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 May 9th, 2005 25

2
  1                        Appearances
  2  Derry Millar      )             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    )            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   )              Aazhoodena  (Army Camp)
 18  William Henderson )              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     )
 15  
 16  Mark Sandler       ) (np)       Ontario Provincial 
 17  Andrea Tuck-Jackson )            Police
 18  Leslie Kaufman     )  (np)
 19  
 20  Ian Roland       )   (np)       Ontario Provincial 
 21  Karen Jones      )              Police Association &
 22  Debra Newell     )   (np)       K. Deane
 23  Ian McGilp       )   (np)
 24  Annie Leeks      )
 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  Megan Mackey     )
 19  
 20  David Roebuck    )   (np)       Debbie Hutton
 21  Anna Perschy     )   (np)
 22  Melissa Panjer   )   (np)
 23  Danya Cohen-Nehemia ) (np)
 24  
 25

1 APPEARANCES (cont'd) 2 3 Ron LeClair ) Jacqueline Derbyshire 4 Marlene Bergman 5 Glenna Ladell 6 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 6 4 5 GLENNA MAUREEN LADELL, Sworn 6 Examination-In-Chief by Ms. Katherine Hensel 11 7 Cross-Examination by Ms. Karen Jones 48 8 9 MARLENE BERGMAN, Sworn 10 Examination-In-Chief by Ms. Katherine Hensel 58 11 12 JACKALINE PATRICIA DERBYSHIRE, Affirmed 13 Examination-In-Chief by Ms. Susan Vella 80 14 Cross-Examination by Mr. Andrew Orkin 168 15 Cross-Examination by Mr. Peter Rosenthal 173 16 Cross-Examination by Ms. Karen Jones 178 17 Cross-Examination by Mr. Al O'Marra 193 18 Re-Direct Examination by Ms. Susan Vella 197 19 20 Certificate of Transcript 202 21 22 23 24 25

1 EXHIBITS 2 No. Description Page 3 P-382 Document Number 50002248, Nurse 4 Glenna Ladell's notes, Sept. 07/95 5 Re: Mr. Anthony George 37 6 P-383 Document Number 5000249, Nurse Glenna 7 Ladell's notes, Dept. 07/95 Re: Mr. 8 Anthony George 37 9 P-384 Document Number 5000245, Code Blue 10 record of Dudley George made by Nurse 11 Glenna Ladell, Sept. 07/95 Cardiopulmonary 12 resuscitation record. 38 13 P-385 Document Number 5000246, Record of Dudley 14 George's death, September 07/95. 15 Pronounced dead by Dr. Marr at 00:20 16 hours. 38 17 P-386 Document Number 5000247, Nurse Glenna 18 Ladell's notes September 07/95 Re: Mr. 19 Anthony George. 50 20 P-387 Document Number 1000047, Strathroy 21 Middlesex General Hospital Documentation 22 of Mr. Cecil Bernard George, pages 318 23 to 364, September 07/95. 115 24 25

1 EXHIBITS (continued) 2 Exhibit No. Description Page No. 3 P-388 Document Number 5000243, Emergency 4 and Outpatient Record of Mr. Anthony 5 George, September 07/95. 125 6 P-389 Document Number 5000250, Pages 2924 to 7 2930, ECG strip of Mr. Anthony George. 141 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

1 --- Upon convening at 10:30 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 MR. DERRY MILLAR: Good morning, 7 Commissioner. 8 COMMISSIONER SIDNEY LINDEN: Good 9 morning, everybody. 10 MR. DERRY MILLAR: Before we start, I 11 thought I would just take a moment to welcome a guest 12 that we have today with us. 13 COMMISSIONER SIDNEY LINDEN: I recognize 14 him. I do recognize him. 15 MR. DERRY MILLAR: It's your brother, Mr. 16 Justice Allan Linden of the Federal Court of Appeal has 17 come down to visit us for this morning. 18 COMMISSIONER SIDNEY LINDEN: Check up on 19 his brother. 20 MR. DERRY MILLAR: He never said that, 21 actually. 22 COMMISSIONER SIDNEY LINDEN: No. 23 MR. DERRY MILLAR: Now, Commissioner, 24 before we start, I just wanted to tell the parties -- 25 I've put out on the -- we put out on the desk this

1 morning, two (2) volumes of materials and the two (2) 2 volumes are transcripts of postal codes. And they've 3 been tabbed actually to -- the numbers are supposed to 4 conform to the numbers on the schedules that I've 5 provided to the parties last week. 6 So if people are wondering what the tab 7 numbers refer to, that's what they refer to. 8 And just so everyone knows this morning, 9 we're going to -- today we're going to be dealing with 10 the three (3) nurses, Ms. Ladell, Ms. Bergman, and Ms. 11 Derbyshire, tomorrow morning Dr. McCallum and then Deputy 12 Commissioner, of course. 13 And I understand this morning we'll break 14 at 12:30 for lunch? 15 COMMISSIONER SIDNEY LINDEN: If that's 16 okay, yes, at 12:30. 17 MR. DERRY MILLAR: Thank you. 18 MS. KATHERINE HENSEL: Good morning, 19 Commissioner, the Commission calls, as its next witness, 20 Mrs. Glenna Ladell. 21 22 (BRIEF PAUSE) 23 24 THE REGISTRAR: Good morning, Mrs. 25 Ladell.

1 MS. GLENNA LADELL: Good morning. 2 THE REGISTRAR: Mrs. Ladell, do you 3 prefer to swear on the Bible or affirm this morning? 4 MS. GLENNA LADELL: The Bible's fine. 5 THE REGISTRAR: Very good. Would you 6 take the Bible in your right hand, please. And state 7 your name in full for us please, for the record. 8 MS. GLENNA LADELL: Glenna Maureen 9 Ladell. 10 THE REGISTRAR: Thank you. 11 12 GLENNA MAUREEN LADELL, Sworn: 13 14 THE REGISTRAR: Thank you. 15 16 EXAMINATION-IN-CHIEF BY MS. KATHERINE HENSEL: 17 Q: Good morning, Mrs. Ladell. 18 A: Good morning. 19 Q: Just for the record, your date of 20 birth is August 31st, 1939? 21 A: Yes. 22 Q: And you are -- or you were, in your 23 professional career, a registered nurse? 24 A: Yes. 25 Q: And you graduated from the Toronto

1 Western Hospital School of Nursing in 1960, I understand? 2 A: That's correct. 3 Q: And you subsequently worked for one 4 (1) year at that hospital? 5 A: That is right. 6 Q: You then received your Bachelor of 7 Science and Nursing in 1965? 8 A: Right. 9 Q: From the University of Western 10 Ontario? 11 A: That's correct. 12 Q: And that was a three (3) year 13 program? 14 A: No. 15 Q: Oh. 16 A: Two (2) year. 17 Q: Two (2) year program. Thank you. 18 And upon graduating from that program, you 19 started working at the Strathroy Middlesex General 20 Hospital in August of 1965? 21 A: That's correct. 22 Q: And you worked there until January of 23 2000 when you retired? 24 A: That's right. 25 Q: I also understand that you became a

1 nursing supervisor in 1966? 2 A: That's right. 3 Q: And you served in that capacity until 4 your retirement in 2000? 5 A: Yes, that's right. 6 Q: In 1995, you were working as a 7 nursing supervisor, then? 8 A: That's right. 9 Q: And, you were working in a part-time 10 capacity at that time? 11 A: Yes. 12 Q: Can you describe for us, Mrs. Ladell, 13 the general duties of a nursing supervisor? 14 A: As a nursing soper -- supervisor, 15 particularly when I worked mainly on the 3:00 to 11:00 16 shift, I was responsible for the hospital as a total. 17 Especially after 5:00 p.m. on the -- on the particular 18 day, as none of the administration staff were there, a 19 lot of the hospital departments, for -- for example, 20 pharmacy, stores, business office, they were all closed. 21 So we had access to those departments, as 22 required, to get whatever the staff might require or 23 information that was required of any other people during 24 that time. 25 Q: So, it did fall on your shoulders to

1 keep the hospital running smoothly, particularly after 2 5:00 p.m.? 3 A: That's right. 4 Q: Turning now to September 6th, 1995, I 5 understand that on that day you were working as a nursing 6 supervisor at the Strathroy Middlesex General Hospital 7 and that you were scheduled to work from 3:00 to 11:00 8 p.m.? 9 A: That's right. 10 Q: And you did in fact work that shift-- 11 A: Yes, I did. 12 Q: -- from 3:00 to 11:00? 13 A: Yes, I did. 14 Q: Okay. And, at some point during your 15 shift, perhaps towards the end of it, did you receive 16 information that something unusual was going to happen? 17 A: Yes, Lisa Seeley, the Emergency Nurse 18 for 3:00 to 11:00, in the Emergency Department, had 19 received a phone call and I believe it was from 20 Wallaceburg Dispatch, to say that there was something 21 happening. 22 And because we were the closest hospital, 23 they say we possibly could be getting some patients if, 24 you know -- if something did happen. 25 Q: And, did you receive any specific

1 information about what might be happening? 2 A: Not particularly that I recall. 3 Q: Okay. Were you aware that -- what 4 might be happening -- happening -- might be related to 5 events occurring at Ipperwash Provincial Park? 6 A: I don't recall really other than that 7 there was something going on, but I don't remember any 8 specific details. 9 Q: Okay. And at that time, were you 10 aware in general terms that there was an occupation 11 occurring at Ipperwash Provincial Park? 12 A: Not particularly. 13 Q: All right. So as a result of the 14 information that you received from Ms. Seeley what did 15 you do? 16 A: I was giving, as we usually did, 17 Marlene Bergman, the night supervisor comes in at 11:00 18 and so I would give her a report. And because something 19 was happening and there aren't a lot of people working 20 the night shift, then I decided that maybe I should stay 21 for a while just to see if my assistance was needed as an 22 extra pair of hands. 23 Q: All right. And at that time, were 24 you were working in the Emergency Department or were 25 you --

