDEN: You have a 2 sixteen (16) page CV. 3 THE WITNESS: I hope that you don't have 4 to read it all today, sir. 5 6 CONTINUED BY MS. KATHERINE HENSEL: 7 Q: Don't worry, I'll take over some 8 parts. I understand that you have also lectured at the 9 Ontario Police College in the past on a variety of topics 10 related to forensic pathology? 11 A: Yes. To the general investigative 12 course that was held then and also the homicide course. 13 Q: All right. I note also from 14 reviewing your -- your curriculum vitae that you have 15 published twenty-six (26) articles in peer reviewed 16 publications in -- on topics relating to forensic 17 pathology? 18 A: Most of them related to forensic 19 pathology -- 20 Q: Okay. 21 A: -- or some area of pathology. 22 Q: And that was in addition to a -- a 23 number of other presentations and publications in -- in 24 other media? 25 A: Yes, at meetings.


1 Q: Okay. And I understand further -- if 2 -- Commissioner, if you'd like to refer to Tab 14 of the 3 brief in front of you, there is an expert witness -- a 4 summary of expert witness testimony for Dr. Shkrum. And, 5 by the way, the benefit of Counsel, both the -- the 6 curriculum vitae and the summary were distributed 7 electronically with the outline of Dr. Shkrum's 8 anticipated evidence. 9 Just briefly, Dr. Shkrum, I note from that 10 summary that you have provided expert testimony at a 11 number of levels of trial court in -- in Canada on -- in 12 the areas of pathology, forensic pathology and causes of 13 death? 14 A: Yes. This -- this lists my 15 testimony in the Province of Ontario. I -- 16 Q: Okay. 17 A: -- I did testify also in North 18 Carolina, and that's not listed here. 19 Q: All right. Thank you. And I note 20 that you've listed there over seventy (70) different 21 proceedings? 22 A: It's approximately seventy (70), yes. 23 Q: Yeah. I understand that you conduct 24 an average of forty (40) medical/legal autopsies per 25 year?


1 A: That was at the time that -- in -- I 2 think back in 1997, when I testified at the trial, but 3 actually it's now over a hundred (100) -- a hundred (100) 4 cases. 5 Q: Okay. 6 A: Because of our regional forensic 7 unit, we not only deal with our cases in the London area 8 but we also get referrals of problematic cases, 9 homicides, suspicious deaths, from -- from all over 10 Southwestern Ontario. 11 Q: Okay. And for the Commission's 12 benefit, Dr. Shkrum, can you provide a description of -- 13 or what is the distinction between a medical/legal 14 autopsy and any other autopsy? 15 A: In -- in the Province of Ontario 16 there -- there are two (2) processes by which an autopsy 17 can occur. 18 Q: Hmm hmm. 19 A: One that I've -- I've alluded to 20 already, regarding information for families, is that if 21 someone dies, usually in a hospital setting, there may be 22 a desire, either by family or the clinicians, the medical 23 doctors taking care of that individual in the hospital, 24 to have an autopsy performed. 25 That -- in that case then, authorization


1 or consent is needed from the family to proceed with the 2 autopsy. And this autopsy can be a complete autopsy with 3 examination of all organs and tissues in the body, or it 4 can be limited to a certain area of the body. But the 5 key thing is it requires the consent of the next of kin. 6 So, that's the so-called hospital -- 7 hospital autopsy, because that's the usual setting that 8 that occurs in. 9 The other type of autopsy is the medical/ 10 legal autopsy and that's governed by statues in different 11 jurisdictions and Ontario; it's governed by the Coroner's 12 Act. And there are certain types of deaths that require 13 investigation that have medical-legal implications. 14 And again in a nutshell, these would be 15 deaths that occurred suddenly and unexpectedly because of 16 a disease process. So, someone basically drops dead; the 17 Coroner will investigate that kind of case. It's 18 probably the most common scenario that the Coroner 19 investigates. 20 The other types of deaths investigated by 21 the Coroner would be unnatural deaths, so that would be 22 accidents, suicides and homicides. 23 So, in that case, the Coroner will order 24 an autopsy to be done and the pathologist will perform 25 that autopsy.


1 Q: Right. So, in addition to the over 2 one hundred (100) medical-legal autopsies that you 3 perform each year, you also perform hospital autopsies? 4 A: Yes, I do. 5 Q: All right. And roughly how many per 6 year would yo perform? 7 A: Well our facility, we do 8 approximately -- about six hundred (600) autopsies in 9 total. 10 Q: Hmm hmm. 11 Q: Of which almost four hundred (400) 12 are Coroner's autopsies. I do about -- about 25 percent 13 of those, you know, about a hundred (100) and I would 14 either do or supervise, because we do have a residency 15 training program where we train pathologists or residents 16 or doctors who become pathologists, I probably either do 17 or supervise probably another forty (40) or fifty (50) a 18 year. 19 MS. KATHERINE HENSEL: Thank you, Dr. 20 Shkrum. Commissioner, I would like to tender Dr. Shkrum 21 as an expert in the area of forensic pathology in 22 general, and in particular with respect to the 23 pathological issues dealing with the death of Dudley 24 George. 25 And I would also like to enter his


1 curriculum vitae as an exhibit. 2 THE REGISTRAR: P-378, your Honour. 3 COMMISSIONER SIDNEY LINDEN: P-378. 4 5 --- EXHIBIT NO. P-378: Curriculum Vitae of Dr. 6 Michael James Shkrum. 7 8 MS. KATHERINE HENSEL: As well as the 9 summary of his expert medical testimony. 10 THE REGISTRAR: P-379. 11 COMMISSIONER SIDNEY LINDEN: P-379. 12 13 --- EXHIBIT NO. P-379: Expert witness' testimony 14 Ontario Dr. Michael James 15 Shkrum. 16 17 COMMISSIONER SIDNEY LINDEN: Does anybody 18 have any questions or wish to comment on the 19 qualifications of the doctor? 20 No? That's fine then. The doctor is 21 recognized as an expert -- 22 MS. KATHERINE HENSEL: Thank you, 23 Commissioner. 24 COMMISSIONER SIDNEY LINDEN: -- according 25 to pathology and matters you mentioned.


1 (VOIR DIRE CONCLUDED) 2 3 MS. KATHERINE HENSEL: Thank you. 4 5 EXAMINATION-IN-CHIEF BY MS. KATHERINE HENSEL: 6 Q: Just one (1) more question before the 7 break, Dr. Shkrum, could you explain to us the 8 distinction or what exactly is forensic pathology, as 9 distinct from pathology as a field? 10 A: Well, I take one step backwards -- 11 Q: Hmm hmm. 12 A: -- to just define what pathology is 13 and it's been mentioned a number of times. But it is a 14 speciality area of medicine which deals with how diseases 15 affect various organs and tissues in the body. 16 So, what this means in practical purposes 17 is that anything that's removed during surgery, whether 18 the surgery occurs in an operating room or in a doctor's 19 office, that specimen, that biopsy, it could be a small 20 specimen or it could be a large, resected tumour, comes 21 to the laboratory, the pathology laboratory, where it's 22 examined by a pathologist. 23 The pathologist will look at it, describe 24 it, and then from that -- from that biopsy or from that 25 large tumour, take samples of tissue and those samples


1 will be, in turn, made into microscopic slides and then 2 he or she will look down the microscope and make a 3 diagnosis. 4 So, to put it simply, it it -- is 5 something -- does somebody have cancer, does somebody 6 have a benign lesion? Obviously it has a great import to 7 how that patient will be treated subsequently. 8 So, that's a branch of pathology called 9 surgical pathology, because it deals with surgically 10 removed specimens. 11 Another branch deals with cytopathology, 12 the study of individual cells; so PAP smears. Women that 13 have routine PAP smears, those PAP smears -- could be if 14 they're abnormal would be read by a pathologist and then 15 obviously if there are abnormalities there, there would 16 be further followup. 17 So that's cytopathology. And then there's 18 obviously a branch of autopsy pathology where a 19 pathologist will perform autopsies. 20 Working in a -- in an academic centre, a 21 teaching centre, we obviously do teaching; there's 22 various research activities. I'm part of a group of 23 about two (2) dozen pathologists, because of the merger 24 of the different departments, and we all have our sub- 25 speciality areas.


1 So, there are pathologists who specialist 2 in -- in brain, neuro-pathologists, or specialise -- 3 pathologists specialize in lung pathology, so other lung 4 pathologists. 5 So, just like you have specialists in the 6 clinical setting, you have specialists in the pathology 7 setting. 8 Getting back to your question, the 9 forensic pathologist then is a -- a sub-specialist who 10 obviously deals with forensic matters. 11 We deal with how diseases can affect a 12 person causing them to die suddenly or unexpectedly; so 13 we look at that facet. And we also look at how various 14 agents may cause someone to die -- external agents such 15 as motor vehicle trauma, sharp trauma, different types of 16 trauma; how -- how they could cause someone to die. And 17 again, the main tool we use for that is the performance 18 of an autopsy. 19 Q: All right. Thank you, Dr. Shkrum. 20 Commissioner, would this be an appropriate time for a 21 morning break? 22 COMMISSIONER SIDNEY LINDEN: I think it 23 would be. 24 MS. KATHERINE HENSEL: Thank you. 25 COMMISSIONER SIDNEY LINDEN: Thank you


1 very much. We'll have a morning break now. 2 THE REGISTRAR: This Inquiry will recess 3 for 4 fifteen (15) minutes. 5 6 --- Upon recessing at 10:22 a.m. 7 --- Upon resuming at 10:40 a.m. 8 9 THE REGISTRAR: This Inquiry is now 10 resumed. Please be seated. 11 12 (BRIEF PAUSE) 13 14 CONTINUED BY MS. KATHERINE HENSEL: 15 Q: Dr. Shkrum, I just have one (1) more 16 question on the general area of forensic pathology, it -- 17 and you expertise in that area. 18 It's within your expertise to determine 19 cause of death? 20 A: Yes, that's actually the -- 21 Q: Hmm hmm. 22 A: -- it's -- the bottom line of our 23 reports is the determination of the cause of death. 24 Q: All right. Thank you. 25 All right. Turning now to September of


1 1995, I understand that on September 8th, 1995, you were 2 called upon to perform a postmortem examination on 3 Anthony Dudley George at the Victoria Hospital in London; 4 is that correct? 5 A: Yes, I was actually contacted the day 6 before and then the actual autopsy was done on September 7 8th? 8 Q: All right. And, can you describe how 9 you came to be contacted on that? 10 A: I was actually contacted by Dr. 11 Cairns -- Jim Cairns, who was the Deputy Chief Coroner 12 for the Province of Ontario asking whether I could 13 perform the autopsy on -- on Mr. George. 14 Q: All right. Okay. And, Commissioner, 15 if you will turn to Tab 6 of the brief in front of you, 16 the document that appears there, and also Dr. Shkrum, is 17 the report of the postmortem examination for Anthony 18 O'Brien George. That item has been entered in these 19 proceedings as Exhibit P-359. 20 Do you recognize that document Dr. Shkrum? 21 A: If you just bear with me I just want 22 to make sure all the pages are there. 23 Q: Okay. 24 25 (BRIEF PAUSE)


1 A: Yes, this is a report that I prepared 2 on -- on Mr. George. It also has an appended body 3 diagram, and -- 4 Q: Hmm hmm. And -- 5 A: -- a radiology report. It does not 6 include a toxicology report that was done. 7 Q: All right. And, I believe a 8 toxicology report actually appears in the Brief of 9 Documents; that would be -- 10 A: Item Number 4, actually. 11 Q: Yeah. And, for the record, that's 12 Inquiry Document Number 1000099. And I would ask that 13 the toxicology report be entered as the next exhibit? 14 THE REGISTRAR: Exhibit P-380, Your 15 Honour. 16 COMMISSIONER SIDNEY LINDEN: P-380. 17 18 --- EXHIBIT NO. P-380: Document Number 1000099 Nov. 19 09/'95 Report of the Centre 20 of Forensic Science re. 21 Anthony O'Brien George. 22 23 COMMISSIONER SIDNEY LINDEN: And that's 24 at our Tab 4? 25 MS. KATHERINE HENSEL: Yes.


1 CONTINUED BY MS. KATHERINE HENSEL: 2 Q: Okay. Dr. Shkrum, can you describe, 3 if you will, how you began that postmortem examination? 4 A: Maybe I should just outline the 5 general steps of an autopsy first and then we'll get into 6 the -- 7 Q: Okay. 8 A: -- specifics as to what was found 9 here. There are a number of steps in the performance of 10 the autopsy. 11 The first step is the -- the collection of 12 information from -- from various sources. So the coroner 13 investigates. The coroner provides information and 14 actually also issues a warrant for postmortem examination 15 that orders or allows the autopsy to proceed. And on 16 that warrant, there is information provided there. 17 If there is involvement by other 18 individuals such as police, there would be other 19 information coming from -- from those individuals as 20 well. 21 So, the first step is the -- is the 22 collection of information prior to the actual beginning 23 of the autopsy. 24 The next step is the external examination 25 of the -- of the deceased. During that process the


1 individual is identified by various means, identifying 2 features such as height, weight, tattoos, that sort of 3 thing is -- things are noted. 4 If there are any -- evidence of any 5 trauma, external injuries, that is noted at that time. 6 And, if necessary, depending on the case, evidence may be 7 collected from the surface of the body. 8 The next step is the internal examination 9 or the actual dissection of organs and tissues in the 10 body. So, this involves opening the body cavities; 11 examining those organs and tissues within the body; 12 removing those organs and tissues; taking the samples 13 from those organs and tissues for a later microscopic 14 examination. 15 During the course of the examination of 16 the organs, body fluids such as blood, may be collected 17 if necessary for toxicological analysis or analysis of 18 drugs and -- and poisons, things like that. 19 During this process, obviously, there -- 20 there's various types of documentation done; notes are 21 made; diagrams may be made; photographic images are 22 taken, depending on the -- on the complexity of the case. 23 Following the internal examination, then - 24 - that concludes really the -- probably the first step of 25 the autopsy. As I said, sometime later there will be


1 microscopic slides examined. There may be other reports 2 that come forward, such as a toxicology report. Other 3 specialists may be consulted. 4 All of those reports come together to 5 perform the autopsy report, which is issued sometime 6 later. 7 Q: All right. 8 All right. And so you undertook the 9 process that you described with Mr. George? 10 A: Yes. 11 Q: Beginning on the morning of September 12 8th? 13 A: Yes. 14 Q: Okay. And I note in the report of 15 the postmortem examination that the time that the 16 examination commenced was at 09:40 hours -- 17 A: Yes. 18 Q: -- is that correct? Okay. 19 And can you describe who else was present 20 during that examination? 21 A: There were actually, in total, eleven 22 (11) people present, including myself. 23 Q: Hmm hmm. 24 A: There were police officers -- do you 25 want me to mention the specific names?


1 Q: Yes, please. 2 A: Staff Sergeant J. Kaiser, that's -- 3 Q: Hmm hmm. 4 A: -- K-A-I-S-E-R. Identification 5 Office C. Stewart, that's S-T-E-W-A-R-T. Detective 6 Constable R. Martin, M-A-R-T-I-N. These are all officers 7 associated with the London OPP. 8 There were two (2) SIU investigators; D. 9 Andrews and S. Thompson. Thompson with a "P". 10 There was a firearms specialist from the 11 Centre of Forensic Sciences, F. Nielson, N-I-E-L-S-O-N. 12 There was a pathology assistant who helped 13 with the -- with the examination of the deceased; G. 14 Rixon, R-I-X-O-N. 15 There were two (2) pathology residents, 16 Dr. K. Alanen, A-L-A-N-E-N, and S. Smith, S-M-I-T-H. 17 And I don't think listed in the report, 18 but there was briefly, a radiology technologist -- 19 Q: Hmm hmm. 20 A: -- C. and it's -- I'll have to spell 21 the last name, it's -- I spell it slowly, S-C-H-I-A-P-P- 22 A-P-I-V-T-K-A. 23 I'll repeat that, so S-C-H-I-A-double P-A- 24 P-I-U-T-K-A. 25 Q: And the last four (4) individuals you


1 -- you mentioned, Mr. Rixon, Dr. Alanen and Dr. Smith and 2 the radiology technologist who's name you spelled, were 3 they all working with you at -- in your offices at the 4 centre or...? 5 A: No, they were working under my 6 supervision. 7 Q: Under your supervision. 8 A: Mr. Rixon and Doctors Alanen and 9 Smith would have been there for most of the -- 10 Q: Hmm hmm. 11 A: -- for most of the postmortem 12 examination. The radiology technologist would have been 13 there a brief time just simply taking x-rays of -- of the 14 chest and leg which we'll discuss later. 15 Q: All right. Thank you. And could you 16 describe, if you will, your initial observations on 17 beginning that -- that examination? 18 A: Yeah, I'm assuming that 19 identification is no issue, but identification was done 20 visually -- 21 Q: Hmm hmm. 22 A: -- by one of the officers and then 23 subsequently confirmed by fingerprint comparison. 24 Q: Okay. 25 A: I noted that the deceased was one


1 hundred and sixty-nine (169) centimetres long or about 2 five (5) foot eight (8) inches. 3 He weighed eighty-six (86) kilograms, or 4 about a hundred and eighty-nine (189) pounds. 5 His stated age was thirty-eight (38) 6 years. I noted a tattoo above his left nipple and there 7 were various scars on -- on -- scars on various parts of 8 the body. 9 There was sand on his hands and feet. 10 When I examined him on September 8th, he was unclothed. 11 There were signs of resuscitation efforts. 12 He had an endotracheal tube or an ET tube 13 that had been inserted into his mouth to attempt to 14 assist breathing. There were IV lines, or intravenous 15 lines in both arms. 16 In addition, in the plastic body-bag that 17 he was received in, there were a number of items which 18 appeared to be hospital sheets, a towel, pillow case; 19 these were variably bloodstained. There was also the 20 case from a catheter tip, catheter containers and a 21 tourniquet. 22 Q: And were those each attached to Mr. 23 George's body or -- 24 A: No, those items were loose -- 25 Q: All right.


1 A: -- inside the body bag. 2 Q: Okay. And can you describe the 3 appearance of the blood you noticed on initial 4 examination, both you noted on the -- on the hospital 5 flannel sheet and on his body. 6 A: I'm not sure what you mean by that. 7 Q: Just in terms of, you know, the 8 volume of blood that you would have observed on his body 9 and in the sheet or the amount? 10 A: I can't really say how much was 11 there. I just say in my report -- 12 Q: Hmm hmm. 13 A: -- that there were, you know, 14 variably blood -- blood stained and I really can't 15 quantify how much blood was there. 16 Q: Thank you. And that's the extent of 17 your initial observations on external examination? 18 A: Yes, there were injuries present -- 19 Q: Hmm hmm. 20 A: -- and again, I can elaborate on 21 those shortly. 22 Q: Okay. And you mentioned earlier the 23 signs of resuscitative efforts, that was the endotracheal 24 tube you referred to and also just what items did you 25 associate with -- beyond that with resuscitative efforts?


