1 2 3 IPPERWASH PUBLIC INQUIRY 4 5 6 7 ******************** 8 9 10 BEFORE: THE HONOURABLE JUSTICE SIDNEY LINDEN, 11 COMMISSIONER 12 13 14 15 16 Held at: Forest Community Centre 17 Kimball Hall 18 Forest, Ontario 19 20 21 ******************** 22 23 24 April 26th, 2005 25

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

3
  1                   APPEARANCES (cont'd)
  2  Janet Clermont   )              Municipality of 
  3  David Nash       )   (np)       Lambton Shores
  4  
  5  Peter Downard    )   (np)       The Honourable Michael
  6  Bill Hourigan    )   (np)       Harris
  7  Jennifer McAleer )
  8  
  9  Ian Smith        )   (Np)       Robert Runciman
 10  Alice Mrozek     )   (np)
 11  Harvey Stosberg  )   (np)       Charles Harnick
 12  Jacqueline Horvat )   (np)
 13  Douglas Sulman, Q.C. )           Marcel Beaubien
 14  Trevor Hinnegan     ) (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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1 and the knowledge that you have now with respect to the 2 circumstances of -- of Dudley George's death, is there 3 anything that you would have done differently that night 4 which might have resuscitated Dudley George? 5 A: No, unfortunately. 6 Q: All right. And to be clear, when you 7 first examined him, there were no vital signs present? 8 A: No. 9 Q: Correct? 10 A: Correct. 11 Q: Yeah. 12 13 (BRIEF PAUSE) 14 15 Q: And given the nature and -- and 16 severity of his injuries as you assessed them, and the 17 fact that he had lost his vital signs and signs of any 18