1 A: We worked there as required. 2 Q: Okay. 3 A: But, like a -- from eleven o'clock 4 til -- I would give report to the night supervisor, 5 Marlene. 6 Q: All right. And as a result of the 7 information you received, did you yourself, participate 8 in any preparations for the arrival of patients, or 9 anticipating the arrival of patients? 10 A: I believe that we were notified in 11 the -- in the place that we were giving report to each 12 other and I think it was -- I think in the notes 13 somewhere it says about a quarter -- I don't know, twenty 14 (20) or a quarter to 12:00 at that time, we would go to 15 the Emergency and assist with any additional preparation 16 that was required. 17 But the nurse in Emerg. would already have 18 started -- we get a, what we call the OR room or the 19 Emergency room ready for any -- any particular -- well, 20 like, you start -- get the intravenous set up and -- and 21 get a stretcher ready and so on. 22 Get the room kind of organized for 23 whatever might turn up. It's better to be prepared. 24 Q: Of course. All right. So were you 25 in the Emergency Department when the first patient coming

1 from the events at Ipperwash Provincial Park arrived? 2 A: Yes, I was. 3 Q: Okay. And we understand from other 4 witnesses that that was Mr. Nicholus Cotrelle -- 5 A: That's right. 6 Q: -- the young man who was aged sixteen 7 (16) at the time. 8 A: Right. 9 Q: Do you recall -- well, first of all, 10 do you recall what time he arrived? 11 A: 12:04. 12 Q: 12:04. And what can you tell us 13 about the circumstances of his arrival and your 14 observation of him? 15 A: He arrived by ambulance and I did a 16 little initial charting on time, either what I was -- 17 what I saw or what I was told. 18 Q: Hmm hmm. 19 A: I didn't really have any conversation 20 with him per se. I just -- I was recording and that was 21 my job, to record what was happening. 22 Q: Okay. And where were you located at 23 that -- situated at that time in the department? 24 A: I'd be right by his stretcher in the 25 Emergency room.

1 Q: In the Emergency room? 2 A: Yes. 3 Q: Was that the room that we have heard 4 others refer to as the OR or -- 5 A: Yes. 6 Q: And OR stands for? 7 A: Operating room. 8 Q: Operating room. 9 A: But it was just -- and it was an 10 operating room at times, but we also, because it was a 11 large room, that's where we would put any trauma 12 patients, because there was more room and the equipment 13 was right near at hand, that we might require to treat 14 such a patient. 15 Q: And if I could take you, Mrs. 16 Liddell, to Tab 1 of the brief of hospital records, 17 actually, which is the other binder. Well, it says 18 "Hospital Records: Nurse Witnesses" on the front. 19 A: Yes. 20 Q: And, for the record, I am referring 21 to a document that's been identified in these Proceedings 22 as Exhibit P-356. It's Inquiry Document Number 100043, 23 the medical records of Nicholus Cotrelle from Strathroy 24 Middlesex General Hospital. 25 A: Yes.

1 Q: And if I could take you to the nurses 2 notes which, I believe, are the third page of the tab in 3 front of you. 4 A: Yes. 5 Q: And for people looking for them in 6 the database, they are at Front 284, 000284. 7 Now, do you recognize your handwriting 8 amongst any of the notes that appear there? 9 A: Yes, the initial nurses' notes are 10 done by me. 11 Q: And do you recall making those notes? 12 A: Yes, I do. 13 Q: And you note there that the patient, 14 as you've already observed, arrived at 00:04. 15 A: Yes. 16 Q: Four (4) minutes after midnight. 17 A: Yes. 18 Q: And that he had a gunshot to his 19 right posterior back? 20 A: Yes. And that would have been told 21 to me either -- likely he arrived by ambulance and so the 22 -- usually when the ambulance personnel bring a patient 23 into us, they will have some documentation of history 24 that they have gotten from the patient. 25 And they will tell us exactly, you know,

1 where the injury is, what's kind of taken place and so 2 that's where I would get that information. 3 Q: So it wasn't based on your direct 4 observation of his injuries. 5 A: Not necessarily. It would likely be 6 from what the ambulance attendant had told me. 7 Q: You -- You note further that it's a 8 male patient admitted per ambulance as you've already 9 described. "Laceration to left back and abrasion left 10 wrist." 11 A: Yes. 12 Q: Is that -- am I making out your 13 handwriting correctly here? 14 A: Yes. That's right. That's right. 15 Q: And you would have obtained that 16 information on the same basis that you described? 17 A: Yes. Like partly I -- I would see 18 but they would also -- as they were saying I maybe would 19 be observing as well and so then I would write it down. 20 Q: And you also note, pain both sides of 21 back? 22 A: Yes. And that's likely something I 23 would have been told. Not necessarily I would hear the 24 patient say per se. 25 Q: You note further, "Got hit while

1 standing outside of car"? 2 A: And that -- and that's likely what 3 the ambulance had told me because they had already talked 4 to Nicholas 5 Q: All right. And you don't -- you 6 don't recall him -- 7 A: No, I don't remember having any 8 conversation with Nicholas at all. 9 Q: And you note that his blood pressure 10 is 128 over 90? 11 A: And someone would have taken it and I 12 was merely recording. 13 Q: And you also note, "Question mark, 14 223 rifle shell in right back." 15 A: And someone would have said that 16 because I know nothing about shells. 17 Q: And do you -- do you recall today who 18 -- who advised you of that? 19 A: No, I don't. I'm not sure. I don't 20 recall. 21 Q: And just to finish with your notes, 22 examined by Dr. Marr? 23 A: Yes. 24 Q: And your note there, "G. Ladell, 25 R.N.," does that merely signify that you've made these

1 notes? 2 A: Yes, that's right. That's what we 3 are required to do, to sign -- to sign anything that we 4 had documented. 5 Q: And finally, you've noted below it, 6 it appears -- appears to be your handwriting -- 7 A: Yes, it is. 8 Q: "Collar on but no neck pain." 9 A: And that's something the ambulance do 10 -- they put a neck collar on for -- to make -- to prevent 11 injuries. Like it's just a cautionary kind of thing that 12 they put on. 13 Q: And is there anything else that you 14 can recall about the arrival of Mr. Cotrelle that -- that 15 you should -- you feel you should share with us? 16 A: No, I don't. 17 Q: All right. We understand that two 18 (2) other patients arrived shortly afterwards? 19 A: That's correct. 20 Q: And namely, Mr. Anthony George or 21 Dudley George -- 22 A: Yes. 23 Q: -- and Cecil Bernard George? 24 A: Right. 25 Q: Do you recall the order in which they

1 arrived or in which you observed them arriving? 2 A: They came about the -- the same time. 3 But I'm not sure which one actually cam in first. 4 Q: All right. And when they arrived, 5 you were in the OR? 6 A: Yes, I was with Nicholus and then 7 they -- the ambulance and people would bring them right 8 into that same room. And so then I -- I kind of went 9 from -- left Nicholus and went to the -- you go to the 10 most seriously injured. And I went to Dudley George or 11 Anthony George. 12 Q: And did you have anything to do with 13 the treatment of Cecil Bernard George? 14 A: No, I did not. 15 Q: And did you observe -- what were your 16 observations concerning Cecil Bernard George? 17 A: I don't recall anything because I 18 didn't really have anything to do with him. We kind of 19 would stick with, you know, go with another patient 20 instead of trying to see them all at once. 21 Q: So at that point there were three (3) 22 patients in the room? 23 A: That's right. 24 Q: Nicholus Cotrelle, Cecil Bernard 25 George, and Anthony Dudley George?

1 A: Right. 2 Q: Can you describe for us if you will, 3 your observations of Mr. Anthony Dudley George's 4 condition on his arrival? 5 A: He was unresponsive, no movement. 6 His eyes were fixed. There was some bleeding from his 7 chest where he had a wound. But, like, he just -- he was 8 unconscious. There was just no reaction whatsoever. 9 Q: And did you make any direct -- did 10 you participate in taking his vital signs or any other 11 treatment or assessment, directly of Mr. George? 12 A: No, I -- I just mainly recorded. 13 Q: Okay. 14 A: I would maybe help set up, maybe get 15 the doctor oxygen or an endotrachial tube or those kinds 16 of things. I don't remember exactly what I did, but I 17 didn't start the intravenous, I didn't put the monitor 18 on. I didn't, you know, take his vital signs. 19 Q: Okay. And I understand that a code 20 blue was called -- 21 A: That's right. 22 Q: -- shortly after his arrival? 23 A: That's right, because of his 24 condition. That's what we do, we call a code blue which 25 brings extra people to the department and those people

1 each have a specific job. 2 One (1) will be for doing the medication, 3 some will be doing the compressions, some -- you know, 4 they each their specific jobs. And as my job, as the 5 supervisor, I was to be the recorder; that was my main 6 job. 7 Q: Okay. And if I could actually take 8 you to Tab 7 of the same brief of documents. And, for 9 the record, there's two (2) documents that -- that I will 10 be referring Mrs. Liddell to, Inquiry Document number 11 5000248 and 5000249. 12 First of all, if I could take you to 13 Document 5000249, which is the second page -- 14 A: Yes. 15 Q: -- in that tab for you. 16 A: Yes. 17 Q: Do you recognize your handwriting 18 anywhere on that page? 19 A: Yes, approximately the middle -- 20 Q: Hmm hmm. 21 A: -- where I've said the above -- 22 Q: Hmm hmm. 23 A: -- notes were rewritten on September 24 the 7th. 25 Q: Hmm hmm.