1 A: As I mentioned, there -- 2 Q: Yeah. 3 A: -- in addition to the endotracheal 4 tube, there were intravenous lines in the arms. 5 Q: Okay. All right. And, you noted 6 injuries on your initial observations? 7 A: Yes, I did. 8 Q: Can you describe those for us? 9 A: Well, there were really two (2) types 10 of injuries. Let me first deal, maybe, with the 11 relatively minor injuries. 12 The first type of injury consisted of what 13 we call blunt trauma-type injuries; that is, some type of 14 blunt surface impact of the skin or the skin, in turn, 15 impacted a blunt surface. 16 In general terms, these types of injuries 17 are in the form of bruises or contusions, which is simply 18 bleeding underneath the skin's surface; abrasions or 19 scrapes, which is removal of the superficial layers of 20 the skin; and lacerations or tears of the skin, which are 21 deeper into the -- into the soft tissue underlying the 22 skin. 23 So, those are the three (3) sort of, 24 general types of blunt trauma injuries we see at autopsy. 25 In Mr. George's case, there was a bruise


1 or contusion 1 centimetre, or approximately half an inch, 2 on the back of the left wrist. 3 Q: Would -- would it be helpful, Dr. 4 Shkrum, to put up the diagram from your -- from your 5 postmortem report? 6 A: That -- I think that would certainly 7 assist the matter, yes. 8 9 (BRIEF PAUSE) 10 11 Q: And, if you could identify -- there 12 is a laser pointer in front of you on the desk and if you 13 push the silver button there. If you could identify the 14 location of that bruising? 15 A: This is the bruise that I described 16 in the back of the -- on the back of the left hand. 17 Q: All right. And, it's identified on - 18 - on the diagram? 19 A: Yes. 20 Q: Were those identifications or notes 21 made by you? 22 A: Yes. Sorry, maybe you can't hear. 23 Q: All right. Can you see that diagram 24 adequately there? 25 A: It's a bit of an angle. I -- it's


1 kind of difficult for me to make out the writing in some 2 parts there. 3 Q: All right. If it would be helpful 4 you can stand up and there is a mic that you can use, but 5 perhaps for -- 6 COMMISSIONER SIDNEY LINDEN: There's a 7 mic over here on this end of the desk. 8 THE WITNESS: Is this live or -- 9 COMMISSIONER SIDNEY LINDEN: It can be, 10 just -- 11 MS. KATHERINE HENSEL: Yes, it is. 12 COMMISSIONER SIDNEY LINDEN: There it is; 13 it's on now. 14 THE WITNESS: Do you mind if I just 15 stand? 16 COMMISSIONER SIDNEY LINDEN: No, by all 17 means. 18 19 (BRIEF PAUSE) 20 21 THE WITNESS: So, yes, we have a bruise 22 there. 23 24 CONTINUED BY MS. KATHERINE HENSEL: 25 Q: All right. Did you note any other


1 signs of blunt trauma? 2 A: Yes, I did. And I don't think it's - 3 - I don't think it's illustrated on this -- on this 4 diagram, but there were some tiny scrapes or abrasions on 5 the base of his right middle finger. 6 Q: Hm hmm. 7 A: It's not illustrated here. So, it 8 would be at the -- the base of the right middle finger 9 and also the medial aspect or the inner aspect of the 10 right thumb here near the nail bed. And these -- these 11 abrasions, as I say, were small, up to 0.2 centimetres or 12 about an eighth of an inch across. 13 So, these were the relatively small blunt 14 trauma-type injuries. 15 Q: Did you form any opinion as to the -- 16 the origins of those injuries or the mechanism? 17 A: Again, in general, when we see blunt 18 trauma injuries they're not specific as to the source of 19 the injury, unfortunately. On occasion, one can see an 20 actual pattern injury where the injurious surface is 21 reproduced in the wound but, generally speaking, when we 22 deal with blunt trauma they're non-specific as to the -- 23 as to their source. 24 So, I can't say what the source of these 25 injuries was.


1 Q: All right. Thank you. If you could 2 just continue with your observations. 3 A: Next I want to proceed with the -- 4 the major trauma here, and that's a penetrating trauma 5 due to a -- due to a bullet, i.e., a projectile. And on 6 the diagram we have a -- a gunshot wound entry site over 7 the left clavicle, or collarbone. 8 And this is blown up to some degree here. 9 There's an arrow pointing down here and it just shows the 10 wound, enlarged, with some measurements around it; which 11 are still not clear to me but I can -- I can refer to 12 them. 13 Would you like me to elaborate on that -- 14 on that wound? 15 Q: Yes. Yes, please. 16 A: This wound zero point eight (0.8) by 17 0.7 centimetres, or about three eights (3/8) of an inch 18 across. And underlying this wound, one could actually 19 feel a -- a broken -- broken collarbone. 20 Just draw your attention, at the superior 21 limits of this -- of this wound, there was an abrasion or 22 a scraping of the skin surface. In my notes, or my 23 report, I described it as going from about the eleven 24 o'clock position down to the five o'clock position. 25 So if you think of this as a clock face,


1 twelve o'clock pointing towards the top of the head, this 2 abrasion starts here, at about eleven o'clock, and then 3 goes down to about here, around five o'clock. Part of it 4 though is obscured by blood and that was not, as we call 5 it, peeled away because we didn't really want to disrupt 6 this wound to any -- to any extent. 7 Q: All right. And did you make any 8 other observations? I note that there are some other 9 notes there, based on your initial -- just for 10 clarification, on -- on your initial examination of his 11 injuries, did you proceed through all of the injuries 12 that could be detected externally prior to -- to making 13 any other investigations? 14 A: Documenting the injuries? 15 Q: Yes. 16 A: Yes. Yes. 17 Q: All right. 18 A: Yeah. We -- we did the external 19 first. 20 Q: Hmm hmm. 21 A: X-rays were taken, that was the next 22 step. And then we proceeded with the internal 23 dissection. 24 Q: All right then. If you could 25 continue with any other observations that you made on


1 your external investigation. 2 A: Okay. So, as I said, there -- there 3 is evidence of this penetrating trauma. And -- and when 4 we look down on the -- down here, on the right shin, 5 there is a -- what I described in my report, and this is 6 in quotation marks, "Another abrasion," where the -- the 7 superficial layers of the skin have been -- have been 8 removed. 9 And this injury was three point two (3.2) 10 by 1.7 centimetres in extent, or 1 1/4 inches by three 11 quarters -- 3/4 inches. So that -- that's in this area 12 right -- right here. 13 Q: Okay. And did you form any opinion 14 at that point as to the origins of that injury? 15 A: Well, just looking at this injury in 16 isolation, I -- as I said, I described that simply as an 17 abrasion. 18 Q: Hmm hmm. 19 A: But there are other factors here that 20 may -- may be -- may point to a more specific origin for 21 this particular injury. 22 Q: All right. And we will come to those 23 factors -- 24 A: Yes. 25 Q: -- later. Thank you. All right.


1 And in the terms of the gunshot entry wound that you 2 identified earlier, how did you determine that it was a 3 gunshot entry wound? 4 A: Well, first the all, the -- we had 5 the context of what happened here, that there had been 6 gunfire. When this -- we took the X-ray, we could see a 7 projectile that was lodged in the -- in the back. 8 Q: Hmm hmm. 9 A: And that's indicated right here, by 10 the "X", where the -- these projectile -- or two (2) 11 parts of a projectile were recovered. And then we could 12 link this entry wound with a wound tract inside the body, 13 to where this projectile was recovered. So, therefore, 14 this is a gunshot wound entry site. 15 Q: All right. And did you immediately, 16 on a preliminary basis, identify it as such based on your 17 external investigation? 18 A: Yes. I mean, I -- I had a strong 19 suspicion that that was a -- that was a gunshot wound 20 entry site. 21 Q: Okay. All right. If you could 22 continue with your observations based on your external 23 examination. 24 A: I think, at that point, that really 25 sort of concludes some of the salient findings with the


1 external examination. 2 Q: All right. 3 A: There is some blood that was marked 4 here, some bloodstain that was noted on the upper part of 5 the body. 6 Q: All right. 7 A: It's indicated by these wavy lines 8 here. 9 Q: All right. And the other notes that 10 you can -- that you can make out here are evidence of the 11 resuscitative efforts that you -- that you described 12 earlier? 13 A: Yes. So there you can see the 14 intravenous lines; there's one here and -- 15 Q: Further -- A: -- indicated by the 16 -- there's an "X" where the puncture was. It goes to IV 17 line to a bag of Ringer's solution and there's also 18 another IV line here indicated by an arrow going to 19 another bag of intravenous solution. 20 Q: And for the record, you've identified 21 the marks first on the patient's -- 22 A: I'm sorry, yeah, this would be on the 23 -- on the right arm near the elbow and this is on the -- 24 on the left arm near the elbow joint. 25 Q: Thank you, Dr. Shkrum.


1 And on completing your external 2 examination, you then proceeded to do an x-ray or -- 3 A: Yes. 4 Q: -- what was your next step? 5 A: Yes, the x-ray was next. Again, in 6 the course of doing this, obviously notes are being made, 7 a diagram is being prepared, images are being taken -- 8 photographic images, evidence is being collected from the 9 surface of the body. 10 Q: Okay. And it was at this point that 11 the x-ray technologist, that -- that you described 12 earlier as attending, joined you in the examination? 13 A: Yes. 14 Q: All right. And what did they do? 15 A: Again, x-rays were taken of the -- of 16 the chest because of the -- because of this wound here. 17 The strong suspicion was that there was a -- probably a 18 projectile because no exit wound was seen, that it was 19 still in the body and an x-ray was also taken of the leg 20 here as well. 21 Q: All right. And were those x-rays 22 immediately made available to you for examination or a 23 report by a radiologist? 24 A: Yes, the report came subsequent, but 25 I -- I did have access to the x-rays to begin with.


1 Q: Okay. And, were you assisted by a 2 radiologist at that point in -- or are you -- 3 A: No, not at that -- assisted by the 4 Radiology Technologist to take the images, but no, I did 5 not have access to a radiologist at that time. 6 Q: Okay. 7 A: Is there any more reference to this 8 diagram? Otherwise I'll... 9 Q: No, no, I don't -- not at this point. 10 11 (BRIEF PAUSE) 12 13 Q: All right. And if you could tell us 14 what you observed in the -- in the x-rays that you took, 15 that you've described? 16 A: There's a more detailed report by the 17 -- by the radiologist, but yes, it did confirm that there 18 was projectile fragments present, so it did confirm that 19 there was a -- we were dealing with a -- a gunshot wound 20 and it helped in location of that -- those particular 21 projectiles. 22 There was also -- on the x-ray it appeared 23 that it was sort of whited-out compared on -- on the left 24 side, in the left chest compared to the right side, 25 suggesting that there was fluid that accumulated in -- in


1 the -- in the chest. 2 Q: All right. And, was the nature of 3 that fluid readily apparent to you at that point? 4 A: Well, again, a strong suspicion would 5 have been blood. 6 Q: Okay. All right. And what else did 7 you observe on the x-ray? 8 A: I didn't observe any injuries to the 9 leg and I didn't see any metal fragments associated with 10 the -- the wound on the leg. 11 Q: Okay. All right. And just to take 12 you to the x-ray -- the radiologist's report that was 13 included with your report, that's at Tab 6, Inquiry 14 Document Number 1002016 that has been identified as 15 Exhibit P-359. 16 You'll note that there's an x-ray report 17 there noting an examination date of -- and that appears 18 on the last page of -- of that document of September 8th, 19 1995. The actual report was made to you, I believe, it's 20 not clear on the document. 21 A: Yeah, I don't see the date on the 22 report, but typically, though, the -- the formal written 23 x-ray reports in most cases that we see, comes at a later 24 time. 25 Q: All right.


1 A: Many times we look at the x-rays 2 ourselves. I mean, it's a situation we're trying to find 3 a projectile -- 4 Q: Hmm hmm. 5 A: -- we look at those x-rays ourselves 6 to assist us during the course of the autopsy and then 7 the radiologists review the films later. In some cases 8 we do consult with a radiologist at the time of the 9 autopsy. 10 Q: Hmm hmm. 11 A: For example, say in a child abuse 12 case where there's a question of multiple trauma. 13 Q: All right. But, you didn't consider 14 that necessary here? 15 A: It was not necessary here. 16 Q: And the -- the radiologist is 17 identified on this report as Dr. Michael Lefkoe? 18 A: That's correct. 19 Q: And do his observations as noted 20 there accord with your own observations? 21 22 (BRIEF PAUSE) 23 24 A: Yes, they do. 25 Q: All right, thank you. Okay, and you


1 proceeded then to an internal examination? 2 A: Yes, there was actually one (1) other 3 step -- 4 Q: Hmm hmm. 5 A: -- that we took and it's actually 6 alluded or -- 7 Q: Hmm hmm. 8 A: -- mentioned in Dr. Lefcoe's report. 9 Again -- 10 Q: Hmm hmm. 11 A: -- I didn't have this report when we 12 did this particular step -- 13 Q: Hmm hmm. 14 A: But that -- he makes reference in the 15 second -- first paragraph in the very last sentence 16 about, "I do not see --" 17 Q: Hmm hmm. 18 A: "-- any definite free air." So he 19 was referring to air in the -- inside the chest cavity. 20 Q: All right. 21 A: Prior to opening the body, a needle 22 was inserted into the chest to see if there was any air. 23 Again, the suspicion here is that this -- this bullet has 24 passed through the lung -- 25 Q: Hmm hmm.


1 A: Obviously the lung is filled with 2 air. If the person breathes, that air may through the 3 lung into the chest cavity to create a condition called 4 pneumothorax , pneumo simply means "air", thorax refers 5 to the chest. 6 So, you -- 7 Q: Hmm hmm. 8 A: -- can get air inside the chest 9 cavity which could cause severe -- severe respiratory 10 difficulties for -- for an individual. 11 Q: Hmm hmm. 12 A: I did only saw a couple of cc's a 13 very small quantity of air when I aspirated the chest and 14 this is actually then is confirmed by Dr. Lefcoe's report 15 subsequently that -- 16 Q: Hmm hmm. 17 A: -- he did not see any definite free 18 air. 19 Q: Hmm hmm. And the -- the amount of 20 air that you detected, would that be in accordance with 21 regular findings for somebody without -- without any 22 pneumothorax? 23 A: Well, normally you should not see any 24 -- any air in the chest cavity, because it's under 25 negative pressure.


1 Q: Hmm hmm. 2 A: There should not be any air inside 3 the chest at all. 4 Q: Okay. 5 A: So finding any air is abnormal, but 6 for a pneumothorax, to cause difficulty, you know, air in 7 the chest cavity -- 8 Q: Hmm hmm. 9 A: -- you'd probably have to be in the 10 order of, you know, several hundred cc's or more. 11 Q: Okay, and did you form an opinion at 12 the time as to the source of the small amount of air that 13 you did detect? 14 A: Well, I think it did come from the -- 15 from the -- from the injured lung. 16 Q: Hmm hmm. 17 A: I'll describe those wounds shortly. 18 Q: Okay, thank you. And we can discuss 19 this -- we'll come to it as to the potential causality 20 that arose from that pneumothorax, unless you'd like to 21 address that now? 22 A: I don't think the -- 23 Q: Okay. 24 A: -- pneumo -- this small air 25 contributed to -- to Mr. George's death.


1 Q: All right, thank you. All right, and 2 after -- and checking for a pneumothorax, you then 3 proceeded to an internal examination? 4 A: Yes. 5 Q: All right. Can you describe your 6 observations? 7 A: I think before I deal with the 8 injuries -- 9 Q: Hmm hmm. 10 A: -- I saw, I should perhaps just 11 describe other -- other findings in the internal 12 dissection. Again, this is a complete autopsy that was 13 done, all organs and tissues were examined and looking 14 for other abnormalities, disease processes. 15 Prior to the autopsy, I was made aware 16 that he did have a heart murmur -- 17 Q: Hmm hmm. 18 A: This is actually provided 19 information, I think provided by the Coroner at the time, 20 and when we examined his heart, he did have an abnormal 21 heart valve. 22 The heart normally has or heart has -- a 23 normal heart has four (4) sets of valves. This 24 particular valve is the aortic valve. It's a valve that 25 is between the left ventricle, which is the thickest


1 chamber of the heart, the heart has four (4) chambers. 2 So, between the left ventricle and the 3 aorta, which is the large blood vessel that arises from 4 the left ventricle, and supplies blood throughout the 5 body with the exception of the lungs. 6 This valve should normally have three (3) 7 cusps and so it's a three (3) cusp normally, but this -- 8 in this case, it was a bicuspid. There were only two (2) 9 cusps. 10 So, this was likely something that Mr. 11 George had been born with, so he had a bicuspid or a 12 congenital bicuspid valve. 13 Q: Hmm hmm. 14 A: The valve did not itself otherwise 15 look diseased -- 16 Q: Hmm hmm. 17 A: -- in terms of any deposition of any 18 calcium or scarring on -- on the valve. 19 The other disease noted, Mr. George, again 20 in reference to the heart, was a focal narrowing of the - 21 - one of the major vessels that supply the heart muscle. 22 This narrowing was due to a common malady 23 that afflicts North Americans, atherosclerosis or 24 hardening of the arteries, and his -- this particular 25 vessel was narrowed about three-quarters, or 75 percent.


1 But the heart itself did not show any 2 evidence of disease in terms of heart attacks, scarring, 3 that sort of thing; there was no evidence of that. 4 Q: All right. Did either of the -- the 5 abnormalities that you've just described, either the 6 congenital or the -- the hardening -- congenital 7 condition or the hardening of his arteries, did they 8 contribute, in your opinion, to the course of Mr. 9 George's injuries? 10 A: Well, I mean -- 11 Q: And his death. 12 A: -- his injuries, I'm sorry, or his 13 death? 14 Q: Yeah, yeah. 15 A: I don't think they did. I think the 16 bicuspid valve is a -- is a -- is a common, relatively 17 common congenital anomaly of the heart valves. One 18 source I read, it occurs about 1 to 2 percent of the 19 population. 20 If it became scarred or further diseased, 21 it could cause problems, but in this case there was no 22 evidence of that. 23 The narrowing of his coronary vessel, the 24 vessel supplying the heart muscle, potentially that could 25 cause problems in the future, but again, I think in this


1 case it was simply coincidental. 2 Q: All right. And did you observe any 3 other abnormalities unrelated to his -- his injuries? 4 A: No, I did not. 5 Q: Okay. Okay. Moving now to -- to 6 your observations in relation to his injuries can you -- 7 can you describe those for us? 8 A: Yes, well again, we have the entrance 9 wound on the surface of the skin overlying the left 10 collar bone. There was a wound tract that could be 11 demonstrated that passed through the lungs and terminated 12 in the back. 13 And in the course of doing so, it had 14 penetrated -- this wound tract went through a number of 15 blood vessels, particularly in the lung. 16 And in the back, it actually fractured one 17 rib and went right through another rib -- 18 Q: Hmm hmm. 19 A: -- before it finally lodged in the -- 20 in the soft tissue underneath the skin of the back. 21 Q: Right. 22 A: And, sorry, associated with that 23 wound there was 1,000 cc's or a litre, or approximately a 24 quart of blood in the chest cavity, in confirming the 25 radiologist's opinion.


