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

2
  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    )

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       )   (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