1 A: And I've signed it and dated it and 2 the time. 3 Q: Okay. And what was the time? 4 A: At -- September the 8th at 14:45. 5 Q: Okay. 6 A: Which would be the next day. 7 Q: Okay. And can you explain for us 8 what -- what that notation in your charting means? 9 A: It just means that I have given a 10 little better description of what actually happened the 11 night of -- 12 Q: Hmm hmm. 13 A: -- the 7th. 14 Q: Okay. 15 A: I suppose when you're not in the 16 situation, like when you have a crisis like that with 17 three (3) patients, then a lot of things happen and you 18 don't always have time to record everything you likely 19 should have. So I was given the opportunity the next day 20 to more clearly describe what actually happened -- 21 Q: Hmm hmm. 22 A: -- the night that he -- that Dudley 23 George arrived. 24 Q: Okay. And if I could take you to the 25 previous page --

1 A: Yes. 2 Q: -- which is Inquiry Document Number 3 5000248. 4 A: Yes. 5 Q: Do you recognize your notes anywhere 6 on that page? 7 A: Those notes are all mine. 8 Q: Okay. And would you have made those 9 notes at the time on September 7th, at for example, 00:08 10 hours or would they have been made -- 11 A: I -- I rewrote them the next day. 12 Q: Okay. And -- 13 A: And that's what happened, but I had 14 written it all exactly like that. 15 Q: Okay, so you were working, at the 16 time, from another set of notes that would have contained 17 less information, in other -- 18 A: Right. 19 Q: -- words. Okay -- 20 A: Right, and my memory was better then. 21 Q: Okay. And in those notes, you have 22 recorded at 00:08, "Male patient, native Canadian brought 23 in by ? car by ? family"? 24 A: I was in the OR room as you're 25 calling it --

1 Q: Hmm hmm. 2 A: -- and I was not -- I did not 3 personally see how he came or who came with him. 4 Q: Hmm hmm. 5 A: So I am going by what I was told -- 6 Q: Hmm hmm. 7 A: -- that's why the question mark. 8 Q: Hmm hmm. Okay, and you also note 9 that the patient was unresponsive, which you also -- 10 A: Yes. 11 Q: -- observed to us -- 12 A: That's right. 13 Q: "No vital signs visible", that he was 14 attached to monitors? 15 A: Yes, there's a monitor -- 16 Q: Hmm hmm. 17 A: -- with leads that we put on and that 18 gives us an idea of his heart activity -- 19 Q: Hmm hmm. 20 A: And I recall that there was, like, a 21 straight line which would indicate no activity. 22 Q: Okay, all right. And did you 23 participate in the attaching of those monitors yourself 24 or -- 25 A: No, I did not.

1 Q: You were focussed on recording -- 2 A: Yes. 3 Q: -- as you observed. And you also 4 note further on that: 5 "? gunshot wound, no obvious outlet for 6 bullet?" 7 A: And -- yes, and I was told that -- 8 see, that's why the question mark again? I was told that 9 it was a gunshot wound and he had been examined. Like, 10 that's one (1) thing they were looking for, to see if 11 they could find out what -- if it had gone right through 12 and so they had -- I was told that they couldn't find 13 any. It's not because I saw it particularly, it's 14 because it was what I was told. 15 Q: All right. And, finally, no movement 16 by patient. Did you observe Mr. George moving at any 17 point while he was in the ER? 18 A: No. 19 Q: Or, OR? 20 A: No. 21 Q: Can you describe for us any medical 22 treatment administered to Mr. George in an attempt to 23 revive him? 24 A: We did -- we called the Code Blue, 25 and so then we would do compressions on his chest, we

1 would have oxygen on him. We put an endotrachial tube 2 down and -- and that is a better way to give him oxygen 3 deep down. Like, the tube goes down into your throat and 4 you have an oxygen bag on top where you can pump air 5 right down into his chest. 6 We'd start the intravenous, which 7 would give him extra fluid, which would help as well, 8 because he -- there was a fair amount of bleeding from 9 his wounds, so this would increase his body fluids, which 10 is another way to try to revive him. 11 Q: And can you recall how soon after his 12 arrival at 00:08 these -- these efforts began? 13 A: They start immediately. As soon as 14 he comes in the room you immediately do everything you 15 can possibly do to revive a patient. 16 Q: Okay. And if I could take you to Tab 17 4 of the book in front of you, which is Inquiry Document 18 Number 5000248? No, sorry, 5000245. 19 A: Right. 20 Q: Can you tell me what -- what that 21 document is? 22 A: It's called -- what I would call the 23 "Code Blue Record" -- 24 Q: Hmm hmm. 25 A: -- and it's a record that I made at

1 the time that the code was being done. 2 Like, you give events as to what you know, 3 what happened, what date, what time, where, and the two 4 (2) physicians that were present, and, as I say, like the 5 respiration, the bag and the mask and the endotrachial 6 tube, which I talked about and who put it in, which was 7 Dr. Marr and then the closed-chest massage, which is the 8 compressions that were being done. 9 The intravenous, we had two (2) 10 intravenouses, which is what we usually do for someone 11 like this and the -- what the fluid was and who started 12 them. And then there's a place for vital signs. And I'd 13 done it three (3) times during that code procedure and 14 there was no activity; pulse, blood pressure, or anything 15 during that entire code time. 16 And I've also noted over there that at 17 00:19 that the pupils were fixed and dilated, which they 18 had been from when he came in through this whole 19 procedure. 20 And I've also, just for information, noted 21 that no CPR or resuscitation efforts were done during 22 transport to the hospital. Like, if he'd been in an 23 ambulance, then they -- we usually would do that on the 24 transport to the hospital. 25 And then I have the time that he died and

1 who the physician in charge, the nurse in charge, which 2 is always the Emergency nurse or when it's in the 3 Emergency Department. Then I had my name as a recorder. 4 Q: Okay. And the Charge Nurse would 5 have been -- 6 A: Jackie Derbyshire, because she was 7 the Charge Nurse in Emergency that night. 8 Q: Okay. Just -- just to take you back 9 a little bit. 10 A: Yes? 11 Q: You note here the time 00:11? What 12 does that time signify, that's towards the top right 13 beside Dr. Marr's name? 14 A: That is the time she got the 15 endotrachial tube inserted. 16 Q: Okay. 17 A: So he would have had oxygen by mask 18 prior to that because it takes a minute or so to get the 19 endotrachial tube in. So, we always note the time that 20 it's actually inserted. 21 Q: All right. And with respect to your 22 note here at 00:19 that pupils were fixed and dilated and 23 -- did -- so, that would have been information that you 24 were told -- 25 A: Yes.

1 Q: -- rather than what you observed 2 yourself? 3 A: Yes, because it's hard with everybody 4 moving for me to be right up there looking into his 5 pupils because his eyes would have been shut. 6 Q: And, with respect to your note, "No 7 CPR done during transport here," -- 8 A: And I was told that -- like I was 9 told that he had come likely -- by -- by the car, and 10 that nothing had been done. And that's information that 11 I would have been given. 12 Q: Okay. And do you recall who gave you 13 that information? 14 A: No, I do not. 15 Q: Do you recall inquiries being made at 16 the time by the physicians as to the history of his 17 injuries? 18 A: I believe Dr. Marr would try to find 19 that out as part of -- like when she would write up her 20 notes on this case, she would try to find out any 21 background information. But I personally didn't get it. 22 Q: Okay. And you said that she would -- 23 do -- do you recall her actually making inquiries of the 24 nursing staff, or anyone else? 25 A: No, I do not.

1 Q: Okay. And during the time that we've 2 been discussing here, do you recall the presence of any 3 police officers in the -- first of all in the Emergency 4 Department or hospital? 5 A: There were certainly some in the 6 hospital. I don't recall if there was one (1) in the OR 7 at the time that this was going on, but there certainly 8 were police in the hospital. 9 Q: Were there police in the hospital 10 prior to the arrival of any of these patients? 11 A: I do not recall. I do not recall. 12 Q: And the officers that you did 13 observe, they would have been in the Emergency 14 Department, that you observed them? 15 A: There were some in the Emergency 16 Department, and then just across the hall is what we call 17 the admitting office, and there were some in there. 18 Q: Okay. And do you recall roughly how 19 many officers were present? 20 A: No, I don't. I know there were quite 21 a few, but I have no idea as to number. 22 Q: Okay. Were you given any explanation 23 as to the reason for their presence there? 24 A: Well, something like this there 25 usually are police around but I -- I don't -- I don't

1 recall exactly, you know, the circumstances, exactly the 2 extent of what was really taking place. 3 Q: Okay. And -- and you did say 4 something like this, can you be a little more specific 5 about what you meant there? 6 A: I think at the time this was 7 happening, I didn't realize and -- and this is likely why 8 they had given me the next day the opportunity to rewrite 9 my notes, as I think at that time, I didn't realize the 10 extent as to, you know, that it would carry on and -- and 11 go on. 12 Q: Okay. And do you recall how the 13 police officers were dressed that were present in the 14 department? 15 A: Just in police uniform. 16 Q: Were they wearing any extra 17 protective gear? 18 A: They often do have, like, a vest over 19 top, but that's all I remember. 20 Q: And did the presence of police 21 officers in the department have any effect on you, as you 22 went about your work -- 23 A: No. 24 Q: -- with respect to these patients? 25 A: No. My job was to help the patients

1 to the best of my ability, and police do not bother me 2 that way. I guess I've worked enough with them that -- 3 no, they don't affect, you know, make me nervous or 4 anything like that, no. 5 Q: And they didn't pose any impediment 6 at the time? 7 A: No. No, they did not. 8 Q: And did their presence in the -- in 9 the hospital cause you to have any concerns for your 10 safety? 11 A: No. 12 Q: Okay. If I could take -- just to 13 continue with -- with Mr. George, Anthony Dudley George, 14 did you observe him being pronounced dead? 15 A: Yes, I did. That was just at the end 16 of the code. Like I've got 00:19 pupils fixed and 17 dilated, and then just -- 00:20 Dr. Marr pronounced him. 18 And yes, I was right there when she did that and recorded 19 the time. 20 Q: Okay. And if I could just take you 21 to the next tab, that's Tab 5 in the Brief of Documents 22 in front of you, which is Inquiry Document Number 23 5000246 -- 24 A: Yes. 25 Q: -- for the record?