1 Q: And would each of the injuries you've 2 described along the path of the wound, would each of 3 those injuries have resulted in bleeding? 4 A: Yes, they would have. 5 Q: Okay. And in terms of the amount, 6 1,000 cc's, in layman's terms -- lay person's terms, how 7 much blood is that? 8 A: As I said, it's about a litre or a 9 quart. 10 Q: Hmm hmm, yeah. 11 A: So if you think of, you know, what 12 you put in a refrigerator -- 13 Q: Yeah. 14 A: -- quart container or litre container 15 of milk, that's sort of the quantity of blood that was 16 present. 17 Q: Okay, and in terms of a person of Mr. 18 George's size, what would that represent in terms of his 19 percentage of his blood volume? 20 A: Well I would estimate it's probably 21 in the order of maybe 15 to 20 percent of his blood 22 volume. 23 Q: Hmm hmm. 24 A: Again, realizing that there was blood 25 on -- on Mr. George and also on items inside the body


1 bag, so as to the total quantity -- 2 Q: Hmm hmm. 3 A: -- of blood, I don't know how much he 4 lost, but certainly what we measured was a 1,000 cc's in 5 his chest cavity. 6 Q: And would that extent of blood loss 7 on its own, the 15 to 20 percent you've described be a 8 sufficient amount of blood loss to cause death? 9 A: Well, it's certainly significant and 10 certainly it could potentially put someone into -- into 11 shock. 12 Q: Hmm hmm. 13 A: And as I said, I can't quantitate how 14 much total blood was lost, but certainly it would -- it 15 would contribute to a shock state. 16 Q: All right. I'm just wondering, Dr. 17 Shkrum, if it might be useful in terms of the path you 18 have provided a detailed narrative of the path, but it 19 might be useful for the Commissioner if we could just 20 move to the diagram and trace that dia -- or trace that 21 path, which is the second last page of that document. 22 Is that sufficient for -- for your 23 purposes? Is that a large enough field in that diagram? 24 Yeah? 25 A: Yes, I think that's --


1 Q: Yeah. 2 A: -- that's fine. 3 Q: Okay. 4 A: Okay. So just to reiterate, here's 5 the entry wound here. 6 Q: Hmm hmm. 7 A: And here's the recovery point here of 8 the -- of the projectiles. 9 So this -- the trajectory of this 10 projectile, or bullet -- 11 Q: Hmm hmm. 12 A: -- is passed in a downward direction, 13 again, in reference -- in relation to the deceased in a - 14 - in a downward direction. 15 So it would be coming down -- this would 16 be his left side here. So the wound on the front of his 17 body would be approximately here, be coming down in this 18 direction towards the deceased's right, downward, and I 19 estimate it would approximately be about a thirty (30) 20 degree angle. 21 Q: All right. And, for the record, 22 you've indicated a path on the rear view of, or the back 23 view of Mr. George or the diagram of his injuries rather, 24 at approximately a thirty (30) degree angle? 25 A: Approximately thirty (30), so it's --


1 it's a diagonal sort of path in relation to this body 2 diagram. 3 Q: From his left shoulder to the point 4 marked "X" on -- on the diagram? 5 A: That's correct. That's correct. 6 Q: It's to the left-hand side? 7 A: That's right and then the "X" is 8 indicated by a projectile and in brackets, "S" because 9 there was actually two (2) fragments -- projectiles 10 recovered. 11 Q: All right. Thank you, Dr. Shkrum, if 12 you could continue with your observations based on your 13 internal examination? 14 A: Well as I said, the -- the tract went 15 through the -- through the lungs, broke one (1) of the 16 ribs in the -- in -- in the back where the -- near where 17 the bullet was recovered. 18 Q: Hmm hmm. Hmm hmm. 19 A: We could -- we could -- we could feel 20 the bullet in the -- in the back area and an incision was 21 made at that "X", the site of the "X", and the -- and the 22 two (2) projectiles were recovered. This was a -- and 23 I'm not a firearms expert, but this was a -- a jacketed 24 bullet -- 25 Q: Hmm hmm.


1 A: -- the -- one (1) component was lead, 2 which is the main component of most bullets, and lead is 3 relatively soft so to harden that bullet a tougher metal, 4 copper, zinc, is jacketed around it to prevent its 5 disintegration. So, as it passed through the -- through 6 the body it actually separated and -- and formed these -- 7 these two (2) -- these two (2) fragments. 8 Q: All right. And, for your -- for the 9 record and for your reference, if you could turn to Tab 10 10 of the -- the brief of documents in front of you, 11 that's Inquiry Document 1002003? 12 And it contains -- it contains a report 13 that appears to be by a Fin Nielson (phonetic); you've 14 described him earlier as being present for the 15 examination? 16 A: Yes, he was. 17 Q: Okay. And had you seen this report 18 before? 19 A: Yes, I actually did receive a copy of 20 that report. I -- I should just make note that your item 21 10 says April 26th/'96. 22 Q: Hmm hmm. 23 A: Actually, that report is dated 24 January 9th/'96. 25 Q: Yes, that's right.


1 A: And, in fact, on the second page it's 2 January 9th, 1995, which I think is obviously a typo, it 3 should be '96. 4 Q: All right. So, this is document 5 number 1002100 -- or, sorry -- 1002003 Dr. Shkrum is 6 referring to and that is dated January 9th, 1996. 7 From your understanding, was this report 8 prepared as a result of the evidence gathered by Mr. 9 Nielson through you at the examination on September 8th, 10 1995? 11 A: Yes, there are some items in this 12 report that were actually gathered during the course of 13 the -- course of the autopsy. 14 Q: Okay. And just in -- with reference 15 to the bullet that you've described, would that be, by 16 your understanding, item on the second page there, it's 17 identified as item number F151 and described as one (1) 18 vial or one (1) fired copper-jacketed projectile in it -- 19 with -- in the vial? 20 A: Yes. In the left margin it says in 21 quotations, "removed from decease." So, that was at the 22 time of the autopsy. 23 Q: Okay. And Mr. Nielson also in his 24 report, apparently concludes that it was fired from item 25 number F501, which was identified on a -- on the previous


1 page as a 9 millimetre -- 9 millimetre caliber firearm 2 issued to police. 3 A: I'm sorry, I don't think -- this -- I 4 don't think 501 is in the January report. I think it's - 5 - it might be in another report. 6 Q: If you turn to the previous page, it 7 says F510? 8 A: Oh, I'm sorry. Okay. 9 Q: That's all right. 10 A: Okay. 11 Q: Okay. And -- 12 A: Yes, I'm sorry. Yes, F51 -- 501. 13 Q: And, you wouldn't have played any 14 role in the testing that -- 15 A: No, I did -- I did not. 16 Q: And this report would merely have 17 been sent to you to assist with your preparation of -- of 18 the report that you were making and for your information? 19 A: Yes. 20 Q: All right. All right. And can you 21 make any other comments in terms of the trajectory of 22 that bullet? You said that it proceeded at a thirty (30) 23 degree angle; would you have formed an opinion at that 24 point as to the possible positioning of Mr. George when 25 that bullet was fired or entered his body?


1 A: Well, realize though, as a 2 pathologist I deal with a very static situation. And so 3 to answer your question, you know, a number of positions 4 are possible here. 5 Q: Hmm hmm. 6 A: Obviously we have a trajectory at a 7 relatively acute angle entering the body. There would be 8 a number of positions possible. 9 Q: All right. Can you describe any of 10 those positions for us? 11 A: Well, it would be better if you 12 offered a scenario and then I could say whether it's 13 possible. 14 Q: All right. 15 A: Because, as I said, there are a 16 number of scenarios possible here. 17 Q: Okay. Would it have been possible 18 that Mr. George, first of all, was standing at his full 19 height and would have been shot by someone standing at 20 the same level as him, some distance away, on the same 21 level surface -- 22 A: No. 23 Q: -- is that a possibility? 24 A: No. 25 Q: All right. Would it have been


1 possible that Mr. George was kneeling at the time that he 2 was -- he was shot? 3 A: And somebody shooting at -- 4 Q: Hmm hmm. 5 A: -- standing up? 6 Q: Yes. 7 A: It's possible, yes. 8 Q: All right. Would it be possible that 9 someone would be standing at a surface higher than Mr. 10 George, if Mr. George was standing? 11 A: Standing or -- yes. That's possible, 12 yes. 13 Q: But how much higher, if you can say, 14 would that person have to be standing? 15 A: Well, it would have to be at some 16 considerable height -- 17 Q: Hmm hmm. 18 A: -- such as a, say, a tree or a 19 building to shoot down at that angle if -- if Mr. George 20 was fully erect. 21 Q: Okay. Were you able to -- or form 22 any opinion at that point as to how far the person or the 23 -- the firearm that discharged the bullet would have been 24 from Mr. George when it was fired? 25 A: In the course of the examination of


1 the surface of the body, I actually looked in this area 2 for any -- any powder residue, like visible fragments of 3 powder that might be present, and I did not see any 4 evidence for that. 5 During the course of the external 6 examination, gunshot residue was collected and turned 7 over to the -- to the investigating officer. And, again, 8 that was presumably retained or sent off for -- for 9 further testing. 10 Just to see if there was any of that 11 material deposited around the wound. 12 Q: Hmm hmm. 13 A: The wound itself was excised, or 14 removed. And, again, it's referred to in that particular 15 report that it was sent for further analysis to see if 16 there was any residues. So just from me looking at this, 17 I did not appreciate any residues around the wound. 18 Q: Hmm hmm. 19 A: Now, bearing in mind that when I 20 examined him, he was unclothed. There were items of 21 clothing that were later examined -- 22 Q: Hmm hmm. 23 A: -- a few days later. But I did not 24 see any residue here that would indicate something at 25 close range. But, again, further material was collected,


1 further testing was done to determine that this is more 2 likely a distant type of wound that did not allow any 3 deposition of any materials around it from the -- from 4 the firearm. 5 Q: All right. And would you in general 6 be able to form an opinion based on the disruption of 7 tissue internally as to the -- as to the distance of -- 8 of the firearm from -- from the victim? 9 A: No. I -- no. I mean, if -- if it 10 was a contact-range wound, say we're dealing with a 11 suicide, there may be tremendous destruction, if there's 12 a -- a head wound, again, depending on the type of weapon 13 that's used. But no, in this particular case I -- I 14 can't really say what distance the -- the weapon was 15 fired. 16 Q: Okay. And what you've described, is 17 that the extent of your observations of the injuries and 18 disruption resulting from that particular gunshot wound 19 from -- based on your internal examination? 20 21 (BRIEF PAUSE) 22 23 A: Yes. On that particular wound, I 24 think that concludes my observations. 25 Q: All right. Moving down to the


1 abrasion that you'd earlier described and observed -- 2 A: Sorry, I'll just mention one (1) 3 other point. There was some -- a little microscopic 4 section taken of that wound -- 5 Q: Hmm hmm. 6 A: -- just talking about range, just to 7 see if there was any foreign material deposit, and I -- I 8 did not see any, so -- 9 Q: Okay. 10 A: -- just in -- or further response to 11 your -- your last question about distance. 12 Q: Okay, and -- and you were checking 13 for the presence of foreign material, it would -- 14 A: Yes, again -- again using the example 15 of a, say a suicidal gunshot wound -- 16 Q: Hmm hmm. 17 A: -- we, often times, will see evidence 18 of the powder deposited, because it's at close range. 19 But to confirm that we will take a little microscopic 20 sample, look down the microscope and just confirm if 21 there's black or brownish material from the discharge of 22 the weapon. 23 Again, that was done here with, you know, 24 minimal disruption to the actual wound itself and I 25 didn't see any evidence for that.


1 Q: All right, thank you. All right, 2 moving now to the abrasion that you'd -- you'd described 3 earlier. What further investigations or examinations did 4 you perform in relation to that injury? 5 A: Well, again this wound was excised. 6 Again -- 7 Q: Hmm hmm. 8 A: -- as I mentioned before there -- 9 Q: Hmm hmm. 10 A: -- was an x-ray taken. There's no 11 evidence of any bony damage or any deposition of any 12 foreign material that could be appreciated. 13 This wound was actually removed, just like 14 the wound on the clavicle was removed, and again 15 submitted to -- to the firearms examiner for further 16 analysis, and again, that item is listed in that -- in 17 that January '96 report. 18 Q: And that appears at Tab 10. On the 19 second page I note that Mr. Nielson has identified as 20 item F-533, "Removed from deceased right leg." 21 He has noted there is a: 22 "Superficial wound in this specimen, 23 would suggest it was caused by a 24 projectile travelling from the 25 deceased's right to left."


1 A: Yes, he's made that comment. 2 Q: Okay, and can you comment on that 3 comment yourself? 4 A: Again, I'm not a firearms examiner, 5 but in my report I've simply described it as an 6 "abrasion," quote unquote -- in quotation marks. There's 7 been a scrape there. 8 He says it is a superficial wound, so it 9 is like an abrasion. He uses the word "suggests", that 10 it was caused by a projectile. Now, he gives a direction 11 and I -- I'm not sure how he arrived at that opinion. 12 Q: All right. 13 A: And I'd be quite prepared to explain 14 why I have reservations about the direction about that 15 shortly. 16 Q: All right. And that would be based 17 on items that you subsequently examined or... 18 A: No, just the examination of the wound 19 itself. 20 Q: All right. And could you explain why 21 -- what you're -- what your reservations -- 22 A: Reservation -- 23 Q: -- are? 24 A: Well, first of all, it is a scrape. 25 It looks very much -- if I looked --


1 Q: Hmm hmm. 2 A: -- at that in isolation, it looks 3 like an abrasion. The -- it's been advanced that this is 4 a -- and in Mr. Nielson's report that this is a grazing 5 type injury, it doesn't -- 6 Q: Hmm hmm. 7 A: He doesn't say "grazing" but he 8 implies it when he says it's a superficial wound. 9 Q: Hmm hmm. 10 A: Typically, if -- remember when I 11 discussed the entrance wound on the -- on the collar 12 bone, I talked about a scrape, an abrasion there. 13 Q: Hmm hmm. 14 A: That abrasion was ecentric, it was on 15 only part of the wound as opposed to concentric, that is 16 all the way around. 17 When a bullet enters the skin, if it's at 18 a right angle or perpendicular to the skin surface, it 19 equally scrapes the skin around it, because it's 20 spinning. 21 So that forms a concentric abrasion ring 22 all the way around. If it enters at an angle, which in 23 this case it did, it forms a acentric abrasion ring, 24 because the bullet is now at an angle and part of the 25 bullet surface is more exposed than the other parts, so


1 it scrapes that part -- 2 Q: Hmm hmm. 3 A: -- to a greater extent. So it 4 results in a acentric abrasion ring. So it actually 5 gives you an idea of direction the bullet's travelled. 6 So in this case, the bullet is from a 7 eleven o'clock to five o'clock position, it does imply 8 that the bullet's coming from above, and it's actually 9 confirmed by examination of the wound tract within the 10 body. 11 When we look at this wound on the leg, 12 however, there's a scrape that goes -- to me looked it 13 like it went all the way around. 14 In a classical grazing injury, trying to 15 determination direction, when the -- where the bullet 16 enters, you see the abrasion, because it's entered at an 17 angle, it scrapes the surface. 18 And where it exits or leaves the skin 19 surface, it causes a tear. I didn't see that here, 20 unfortunately. 21 Q: Hmm hmm. 22 A: And I just see this abrasion ring 23 going all the way around, so I can't really determine 24 which direction that projectile went. 25 And certainly in standard texts of


1 forensic pathology, there's a -- a very well-renowned 2 forensic pathologist by the name of Dimaio, D-I-M-A-I-O, 3 who has actually published a book on gunshot wounds. 4 He's a medical examination, pathologist, 5 out of Texas where they have a lot of guns, so an expert 6 at this. And he actually says: 7 "On occasion it is difficult to 8 determine the direction of a grazing- 9 type injury." 10 And -- and that's the difficulty I 11 experienced here. 12 Q: And, do the difficulties that 13 Professor Dimaio would describe, are they -- are they 14 similar to the difficulties or his observations -- are 15 the difficulties that he poses, are they in accord with 16 the difficulties you experienced in determining the -- 17 A: I experienced the same difficulties 18 here. Now, there's other contextual information here 19 that implies that this could be a grazing wound -- 20 Q: Hmm hmm. 21 A: -- but for me, I just want to stress 22 this -- for me, just looking at that in isolation, I 23 can't say for certain that it is a grazing-type injury; 24 that is, a grazing injury due to a projectile. 25 Q: Right, as well as not being able to


1 determine the -- the direction. If it were a grazing 2 injury, the direction that -- 3 A: That it's travelled. 4 Q: Yeah. All right. And approximately 5 how large was the excision that -- that you performed of 6 that particular wound have been? 7 A: I didn't -- I didn't document it, but 8 typically when we excise wounds from -- from a deceased, 9 we -- we allow probably at least a centimetre or two (2) 10 around it so as to not disrupt the actual wound itself 11 and then we -- we would typically put a notch on the 12 rectangular piece of skin that's excised -- 13 Q: Hmm hmm. 14 A: -- on the -- on the top surface, on 15 the superior aspect, so that would be the -- the notch 16 would indicate where the head is of the individual. So, 17 that provides orientation to the Examiner as to, you 18 know, which -- which side is which. 19 Q: All right. And, you did that here? 20 A: Well, as I recall, yes I did. 21 Q: Yes. And -- all right. Did you 22 perform any other examinations or investigations in 23 relation to that particular injury? 24 A: Well, we -- we haven't talked about 25 the clothing.


1 Q: No. 2 A: And the clothing was examined on the 3 14th of September. As I mentioned, he was unclothed at 4 the time of the autopsy and I mentioned to the SIU 5 investigator, Mr. Thompson, that at some point I would 6 like to -- to examine the clothing. 7 Q: All right. 8 A: I'm not a clothing examiner expert, 9 but -- but I did want to examine the clothing, 10 particularly to -- to see -- correlate whether there were 11 holes on the clothing that corresponded to the wounds 12 that were described. 13 Q: All right. And just before we move 14 to your examination of the clothing, perhaps if you could 15 describe any other internal examinations or 16 investigations you performed? 17 A: There were -- there were samples of - 18 - of body fluids, specifically blood -- 19 Q: Hmm hmm. 20 A: -- and for stomach contents and fluid 21 from the eye that was collected and this was sent to the 22 Centre of Forensic Sciences to the Toxicologist there to 23 be examined. 24 Q: All right. And, you've described 25 that previously as a standard part of any autopsy you


1 would perform? 2 A: Not on all of our autopsies. 3 Certainly in the Coroner's cases it's now standard to 4 collect samples of blood and urine, if it's present, on 5 all cases. Many of those samples are simply stored and 6 not analysed further, but certainly in -- in suspicion of 7 drug overdose, medication overdose, homicide, suspicious 8 deaths, it's routine to get -- to get further 9 toxicological analysis, because obviously that's where 10 the cause of death may lie. 11 Q: All right. And if you'll turn to Tab 12 4 of the brief of documents in front of you, that's been 13 identified here as Exhibit P-380; that's Document Number 14 1000099. You'll see the report there. 15 You mentioned earlier that that would have 16 been appended to your initial postmortem examination 17 report? 18 A: Yes. 19 Q: Okay. And can you describe for us 20 the findings of the -- as a result of the toxicology test 21 that you've described? 22 A: The analyst here, B. Yen, Y-E-N, 23 analysed the heart blood and the femoral blood. The 24 femoral blood is the -- femoral vein is a blood vessel 25 that leads from the pelvis down into the -- into the


1 thigh. So there was a blood sample from that site as 2 well. 3 So he analysed those two (2) -- two (2) 4 samples. In the heart blood, he determined that there 5 was tetrahydrocannabinol. So, it's T-E-T-R-A tetra hydro 6 -- H-Y-D-R-O cannabinol -- C-A- double ŻA-B-I-N-O-L. He 7 determined that was present at a level of 3.0 ng, which 8 is nanograms per millimetre, ml. 9 He did not detect any barbiturates, 10 cocaines or metabolite, morphine, and commented that: 11 "There are no other significant findings." 12 And he also mentions methamphetamine and 13 phencyclidine, or PCP included, using a general drug 14 screen procedure. And there was no alcohol detected on 15 analysis of the femoral blood. 16 Q: All right. So the only -- the only 17 finding of any significance would have been the 18 tetrahydrocannabinol that you've described? 19 A: Yes. Or -- or THC for short. 20 Q: Thank you. 21 A: And it's a -- it's a metabolite of 22 marijuana. 23 Q: All right. And can you described the 24 level, what three point-o (3.0) ng per millilitre would - 25 - what that would signify?