1 A: Yes. 2 Q: And just as a housekeeping matter, I 3 should at this point pause and ask to have entered as 4 exhibits, the nurse's notes that appear at Document 5 Number 5000248. 6 THE REGISTRAR: P-382, Your Honour. 7 COMMISSIONER SIDNEY LINDEN: Okay. 8 9 --- EXHIBIT NO. P-382: Document Number 50002248, 10 Nurse Glenna Ladell's notes, 11 Sept. 07/95 Re: Mr. Anthony 12 George 13 14 MS. KATHERINE HENSEL: And at 5000249. 15 THE REGISTRAR: P-383, Your Honour. 16 THE CHAIRPERSON: 383. 17 18 --- EXHIBIT NO. P-383: Document Number 5000249, 19 Nurse Glenna Ladell's notes, 20 Dept. 07/95 Re: Mr. Anthony 21 George 22 23 MS. KATHERINE HENSEL: And as well, what 24 Mrs. Ladell has described as the Code Blue sheet which is 25 titled Cardio Pulmonary Resuscitation Record which is

1 Inquiry Document Number 5000245. 2 REGISTRAR: P-384, Your Honour. 3 4 --- EXHIBIT NO. P-384: Document Number 5000245, Code 5 Blue record of Dudley George 6 made by Nurse Glenna Ladell, 7 Sept. 07/95 Cardiopulmonary 8 resuscitation record. 9 10 MS. KATHERINE HENSEL: Okay, turning to 11 the next document, which is Inquiry Document Number 12 5000246 for the record. And if I could ask that this be 13 entered as the next exhibit? 14 REGISTRAR: P-385. 15 16 --- EXHIBIT NO. P-385: Document Number 5000246, 17 Record of Dudley George's 18 death, September 07/95. 19 Pronounced dead by Dr. Marr 20 at 00:20 hours. 21 22 MS. KATHERINE HENSEL: Thank you. 23 THE CHAIRPERSON: P-385. 24 25 CONTINUED BY MS. KATHERINE HENSEL:

1 Q: Mrs. Ladell, do you recognize that 2 document? 3 A: Yes, I have completed the top half, 4 which was my requirement. 5 Q: Your -- your requirement -- 6 A: As a supervisor, and because I was 7 looking after him and Mrs. Bergman was busy with other 8 matters, then I just carried on and -- and did it as if I 9 was supervisor at that time. 10 Q: Okay. All right. Okay, do you 11 recall once Mr. George was pronounced dead -- 12 A: Yes. 13 Q: -- what happened next? 14 A: We would try to notify his next of 15 kin, which I have on this Document 5000246, I've said 16 that I -- that they had come in and that they were 17 notified at 00:55. 18 Q: Okay. 19 A: And then at -- at 1:00, then I 20 notified the Coroner, Dr. Perkin, which is something we 21 do for deaths of -- of this type. 22 Then Dr. Marr would say to me that the 23 Coroner needed to be called, and -- and that was another 24 job a supervisor would do, so I have carried and done 25 that same thing as well.

1 Q: Okay, and when you say deaths of this 2 type, what do you mean by that? 3 A: Suspicious or unknown cause -- deaths 4 in an emergency like this, unless it's something that we 5 know -- have a big history on, then the Coroner is always 6 called. 7 Q: Okay. All right, at any point was 8 Mr. George identified to you as Anthony George? 9 A: Yes, he was identified by his 10 brother, Maynard George, and by his sister, Pamela George 11 to me. 12 Q: Okay? 13 A: And this is a requirement as well. 14 We have to have possible -- positive identification of 15 the patients, and this is -- was one (1) of my jobs, and 16 it was done to me. 17 Q: Okay. And where did that take place? 18 A: It would take place -- I don't recall 19 whether he -- I would think that likely, by this time, we 20 had moved him to the small room on the side, but I don't 21 recall exactly. 22 Q: Okay. All right. And had Dr. Perkin 23 arrived at the hospital by that point? 24 A: He didn't arrive until about quarter 25 to 2:00.

1 Q: Okay. 2 A: I had called him at 1:00. He lives 3 out of Strathroy, so it took him a few minutes to get to 4 the hospital. 5 Q: Okay. And can you describe your 6 conversations with him once he did arrive? 7 A: Well, I -- I would just, you know, 8 tell -- when -- over the phone I would tell him that, you 9 know, we had this patient and that Dr. Marr had asked for 10 me to call him. 11 And when he came in, usually he will talk 12 -- well, I -- he -- I -- I'm not -- I don't recall 13 exactly what he said to me at that point, but he would 14 have a discussion with the doctor in charge, which would 15 be Dr. Marr, to find out all of the particulars about 16 what has happened. 17 And then I would identify the patient to 18 him, and he -- the two (2) of us together in the room, he 19 would examine the body and I would be in the presence. 20 Q: And your identification of Mr. 21 George, to Dr. Perkin, would have been based on his 22 family members -- 23 A: Yes. 24 Q: -- Maynard George's --? 25 A: I have to have a positive

1 identification to me, and then I identify the body to the 2 Coroner. 3 Q: Okay. Now, taking you back, for a 4 moment, to your conversation with Maynard George and 5 Pamela George, -- 6 A: Yes. 7 Q: -- was it you that notified them of 8 Mr. George's death? 9 A: Yes, I did. And that was also a job 10 that we did as a supervisor. 11 Q: Okay. After the arrival of Dr. 12 Perkins, can you describe what went on in relation to -- 13 to Mr. George? 14 A: Well, I would take him into the room 15 where Dudley George was, and positively identify the 16 patient to him, and then he examines the body. 17 Q: Okay. Now, we have heard evidence 18 here, Mrs. Ladell, that Mr. George's family did conduct a 19 smudging ceremony with -- 20 A: Yes -- 21 Q: -- his -- 22 A: -- they did. 23 Q: Were you present for that? 24 A: No, I was not allowed to be in the 25 room.

1 Q: Okay. And did you have any 2 conversations with any of his family members about that 3 ceremony? 4 A: No, they -- well, they just said that 5 they wanted to do it, and I kind of wanted to go in 6 because I felt that he was still my responsibility. 7 Q: Hmm hmm. 8 A: And they wouldn't allow me to go in, 9 so I had to wait outside the door, but I don't remember 10 who I spoke to. 11 Q: Okay. And if I could take you to -- 12 first of all, was there anyone else present, other than 13 his family members at the time? 14 A: For that service? 15 Q: Yes. 16 A: There were several people in there, I 17 have no idea who they were. 18 Q: Okay. If I could take you to Tab 7 19 which has been identified as -- the document there has 20 been identified as Exhibit P-382. 21 Now, there you have noted, 22 "Religious native rights performed by 23 family in presence of Constable 24 Murphy." 25 Is that a correct interpretation of your

1 handwriting? 2 A: Yes, that's my handwriting. 3 Q: Okay. 4 A: Yes. 5 Q: Does that refresh your memory as to 6 who was in the room at the time? 7 A: No, I just remember there were 8 several people around, but I have no idea who they all 9 were. 10 Q: Okay. Did you have any further 11 conversations with any members of Mr. George's family 12 after that time? 13 A: Not that I recall. 14 Q: Okay. And do you recall -- with 15 respect to the -- to the ceremony that you referred to 16 earlier, do you recall any concerns being raised, or 17 experienced by you, concerning the presence of oxygen in 18 the hospital, or oxygen lines and open flame? 19 A: I don't remember. 20 Q: You don't recall? 21 A: I don't remember. 22 Q: And -- all right. And then we 23 understand that Mr. George's body would then have been 24 taken to the morgue, is that correct? 25 A: Yeah, well it was first after --

1 Q: Hmm hmm. 2 A: -- Dr. Perkin examined the body -- 3 Q: Hmm hmm. 4 A: He and the constable took the body to 5 x-ray, to have some x-rays, which is not unusual either-- 6 Q: Hmm hmm. 7 A: -- to give a little more clarity to 8 exactly, you know, for Dr. Perkin's records, exactly what 9 had taken place. 10 And then he was brought back to the 11 Emergency Department. And then at three o'clock, Marlene 12 and I took the body to the morgue, which is another 13 nursing supervisor job. 14 Q: Okay, and by "Marlene" you mean 15 Marlene Bergman? 16 A: Marlene Bergman, yes. 17 Q: Okay. And do you recall taking any 18 of Mr. George's effects with him to the morgue? 19 A: His clothes went with him. Any 20 valuables were taken to the business office -- 21 Q: Okay. 22 A: -- which is ordinary procedure as 23 well. 24 Q: Okay. Do you recall if -- taking any 25 valuables to -- to the business office in this case?