1 A: Well, in -- in Mr. Yen's (phonetic) 2 comments on the notes -- note number 1 on the bottom of 3 his report, he just says that: 4 "The above tetrahydrocannabinol 5 concentration in the blood indicates 6 possible recent use of marijuana and/or 7 hashish." 8 Q: Okay. And do you have any comments 9 or can you add any further explanation for the -- the 10 phrase, "possible recent use?" 11 A: I -- I'm not a toxicologist, I don't 12 know what he means by -- by "recent." It may be a matter 13 of hours, maybe days, I don't know. 14 Q: Thank you. All right. And were 15 those the extent of your investigations and examinations 16 internally on -- on Mr. George that day? 17 A: Yes. I mean, as -- as I said, there 18 was -- there were microscopic slides looked at later but 19 that was the extent of the -- the autopsy that day. 20 Q: Okay. And just in terms of -- did 21 you perform the -- the examination of the microscopic 22 slides that you've described? 23 A: Yes. 24 Q: All right. And what were you -- can 25 you describe your examinations and your findings in that


1 regard? 2 3 (BRIEF PAUSE) 4 5 A: I'm just going to go to item number 6 6. 7 Q: Okay. That has been identified here 8 as Exhibit P-359. 9 10 (BRIEF PAUSE) 11 12 Q: 100201 -- 13 A: Yes, it would be 1002016. 14 Q: 2016. 15 A: And on page 4 of the report, under 16 Section 5, "Microscopic and Laboratory Findings in 17 Brief." Do you want me to go through each of those and 18 what they mean or -- 19 Q: If you could just describe for us 20 anything of significance. 21 A: Okay. Again, a reiteration, 22 regarding the coronary artery, the left anterior 23 descending branch, one (1) of the three (3) major vessels 24 that supplies the heart muscle, again, I reiterate, there 25 was atherosclerotic stenosis; stenosis means narrowing to


1 a degree of 75 percent. 2 Above that line, I mentioned, in the 3 heart, in the left ventricle, which is the largest 4 chamber of the heart, there were some enlarged muscle 5 fibres. But I mentioned they were simply occasional. 6 And the heart itself appeared to be of normal weight. 7 The lungs were congested. There was just 8 more fluid in them, more blood. And this is a non- 9 specific finding frequently seen after death. And in 10 fact, the congestion was to a degree that in some areas 11 the blood had actually gone into the air spaces. So when 12 it says "focal intra-alveoli" or "haemorrhage," some of 13 that blood has just entered into the air spaces; again, a 14 non-specific finding. 15 The liver showed mild fatty chain. So 16 there was some fat that had deposited in the liver cells. 17 The colon, there was -- I put in question 18 mark because it wasn't well preserved. Odoly (phonetic) 19 simply means there's been breakdown of the tissue after 20 death. And there was maybe a small polyp or growth in 21 the colon, but it could not be analysed too well because 22 of the condition of the tissue. 23 The prostate gland. Mr. George was 24 starting to develop some enlargement of his prostate, at 25 least under the microscope, there was an occasional


1 nodule there. 2 The next line, "Soft tissue entry wound." 3 As I mentioned before, there was some recent haemorrhage 4 or bleeding into the fat. That's not really a mystery; 5 we knew that that was the -- 6 Q: Hmm hmm. 7 A: -- that was an entry site, and 8 there's a little spicule of bone, so this means there's a 9 little fragment of bone seen under the microscope, 10 probably a reflection of his broken clavicle, some of 11 that bone had found it's way into the entry site. 12 Examination the brain under the 13 microscope, shrunken neurones in a region of the brain 14 called the Hippocampus. The Hippocampus is an area that 15 can be affected by a lack of blood flow. 16 In this case there were shrunken neurones 17 but it may suggest that there has been a lack of blow 18 flood but also this may be simply non-specific that we 19 frequently see this change in other cases and it may 20 simply be an artefact. 21 The next line says again there's been 22 break down of tissue in the brain, because of the post 23 mortem interval, autolytic changes. 24 Q: Hmm hmm. 25 A: Auto simply means self-digestion, and


1 the enzymes in the body start to digest tissues and 2 they're difficult to -- to study under the microscope. 3 And then, "postmortem toxicology, see 4 attached report." We've discussed that. 5 And then there were a number of other 6 organs that were examined, pancreas, stomach, kidney, 7 testes, urinary bladder, thyroid, adrenal, pituitary, 8 spleen, bone marrow. 9 These showed no abnormality, but again 10 it's recurrent theme of breakdown or autolysis because of 11 the postmortem interval that these tissues were starting 12 to break down and making their interpretation relatively 13 difficult. 14 Q: All right. But you have described 15 that that would be typical, given the interval between 16 the time of death here, approximately, and the time of 17 the examination? 18 A: Yes. 19 Q: Okay. All right, is there -- are 20 there any other comments that you can make, based on your 21 internal examination of Mr. George, or that you should 22 make before we move on to your examination of his -- some 23 of the external, his clothing, for example? 24 A: I can't think of anything now. I'm 25 sure there might be other questions about --


1 Q: Okay. 2 A: -- that, but I just can't think of 3 anything else right now, so. 4 Q: All right. I note in your report, 5 Exhibit P-359, on the second -- second page, you make 6 reference to a September 14th examination of -- of 7 clothing? 8 A: Yes, this was done about quarter to 9 5:00 in the afternoon and clothing was brought by the SIU 10 investigators, Thompson and Miller. 11 Q: All right. And you note that you 12 examined a blue speckled t-shirt? 13 A: Yes. 14 Q: And that it was previously cut in 15 front? 16 A: Yes, that was likely done in the 17 Emergency department -- 18 Q: Hmm hmm. 19 A: That's -- that's typical that in the 20 course of trying to resuscitate an individual, clothing 21 is removed and frequently by cutting, just to allow 22 access to the -- to the body surface. 23 Q: Okay. And you also note that there 24 was a .5 centimetre hole in the left seam? 25 A: Yes.


1 Q: And that was 20.5 centimetres to the 2 left of the label. 3 Which label would that be? 4 A: That would be the label on his 5 collar. 6 Q: Okay. So that hole would have been 7 in the back of the t-shirt? 8 A: Well, it would have appeared on the 9 back, but realizing the -- 10 Q: Hmm hmm. 11 A: -- t-shirt was flayed or splayed open 12 because of the -- 13 Q: Hmm hmm. 14 A: -- cut in the front, so in fact, it 15 was -- 16 Q: Hmm hmm. 17 A: -- probably the front of the t-shirt 18 corresponding to the entry site. 19 Q: Okay. And you also noted dry stains. 20 Would those have been just based on a visual observation, 21 dry blood stains? 22 A: I didn't say -- I didn't specify 23 blood -- 24 Q: Hmm hmm. 25 A: -- but likely they -- they were blood


1 stains. 2 Q: And you also noted sand on the front 3 and back? 4 A: Yes. 5 Q: Was there any other observations that 6 you would have made of that particular garment -- 7 A: No. 8 Q: -- of any significance? 9 A: No. 10 Q: You also examined some grey pants and 11 article -- that article of clothing? 12 A: Yes. 13 Q: All right. And you note that they 14 were tied with a cord? 15 A: Yes. 16 Q: They remained tied with a cord? 17 A: I assume they did -- 18 Q: Yeah -- 19 A: -- I don't think we untied it. 20 Q: Okay. And could you just describe, 21 if you will, your -- the findings based on that 22 examination? 23 A: Well, I was really focussing, and I 24 did examine the -- all the surface area of the pants, but 25 I was really focussing on the -- on the area that


1 corresponded to the abrasion I described on the shin. 2 And focussing on that area, so on the 3 right outer pant leg -- 4 Q: Hmm hmm. 5 A: -- there was an "L" shaped tear which 6 was 1.7 centimetres long it was a vertical orientation. 7 So this is about three-quarters (3/4) of an inch long. 8 Q: Hmm hmm. 9 A: And, so it's vertical and then 1.5 10 centimetres horizontally; so an L-shaped tear. And then 11 I give a -- I gave a distance from the lower cuff, 12 twenty-three (23) centimetres from the lower cuff, eight 13 (8) centimetres from seam; so we have one tear. 14 And then, on the inner pant leg I noted 15 that, first of all, there were reddish brown stains 16 inside, and there were also two (2) holes, smaller holes, 17 zero point eight (0.8) and one (1) centimetre across. So 18 approximately a third (1/3) to half (1/2) an inch across. 19 And again, I -- I've given a distance from the seam, one 20 point five (1.5) or -- centimetres, or about half (1/2) 21 an inch, three point five (3.5) centimetres or one and a 22 half (1 1/2) inches respectively from the seam observed. 23 And these were twenty-five point five (25.5) centimetres, 24 or approximately a foot above the lower cuff. 25 I noted some other holes in the left


1 pocket, so this would be much higher up. And there were 2 also some red stains on the front of the pants and 3 spatter-like streaks on the back. 4 Q: All right. And those red stains, 5 just based on your visible -- visual examination, did you 6 assume them to be bloodstains at the time? 7 A: I assumed they were, but I didn't do 8 any further testing in that regard. 9 Q: Okay. And can you relate your 10 findings for us as you've described them there to your 11 earlier observations of the abrasion that appeared on -- 12 on Mr. George's leg? 13 A: Well, as I said, these -- these 14 tears, the three (3) of them, the L-shaped tear, the 15 larger tear, and these two (2) holes, appear to be in 16 approximately the same area as that abrasion on -- on the 17 leg. 18 Q: Okay. 19 A: And I realize I'm not a clothing 20 examiner but, you know, there -- there were holes there. 21 Q: All right. 22 A: And again, as I mentioned before, in 23 the context of what happened it -- it did suggest 24 something. 25 Q: Okay. And were you, based on this


1 examination, were you able to determine by any means the 2 source of the damage to the clothing? 3 A: Well, they -- those holes could be 4 due to -- to a projectile, it's possible; but, again, I'm 5 not a clothing examiner. The clothing was sent off for 6 further examination. And -- but, you know, those holes 7 could have been caused by a projectile. 8 Q: And just for the record, the items 9 that you've described also are -- are itemized at Tab 10, 10 that would be the -- the January 9th, 1996 report by Mr. 11 Nielson, on the second page. He has listed as Item F-10: 12 "Seized by police. one (1) pair of 13 grey coloured trousers." 14 And he has described: 15 "Three (3) holes in line were found in 16 the wearer's lower right leg. They 17 could have been made by a projectile." 18 And do you have any comments on his 19 observations there? 20 A: No, nothing further. 21 Q: All right. You also examined and -- 22 and we've -- you've described your examination of a blue 23 T-shirt. Actually, you've described it as blue speckled 24 T-shirt in -- in your report. And he's -- is it -- is it 25 speckled with blue or blue with speckles, by your


1 recollection? 2 A: Let me -- I'm just going to refer to 3 my report again. 4 Q: All right. Thank you. Just to -- to 5 verify that that's actually the same article of clothing. 6 7 (BRIEF PAUSE) 8 9 A: I just simply said, "Blue speckled T- 10 shirt," I -- I don't recall. 11 Q: You can't -- all right. And he's -- 12 identified that item as Item F-12, that's Mr. Nielson's 13 report: 14 "Seized by police. [And] There's a 15 small hole in the ribbing of the neck 16 on the wearer's left side. No close- 17 range firearms discharge residues were 18 found." 19 And you've already described, I believe, 20 your examination of that -- 21 A: Yes. The hole was small, I -- I 22 described it as about, you know, zero point five (0.5) 23 centimetres. The ribbing I assume to the seam that I 24 described -- 25 Q: Hmm hmm.


1 A: -- and it was on the left side. 2 Q: All right. And you also refer in 3 your report to: 4 "A black T-shirt inscribed with 5 Michigan Wolverines insignia." 6 A: Yes. 7 Q: "No holes. [And] Sand present." 8 You also note that -- if you can describe 9 your further note there for us, you make some reference 10 to tissue -- possible tissue? 11 A: Yes. There was a zero point seven 12 (0.7) by zero point two (0.2) centimetres, so about a 13 quarter (1/4) of an inch in maximal dimension, and then I 14 put, question mark, "tissue on the edge of the right 15 sleeve." 16 Q: Okay. All right. And were you 17 advised that this article of clothing was worn by Mr. 18 George, or? 19 A: It was presented to me as -- 20 Q: Hmm hmm. 21 A: -- items of clothing that he had 22 worn. 23 Q: Okay. And would there have been any 24 significance to your -- or can you describe any 25 significance to your observation of possible tissue on


1 the edge of the right sleeve? 2 A: Again, not knowing the source of that 3 tissue -- 4 Q: Hmm hmm. 5 A: -- I did not do any further analysis. 6 I did not want to -- 7 Q: Hmm hmm. 8 A: -- alter this -- this shirt. 9 Q: Hmm hmm. 10 A: Now, again, whether he wore the shirt 11 or it was applied to his body in some way, I mean that's 12 another possibility. 13 Q: Okay. And you also examined a pair 14 of blue, white, red runners? 15 A: Yes. 16 Q: Okay. And can you explain your -- 17 the reason for your -- your examination of those runners 18 and your observations? 19 A: I noted that there were stains on the 20 right heel. 21 Q: Hmm hmm. 22 A: Again, possibly blood stains, and I 23 noted the heel thickness was three (3) centimetres, or a 24 little bit over an inch in thickness. 25 And again, that might have played some


1 consideration with his height and the height of the 2 runners as to -- as to trajectory. 3 Q: All right. And beyond what you've 4 described in relation to the pants and the possible 5 source of the abrasion injury on Mr. George's leg as well 6 as the hole in the blue tee shirt, or blue speckled tee 7 shirt. 8 Did you make any other observations or 9 conclusions based on your examination of his clothing? 10 A: No, I did not. 11 Q: Okay. All right. 12 13 (BRIEF PAUSE) 14 15 Q: All right. Turning now to the loss 16 or the blood -- the evidence of blood loss that you 17 described in Mr. George, can you describe the probable 18 effects? 19 First of all, the timing, how long it 20 would have taken insofar as you're able to provide an 21 opinion for him to lose that amount of blood based on the 22 injuries you observed? 23 A: You know, I can't give a specific -- 24 Q: Hmm hmm. 25 A: -- time sequence as to the course of


1 events, but generally speaking, when someone goes into 2 shock, they may be conscious for a period of time and, 3 again, it depends on the -- the -- how fast blood is 4 lost, but they would be perhaps unconscious for a period 5 of time. 6 Q: Hmm hmm. 7 A: And as they're going into shock, so 8 blood pressure starts to drop as they're losing blood, 9 their heart would start to beat more quickly, trying to 10 pump what blood is left more efficiently throughout the 11 body. 12 They might be breathing more heavily, but 13 eventually a point would be reached, though, that there 14 wouldn't be enough blood to be pumped effectively 15 throughout the body -- 16 Q: Hmm hmm. 17 A: They would begin to be -- feel faint, 18 lose consciousness. The heart may continue to beat, they 19 may breath for a period of time, but eventually all these 20 basic body functions would cease because of the lack of 21 blood flow, particularly to the brain, particularly the 22 vital centres of the brain that control -- control 23 breathing and -- and the heart rate. 24 Q: Okay. And you had described that you 25 couldn't provide a specific time range that it would have


1 occurred, based on the injuries that you observed in Mr. 2 George. 3 A: It could be in a matter of minutes -- 4 Q: Hmm hmm. 5 A: -- and then once the -- what's 6 called, cardiorespiratory arrest occurs, that is the 7 heart stops beating and breathing stops, there would be a 8 window of opportunity of a few minutes where, if 9 resuscitation, again speaking in general terms, if 10 resuscitation occurred, one could -- if one revived a 11 person, they would not suffer irreversible brain death. 12 Q: Okay. And in terms of a timely 13 intervention, timeliness being described as affecting the 14 survivability of these particular injuries, how long from 15 the point of injury would you estimate -- 16 A: Again, I can only be circum -- 17 Q: -- would you need to make that 18 intervention? 19 A: -- circumspect here. I think 20 probably I testified previously, you know, it could be in 21 a matter of minutes, maybe ten (10), fifteen (15) 22 minutes, but if there's bleeding from multiple sources 23 inside the body, I can only be circumspect. 24 It would probably be in the course of 25 minutes --


1 Q: All right. 2 A: Realizing that in -- certainly in the 3 forensic literature, people can suffer devastating 4 injuries, internal injuries yet still have purposeful 5 activity, be conscious for an extended period of time. 6 Arguably, those are exceptional cases, but 7 there really is a range of human response to injury. 8 Q: And we've heard from witness, Dr. 9 Saettler, who's a -- a general surgeon, that if there 10 were to be intervention, effective intervention, with 11 this type of injury if would require invasive thoracic 12 intervention. 13 In other words, the -- the chest 14 would have to be cracked open and the injuries that -- 15 that you've described would need to be sutured 16 immediately. 17 Can you make any further comments on -- on 18 what type of intervention would be necessary to affect -- 19 to affect the survivability of this -- this particular 20 type of injury? 21 A: Well, I -- I deal with a skewed 22 population, obviously, I mean I don't -- I don't treat 23 individuals. I'm not a surgeon, but I -- I would agree. 24 I mean, I think this would have to be a heroic -- timely 25 heroic intervention in terms of opening the chest,


1 locating the bleeding sources and providing the necessary 2 fluid resuscitation; blood, intravenous fluids to -- to 3 try to maintain blood pressure, maintain flow of blood, 4 particularly to the brain. 5 Q: All right. And we have heard that it 6 took somewhere in the area of fifty-five (55) minutes for 7 Mr. George to reach -- from the time of his injury and 8 that's an approximate time -- for him to reach the 9 hospital. 10 In your view, could that have been -- that 11 intervention have been effectively performed after fifty- 12 five (55) minutes? 13 A: I'm not a -- I'm not a trauma 14 specialist, per se, in terms of treating individuals. I 15 can say, though, that, you know, I think the likelihood 16 that the bleeding occurred over a number of minutes, 17 period of minutes, probably sooner than later though. 18 Q: Okay. We've also heard from the 19 treating physicians, Drs. Marr and Saettler that in their 20 estimation, prior to his arrival in the hospital, they 21 estimated that his heart had stopped beating at least 22 five (5) to ten (10) minutes prior to his arrival. 23 Based on the resuscitative efforts that 24 you -- you would have made note or observed evidence of - 25 - or, can you make any -- any comments on their -- their


1 observations in that regard? 2 A: I -- I can't say specifically, you 3 know, as to how they arrived at those conclusions. It 4 sounds reasonable. 5 Q: Okay. 6 A: But I -- I don't know what the basis 7 for that was. 8 Q: All right. And I understand that you 9 are not able, based on you examinations, to provide a 10 specific time of death? 11 A: No, I cannot. I know that he was 12 formerly pronounced dead shortly after midnight after 13 some initial resuscitative efforts, but again, I just 14 want to emphasize that the -- the -- what you see on -- 15 on TV or movies or read in books where pathologists, by 16 looking at certain changes in the body that occur after 17 death, I can -- I can accurately determine the time of 18 death; that's really the myth. 19 The -- the -- and you actually used a word 20 before, "estimate." 21 Q: Hmm hmm. 22 A: At best we can only estimate the time 23 of death based on certain changes, stiffening of the 24 body, settling of blood in the body, what's called, 25 "lividity." We can only estimate. And, again, as


1 pathologists, we actually work at a disadvantage because 2 we see these individuals at some time later after they've 3 been removed from a death scene and in -- in the process 4 of that, those changes have evolved, the person has been 5 moved, they've been manipulated, so stiffening of the 6 body may be -- may be broken. So we really can't say for 7 certain when -- when a person died. 8 Q: All right. 9 A: Unfortunately, that -- that's the 10 science of -- of time/death estimation, the keyword is 11 estimation. 12 Q: Okay. And based on all the 13 examinations and investigations you've described, did you 14 form an opinion as to the cause of Mr. George's death? 15 A: Yes, in -- in my report on the -- 16 page 4 on item number 8, I indicated that the cause of 17 death was a gunshot wound of the upper chest. 18 Q: All right And, can you expand on 19 that opinion at all, or? 20 A: Yes, based on the -- on the wound 21 tract with the multiple sources of bleeding within -- 22 within the chest cavity, the -- the amount of blood in 23 the chest cavity, the cause of death is the gunshot 24 wound; the mechanism of death, that is the disturbance 25 that caused his death would have been a shock-like state


1 with eventual cessation of blood flow to the brain and 2 eventual cardiorespiratory arrest, that is, his heart 3 stopped beating and he stopped breathing. 4 Q: All right. Thank you, Dr. Shkrum. 5 A: You're welcome. 6 Q: I have no further questions for you, 7 however, I'm sure My Friends will have some. Perhaps if 8 we could canvass Counsel for the other parties as to 9 their -- their estimates of cross-examination time? 10 COMMISSIONER SIDNEY LINDEN: Would you 11 please give me the usual estimate of who wishes to 12 examine and for how long? 13 Yes, Mr. Orkin...? 14 MR. ANDREW ORKIN: Fifteen (15) minutes 15 or less, Commissioner. 16 COMMISSIONER SIDNEY LINDEN: Fifteen (15) 17 minutes or less? 18 Ms. Esmonde...? 19 MS. JACKIE ESMONDE: Ten (10) to fifteen 20 (15) minutes. 21 COMMISSIONER SIDNEY LINDEN: And, Ms. 22 Jones...? 23 MS. KAREN JONES: About half an hour. 24 COMMISSIONER SIDNEY LINDEN: About half 25 an hour?


1 And, Mr. O'Marra...? 2 MR. AL O'MARRA: Just in that Dr. Shkrum 3 acted under the warrant of the Coroner for the postmortem 4 examination, I just reserve some time, if necessary. 5 COMMISSIONER SIDNEY LINDEN: That's fine. 6 So, we should be able to complete your 7 examination this afternoon. 8 THE WITNESS: Great. 9 COMMISSIONER SIDNEY LINDEN: So we'll 10 break for lunch now and come back about 1:15 or so. 11 MS. KATHERINE HENSEL: Thank you. 12 COMMISSIONER SIDNEY LINDEN: Thank you. 13 THE REGISTRAR: This Inquiry stands 14 adjourned until 1:15. 15 16 --- Upon recessing at 12:04 p.m. 17 --- Upon resuming at 1:16 p.m. 18 19 THE REGISTRAR: This Inquiry is now 20 resumed, please be seated. 21 22 (BRIEF PAUSE) 23 24 COMMISSIONER SIDNEY LINDEN: Yes, Doctor? 25 Thank you very much.


1 Yes, Mr. Orkin, I'll let you introduce 2 yourself. You will in any event. 3 MR. ANDREW ORKIN: I'm not sure how to 4 take that, Commissioner, but thank you anyway. 5 COMMISSIONER SIDNEY LINDEN: Well, I'm 6 not going to make any more mistakes. 7 8 CROSS-EXAMINATION BY MR. ANDREW ORKIN: 9 Q: Good afternoon, Dr. Shkrum. 10 A: Good afternoon. 11 Q: My name's Andrew Orkin, I'm co- 12 Counsel to the Dudley George Estate and the Sam George 13 Group of Family Members. I have a few questions for you. 14 As I announced earlier, it will be fifteen (15) minutes 15 or less and I think probably quite a bit less. 16 Dr. Shkrum, you'd indicated that -- am I 17 pronouncing your name correctly? 18 A: That's right, the "k" is silent. 19 Q: It's a silent "k". That's very 20 helpful, I was wondering how to do that consonant 21 cluster. 22 A: It's a lot of consonants; just one 23 (1) vowel, so. 24 Q: It is. You indicated that you had 25 practised pathology, forensic pathology, in at least two


1 (2) North American jurisdictions? 2 A: That's correct, in North Carolina and 3 Ontario. 4 Q: And that would mean that you're 5 reasonably or perhaps even quite familiar with the 6 general, regulatory and ethical frameworks surrounding 7 the conduct of autopsies? 8 A: Yes, and that framework has evolved 9 in the -- in the last few years in the province of 10 Ontario, particularly. 11 Q: Yes, indeed. By definition, an 12 autopsy is a form of an interference with a body of a -- 13 of a deceased; is it not? 14 A: Well, you say, "interference," I 15 would say it's an investigation. 16 Q: I'm -- I'm using the word in a 17 completely neutral sense. In other words, were the 18 autopsy not occurring, that contact would not be 19 occurring? 20 A: That's correct 21 Q: It's an engagement with the -- the 22 word you used was, "investigation" -- 23 A: Yes. 24 Q: -- which is -- which is fine. 25 You mentioned that some autopsies occur by


1 way of a regime of consent of relatives of the deceased; 2 is that correct? 3 A: Yes. 4 Q: And others -- and those autopsies 5 occur not because there is a statutory or regulatory 6 requirement that they be undertaken, but because there is 7 some other interest in an autopsy being conducted, a 8 clinical -- 9 A: Yes, yes. There may be issues that 10 the family has raised -- 11 Q: Right. 12 A: -- familial disease, perhaps clinical 13 care issues, effectiveness of the treatment and similarly 14 -- similar questions could be raised by the clinical team 15 that's taken care of that individual. 16 Q: And in the context where the consent 17 of the family is sought, or family members is sought for 18 that investigation involving the body or corpse of a 19 deceased, it's out of respect for and in full 20 acknowledgement of the interest of those family members 21 and their relationship with that -- that deceased person, 22 that their consent is sought; is that correct? 23 A: Yes, and it's a legal requirement. 24 You can not perform an autopsy on -- in that situation 25 without the consent of the next of kin.


1 Q: That was my next question, and that 2 interest has recognition at law, which you've just 3 confirmed. 4 A: Yes. 5 Q: Now, in other contexts you mentioned 6 that autopsies occur by means of the permissive or 7 perhaps, in other circumstances, obligatory requirements 8 of the statute -- of a statute or statutory regime? 9 A: Yes, there's a statutory requirement 10 in certain types of deaths, in this province. And 11 obviously in other jurisdictions as well. 12 Q: And are there other -- other contexts 13 in which the statute is merely permissive but not 14 obligatory? 15 A: I -- I -- 16 Q: I'm not sure where and perhaps not in 17 this -- 18 A: I've -- offhand, I'm not aware of the 19 -- such a situation. No, I'm sorry, there may be 20 jurisdictions where it may be quite localized 21 jurisdictions where the permission of the family is 22 sought in a medical/legal investigation, but potentially 23 that could be counter productive. 24 Obviously if it's a homicide and the 25 family members are suspects then you don't want that kind


1 of permission. 2 Q: Absolutely. Now, in the context of 3 an investigation, by definition one is investigating in 4 order to obtain information that is otherwise -- would 5 otherwise not be available were that investigation not 6 occurring, by means of -- of detailed examination of -- 7 of the body of the deceased. 8 A: Yes. 9 Q: The product of an autopsy is 10 information? 11 A: Yes. 12 Q: And we've identified a second ago 13 that one of the -- obviously one of the parties, major 14 parties, that has an interest in those investigations 15 occurring is the estate, for reasons of good governance 16 and -- and -- and knowledge about the circumstances in 17 which people have died. 18 The estate has an interest in the 19 obtaining of that information which is why it's enacted 20 statutes; is that fair? 21 A: Yes, that's fair. 22 Q: And likewise, in seeking the consent 23 or even making obligatory the seeking of consent under 24 some circumstances, we recognize as a society that the 25 interests of family members also exists and -- and is


1 compelling in that information? 2 A: I think it would be. Again in this 3 system we have in Ontario, the coroner's system, as 4 pathologists we don't usually have direct interaction 5 with the family. We would rely on the intermediary of 6 the coroner dealing with the family. 7 Q: But the -- nevertheless is an 8 institutional mechanism? 9 A: Yes, there is -- 10 Q: Right. 11 A: And certainly if there are any 12 concerns raised, speaking in general terms, about the 13 conduct of an autopsy, for example, religious reasons. 14 Q: Right. 15 A: If there is some need to perform a 16 particular type of dissection or there's a time frame for 17 release of that body, then that should be communicated to 18 us, hopefully by the -- by the coroner involved in the 19 investigation and we will try to -- to comply with that 20 as best as we can. 21 Q: Talking then about information, in 22 the -- in the context of -- of -- of family member 23 consent, what are the provisions that are made either as 24 -- as a result of regulations or as a result of good 25 practice for the transmission of that information to


1 relatives in recognition of that interest that we've 2 recognized -- that we've just talked about? 3 A: So you're asking how's the 4 information transmitted? 5 Q: Yes. 6 A: Are you talking about medical-legal 7 cases or hospital cases? 8 Q: Either or both. 9 A: Okay. 10 Q: Could we look at the -- if it's 11 different, perhaps you could briefly explain how it's 12 different? 13 A: Okay, with the hospital cases, and 14 bearing in mind that with a hospital death you're 15 dealing -- 16 Q: This is a clinical situation? 17 A: A clinical situation where you are 18 dealing with a disease, so someone who dies of natural 19 circumstances. 20 If there are no issues raised from a 21 medical-legal point of view, say, some -- some problem 22 with the care of that individual, if -- and the relatives 23 give consent, then there are reports obviously generated 24 by the pathologist. 25 There is a report initially that


1 summarizes the findings of the autopsy, the actually 2 autopsy done. This report usually goes out within a few 3 days to the clinical team and to the family doctor if 4 there is one. And the family can contact the respective 5 physicians, family doctor or someone on that clinical 6 care team to discuss those results. 7 If the clinical person needs clarification 8 as to the findings, then they -- they can contact the 9 pathologist in -- in that interim. Some time later and I 10 use that in a broad sense because it may take some months 11 before the final report is available. 12 The report is -- the final report with 13 much more detail is sent to the same individuals, family 14 physician and the -- the attending physician that took 15 care of the person in the hospital. 16 And then that physician in turn can share 17 that information with the family. And they'll have a sit 18 down, have a conference and again may require input from 19 the pathologist as to the meaning of certain -- certain 20 items in that report. 21 So that's from the hospital case point of 22 view. If you have a coroner's case or medical/legal 23 case, the information that I have from, again, speaking 24 in general terms, from the autopsy proper, that 25 information's conveyed to the coroner that's


1 investigating the case. 2 And then the assumption is made with that 3 information and the coroner will in turn communicate with 4 the next of kin as to the immediate results of the 5 autopsy. There's no written report that I generate at 6 that point. 7 In some months later, depending on the 8 complexity of the case, realizing that there may be 9 multiple reports that are being gathered or being 10 prepared in that -- in that interim period, a final 11 report is issued. 12 There's a limited distribution of that 13 report. It goes to the investigating coroner, the local 14 coroner, the regional coroner, the coroner that presides 15 over the coroners in that region, to the Crown Attorney's 16 office and to the Chief Coroner's office. And that is -- 17 that is the very limited distribution. 18 If that person died in hospital, say they 19 were in an accident and subsequently died in hospital, 20 then the local coroner will issue a release form that 21 allows that report -- pathology report to be released to 22 the medical records of the hospital. 23 And then it would be available to the -- 24 say the attending physician that took care of that 25 individual.


1 Q: So in the latter case of -- of 2 medical/legal autopsies as you've referred to them, the 3 circle of distribution is -- is officially limited? 4 A: Yes. 5 Q: Both in times of -- 6 A: From my perspective, yes, when I send 7 my report out. Now once that report goes out, other 8 people can have access to it. But it has to be through 9 the commission of the coroner's office. 10 Q: Are you aware, perhaps, of the -- of 11 an answer to the question of to whom under that the 12 latter circumstance, the report -- the final report, once 13 it has been issued, may not go? 14 A: I'm not -- I'm not aware of the -- 15 Q: You're not aware of that. 16 A: I'm not aware of that. 17 Q: Just by way of context to this line 18 of questioning, it was eighteen (18) months before the 19 siblings and representatives of the Estate of Dudley 20 George saw the autopsy report. And this was at the 21 beginning of the trial of -- of Sergeant Kenneth Dean as 22 it began in April 1997. 23 There has been evidence from Sam George, 24 one of the George Family members of the difficulty they 25 experienced after the death in seeing a report, an


1 official report as to the injuries that their relative 2 had sustained. 3 Was there, as far as you -- you 4 experienced, any form of an actual or perceived lock 5 down, for lack of a better term, on the final autopsy 6 report that you prepared? 7 A: Sir, I'm not aware of that. My 8 report is dated March 11th, 1996 and so it's 9 approximately six (6) months after the fact. I know this 10 report was typed up in early February. I may have been 11 waiting for the receipt of Dr. -- Mr. Nielson's report in 12 January in relation to that leg wound. 13 I know I had a meeting in February I had 14 to attend so that's when my report was issued. But 15 beyond that I don't know how the -- you know, how the 16 report was distributed. Who made requests for that 17 report, I don't know, sir. 18 Q: Do you have any reaction as either a 19 pathologist or as a -- as a family man to a period of -- 20 of more than eighteen (18) months before family members 21 get to see a report of this kind under circumstances such 22 as these? 23 A: Again, I'll speak in general terms. 24 As -- as a medical leader of the autopsy service and -- 25 and a director of forensic pathology unit we do get


1 inquiries directly in our department about reports; not 2 Coroner's cases, medical/legal reports as well as -- as 3 autopsy reports. 4 I take those -- or hospital cases -- I 5 take those -- that -- that seriously and if it's a 6 hospital case I -- if the case is another pathologist's 7 I, you know, certainly remind them that they should get 8 their reports out expeditiously. There -- there are 9 obviously serious matters that ride on hospital -- even 10 hospital cases; there's insurance matters and, you know, 11 other sort of things that have to be dealt with the 12 estate. 13 With Coroner's cases, again, I certainly 14 strongly urge the pathologist to -- to complete the 15 reports quickly, particularly when there's inquiries 16 being made. It may be held up for other reasons as I 17 said because of other reports that are being generated, 18 but once those reports go out, then it becomes a matter 19 of the -- of the Coroner's office, the -- the issuance of 20 those reports and how that's done and how that -- what 21 that mechanism is. 22 I know that families can -- can write 23 letters to inquire about reports or phone the Coroner's 24 office and get -- get -- eventually get access to 25 reports. I don't know on the particular case, you know,


1 what -- what -- what the, you know, mechanism came into 2 play; I really don't know. 3 Q: Yes. And there is no way you could 4 know that. 5 A: No. Once my report was -- 6 Q: I'm not, in any way, implying that 7 you were contacted and -- and refused -- 8 A: Yeah. 9 Q: -- I'm just attempting to get your -- 10 A: I -- I don't know once my report was 11 issued what -- what the distribution of that report was 12 other than my -- my distribution, but what -- what the 13 subsequent distribution was, I don't know. 14 Q: Now, with your knowledge as a -- as a 15 -- as a pathologist and -- and to some extent, for lack 16 of a better word, someone involved in the -- in the 17 system of -- of forensic pathology, would you have a 18 recommendation for the Commissioner that arises from your 19 experience and knowledge and -- and lengthy practice as 20 to an appropriate approach to this question of relative - 21 - relatives' access in a timely way to pathologists' 22 final reports? 23 A: I thought -- I was going to say that 24 was the Commissioner's job to make a recommendation. I 25 just wanted --


1 Q: It is, but informed -- informed by 2 learned experts. 3 A: Well, I -- I know the -- the Chief 4 Coroner's officer has certainly made efforts and -- and 5 certainly there has been a recent memorandum that's been 6 issued that we should try to complete our reports as 7 expeditiously as possible, particularly once results are 8 made available, particularly, say, toxicology results. 9 You know, if there's a result available and the cause of 10 death is defined, get the report out as quickly as 11 possible. So certainly there's steps been made to try an 12 encourage that. 13 But you know, you run into problems, you 14 know, if you're waiting for other reports, if there's -- 15 there's a backlog of cases. I mean, forensic 16 pathologists are very busy people, there are some very 17 busy forensic units. We're sort of moderate in terms of 18 our volume, but Toronto's very busy, Hamilton's busy; 19 there's a backlog of cases in these places. 20 I think if there's a case that demands 21 immediate attention, I'm sure any pathologist would try 22 to get, you know, that case out as -- as soon as possible 23 if there has been an inquiry made, but once that report 24 is out, you know, other mechanisms come into play that we 25 may not have any -- any control over.