1 A: I think Marlene took those. 2 Q: Okay. 3 A: Marlene Bergman took those. 4 Q: All right. Okay. And did you have 5 any further involvement with Mr. George or his family 6 that evening? 7 A: No. 8 Q: Did you have any further involvement 9 with any of the other patients that had come in, Mr. 10 Cotrelle or Cecil Bernard George? 11 A: I took -- I helped take one (1) end 12 of the stretcher when Nicholus Cotrelle was admitted to 13 2-South -- 14 Q: Hmm hmm. 15 A: And that was, I think, about 2:30. 16 Q: Okay. Right, I just have one (1) 17 further area of questioning. Just to go back to the time 18 when resuscitation efforts were being conducted on Mr. 19 George, do you call whether Mr. Cotrelle was moved out of 20 the room at anytime? 21 A: Yes, he was. 22 Q: Okay. We've heard evidence from Mr. 23 Cotrelle that he was actually present in the room for 24 quite some time. Do you recall when he would have been 25 moved out?

1 A: I don't know the exact time. I know 2 he was moved out, but I don't know exactly what time he 3 was moved out. 4 Q: Okay. Do you know when he would have 5 been moved out in relation to Mr. George being 6 pronounced? 7 A: No. 8 Q: Okay. 9 A: I don't recall. 10 Q: Okay. All right. Thank you, Mrs. 11 Ladell,-- 12 A: You're welcome. 13 Q: -- those are all my questions. 14 A: Thank you. 15 Q: My Friends -- Counsel for the parties 16 may have some further questions for you, all right? 17 A: Thank you. 18 COMMISSIONER SIDNEY LINDEN: Does anybody 19 wish to examine this witness? Ms. Jones? How long do 20 you anticipate you might be? 21 MS. KAREN JONES: About two (2) minutes. 22 COMMISSIONER SIDNEY LINDEN: Fine. 23 24 (BRIEF PAUSE) 25

1 MS. KAREN JONES: Good morning, Mr. 2 Commissioner. 3 COMMISSIONER SIDNEY LINDEN: Good 4 morning. 5 6 CROSS-EXAMINATION BY MS. KAREN JONES. 7 Q: Good morning, Ms. Ladell. 8 A: Good morning. 9 Q: My name's Karen Jones and I'm one (1) 10 of the lawyers for the Ontario Provincial Police 11 Association. 12 A: Yes. 13 Q: I just have a couple of things that I 14 wanted to make sure were clear. You were earlier taken 15 to the records of Mr. Anthony Dudley George -- 16 A: Yes. 17 Q: -- in the binder? 18 A: Yes. 19 Q: And you were asked to look at two (2) 20 pages, and the numbers were Inquiry Document Number 21 5000248 and 249. And you told us that those were the 22 notes that you made after the fact? 23 A: That's correct. 24 Q: And I take it if you turn -- do -- do 25 you have -- do you have the document numbered 5000247 in

1 that binder in front of you? It's at Tab 6 I think, of 2 your book. 3 A: Yes, I have it. 4 Q: Okay. Do you see the document number 5 at the very top? 6 A: Yes, I do. 7 Q: And the ending 247? 8 A: Yes. 9 Q: And there's a note there dated 10 September 7th, 1995 at 0:08? I take it that that is your 11 original note? 12 A: That is correct. 13 Q: Okay. Is that -- 14 A: And I've stroked -- see I've stroked 15 out ambulance because I wasn't sure how he came, and then 16 later I learned that he came by car, and that's why that 17 error is there. 18 Q: Right. And Mr. Commissioner, I 19 wonder just for the sake for completeness, if we could 20 have all of Ms. Ladells's records in -- for her nursing 21 notes? And I'm not sure if it makes sense to add this as 22 a new exhibit or to have it included in the two (2) 23 previous pages that were her notes? 24 Okay. That sounds like it would be a 25 separate exhibit.

1 COMMISSIONER SIDNEY LINDEN: Separate 2 exhibit? That's fine. 3 THE REGISTRAR: P-386, Your Honour. 4 COMMISSIONER SIDNEY LINDEN: P-386. 5 MS. KAREN JONES: Thank you. 6 7 --- EXHIBIT NO. P-386: Document Number 5000247, 8 Nurse Glenna Ladell's notes 9 September 07/95 Re: Mr. 10 Anthony George 11 12 CONTINUED BY MS. KAREN JONES. 13 Q: And I just had one (1) question, or a 14 couple of questions to ask you about the notes that you 15 made with Mr. Nicholas Cotrelle. And I think those are 16 in the binder in front of you too. 17 And we had looked at your -- 18 A: Excuse me, what tab are we looking 19 at? 20 Q: It's Tab 1 in your book. 21 A: Oh, is it number 1? 22 Q: Yes, I think so. 23 A: Yes. 24 Q: And then looking at the first page of 25 the nurses notes --

1 A: Yes. 2 Q: -- which is Inquiry Document 100043. 3 A: Yes. 4 Q: You -- we had earlier had up on the 5 screen, your note that -- it looks like it's dated 00 -- 6 it looks like originally eight (8) and then a written 7 over four (4), can you help us with that? 8 A: The clocks aren't always the same, 9 and so we try to co-ordinate everything to have it in 10 better chronological sequence. 11 Q: Okay. 12 A: And so I'm not sure exactly what was 13 there initially. 14 Q: Okay. Something was there and then 15 you wrote a 4 over it, is that right? 16 A: Yes. Yes, I did. 17 Q: Okay. And then that leads to my next 18 question which is that -- can you help us understand, 19 when you put a time down on a chart -- 20 A: Yes. 21 Q: -- are you referring to the time you 22 take from your watch or the time you take from the clock 23 in the room or something else? 24 A: I never wore a watch. 25 Q: Okay.

1 A: It would be the clock in the room. 2 Q: Okay. And so when you talk about a 3 discrepancy in clocks and time and -- and you're not sure 4 what the original entry was there, can you help us with 5 what you would have been looking at at first to get the 6 original time because you then subsequently changed it to 7 something else. 8 A: Part of it is -- and I'm not sure 9 whether it's here. Yes, there's another exhibit, 10 1000043; it's two (2) pages in front of that. 11 Q: Yes? 12 A: And it is the Emergency and 13 Outpatient Record. 14 Q: Yes. 15 A: And so, we try to have that time -- 16 Q: Okay. 17 A: -- and our time the same. 18 Q: Okay. 19 A: So, whenever they come in, then the 20 admitting people will put a time of entry. 21 Q: Yes. 22 A: And so that's that time. So, we -- 23 we had that time to correspond with this time -- 24 Q: Okay. 25 A: -- so that they're all the same.

1 Q: Okay. And so, at some -- I'm sorry, 2 and I don't want to make this more confusing. 3 A: That's okay. 4 Q: If you can help us with process on 5 evenings or nights, when someone comes into the Emergency 6 Department who would fill out the Emergency and 7 Outpatient Record? 8 A: This emergency? 9 Q: Yes. 10 A: The top part is filled out by the 11 admitting person. 12 Q: Okay. 13 A: And then where Marlene Bergman has 14 signed -- 15 Q: Yeah. 16 A: -- then someone in the Emergency part 17 or whoever is looking after as a nurse -- 18 Q: Yeah. 19 A: -- the nurse's assessment that's -- 20 and she would fill in the attending doctor -- 21 Q: Okay. 22 A: -- and then the latter part is done 23 by the attending doctor. 24 Q: Okay. And do you have a person who 25 works at the desk in the Emergency Department twenty-four

1 (24) hours to do -- 2 A: Like a secretary? 3 Q: Yeah, to fill out -- 4 A: No. 5 Q: Okay. Who -- 6 A: We only have them and they only work 7 the day shift -- 8 Q: Okay. 9 A: -- unless it's changed, but when I 10 was there it was only the day shift. 11 Q: Okay. 12 A: So, this top part is always done by 13 the admitting person and there is one (1) -- someone 14 there twenty-four (24) hours a day. 15 Q: And by "the admitting person," do you 16 mean the nurse who would have done the admitting or who-- 17 A: No, no. This -- this -- this typed 18 part -- 19 Q: Yes. 20 A: -- at the top is done by Admitting -- 21 I guess you'd call her an officer. She is not a nurse. 22 Q: Okay. 23 A: She looks after the switchboard, she 24 looks after these admissions. Particular, like in the 25 night, she's the only person in that office.

1 Q: Okay. 2 A: And then, she brings this chart over 3 to the Emergency Room, which is just across the hall. 4 Q: Okay. 5 A: And then, it is the responsible of 6 the nurse and the doctor to complete that document. 7 Q: Okay. And so, do I take it from what 8 you've said, then, that you would have seen the Emergency 9 and Outpatient Record with the time of 00:04 on it? 10 A: Yes. 11 Q: And then, you would have changed the 12 time -- 13 A: That's right. 14 Q: -- in your own documentation -- 15 A: That's right. 16 Q: -- so that it was the same as that? 17 A: Corresponding, right. 18 Q: Okay. So, it -- that time of 00:04 19 corresponds to whatever the admitting person was looking 20 at -- 21 A: That's right. 22 Q: -- not with the clock in the OR? 23 A: Because likely, her clock is a -- a 24 minute or two (2) off my clock. 25 Q: Okay.