1 Q: That's very helpful, thank you. I 2 have, Commissioner, with your permission, a couple more 3 questions I'd like to explore. 4 You talked this morning about the nature 5 of the projectile or bullet that entered Mr. George's 6 body in the vicinity of the clavicle and you described 7 that bullet as a metal-jacketed bullet; is that correct? 8 A: Yes. 9 Q: Could you remind us and perhaps 10 elaborate a little on -- from you knowledge of -- of 11 these things about two (2) things, firstly the -- the -- 12 if you could elaborate on the characteristics of those 13 projectiles and their behaviour inside human bodies and 14 secondly, from you knowledge -- I'll -- I'll pause there. 15 I hear... 16 COMMISSIONER SIDNEY LINDEN: Carry on. 17 You haven't finished your question yet. 18 MR. ANDREW ORKIN: I'm -- I'm pausing in 19 order not to have a bifurcated question. I was -- I was 20 asking Dr. -- 21 THE WITNESS: It's almost trifurcated 22 there. 23 24 CONTINUED BY MR. ANDREW ORKIN: 25 Q: Almost trifurcated. But to elaborate


1 on the character of those projectiles in -- in their 2 behaviour inside human bodies? 3 A: Okay. Realizing I'm not a firearms 4 expert and I -- 5 Q: Understood. 6 A: -- you know, as a pathologist's point 7 of view of -- I can comment on the injury potential of -- 8 of this kind of projectile. 9 As I said before, that a projectile is 10 composed of lead and -- and in lower calibre weapons; 11 handguns, rifles, you know, 22 calibre, this sort of 12 thing, there -- they're just all lead projectiles and 13 they're fired at -- fired at a relatively low velocity. 14 Q: Hmm hmm. 15 A: Say in the order of a few hundred 16 feet per second. As you fire a bullet at a higher 17 velocity, the potential is for that soft lead to start to 18 fragment, and it starts to break apart because it's soft. 19 Q: Hmm hmm. 20 A: And I guess, you know, the deceptive 21 thing with these projectiles is they look so small, but 22 they're fired at a great velocity. 23 So as you increase the velocity, it 24 acquires more energy. 25 Q: Hmm hmm.


1 A: And if you remember your high school 2 physics -- 3 Q: I don't. 4 A: Okay, well, this -- I remember this 5 part. Kinetic energy is proportional to velocity 6 squared. 7 Q: Hmm hmm. 8 A: So if you have something, a 9 projectile, and you double its velocity, you quadruple 10 its -- 11 Q: Quadruple -- 12 A: -- energy. It's two (2) to the power 13 of two (2). 14 Q: Hmm hmm. 15 A: So when you start to deal with high 16 velocity weapons that are firing a projectile at, you 17 know, say a thousand (1,000) feet plus per second, it's 18 much more energy involved than, just simply say, a .22 19 rifle. 20 Q: Hmm hmm. 21 A: So as that bullet enters into the 22 body, for a very temporary period of time it creates a 23 cavity of energy around it and that energy dissipates 24 quite widely and expands the tissue and causes a fair 25 amount of tissue destruction.


1 And then that cavity collapses into what's 2 -- what's called a permanent cavity, or actual wound 3 tract. 4 So as pathologists, we see that wound 5 tract at autopsy. We see the permanent cavity, but we 6 can't appreciate the -- well, at least not directly -- 7 Q: Hmm hmm. 8 A: -- the temporary effects of that, 9 because that energy is dispersed quite widely. So higher 10 velocity weapons can cause a tremendous amount of 11 destruction and -- internally. 12 In fact, the -- the organs can actually be 13 torn apart quite massively. 14 Q: And is that a specific function of 15 the power of the weapon that fired the projectile or the 16 projectile itself coated with a metal or is it a 17 combination of those two (2) things? 18 A: Well my understanding of -- of these 19 projectile, and I'm not a firearms expert -- 20 Q: Hmm hmm. 21 A: -- is that the jacket is put on that 22 projectile so as it passes through it's less likely to 23 fragment. 24 Q: Right. 25 A: Okay. It's to be kept relatively


1 intact, to pass through a number of structures within the 2 body. 3 But the -- the wounding ability, one of 4 the major factors in the wounding ability is the velocity 5 of that projectile. The higher the velocity, the greater 6 the energy. 7 Q: Thank you, doctor. My third and last 8 area of questioning concerns your indication that, 9 particularly with the expertise coming out of such places 10 as Texas, there is a fair amount of knowledge about the 11 nature of wounds that bullets -- bullet-caused injuries 12 cause, as opposed to other kinds of injuries, and one can 13 sometimes identify whether or not a particular wound was 14 caused by a firearm projectile. 15 Is that the case? 16 A: Yes, I mean there are some gunshot 17 wounds, shotgun wounds can be quite complicated in 18 appearance and obviously there are individual 19 pathologists with varying levels of experience dealing 20 with those kind of injuries. 21 Q: Commissioner, with your permission, 22 and if the picture is available, I questioned Dr. Marr 23 when she was on the stand about an injury on the side of 24 -- of Nicholus Cotrelle and she indicated that she did 25 not have the expertise to indicate whether or not, in her


1 opinion, that wound was caused by a bullet. 2 And I wondered whether we might take 3 advantage of -- of this expert's presence to ask him the 4 same question using that photograph, if it's available? 5 COMMISSIONER SIDNEY LINDEN: I presume 6 the doctor has never examined Mr. Cotrelle -- 7 MR. ANDREW ORKIN: He's never examined -- 8 COMMISSIONER SIDNEY LINDEN: Is this from 9 the photo? 10 MR. ANDREW ORKIN: It's from the 11 photograph. 12 COMMISSIONER SIDNEY LINDEN: To see what 13 he can do or -- 14 MR. ANDREW ORKIN: Correct. 15 COMMISSIONER SIDNEY LINDEN: -- can't do 16 from the photograph? Ms. -- 17 MR. ANDREW ORKIN: With your permission, 18 Commissioner. 19 MS. KATHERINE HENSEL: I would ask Dr. 20 Shkrum, you know, I'll leave it in your hands, Dr. Shkrum 21 to advise us as to whether you have adequate information 22 or -- to draw any conclusions based on this picture. 23 THE WITNESS: Well, I was going to ask 24 Mr. Orkin, perhaps, some questions as I look at this 25 photograph. If I -- you know, I might have some -- I


1 mean, it's the first I've seen of this photograph and -- 2 COMMISSIONER SIDNEY LINDEN: Well, if you 3 don't feel you can answer the questions, you're the best 4 one to tell us. 5 THE WITNESS: Okay. 6 COMMISSIONER SIDNEY LINDEN: All right, 7 so then let's take a look. 8 THE WITNESS: So again I'll have to stand 9 right here. 10 MR. ANDREW ORKIN: Absolutely. 11 COMMISSIONER SIDNEY LINDEN: You want to 12 cut the lights? 13 14 CONTINUED BY MR. ANDREW ORKIN: 15 Q: Sir, just by way of background from 16 the testimony that was presented in this -- in this 17 context, if may, Commissioner, the -- the wound is -- it 18 was photographed on the middle side to back of a young 19 man who was driving a bus and it was one of the injuries 20 he suffered -- was found to have suffered immediately 21 after that bus was -- was engaged in an interaction with 22 the police in which it was fired upon. 23 MR. ANDREW ORKIN: And the question I -- 24 may I proceed on that basis, Commissioner? 25 COMMISSIONER SIDNEY LINDEN: I think so.


1 I'm not sure. There doesn't seem to be any objections. 2 Ms. Jones, you may want to -- 3 MR. ANDREW ORKIN: Attempting to 4 paraphrase the -- 5 COMMISSIONER SIDNEY LINDEN: -- question 6 the way you put it. 7 MR. ANDREW ORKIN: -- the context 8 neutrally. 9 COMMISSIONER SIDNEY LINDEN: We want to 10 make the context fair. 11 MR. ANDREW ORKIN: Absolutely, 12 Commissioner. 13 MS. KAREN JONES: Mr. Commissioner, of 14 course it's very difficult in a circumstance like this to 15 provide sufficient information about a matter. One of my 16 concerns when I listen to Mr. Orkin, is even on Mr. 17 Cottrelle's own version of events, he talks about glass 18 shattering around him, for example. 19 COMMISSIONER SIDNEY LINDEN: Yes? 20 MR. KAREN JONES: And it seems to me that 21 there would be a number of components that would be 22 important to make clear in providing any information to 23 Dr. Shkrum. 24 COMMISSIONER SIDNEY LINDEN: Well I -- do 25 you want to add some more factors, or are you --


1 MR. ANDREW ORKIN: Commissioner, I hadn't 2 yet asked the question I was going to ask and my question 3 was going to make that very clear. 4 COMMISSIONER SIDNEY LINDEN: Yes. 5 MR. ANDREW ORKIN: So with your 6 permission, I'll proceeds if I may. 7 COMMISSIONER SIDNEY LINDEN: Carry on. 8 9 CONTINUED BY MR. ANDREW ORKIN. 10 Q: The evidence that was led, in this 11 particular circumstance, was that there were things 12 flying around in the bus, including glass and judging 13 from the holes in the bus, some bullets. 14 And I was interested, sir, whether with 15 your knowledge of -- of bullet wounds and some of the 16 science that surrounds identifying, is it possible that 17 this wound was caused -- this graze was caused by a 18 bullet or is it something you would rule out? 19 COMMISSIONER SIDNEY LINDEN: Just before 20 you answer the question -- 21 MS. KAREN JONES: And again, Mr. -- 22 COMMISSIONER SIDNEY LINDEN: Just before 23 you answer the question. 24 MS. KAREN JONES: And again, Mr. 25 Commissioner, one of my concerns is that accurate and


1 sufficient information be provided to Dr. Shkrum. I -- I 2 frankly haven't heard evidence about bullets flying 3 around or if -- if so, where on the bus that occurred? 4 And, for example, things like the 5 trajectory in the path of those bullets. I may have 6 missed that, Mr. Commissioner, but I think not. 7 MR. ANDREW ORKIN: Commissioner, my 8 question is -- is neutral about whether or not this 9 expert thinks a bullet that hit that bus caused this 10 wound. 11 I'm asking simply whether or not he would 12 rule out on the basis -- on the simple basis of the 13 photograph before him, is there any feature of this 14 photograph that would rule out it having been caused by a 15 bullet. 16 And perhaps that's where I should stop. 17 But that is the limit of my -- my inquiry. 18 COMMISSIONER SIDNEY LINDEN: Do you have 19 objection, Ms. Jones? 20 MS. KAREN JONES: I actually have to say 21 this, Mr. Commissioner, I'm sorry I was just listening to 22 Mr. Ross and I'm not sure I heard all of -- 23 COMMISSIONER SIDNEY LINDEN: We need to 24 have you at the microphone. 25 MS. KAREN JONES: I was just saying while


1 Mr. Orkin was speaking, I was listening to Mr. Ross and 2 I'm not sure I heard completely what Mr. Orkin said. 3 COMMISSIONER SIDNEY LINDEN: Well let -- 4 let's start over again then. 5 Mr. Orkin, do you want to put the question 6 again or do you want to -- 7 MR. ANDREW ORKIN: Commissioner, perhaps 8 it would be helpful if I made this completely 9 hypothetical. 10 COMMISSIONER SIDNEY LINDEN: Well that 11 might make it a little easier. 12 13 CONTINUED BY MR. ANDREW ORKIN. 14 Q: If I could ask the expert to now do a 15 well known legal trick and that's turn your mind off on 16 everything I've just said. 17 And let me ask you is if you were 18 presented at a medical conference with this photograph 19 and told of the approximate position on -- on a human 20 body as to where it was, is there any feature in your 21 opinion on this photograph that would rule out it being 22 caused by a firearm projectile? 23 Completely hypothetically and neutral to 24 the circumstances that I earlier described. 25 COMMISSIONER SIDNEY LINDEN: That's why


1 this Commission, this Inquiry, has been so much fun so 2 far. 3 Yes, Mr. O'Marra...? 4 MR. AL O'MARRA: I understand the 5 interest -- hopefully of Dr. Shkrum in -- in saying that 6 question is -- is fair in the sense that he's able to -- 7 to answer it and it sounds to me like My Friend is 8 putting a negative proposition to the witness based on an 9 examination of a photograph. 10 COMMISSIONER SIDNEY LINDEN: Would you 11 rather it be put at a positive? 12 MR. AL O'MARRA: In -- in the positive -- 13 COMMISSIONER SIDNEY LINDEN: Could it be 14 caused by a projectile, in other words? 15 MR. AL O'MARRA: Yes. 16 MR. ANDREW ORKIN: I prefer that 17 question, Commissioner -- 18 COMMISSIONER SIDNEY LINDEN: Yes, you 19 do -- 20 MR. ANDREW ORKIN: -- it's the one I was 21 avoiding because I thought it would draw objections. But 22 if Mr. O'Marra is posing it I -- I invite the -- 23 COMMISSIONER SIDNEY LINDEN: Well either 24 way. 25 MR. ANDREW ORKIN: -- the answer.


1 THE WITNESS: So am I answering your 2 question or Mr. O'Marra's question? 3 COMMISSIONER SIDNEY LINDEN: Which way? 4 MR. ANDREW ORKIN: I'm happy with either, 5 Commissioner. 6 COMMISSIONER SIDNEY LINDEN: All right. 7 Can you answer the question? If you don't feel 8 comfortable, you don't need to be reminded that you don't 9 have to answer. 10 THE WITNESS: Okay. In the usual 11 sequence of events if we're consulted on a -- on a -- on 12 a photograph is that I would have the opportunity to look 13 at this photograph in advance. And as a pathologist, 14 obviously I deal mainly with deceased individuals, but on 15 occasion we're asked to look at living individuals, in 16 particularly the photographic images. 17 So, it's not unusual sometimes for a 18 pathologist to look at injuries from a living individual. 19 20 21 CONTINUED BY MR. ANDREW ORKIN: 22 Q: I've done that before, so thank you. 23 A: This -- this -- in fact, arguably, 24 pathologists are probably much better acquainted with 25 injuries on the skin surface than other physicians are,


1 particularly because we have the luxury of time to 2 examine those injuries. 3 In an emergency setting, injuries such as 4 this are not important; it's really trying to -- you're 5 trying -- emergency physicians, trauma specialists are 6 trying resuscitate an individual, they're not really 7 concerned about these kinds of injuries. 8 Now, looking at this particular 9 photograph, again, we're just looking at this in 10 hypothetical -- 11 Q: Yes. 12 A: -- in isolation, it's -- it's a 13 projected image, there's a big shadow here. I don't see 14 the edges of this very well, but it gets back to the same 15 problem I had initially with the leg wound. 16 Q: Yeah. 17 A: You know, I would just call this an 18 abrasion. As to whether it was caused by a projectile of 19 some type, I -- I don't know. 20 Q: Thank you. And that -- the answer 21 was helpful and not unexpected. Thank you very much, Dr. 22 Shkrum. 23 COMMISSIONER SIDNEY LINDEN: Thank you 24 very much. 25 MR. ANDREW ORKIN: And Commissioner,


1 thank you for your indulgence. 2 COMMISSIONER SIDNEY LINDEN: Thank you, 3 Mr. Orkin. 4 Ms. Esmonde...? 5 6 (BRIEF PAUSE) 7 8 CROSS-EXAMINATION BY MS. JACKIE ESMONDE: 9 Q: Good afternoon, Doctor. My name is 10 Jackie Esmonde. I'm going to be asking you some 11 questions on behalf of the Aazhoodena and George Family 12 Group. 13 And, thanks to Mr. Orkin I only have two 14 (2) areas that I'd like to cover with you, those are Mr. 15 George's possible position at the time of the fatal 16 shooting and the effect of the injuries on him 17 immediately thereafter. 18 Now, first of all, I'm not sure if this is 19 something you can do or not, but based on your 20 examination of the wound tract and the wound -- I'm 21 talking about the fatal wound -- are you able to, with a 22 pen for example, show us the -- what you approximate to 23 be the angle of entry? 24 A: Perhaps I should just stand so that 25 everybody -- everybody can see this.


1 Q: Okay. 2 A: So, I -- I estimated that it was at 3 diagonal, perhaps about a thirty (30) degree angle in 4 this sort of direction. 5 Q: Okay. 6 A: As so. 7 COMMISSIONER SIDNEY LINDEN: The 8 perpendicular would be the shoulder? Some imaginary 9 perpendicular line? 10 THE WITNESS: I think the perpendicular 11 was actually probably relative to the spinal column. 12 COMMISSIONER SIDNEY LINDEN: Relative to 13 the spinal column? 14 THE WITNESS: Yes. 15 COMMISSIONER SIDNEY LINDEN: So, it would 16 be thirty (30) -- 17 THE WITNESS: So, a thirty (30) degree 18 angle relative to the spine -- relative to the vertical, 19 actually. So, it went to the -- at that angle -- sorry. 20 It went at that angle to the right and 21 towards the back of the deceased. 22 23 CONTINUED BY MS. JACKIE ESMONDE: 24 Q: Okay. So, it's quite a steep angle. 25 A: I described it earlier as being


1 acute. 2 Q: Acute. 3 A: Acute angle. 4 Q: And, you had said earlier that there 5 are a number of scenarios, a number of different 6 positions Mr. George could have been in depending, I 7 assume, on how far apart he was -- he was from the 8 shooter, the level of ground, how high -- people's 9 height? 10 A: Yes. You've touched on a number of 11 variables there, yes. 12 Q: Now, if you were to assume that Mr. 13 George and the shooter were of approximately the same 14 height and they were standing on fairly level ground, 15 those are background assumptions I'd like you to make, 16 and we know that they -- that Mr. George was not shot at 17 close range based on your examination of the wound; is 18 that right? 19 A: Yeah. And, in subsequent analysis 20 that was done. 21 Q: And a subsequent -- of the clothing 22 and so on? 23 A: Yes. 24 Q: Okay. Now, would it be fair to say 25 that it's quite likely that Mr. George was, in fact, bent


1 over at the time that the bullet entered? 2 A: In the scenario you're describing, 3 yes, it would appear he would have been bent over. 4 Q: At almost ninety (90) degrees? 5 A: Approximately, yes. 6 Q: Now, in terms of the relationship of 7 the fatal wound and the wound on his leg, I take it 8 you're not able to tell which injury occurred first? 9 A: I cannot do that. I cannot say what 10 the sequence -- which followed which. 11 Q: But the wound on the leg was fairly 12 close in time to the fatal shot; is that right? 13 A: I can't say that for certain. 14 Q: Okay. 15 A: No. 16 Q: Did it seem to be a fresh wound? 17 A: It appeared to be, yes. But again, I 18 didn't -- I didn't do any further analysis of that wound 19 as I would normally do, because I wanted to keep the 20 wound intact and to be analysed by -- by the firearms 21 people. 22 Q: And I'm going to put a scenario to 23 you and you can tell me if this is consistent with what 24 you saw when you examined the body and the clothing. 25 Now, if you were to assume that he was


1 shot in the leg first -- and first of all, can I ask you, 2 based on your examination of the wound, could you tell if 3 that was the kind of wound that would cause him pain? 4 A: It's possible, yes. 5 Q: Okay. 6 A: Yes. 7 Q: So, the scenario I put to you is he - 8 - I assume that he shot first in the leg and then perhaps 9 bends down to -- to feel his leg to see what the source 10 of the pain is; would that be a consistent position for 11 him to have been in, in order to receive the fatal shot? 12 A: That is a possible scenario, yes. 13 Q: And I take it you can't tell from the 14 examinations that you undertook what Mr. George was doing 15 with his hands or his arms? 16 A: No, and I testified to that effect in 17 1997. 18 19 (BRIEF PAUSE) 20 21 Q: Would you agree with me that, 22 assuming as the scenario I've set out to you about people 23 of generally the same height on fairly level ground, 24 would you agree with me that it -- the most likely 25 position that he would have been in at the time of the


1 fatal shot would be bent over at almost a ninety (90) 2 degree angle? 3 A: Well -- or his body inclined or bent 4 over in some -- some way. 5 Q: Yes, okay. Okay. In what way? 6 A: Well bent either at the waist or -- 7 or I think earlier it was offered, you know, he could 8 have been crouched. 9 Q: Right. 10 A: You know, I mean, these are 11 possibilities. 12 Q: Are you able to tell which scenario 13 is more likely than the others? 14 A: I can't tell, no. 15 Q: You can't. Now, in terms of the 16 effect of the injuries, and you told us earlier about the 17 internal bleeding that would have resulted from the wound 18 and that that would have begun fairly quickly -- 19 A: Yes. 20 Q: -- after -- after he was injured. 21 And -- now he also had a broken collar bone -- 22 A: Yes. 23 Q: -- and that's a fairly painful type 24 of injury, I understand. 25 A: yes, again, I've not experienced it


1 personally, I've not treated individuals, but I 2 understand it can be painful -- 3 Q: Okay. 4 A: -- or certainly discomfort associated 5 with it. 6 Q: And I believe you also, I learned 7 this from reviewing your testimony at the Deane trial, 8 that there's a -- a kind of a typical position that a 9 person with a broken collar bone may take? 10 A: Yes, I did some background reading at 11 the time of the -- of the 1997 proceedings and there may 12 be a typical position assumed by individuals with a 13 broken collar bone. 14 Q: Okay. Could you describe that for 15 us? 16 A: Well, at the time I think I described 17 it, if the collar bone's broken, if you think of the 18 collar bone as -- it's like a strut. 19 If you break the strut then the weight of 20 the arms will pull the -- will pull the shoulder down, 21 just because of the weight and that strut has been 22 disruptive. 23 So, the individual may want to hold their 24 arm up to relieve that -- relieve that sort of downward 25 movement of the arm, to relieve the discomfort.