1 A: They are supposed to be all the same, 2 but that's very hard to do -- 3 Q: Yeah. Yes. 4 A: -- in a large place. 5 Q: Okay. 6 A: To have them all exactly the same 7 time. 8 Q: Right. Okay. And those are my 9 questions. Thank you very much. 10 A: Thank you. 11 COMMISSIONER SIDNEY LINDEN: Thank you 12 very much, Ms. Jones. Thank you very much, Mrs. Ladell. 13 MS. KATHERINE HENSEL: Thank you, Mrs. 14 Ladell. 15 16 (WITNESS STANDS DOWN) 17 18 MS. KATHERINE HENSEL: I believe these 19 Witnesses' Counsel -- actually I should have introduced 20 him while he was here, but I will when he comes back in, 21 has gone to locate the next witness, Marlene Bergman, 22 she's on the premises. 23 COMMISSIONER SIDNEY LINDEN: Is she here 24 or should we take a short break? 25 MS. KATHERINE HENSEL: Yeah. Yeah, we

1 can -- if we take a short break that would be... 2 COMMISSIONER SIDNEY LINDEN: We can take 3 a short break now. 4 MS. KATHERINE HENSEL: Okay. Thank you. 5 THE REGISTRAR: This Inquiry will recess 6 for ten (1) minutes. 7 8 --- Upon recessing at 11:20 a.m. 9 --- Upon resuming at 11:35 a.m. 10 11 THE REGISTRAR: This Inquiry is now 12 resumed, please be seated. 13 MS. KATHERINE HENSEL: Thank you, 14 Commissioner, I was remiss this morning in not 15 introducing Counsel for the witnesses today, Ron LeClair, 16 who is seated back -- 17 COMMISSIONER SIDNEY LINDEN: Good 18 morning. 19 MS. KATHERINE HENSEL: -- a few tables 20 back. 21 MR. RON LECLAIR: Good morning. 22 MS. KATHERINE HENSEL: The Commission 23 calls, as its next witness, Marlene Bergman. 24 THE REGISTRAR: Good morning, Ms. 25 Bergman. How are you this morning? Do you prefer to

1 swear on the bible or affirm? 2 MS. MARLENE BERGMAN: Bible. 3 4 MARLENE BERGMAN, Sworn: 5 6 EXAMINATION IN-CHIEF BY MS. KATHERINE HENSEL: 7 Q: Good morning, Mrs. Bergman. 8 A: Good morning. 9 Q: I should remind you before we begin 10 to speak directly into the mic, and you might want to 11 move it a little bit closer to you, if you're... 12 13 (BRIEF PAUSE) 14 15 Q: Our court officer will help you with 16 that. 17 18 (BRIEF PAUSE) 19 20 Q: Thank you. Just for the record, Mrs. 21 Bergman, your date of birth is May 16th, 1941? 22 A: Yes. 23 Q: And I understand that you graduated 24 from the St. Thomas Elgin Hospital School of Nursing 25 Program in 1962?

1 A: That's right. 2 Q: And that was a three (3) year 3 program? 4 A: Yes. 5 Q: Shortly afterwards you started 6 working with the Strathroy Middlesex General Hospital as 7 a registered nurse? 8 A: Correct. 9 Q: And that was also in 1962? 10 A: Yes. 11 Q: And in 1973 you became a nursing 12 supervisor at the same hospital? 13 A: Yes. 14 Q: And you served in that capacity until 15 your retirement in 1996? 16 A: Yes, that's right. 17 Q: And I understand that as a nursing 18 supervisor, you were responsible for supervising nursing 19 operations throughout the hospital? 20 A: That's correct. 21 Q: And also you pitched in and assisted 22 other nurses when you were required? 23 A: That's correct. 24 Q: Now, turning now to September 6th, 25 1995, I understand that you went on duty at 11:00 p.m.

1 that night? 2 A: Yes, that's correct. 3 Q: And that you received information 4 around that time that you might -- your hospital might be 5 receiving some patients? 6 A: Correct. 7 Q: Okay. Can you tell us where you 8 received that information? 9 A: In the nursing office. 10 Q: Hmm hmm, okay. And was there a 11 particular nurse that gave you that information, that you 12 can recall? 13 A: Yes, Lisa Seeley. 14 Q: Okay, and what did she tell you? 15 A: That dispatch had phoned and there 16 was ambulances at the Ipperwash Park area -- 17 Q: Hmm hmm. 18 A: -- and we were the closest hospital. 19 Q: And did she get any information or 20 did you get any information about the number of patients 21 that might be coming? 22 A: No. 23 Q: Okay. After that phone call, did you 24 receive any further information about the patients that 25 might be coming in?

1 A: Not until the Emergency nurse called 2 me. 3 Q: Okay. 4 A: And she had received a dispatch. 5 Q: Okay, and what was that dispatch? 6 A: That we would be receiving at least 7 two (2) patients, one (1) by ambulance and one (1) by 8 car. 9 Q: Okay. Do you remember about what 10 time that would have occurred? 11 A: About twelve (12) -- 11:20 or -- no, 12 sorry, 11:40, about that time. 13 Q: And we've also heard from your 14 colleague, Mrs. Glenna Ladell earlier today that she 15 stayed on -- on duty, that she was the nursing supervisor 16 for the shift before, and that she stayed on duty? 17 A: That's correct. 18 Q: Okay, and that she provided you with 19 a report of what had happened during the day and also a 20 briefing on -- on the information she had also received 21 from Ms. Seeley? 22 A: Yes. 23 Q: Prior to the arrival of any patients, 24 do you recall whether there were police officers present 25 at the hospital?

1 A: No. 2 Q: We've heard from Mrs. Ladell and 3 other witnesses that the first patient to arrive in the 4 Emergency Department was Nicholus Cotrelle, and that he 5 arrived at approximately four (4) minutes after midnight? 6 A: That's correct. 7 Q: And can you recall observing his 8 condition at that time, when he arrived? 9 A: He -- he arrived by ambulance, and 10 his condition -- he was conscious. 11 Q: Hmm hmm, okay. Did you see him 12 actually come into the hospital? 13 A: Yes, I did. 14 Q: Okay. Were -- where were you when he 15 arrived? 16 A: I was in the Emergency Department. 17 Q: Okay, and he was conscious. Was 18 there anything else significant about his medical 19 condition that you can recall? 20 A: On arrival? 21 Q: Hmm hmm? 22 A: When he came in the door -- 23 Q: Yes? 24 A: -- he was on the stretcher -- 25 Q: Okay?

1 A: -- and -- and we took him straight 2 into the trauma room, or the OR we call it. 3 Q: Okay, and what happened then? 4 A: He was examined by Dr. Marr, who was 5 in the hospital. 6 Q: Hmm hmm. Okay, do you recall having 7 any conversations with Mr. Cotrelle or hearing him speak 8 to anyone? 9 A: I -- I heard him say that he was in a 10 car with glass crashing around him. 11 Q: Okay. And was that -- when he was 12 speaking, was he describing -- was that in reference to 13 how his injuries may have occurred? 14 A: Yes, I think so. 15 Q: Okay. And can you describe Mr. 16 Cotrelle's -- as far as you were able to observe, his 17 emotional or psychological state when he arrived? 18 A: He -- 19 Q: Did he appear calm? 20 A: -- was quite calm when he arrived. 21 Q: Okay, and we understand that shortly 22 after Mr. Cotrelle's arrival, two (2) other patients 23 arrived at the hospital? 24 A: That's correct. 25 Q: Okay. Did you observe the arrival of

1 those two (2) patients? 2 A: I did. 3 Q: Okay, we have heard evidence that 4 Cecil Bernard George and Anthony Dudley George arrived at 5 the hospital. 6 Where were you located when they arrived? 7 A: I -- I was in the emergency room -- 8 Q: Hmm hmm? 9 A: -- but my contact with them was with 10 Mr. Anthony George first, and Mr. Cecil George second. 11 Q: Okay, and did you observe them being 12 brought into the -- when you said you were in the ER, or 13 the Emergency room do you mean the trauma room, or we've 14 heard it described as the OR as well? 15 A: I -- yes, I think I was in that room 16 at -- with the other patient. 17 Q: Okay. And just in terms of their 18 arrival, did you note the order that they were brought 19 in? 20 A: That's not -- they were just one (1) 21 after the other. 22 Q: Okay, in -- in quick succession would 23 you say? 24 A: Yes, fairly quick. 25 Q: So, do you recall who was brought in

1 first? 2 A: No, just my contact with them -- 3 Q: Hmm hmm, okay? 4 A: -- which one (1) was first. 5 Q: Okay, and which patient did you first 6 have contact with after Mr. Cotrelle? 7 A: Mr. Anthony George. 8 Q: Okay, and can you describe the nature 9 of that contact? 10 A: It was -- I assisted in putting the 11 leads on Mr. George. 12 Q: Okay. Did you observe his condition 13 when he first arrived? 14 A: He wasn't breathing. 15 Q: Okay. And Mrs. Ladell described to 16 us this morning the calling of a code blue? 17 A: Yes. 18 Q: Do you recall that? 19 A: Yes. 20 Q: And she also described for us that 21 under code blue circumstances each member of the nursing 22 team would take on different roles? 23 A: Correct. 24 Q: And can you describe for us your role 25 on the team that was treating Mr. George?

1 A: My role would have been the recorder 2 but -- 3 Q: Hmm hmm? 4 A: -- but Mrs. Ladell was there, and she 5 took over role, but I went right next to Mr. Cecil 6 George. 7 Q: Okay. So, you mentioned that you put 8 leads on -- on Mr. George -- Anthony George -- 9 A: Yes. 10 Q: -- monitors. What was the -- the 11 purpose of those monitors? 12 A: It -- the purpose of the monitors is 13 -- is to give us the heart activity. 14 Q: Hmm hmm. Okay. And did you engage 15 in any other treatment or assessment of Mr. George? 16 A: No, I didn't. 17 Q: Okay. All right. You mentioned 18 earlier that you then turned to Mr. Cecil Bernard George? 19 A: Yes. 20 Q: Okay. Were you aware at the time of 21 the circumstances surrounding his arrival at the 22 hospital; how he came to be at the hospital? 23 A: No. 24 Q: Okay. Do you know who had delivered 25 him to the hospital?

1 A: He came into the room by stretcher -- 2 Q: Okay. 3 A: -- with the ambulance attendant. 4 Q: All right. And did you know why the 5 ambulance -- or did you know any of the ambulance 6 attendants that brought Cecil Bernard George in? 7 A: No, I didn't. 8 Q: Okay. Were you aware that they were 9 St. John Ambulance attendants? 10 A: Not at the time. 11 Q: Okay. Would it be unusual for you -- 12 for a St. John Ambulance driver to deliver a patient to 13 your hospital, in your experience? 14 A: Not unusual, but not too often. 15 Q: Okay. Describe for us, if you will, 16 what Cecil Bernard George's condition was as far as you 17 observed it when you first encountered him? 18 A: When I first observed him, he -- he 19 was conscious. He was a bit vague and -- and but he 20 would react to verbal command. 21 Q: Okay. And when you say, "vague," can 22 you expand on that a little bit? 23 A: On the conscious of the patient? 24 Q: Hmm hmm. Well, you -- you mentioned 25 that he was vague, does that mean that he...

1 A: You would ask him a question and he 2 might say, "yes" and then "no." 3 Q: To the same question? 4 A: Yes. 5 Q: All right. And that he would respond 6 to a verbal command? 7 A: If you asked him to move his arm or - 8 - or his leg, he would. 9 Q: Did he complain of any injuries at 10 that time? 11 A: The ambulance drivers were the ones 12 that told me he had a head injury and abdominal injuries. 13 I can't recall him telling -- verbally coming from him at 14 the time. 15 Q: Okay. And was he -- did he have a 16 neck collar -- 17 A: Yes. 18 Q: -- at the time? All right. 19 A: Yes. 20 Q: Okay. We -- we have heard from other 21 witnesses, Mrs. Bergman, that he -- he didn't know a neck 22 collar was put on his neck to -- to brace him. 23 A: He didn't know? 24 Q: No. No, he -- that he wasn't wearing 25 a collar.

1 A: Oh, okay. 2 Q: But you can recall him wearing a 3 collar? 4 A: It would be in my notes if he... 5 6 (BRIEF PAUSE) 7 8 Q: If I could take you, Mrs. Bergman, to 9 the other binder that's in front of you, the black 10 binder. 11 A: The black binder? 12 Q: There's tabs. Not the one that -- 13 that we provided to you earlier -- 14 A: Oh. 15 Q: -- it's the one that's on the desk 16 there. It just contains copies of the -- the nursing 17 notes that we did provide to you -- 18 A: Hmm hmm. 19 Q: -- last week. If you could turn to 20 Tab 2 of that and for the record, that's Inquiry Document 21 Number 1000047, and that would be the third page; nursing 22 notes do appear there. 23 A: Hmm hmm. I have written he has a 24 neck collar on. 25 Q: Okay. All right. And that accords

1 with your memory at the time? 2 A: Yes. 3 Q: And, for the record, that was on -- 4 the page number is front 338. 5 A: Okay. 6 Q: Did you -- did you observe any 7 lacerations or any other types of injuries on Mr. George? 8 A: He had a cut to his upper right lip. 9 Q: Okay. Any others? 10 A: And -- and I didn't note the one that 11 was on the back of his head. 12 Q: Okay. And were they bleeding at the 13 time? 14 A: Not profusely. 15 Q: And what did you do to treat Mr. 16 George for his injuries at that time? 17 A: At that time, I started an IV, did 18 his blood pressure and his vitals. 19 Q: Okay. 20 A: And by that time, another nurse had 21 come on and -- and she was a primary nurse for him then. 22 Q: And who was that nurse? 23 A: Dawn Wolf. 24 Q: Okay, and I understand also that Dr. 25 Marr -- both Dr. Marr and Dr. Saettler also then treated

1 Mr. George? 2 A: Yes. 3 Q: Okay. While you were treating Cecil 4 Bernard George, I understand that there were also 5 resusitative efforts going on with respect to Anthony 6 Dudley George -- 7 A: Yes. 8 Q: -- and that he was eventually 9 declared -- declared dead at twenty (20) minutes after 10 midnight. 11 Did you observe any of that going on at 12 the time? 13 A: No. 14 Q: Okay. Were you focussed on -- 15 A: I was focussed on the patient I was 16 with. 17 Q: Okay, and that was -- 18 A: You would see in the room the action, 19 but -- or if they needed you for something. 20 Q: Okay. Okay, and I understand also 21 that Cecil Bernard George was eventually moved out of the 22 emergency department? 23 A: Yes. 24 Q: Did you have anything to do with 25 that, or...

1 A: Not Cecil Bernard, no. 2 Q: Okay. And can you describe Mr. 3 George's state, his manner, during the time that you had 4 interactions with him? 5 A: He was calm. 6 Q: He was calm? Right -- 7 A: Hmm hmm. 8 Q: You'd also earlier described a 9 certain vagueness? 10 A: Yes. 11 Q: Okay. And while you were in the 12 trauma room or OR, were there police officers present in 13 that room? 14 A: At the time I wasn't aware of it, but 15 there were after. 16 Q: Okay. And after -- after when? 17 A: After the code was called and it -- 18 things were back to a little bit normal. 19 Q: All right, so -- and was it your 20 impression at the time that either Nicholus Cotrelle or 21 Cecil Bernard George were in police custody? 22 A: I wasn't aware of it at the time? 23 Q: Okay. Did you observe police 24 officers staying fairly close to those two (2) patients 25 during your time there?

1 A: I really wasn't watching them. 2 Q: Okay. You were focussed on the 3 patients at -- 4 A: Yes. 5 Q: -- the time? Okay, did you have any 6 interactions with any members of Mr. George's -- by that, 7 I mean Cecil Bernard George's family that evening? 8 A: No. Oh, I -- I -- 9 Q: Hmm hmm. 10 A: -- recall a telephone call from a 11 brother and it's recorded. 12 Q: A brother of Cecil Bernard George 13 or -- 14 A: Yes. 15 Q: -- Anthony George? 16 A: Oh, I'm sorry. It's Anthony George. 17 Q: Okay. 18 A: Okay. 19 Q: And can you describe that telephone 20 call for us? 21 A: I can't describe the exact words but 22 he -- 23 Q: Hmm hmm. 24 A: -- was inquiring about Anthony George 25 and he said he was a brother --

1 Q: Hmm hmm. 2 A: -- that was later, and the family had 3 come and been there and gone, so I referred them to the 4 family. 5 Q: Okay. And that -- would that be 6 standard procedure, if family -- 7 A: Once the family's notified. 8 Q: Okay, you refer other members of the 9 family to those family members -- 10 A: To family -- 11 Q: -- who -- 12 A: Yes. 13 Q: -- were notified? Okay. Okay, and 14 do you recall the arrival of the Coroner at the hospital? 15 A: I didn't see him come in the door, 16 but I knew he was there. 17 Q: Okay. And that was in relation to 18 Anthony -- he was there in relation to -- 19 A: Yes. 20 Q: -- George? 21 A: Yes. 22 Q: Okay. Did you participate in the 23 identification of Mr. George by his family members? 24 A: No, I did not. 25 Q: Okay. Did you assist the Coroner or

1 interact with the coroner in any way once he had arrived? 2 A: No. 3 Q: Okay. Were you aware of what he was 4 doing while he was there? 5 A: No. 6 Q: Okay. And Mrs. Ladell testified 7 earlier that Mr. George -- Anthony Dudley George was 8 eventually moved to morgue -- 9 A: Hmm hmm. 10 Q: Do you recall -- did you participate 11 in transporting his body to the morgue? 12 A: Yes. 13 Q: Okay. And were you accompanied, at 14 that time, by a police officer? 15 A: Yes. 16 Q: And beyond accompanying you, did that 17 police officer do anything in relation to Mr. George's 18 body? 19 A: Not that I recall. 20 Q: Do you recall him doing any 21 fingerprinting on Mr. George? 22 A: There was another officer that came 23 in for the fingerprinting but I just directed him down 24 there. 25 Q: Okay. So you weren't present when

1 that happened? 2 A: No. 3 Q: And just one (1) final question, Mrs. 4 Bergman, in terms of your -- you performing your nursing 5 duties that evening or over that night in the hospital, 6 did the presence of police, at any time, interfere with 7 your performance of those duties? 8 A: No. 9 Q: Did it -- I'm sorry to interrupt 10 you, please continue. 11 A: Not that I recall. 12 Q: And did -- did their presence give 13 rise to any concern on your part as to how events were 14 unfolding either at the hospital or anywhere else? 15 A: Not -- like were we anxious? Is that 16 what you're referring to? 17 Q: Yeah or did experience any -- any 18 concern about their presence, in terms of you performing 19 your duties or perhaps your personal safety? 20 A: Not interfering with our duties, no. 21 Q: All right. Thank you, Mrs. Bergman, 22 those are all my questions. 23 A: Okay. 24 COMMISSIONER SIDNEY LINDEN: Thank you 25 very much.