1 Also the -- the muscle that inserts from 2 the collar bone up to the -- up to their -- to their 3 skull area, may pull on the collar bone; it's called the 4 external mastoid muscle. It's a big, thick muscle that 5 runs along the side of the neck. 6 And so they may want to incline their 7 heads towards the direction of the fracture, just to 8 relieve that pressure as well. 9 So, -- so, you know, these individuals may 10 -- may assume that kind of position just to relieve the 11 discomfort. 12 Q: Now, Mr. George also had two (2) 13 broken ribs? 14 A: Yes, he did. 15 Q: And that would also cause him some 16 pain? 17 A: It could have, yes. 18 Q: And would you agree with me, based on 19 your knowledge, that given these -- these broken bones, 20 he would have -- his mobility in the upper area wold have 21 been restricted by pain. 22 A: Again, I'm not dealing with -- I 23 don't -- I obviously don't treat people -- 24 Q: Right. 25 A: -- with broken collar bones, but I


1 think he'd have some difficulty moving his -- his left 2 arm. 3 Q: Okay. And would you agree with me 4 that it would be difficult for an individual with Mr. 5 George's injuries, that's including the internal bleeding 6 and the broken bones, to -- to physically throw a gun any 7 great distance? 8 A: Yeah, again, I don't know. I'd think 9 he'd have difficulty moving his arms. Whether he'd be 10 able to throw something, you know, with a partly raised - 11 - I just don't know. 12 You're probably better to ask that in 13 somebody that actually treats broken collar bones. 14 Q: Okay. Thank you very much, sir. 15 A: Okay. 16 Q: Those are all my questions. 17 COMMISSIONER SIDNEY LINDEN: Ms. 18 Jones...? 19 20 (BRIEF PAUSE) 21 22 CROSS-EXAMINATION BY MS. KAREN JONES: 23 Q: Good afternoon, Dr. Shkrum. 24 A: Good afternoon. 25 Q: My name's Karen Jones and I'm one (1)


1 of the lawyers for the Ontario Provincial Police 2 Association. 3 Dr. Shkrum, I just wanted to go back a 4 little bit and make sure that it's clear what information 5 you had when you wrote your postmortem examination 6 report, which as you noted, is dated March of 1996. 7 And, I take it from your evidence that in 8 addition to the -- your own examination that you 9 conducted, both the external examination and the internal 10 examination an the benefit of radiography and the other 11 tools that you had in place, that there would have been 12 or could have been, for example, swabs taken both of any 13 clothes that Mr. George was wearing and of the areas 14 around wounds or things themselves, for -- for example, 15 foreign material? 16 A: Yes, there was other evidence 17 collected. 18 Q: Yeah. And, would you, as a matter of 19 course, get the reports of -- get the reports of that 20 testing back before your write your exam -- before you 21 write your report? 22 A: Not necessarily. 23 Q: Okay. And, can you tell us in this 24 case whether or not you had the reports of the forensic 25 testing back before you wrote your exam -- your report?


1 A: I -- I think I had the toxicology 2 report -- 3 Q: Yes. 4 A: -- because that was appended to my 5 report. 6 Q: Yes. 7 A: I had the -- I think I -- I got -- 8 obviously I got Mr. Nielsen's report of January of 1996, 9 but I think there were some subsequent reports that came 10 out after mine, so obviously I wouldn't have had those. 11 Q: Okay. And, would you have received 12 copies of those subsequent reports? 13 A: I have some; others I -- I may not 14 have received. 15 Q: Okay. I -- and -- and, can you help 16 us in understanding what you did get? First of all, do 17 you have your file with you today? That -- 18 A: Yes, I do. 19 Q: -- that's the first question I should 20 ask. 21 A: Yes, I do. 22 Q: Okay. And, perhaps you could just 23 look at that, Dr. Shkrum, just so it's clear from your 24 report and your answers what material and what 25 information you rely on.


1 (BRIEF PAUSE) 2 3 A: Excuse me for a moment, I just have 4 to go to my -- 5 Q: I'm sorry to inconvenience, Dr. 6 Shkrum. 7 A: No inconvenience. 8 Q: Okay. 9 10 (BRIEF PAUSE) 11 12 A: Just to make things easy, I'm just 13 going to cross-reference to the list that's provided -- 14 Q: That would be fabulous -- that would 15 be fabulous. 16 A: So, just -- just bear with me here. 17 Q: Yeah. 18 19 (BRIEF PAUSE) 20 21 Q: It's a good thing you've got a long 22 table there, Dr. Shkrum. 23 24 (BRIEF PAUSE) 25


1 Q: And you've talked, Dr. Shkrum, today 2 about the injuries that you saw and you noted on your 3 postmortem report. 4 And I just wanted to clarify and confirm 5 that you saw no damage at all to the left shoulder joint? 6 A: I did not see any visible damage. 7 Q: Right. 8 A: I didn't examine the joint, per se. 9 Q: Okay. No damage to the upper left 10 back or shoulder muscles? 11 A: I didn't examine that area. 12 Q: Okay. And no damage at all that you 13 noted or you saw to the right arm or shoulder? 14 A: No visible damage. 15 Q: Okay. And no damage to the chest 16 below the area of the bullet wound, externally I mean, 17 which I think you told us was above the clavicle or 18 supra-clavicular. 19 A: It was through the -- 20 Q: Is that right? 21 A: Well, through the clavicle area. 22 Q: Through the clavicle. 23 A: Yes. 24 Q: Okay. 25 A: You know, other than the collarbone


1 and the two (2) ribs in the back, I did not see any other 2 damage to the -- to the chest wall. 3 Q: Okay. I then wanted to ask you some 4 questions about the bullet path. And I take it from your 5 evidence that at least internally, the wound from the 6 entrance point to the area where the location of the 7 bullets was found, was essentially a straight and true 8 path? 9 A: Yes, that was my impression. 10 Q: Okay. And because of that being 11 essentially a straight and true path, that allows you to 12 extrapolate from that, at least to some degree, the angle 13 at which the bullet would have hit Mr. George? 14 A: Yes, it does and -- 15 Q: Yeah. 16 A: -- obviously various scenarios that 17 are -- have been -- 18 Q: Sure. 19 A: -- offered there. 20 Q: Sure. And if you extend that line to 21 try and help determine the angle at which the bullet 22 would have hit Mr. George -- sorry, let me go back a 23 little bit. 24 I -- when you're looking at trajectory or 25 looking at a line a bullet would follow, do you assume


1 that when it comes from a gun to the point of contact 2 that it goes in a straight line or do you assume that 3 there's a curve or some curve? 4 A: We assume it's a straight line, 5 although there are exceptions. 6 Q: Sure. 7 A: Bullets can deviate from their path 8 for a number of reasons. 9 Q: Okay. And sorry, by "curve" I mean 10 an arc, up -- 11 A: Well, I guess, strictly speaking, if 12 a bullet is fired at a distance -- 13 Q: Yes. 14 A: -- it does follow an arc. 15 Q: Yes. 16 A: I mean, you liken it to like a 17 football being thrown -- 18 Q: Right. 19 A: I mean the bullet's spiralling -- 20 Q: Yes. 21 A: -- just like a football and -- 22 Q: Right. 23 A: -- there's an arc being followed, 24 although the -- 25 Q: That's right.


1 A: -- arc with a football is probably 2 much more pronounced. 3 Q: More pronounced, yes. 4 A: But just because of gravitational 5 effects -- 6 Q: Right. 7 A: -- that bullet starts to -- to arc 8 downwards. 9 Q: Right. 10 A: But I think you mean -- your next 11 question I'm anticipating, but the arc -- I think the 12 degree of arc relative to the distance travelled in the 13 body is probably not that great. 14 I think essentially it's probably a 15 straight line. 16 Q: Oh, actually my question was going to 17 be a little bit different than that, and that was -- 18 A: Hmm hmm. 19 Q: -- wouldn't the arc determine, in 20 part, on how far a distance there was between the person 21 who was shooting and the person who was being shot? 22 A: Yeah, that's sort of -- I -- I don't 23 think I can really answer that question. 24 Q: That's not in your area of expertise? 25 A: I can say what happened when the


1 bullet got in there, but I can't really say -- and, 2 again, not being 3 an expert on the particular weapons being used here -- 4 Q: And, Dr. Shkrum, that's absolutely 5 fair enough and one of the reasons that -- that it's so 6 helpful to have you here is because you can help outline 7 the boundaries of your expertise in a way that's useful 8 for us. 9 So when you're talking about different 10 scenarios about what might be possible in terms of 11 positioning and that kind of thing, of, for example, Mr. 12 George, you can talk about that in very, if I can put it 13 this way, sort of general and rough scenarios. 14 But not -- but some of the factors that 15 you might not take into account, for example, would be 16 distance and the effect of distance on that? 17 A: I'm sorry, the effect of distance on 18 the? 19 Q: The effect of -- of distance on, for 20 example, things like trajectory. That may not be some -- 21 that may be something that a different kind of expert may 22 speak about differently than you would. 23 A: I would think so, again -- 24 Q: Yeah. 25 A: -- not knowing how this bullet as it


1 exits from this particular weapon -- 2 Q: That's right. 3 A: -- and how it behaves, I don't think 4 I really can comment on that. 5 Q: Right, okay. But if I -- if I 6 understand your evidence properly, Dr. Shkrum, what I 7 hear you saying is that because of the angle of the 8 direct line between the entrance wound and where the 9 bullet was, that not only would the bullet have entered 10 Mr. George at an acute angle, that is in relation to the 11 front of his body, but there also would be -- he wouldn't 12 have been looking or likely not have been face on to the 13 person who shot him; that he would have been twisted or 14 he would have been facing away from him, at least to some 15 small degree to get that thirty (30) degree angle? 16 A: That's possible, yes. 17 Q: Okay. And so, for example, if Mr. 18 George was facing directly at the person who shot him, it 19 would be possible, for example, in order to get that 20 thirty (30) degree angle for him to be twisted a bit to 21 the right so that his left clavicle is ahead of his 22 right? 23 A: In the scenario you're describing, 24 realizing that -- 25 Q: Yeah.


1 A: -- if he wasn't facing and the shot 2 came from a -- a direction -- in that direction -- 3 Q: Sure. 4 A: -- where the -- where the 5 Commissioner is sitting, that's possible as well. So, 6 again, there -- there are a number of scenarios. 7 Q: There are a number of scenarios, one 8 (1) -- one (1) would be dependent that Mr. George should 9 have angled his torso or twisted his torso; another 10 would be that he wasn't face on to the person who was 11 shooting him. 12 A: Yeah, there are a number of 13 possibilities. 14 Q: Right. And that's something that 15 would be hard to determine or someone would have to give 16 you a specific scenario for you to respond to about that. 17 A: Yes. 18 Q: Yeah. And you were asked some 19 questions earlier about a possible scenario in terms of 20 looking at the angle of entry, the acute angle. 21 And I take from your answer that one (1) 22 of the main factors that you'd look as to whether or not 23 a scenario was possible was a height differential; that 24 is, that Mr. George either through bent knees or bending 25 over would have had to -- or a different level of ground,


1 would have had to have been lower than the person that 2 shot him? 3 A: That -- that -- that's implied, yes. 4 Q: Right. And, that lower -- that 5 lowering could come out -- could come -- could occur 6 either by Mr. George bending over or Mr. George bending 7 his knees so he was in a crouched position or a 8 combination of both? 9 A: It's possible, yes. 10 Q: Sure. I, then, Dr. Shkrum, just 11 wanted to ask you a few questions about the abrasion on 12 the leg and I think that you were clear this morning and 13 in your report that you called it an abrasion. 14 And I think you told us that meant it 15 would essentially be a scraping of skin? 16 A: Yes. 17 Q: And that -- I take from that that you 18 can't say how that scraping occurred? 19 A: Not in isolation, no. 20 Q: No? And when you say, "not in 21 isolation," what other information do you need or would 22 you need to have in order to be more specific about that? 23 A: Well, as I said, if there are more 24 specific features to the wound itself -- 25 Q: Okay.


1 A: -- in terms of scraping on one (1) 2 side and tearing on the other aspect -- 3 Q: Okay. 4 A: -- that would put it more in a -- in 5 a grazing-type of injury. 6 Q: Right. 7 A: We have the holes in the pants. 8 Q: Yes. 9 A: If there had been further analysis 10 that perhaps some -- some material had been transferred 11 from the projectile onto the pants, that might have been 12 helpful. 13 Q: Okay. 14 A: And, obviously we have the context of 15 the situation where there is gunfire, but again, strictly 16 speaking the abrasion could have been caused by just 17 simply scraping, so... 18 Q: Sure. 19 A: Looking at it in isolation I can't 20 say for certain -- 21 Q: Okay. 22 A: -- that that's a grazing injury. 23 Q: Right. And -- and again, just to go 24 back in terms of the issue of abrasion, that's because 25 you found that there was concentric abrading; that is, it


1 was equivalently abraded all around -- 2 A: That's right. 3 Q: -- the scrape as opposed to on one 4 (1) part more than the other? 5 A: That's correct. 6 Q: And when you talk about the 7 relationship between material and the wound, I take it 8 that there are occasions, for example, if a bullet hit an 9 area coming through material that it would leave a mark? 10 A: That's possible, yes. 11 Q: Yeah. And are there other ways that 12 the bullet and fabric would interact in a way that would 13 help you? 14 A: Well, some of that fabric could have 15 been transferred into the wound itself. 16 Q: Right. 17 A: That's possible. 18 Q: Sure. 19 A: But again, as I said, I didn't 20 examine that wound any further. I didn't want to disrupt 21 it so it was obviously turned over as evidence. 22 Q: Okay. And just -- and just again to 23 confirm your evidence, Dr. Shkrum, that you can't say 24 when that abrasion occurred? 25 A: No, I cannot.


1 Q: Okay. Is -- can you place it within 2 a day or two (2) days? 3 A: No, I can't. Normally if I was 4 dealing with a -- an injury like that -- 5 Q: Yes. 6 A: -- I would take a microscopic section 7 of it -- 8 Q: Yes. 9 A: -- and look at it down the 10 microscope. And, you know, as well all know that if you 11 -- if you have trauma on the body you -- you have -- a 12 healing process occurs. 13 Q: That's right. That's right. 14 A: And looking down a microscope you can 15 see it and which stage that healing process is. And you 16 can make an assessment then or give it an estimate -- 17 Q: Yes. 18 A: -- as to the time frame of that 19 particular injury. In this instance though I -- I felt I 20 should not disrupt that wound. 21 Q: Yeah. Okay. And in terms of -- you 22 talked a little bit about the length and the width of the 23 abrasion. But I take, because of your language that it 24 is abrasion, that it would be very shallow. You know, 25 essentially as you said, a scraping of skin.


1 A: Yes. I -- I don't think I recall 2 giving it a -- a depth. 3 Q: No. I actually didn't hear that and 4 I was wondering if you had measured one or if you could-- 5 A: I don't think I measured one. I 6 think I said that there was some tissue exposed. Let me 7 just refresh my memory here. A dried central yellow 8 area. 9 So whether that was skin or fat, I -- I 10 just don't recall how deep it went. If -- if it was fat, 11 then you're perhaps looking at, you know, the order of 12 probably millimetres, you know, in that sort -- sort of 13 range. So it would not have been deep; it was 14 superficial. 15 Q: Okay. And there's certainly nothing 16 about it that -- that would have prevented a person from 17 walking or from running or from carrying on activities of 18 daily living? 19 A: Well, I think there would have been 20 pain associated with it. 21 Q: Sure. 22 A: But there certainly -- it was not a 23 broken leg. 24 Q: Sure. 25 A: And so certainly the -- an individual


1 with an injury like that could continue to walk. 2 Q: Sure. Pain as in for example, if you 3 fell and scraped your knee? 4 A: That's right. 5 Q: That kind of pain? 6 A: I mean we all experienced -- we've 7 all experienced that kind of pain. 8 Q: That's right. An abrasion kind of a 9 pain? 10 A: Yes. 11 Q: Okay. 12 13 (BRIEF PAUSE) 14 15 Q: And lastly, I wanted to, Dr. Shkrum, 16 ask you a few questions about the effect of Mr. George's 17 injuries on activity. And I wanted to start off with 18 sort of the general topic of blood loss. 19 You've told us that over a period of time 20 as Mr. George had bleeding into his chest cavity, that 21 there would be a number of things that would happen 22 internally with him. And over a period of time would 23 result in him going into shock. 24 A: Yes. And eventual unconsciousness. 25 Q: Right. And you told us, quite


1 fairly, I think earlier, that you couldn't say with any 2 kind of certainty or with any kind of specificity, how 3 long it would take for Mr. George to go into shock. 4 And be in a position where he couldn't 5 carry on purposeful activity? 6 A: No, I cannot. 7 Q: Okay. And I take it that there -- if 8 you looked across a population of people that had the 9 same or similar injuries, that you could see a wide 10 variation in terms of how long it would take for 11 different people to go into shock? 12 A: Yes. I think there would be 13 variation and I -- I mentioned this before that there are 14 -- there are certainly reports of more horrendous 15 injuries -- 16 Q: Sure. 17 A: -- you know, that would seem to be 18 immediately fatal and yet people can still carry on 19 purposeful activity for some period of time. So there 20 obviously is a spectrum. 21 Q: Sure. And by purposeful activity, 22 that could include, for example, running? 23 A: It's possible. 24 Q: It could include walking? 25 A: Possible.


1 Q: It could include walking for some 2 distance, a hundred (100) feet or more? 3 A: I'm not sure about that distance but 4 a person could walk some distance, yes. 5 Q: Yeah. And I think the point that you 6 are making is until there is certain -- Mr. George 7 reached a certain level of sort of physiological 8 imbalance or was in a certain level of shock, he would be 9 able to carry on purposeful activity? 10 A: It's possible, yes. 11 Q: Yeah. And then, in terms of the 12 broken clavicle, you spoke a little bit about the 13 purpose of the clavicle and I take it that it's the bone 14 that connects the arm and the shoulder to the body at the 15 sternum or the chest? 16 A: Sounds good. 17 Q: Okay. And, it holds -- in -- in 18 essence, it holds the shoulder up and back? 19 A: It helps, yes. 20 Q: Yeah. And, I think you -- as you 21 confirmed that if it's broken the shoulder could sag down 22 and forward? 23 A: It could, but again, this is based on 24 my background information, but -- 25 Q: Yeah.


1 A: -- again, somebody that deals with 2 this in a clinical situation could present maybe a 3 number of scenarios. 4 Q: I understand that. And I take it 5 that the muscles that are used to raise and lower the arm 6 are, for the most part, the back and the shoulder 7 muscles? 8 A: They would -- they would make a 9 principle contribution to the shoulder -- shoulder 10 movement. 11 Q: Right. And so, regardless of whether 12 someone had a broken clavicle or not, they would be able 13 to raise and lower their arm? 14 A: I would say, possibly, but again, I - 15 - I would probably -- may be better to ask that question 16 of somebody that treats it on an emergency basis. 17 Q: Sure. Okay. And, I took -- I took 18 from some of your answers that at least, in your view, 19 one (1) of the limiting or one (1) of the major limiting 20 factors, in terms of movement of the arm, would be pain? 21 A: Certainly pain or discomfort, yes. 22 Q: Yeah, okay. And, I take it that 23 you'd agree, Dr. Shkrum, that as you talked about people 24 going into shock and there being a spectrum, so people 25 could have the same injury and they wouldn't feel the


1 effects of it for different periods of time, the same 2 could be said of pain, that people -- a -- a variety of 3 people could have the same injury and experience 4 different amounts of pain? 5 A: Yes. 6 Q: There would be a spectrum of that? 7 A: Yes. 8 Q: And so, some people could find a 9 small amount of pain very limiting and others may not be 10 bothered by it at all? 11 A: That's right. 12 Q: Okay. And, I also take it that 13 people -- a person can experience pain differently 14 depending on the circumstances? 15 So, for example, if someone was in a high 16 state of excitement or in a very stressful situation, 17 they may well experience pain differently than if they 18 were quiet and calm? 19 A: An excellent example would be a 20 professional athlete. 21 Q: Sure. 22 A: They literally play -- play through 23 their pain, so. 24 Q: Right. And so, in terms of being 25 able to evaluate someone's pain and the effect of that


1 pain on any limitations on movement, it would be highly 2 situational? 3 A: Yes, again and -- 4 Q: Yeah. And highly -- 5 A: -- obviously as a pathologist -- 6 Q: I understand. 7 A: -- I can't really assess that. 8 Q: No, I understand that. And, Dr. 9 Shkrum, those are my questions. Thank you very much. 10 A: You're welcome. 11 COMMISSIONER SIDNEY LINDEN: Thank you 12 very much, Ms. Jones. 13 Mr. O'Marra...? 14 And, this may be the last, subject, of 15 course to re-examination, just to give you an idea. 16 17 CROSS-EXAMINATION BY MR. AL O'MARRA: 18 Q: I should not be very long, 19 Commissioner. 20 Dr. Shkrum, I just wanted to firstly 21 direct your attention back to your postmortem report, 22 Exhibit P-359 and I understand that there was a slight 23 correction that you had anticipated making under the -- 24 on the first page under, "Gunshot Entry Wound," with 25 respect to the 7 centimetres right at the midline?


1 A: Yes, and actually, I made that 2 correction in 1997, it should be to the left of the 3 midline and above left nipple. 4 Q: Okay. Just so that we have that 5 correct on the record and in the report, so it should be 6 changed to -- to left. Thank you. 7 The next area I just wanted to ask you 8 about, Doctor, is, again, with respect to the -- the path 9 of injury relative to the wound itself. You made 10 reference, of course, to the entry wound and the 11 eccentric abrasion, which was highlighted on -- on your 12 drawing. 13 A: Yes. 14 Q: Yes, that you made at the time and 15 that's -- that's consistent with the thirty (30) degree 16 angle continuing in a straight and true passage to where 17 the fragments were found? 18 A: It's consistent with the -- an angled 19 entry, yes. 20 Q: Okay. And -- and, I take it just in 21 terms of questions around positioning, if one were to 22 take a straight line from that path of injury, sometimes 23 we've seen on -- on such shows as Crime Scene 24 Investigations where they take a -- a PowerPoint beam, 25 that if that beam were projected the projectile could


1 have come where -- anywhere where that beam lands? 2 A: Sounds interesting. 3 Q: Yes. Just in terms of the position, 4 correct? 5 A: Yes, I mean, as I said there are a 6 number of scenarios. 7 Q: Yeah. 8 A: And again, I deal with the static 9 situation. I mean, I'm dealing with a deceased 10 individual lying flat on an autopsy table. 11 Q: Okay. And the other area I'd just 12 like to ask you about is with respect to the distribution 13 of your reports. 14 First of all, just so it's clear, under 15 medical-legal autopsies, your authority to conduct the 16 autopsy comes as a result of the coroner's warrant? 17 A: That's correct and in this case a 18 warrant issued by Dr. Perkin, a Strathroy coroner. 19 Q: So that the -- in the context of this 20 injury -- fatality, you would not have had any basis to 21 conduct an autopsy, other than on receipt of that 22 warrant? 23 A: That's correct. 24 Q: Okay. And so you're governed 25 strictly by the terms of the Coroners Act?


1 A: That's correct. 2 Q: Okay. And you mentioned the 3 distribution of your report once it's been finalized? 4 A: Yes. 5 Q: Okay. And that's governed as well by 6 the strict terms of the Coroners Act; correct? 7 A: Yes. 8 Q: Because under Section 28 of the Act, 9 you have to provide your report only to the coroner that 10 you mentioned, the Crown Attorney, the regional coroner 11 and the chief coroner. 12 A: Yes. 13 Q: As well as any other -- and there are 14 no others identified in that line of recipients? 15 A: No. 16 Q: Okay. And then once it receive -- is 17 received into the hands of those individuals, identified 18 in the Coroners Act, then you have no further control 19 over its distribution? 20 A: No. 21 Q: Okay. And that remains in the hands 22 of the -- the chief coroner, the coroner, the regional 23 coroner or Crown Attorney? 24 A: Yes. 25 Q: And in terms of those matters in


1 which you've been involved that have led to prosecutions, 2 do you have any understanding of the distribution of -- 3 of your report? 4 A: Well, certainly that a report would 5 be available, eventually, to police officers. 6 Q: Yes. 7 A: The -- obviously be disclosed as 8 evidence. It would be available to defence lawyers as 9 well, so obviously other individuals would -- would 10 receive that report. 11 Q: And then -- 12 A: In criminal matters. 13 Q: And then you speak on it publicly, 14 it's released publicly for the first time when you give 15 evidence? 16 A: That's correct. I mean forensic, in 17 a sense, means "forum." It -- there's a scrutiny of the 18 public. 19 Q: And you have no control over when you 20 get a chance to speak about it publicly, until you're 21 called as a witness? 22 A: That's right. I mean it is 23 confidential information. 24 Q: Now, reference was made to some 25 experience of post mortem reports being received within a


1 month. Is that your experience with forensic post mortem 2 reports, finalized reports within a month? 3 A: It really depends on the complexity 4 of the case. If it's an uncomplicated case, it -- 5 potentially you could get a report out within a month, 6 ideally or theoretically, you can do that. 7 If there's a great urgency to get a report 8 out it could be done, provided that there are other -- 9 the necessary -- other necessary reports are available 10 for that to be done. 11 But generally speaking, it takes some 12 months. 13 Q: Okay. And those -- the reason that 14 it takes -- and you have your initial examination, but 15 there's also the other reports such as radiology and 16 toxicology or biology or a variety of reports that may be 17 relevant to your determination of cause of death and your 18 findings? 19 A: Yes. 20 Q: And in this instance, you weren't in 21 a position to issue your final report until some six (6) 22 months later? 23 A: That's when it was finally issued. I 24 was probably in a position in February as I mentioned. 25 The report, it was typed up, but actually wasn't issued


1 until about a month later. 2 Q: Okay. Thank you, Doctor, those are 3 my questions. 4 COMMISSIONER SIDNEY LINDEN: Thank you, 5 Mr. O'Marra. 6 Yes, Ms. Hensel...? 7 MS. KATHERINE HENSEL: Commissioner, I 8 have no further questions for Dr. Shkrum. I would like 9 to take this opportunity to thank him for his time and 10 his expertise today. It's been of great assistance. 11 THE WITNESS: Okay, thank you. 12 COMMISSIONER SIDNEY LINDEN: I would also 13 like to thank you for giving us the benefit of your 14 evidence. 15 THE WITNESS: Thank you, sir. 16 COMMISSIONER SIDNEY LINDEN: Thank you 17 very much. 18 THE WITNESS: Thank you, sir. 19 COMMISSIONER SIDNEY LINDEN: So I think 20 that -- 21 MS. KATHERINE HENSEL: Ms. Vella also 22 has -- 23 COMMISSIONER SIDNEY LINDEN: -- hoped too 24 soon. 25 MS. KATHERINE HENSEL: Yeah. Has


1 something to add. 2 THE WITNESS: Oh, I'm done? 3 MS. SUSAN VELLA: Take your time and 4 leave, yes. I'll just carry on if it's all right, 5 though. 6 7 (WITNESS STANDS DOWN) 8 9 MS. SUSAN VELLA: Commissioner, at this 10 time I would like to tender a statement into evidence as 11 an exhibit. It's a statement by Dr. G.W. Perkin who was 12 the local coroner. It's dated September 7, 1995. The 13 Inquiry Document Number is 1000383. 14 We did provide notice to counsel that we 15 were intending to do this and we have received no 16 objection to our advice. And with your lead, 17 Commissioner, I think it is appropriate to read the 18 contents of this statement into the records since we 19 won't be calling Dr. Perkin as a witness so that the 20 public will have the ability to know its contents, on the 21 record. 22 COMMISSIONER SIDNEY LINDEN: I don't see 23 anybody objecting so I presume that your assumption that 24 there are no objections is correct. 25


1 --- EXHIBIT NO. P-381: Document Number 1000383 Sept. 2 07/'95 Statement of Dr. G.W. 3 Perkin, Strathroy Medical 4 Clinic, to Det. Bob Martin, 5 London OPP. 6 7 MS. SUSAN VELLA: Thank you, 8 Commissioner. I'll commence the statement then. And -- 9 and I should indicate the only thing that I will leave 10 out is that the personal addresses and phone numbers of 11 two (2) of the individuals mentioned within the letter. 12 "This statement is dictated in the 13 presence of Detective Bob Martin from 14 the London, Ontario Provincial Police 15 Crime Unit at 16:00 hours of Thursday, 16 September the 7th, 1995 in reference to 17 the death of Anthony O'Brien George 18 whose date of birth is the 17th of 19 March 1957, a member of Stoney Point 20 Band 43, RR Number 2, Forest in 21 Bosanquet Township. 22 Information I received indicated that 23 the above lived in the Ipperwash Army 24 Camp for approximately two (2) years in 25 a trailer and in a camp barrack.


1 My full name is Gary William Perkin, 2 date of birth September the 27th, 1950. 3 Home address [and I'll leave that 4 blank]. Phone number [also I will 5 leave blank]. I have been a medical 6 doctor since receiving my MD in 1974 7 from the University of Western Ontario 8 and have been in general practice at 9 Strathroy Medical Clinic since July of 10 1975. Employed at the Strathroy 11 Medical Clinic, 376 Kerry (phonetic) 12 Street, Strathroy, Ontario, N7G 3E3. 13 For the past approximately fourteen 14 (14) years I have served as a coroner 15 for the Province of Ontario in Area 16 Number 7 serving South Western Ontario, 17 specifically Strathroy Town and 18 surrounding area. My involvement with 19 this case began by a phone call from 20 nursing supervisor, Glenna Ladell at 21 approximately 01:00 hours of 95-09-07. 22 I was informed, while at home, that 23 there had been a fatality as a result 24 of a skirmish at Ipperwash Provincial 25 Park. I travelled from my place of


1 residence to the Emergency department 2 of Strathroy Middlesex General Hospital 3 and was given details regarding the 4 patient by Dr. Allison Marr, the 5 physician on call in the Emergency 6 department on the night in question. 7 Dr. Marr indicated to me that the 8 deceased had arrived by car to the 9 emergency ramp of the hospital at 08:00 10 hours and was moved from the car onto a 11 stretcher by a nursing personnel and 12 ambulance attendants who were at the 13 Emergency department. 14 The patient was attended by Dr. Marr 15 and Dr. Elizabeth Saettler who was in 16 the hospital by coincidence at the same 17 time. Two (2) intravenous lines were 18 started and endotracheal (tube was 19 inserted and external cardiopulmonary 20 resuscitation was instituted for a 21 brief period of time. It became 22 evident to the two (2) physicians that 23 this man was dead on arrival with no 24 vital signs whatsoever, no spontaneous 25 pulse, no respirations, pupils fixed


1 and dilated and the patient was 2 pronounced deceased at 0:20 hours by 3 Dr. Allison Marr in the presence of 4 nursing supervisor Ladell and Constable 5 Christine (phonetic) Murphy in Room 9 6 of the Emergency department of SMGH. 7 The deceased was lying on his back. An 8 endotracheal tube was evident and taped 9 in place; two (2) IV's were in 10 forearms, but shut off. 11 The deceased was wearing a bright- 12 coloured T-shirt which had been cut 13 down the centre by the nurses in the 14 Emergency department during the 15 resuscitation procedure. He had a 16 loose pair of blue jeans with a rope 17 knot and the jeans were pulled down 18 over a somewhat protuberant abdomen. 19 He was wearing running shoes and 20 underwear as well. 21 Examination showed a large amount of 22 blood staining on the cut T-shirt and 23 closer inspection revealed a small hole 24 in the left upper portion of the T- 25 shirt just at the hemline.


1 Corresponding to this, was an apparent 2 entrance gunshot wound over the left 3 clavicle, which was clinically 4 fractured. There was no evidence of 5 injury to the extremities. 6 The body was rolled onto both sides and 7 thorough inspection of the back 8 revealed no evidence of exit wound or 9 other injuries. 10 Following this, I spoke to a Detective 11 Speck of Forest OPP. I relayed my 12 findings to him, gave him my suggestion 13 that some radiographic examinations 14 would be done to determine the presence 15 or not of retained ammunition 16 fragments. And I subsequently assisted 17 x-ray technician Albert Jennings of the 18 Radiology Department at Strathroy 19 Middlesex General Hospital in 20 transporting the deceased to the 21 Radiology Department where two (2) x- 22 rays were done, one (1) an AP of the 23 chest and another a lateral of the 24 chest. 25 This showed the comminuted fracture of


1 the left clavicle, fractures of the 2 approximate 7th, 8th, and 9th ribs on 3 the left side, posteriorly at their 4 insertion of the thoracic spine and two 5 (2) large fragments of radio-opaque 6 fragments, a presumed bullet lying in 7 the subcutaneous soft tissues just to 8 the left of what appears to the be the 9 body of L1. 10 In addition to this, there were four 11 (4) or five (5) small flecks of radio- 12 opaque material lying adjacent the 13 vertebral bodies of T10, 11, and 12. 14 Following the completion of the x-ray 15 examination and viewing of the films by 16 myself, I returned to the Emergency 17 department and relayed my findings to 18 Detective Speck. I then spoke to two 19 (2) relatives of Anthony George, namely 20 a Mr. Reg George who resides at and a 21 Mr. Ron George of Kettle Point who 22 identified himself to be a first cousin 23 of the deceased. 24 I advised these two (2) relatives that 25 an autopsy would be done probably the


1 following day and advised Reg George 2 that I would notify him of autopsy 3 results when they were available. 4 Following this, the two (2) relatives 5 informed me that they and a couple of 6 other relatives wished to view the body 7 of the deceased. This was arranged 8 with the nursing supervisor. And 9 following the relatives' visit, the 10 body was transported to the morgue of 11 Strathroy Middlesex General Hospital 12 under continuous police guard. 13 I informed the police officers that 14 arrangements would be made for an 15 autopsy, either in London or Toronto 16 the following day and would inform them 17 of this. 18 The following morning at approximately 19 08:15 hours I placed a call to the 20 Chief Coroner's Office of Ontario and 21 Dr. Jim Cairns returned my call at 22 approximately 09:15 hours informing me 23 that he would speak to Dr. Mike Shkrum 24 of Victoria Hospital, a forensic 25 pathologist in attempts to arrange the


1 autopsy there. 2 He phoned me back approximately an hour 3 later saying that Dr. Shkrum was 4 available to do the autopsy. 5 I then phoned London Funeral Services 6 and arranged for the transport of the 7 body to Victoria Hospital and advised 8 the nursing staff of the hospital of 9 these arrangements. 10 Care was taken to ensure proper lines 11 of identification of the body by the 12 nursing staff at the hospital. A 13 Coroner's warrant for the postmortem 14 examination and a Coroner's warrant for 15 internment of a deceased were completed 16 and sent along with the body to Dr. 17 Shkrum. I also requested alcohol and a 18 full drug screen be drawn at the time 19 of examination." 20 And it bears the signature of Dr. D. W. 21 Perkin, MD. 22 That completes the statement, 23 Commissioner. 24 COMMISSIONER SIDNEY LINDEN: Thank you 25 very much. Any other business that we need to transact


1 before we adjourn? 2 MS. SUSAN VELLA: There is no further 3 business for this week, Commissioner. 4 COMMISSIONER SIDNEY LINDEN: Then we will 5 adjourn now; we're not sitting next week. 6 MS. SUSAN VELLA: No, we're not. 7 COMMISSIONER SIDNEY LINDEN: The next 8 time we convene is Monday morning on May the 9th, I 9 believe -- 10 MS. SUSAN VELLA: That's correct. 11 COMMISSIONER SIDNEY LINDEN: -- at 10:30 12 a.m. 13 MS. SUSAN VELLA: Thank you. 14 COMMISSIONER SIDNEY LINDEN: Thank you 15 all very much. 16 THE REGISTRAR: This Public Inquiry is 17 adjourned until Monday, May 9th at 10:30 a.m. 18 19 --- Upon adjourning at 2:39 p.m. 20 21 Certified Correct 22 23 24 ____________________ 25 Dustin Warnock