1 MS. KATHERINE HENSEL: Counsel for the 2 other parties may have some questions for you. 3 COMMISSIONER SIDNEY LINDEN: Does anybody 4 have any questions for this witness? I think -- 5 MS. KATHERINE HENSEL: We're all done. 6 COMMISSIONER SIDNEY LINDEN: I think this 7 is a first for us, isn't it? 8 MS. KATHERINE HENSEL: Hmm hmm. 9 COMMISSIONER SIDNEY LINDEN: Thank you 10 very much, Mrs. Bergman -- 11 THE WITNESS: Thank you. 12 COMMISSIONER SIDNEY LINDEN: -- for 13 coming and giving your evidence. And that concludes the 14 -- your evidence today. 15 THE WITNESS: Thank you. 16 17 (WITNESS STANDS DOWN) 18 19 MS. KATHERINE HENSEL: Now I understand 20 our next witness, Mrs. Derbyshire is en route. Do we 21 have an arrival time for her? 22 COMMISSIONER SIDNEY LINDEN: Yes, Ms. 23 Vella? 24 MS. SUSAN VELLA: Yes, Commissioner. As 25 you know we have a third witness scheduled for today. We

1 anticipated that she would not be reached until after 2 lunch and accordingly, she's en route from Strathroy. I 3 tried to get her a little earlier but was unable to do 4 that when I saw the pace of the witness testimony. 5 COMMISSIONER SIDNEY LINDEN: Let the 6 record show that we're speeding right along. 7 MS. SUSAN VELLA: Therefore I 8 respectfully request that we break for lunch early and 9 perhaps we can also come back correspondingly earlier. 10 COMMISSIONER SIDNEY LINDEN: That's fine. 11 We'll break for lunch now, our usual hour and fifteen 12 (15) minutes. We'll adjourn for lunch. 13 THE REGISTRAR: This Inquiry stands 14 adjourned until 1:15 p.m. 15 16 --- Upon adjourning at 12:00 p.m. 17 --- Upon resuming at 1:22 p.m. 18 19 THE REGISTRAR: This Inquiry is now 20 resumed. Please be seated. 21 COMMISSIONER SIDNEY LINDEN: Good 22 afternoon. 23 MS. SUSAN VELLA: Good afternoon. 24 Commissioner, just before I call the next witness I just 25 want to advise Counsel that we distributed, at lunch

1 time, an article from the New England Journal of 2 Medicine. It's an article that Dr. McCallum will be 3 referring to tomorrow during his examination. We sent an 4 abstract of it last week. 5 COMMISSIONER SIDNEY LINDEN: Okay. 6 MS. SUSAN VELLA: The Commission calls, 7 as its next witness, Jacqueline Derbyshire, please. 8 9 (BRIEF PAUSE) 10 11 THE REGISTRAR: Good afternoon, Ms. 12 Derbyshire. 13 MS. JACKALINE DERBYSHIRE: Hi. 14 THE REGISTRAR: Do you prefer to swear on 15 the Bible or affirm? 16 MS. JACKALINE DERBYSHIRE: I'll affirm. 17 THE REGISTRAR: Very good. Could you 18 give us your name in full please for the record? 19 MS. JACKALINE DERBYSHIRE: Jacqueline 20 Patricia Derbyshire. 21 THE REGISTRAR: And could you spell your 22 first name for us please? 23 MS. JACKALINE DERBYSHIRE: J-A-C-K-A-L-I- 24 N-E. 25 REGISTRAR: Thank you very much.

1 2 JACKALINE PATRICIA DERBYSHIRE, Affirmed: 3 4 REGISTRAR: Thank you. 5 6 EXAMINATION-IN-CHIEF BY MS. SUSAN VELLA: 7 Q: Ms. Derbyshire, I understand that you 8 were born on November the 11th, 1946? 9 A: Yes. 10 Q: What is your current employment 11 position? 12 A: I'm currently employed as a 13 Registered Nurse, Strathroy Hospital in the Emergency 14 Department, and -- 15 16 (BRIEF PAUSE) 17 18 Q: Thank you. When you say that you are a 19 job sharer, what does that mean? 20 A: It means that essentially I'm 21 employed half the full time position. There's two (2) of 22 us that share the hours of a full-time position, in the 23 Emergency Department, as far as hours. 24 Q: All right. And what are you -- what 25 is your regular shift?

1 A: My shift is actually rotating -- a 2 rotating type of shift. It's a -- I believe it's a seven 3 (7) week rotation, and we take the number of hours and 4 days in that rotation, and -- and the -- my job sharer 5 and I split it up between ourselves however we actually 6 want to split it up, so long as it's fair and even. 7 And we do -- at the present time, we do 8 twelve (12) hour days, twelve (12) hour nights, and I 9 think there's a couple of eight (8) hour shifts, kind of, 10 to make up the hours. 11 Q: All right. And how long have you 12 worked at the Strathroy Middlesex General Hospital in the 13 Emergency Department? 14 A: I started in the Emergency Department 15 in 1981. 16 Q: And your employment there has been 17 continuance -- continuous since then? 18 A: Yes, it has. 19 Q: I understand you received your 20 nursing diploma from the Ontario Nurse's Association in 21 1968? 22 A: The Ontario College of Nurses. 23 Q: College of Nurses, yes? 24 A: 1968. 25 Q: Thank you. And at that time, did you

1 receive the designation of Registered Nurse? 2 A: Yes. Yes. 3 Q: I understand that you completed your 4 nurse's training at the Sarnia General Hospital, and that 5 that was a three (3) year period? 6 A: That's right. 7 Q: During the course of your three (3) 8 years of training, what areas of nursing did you 9 complete? 10 A: We completed all areas of nursing. 11 Now, that would include medical nursing, surgical 12 nursing, psychiatric, pediatric, operating room, chronic 13 nursing, and medical. 14 Q: I understand that you worked also in 15 the Intensive Care Unit, chronic care, at the Sarnia 16 General Hospital during the course of your training? 17 A: Yes. Actually, the Intensive Care 18 was -- we didn't actually work as staff in the Intensive 19 Care. We did observe, but post -- post my registered 20 nursing, I worked on a surgical floor and floated. In 21 other words, when they were busy in the Intensive Care I 22 would go in, and help in there as well. 23 Q: And over what -- what years did you 24 work at the Sarnia General Hospital then? 25 A: We moved to Strathroy in 1974, and

1 until that time I had been at Sarnia General. 2 Q: So, 1968 to 1974 approximately? 3 A: Yes. 4 Q: Thank you. And when did you move -- 5 you moved into the Emergency Department at -- in 1981? 6 A: That's right. 7 Q: Prior to that, what unit did you work 8 in at the Strathroy Hospital? 9 A: When I first went there in 1974, I 10 actually floated. Now, floated means that you went 11 wherever they needed to have some help. 12 At that time, they -- they were building a 13 new Intensive Care in that hospital, and they were 14 pleased to have someone that had worked in an Intensive 15 Care, and asked me would I mind waiting until it was 16 opened, to actually go into a position there. 17 So -- so for the first few months I 18 floated, and then I went to the intensive care. 19 Q: And did you stay in that unit until 20 1981? 21 A: I did. 22 Q: I understand that when you became a 23 registered nurse, there was no formal training specific 24 to Emergency nursing, or Emergency Department nursing; is 25 that right?

1 A: There was nothing specific. You 2 floated through all the areas of the hospital at some 3 point in time during your training, but there wasn't any 4 intense training in any of the areas. It was more or 5 less to give you an overview of all areas. 6 Q: Is there currently a specific program 7 to -- to -- for Emergency Department nursing? 8 A: Yes, actually there's several -- 9 several courses available. There is a course whereby you 10 can actually go and attend a college and become a 11 specialist in Emergency nursing. And then as a nurse in 12 the Emergency Department, of course, as anywhere else, 13 there's always upgrading and continuing education. 14 But there are specific courses just for 15 the nurses that work in the speciality areas, including 16 the Emergency Room, that is, -- there's a trauma course 17 an -- a trauma nursing care course, and that involves all 18 aspects of trauma. 19 There's also an Advanced Cardiac Life 20 Support, ACLS course, and that of course has to do with 21 your cardiology, and then there's also a course in 22 pediatrics, which offers both trauma and -- trauma and 23 cardiology and pediatric speciality -- just care. 24 Q: Did you receive any diploma 25 recognizing the specialty of Emergency Department

1 nursing? 2 A: Yes. 3 Q: When did you receive that diploma? 4 A: I think it was 1997, and it was from 5 Humber College. 6 Q: Was this a mandatory program? 7 A: No. 8 Q: And I understand you also teach 9 Emergency nursing candidates? 10 A: Yes, I do. 11 Q: Can you explain the basic skills 12 which are required of Emergency Department nurses? 13 A: Emergency Department nurses must be 14 skilled in the areas of trauma, resuscitation of 15 patients. They have to be able to be in charge of a 16 situation or often in charge of the department -- 17 Q: Hmm hmm. 18 A: -- on and off shift. I don't mean 19 off shift, I mean they have to be able to do that when 20 they're on shift. 21 They have to maintain certain standards of 22 practice, and be re-certified in these once a year. And 23 they are expected -- expected to upgrade and continue 24 with their education, as things progress. 25 Q: All right. Since 1981 have you also

1 -- have you participated in any upgrading programs aside 2 from the specialty diploma you received in 1997? 3 A: Yes. Yes. Once -- 4 Q: What -- 5 A: -- a year, or twice a year, I usually 6 try to go to some type of a conference, and these are 7 offered for all medical personnel including, you know, 8 your doctors, nurses and -- and they usually offer a good 9 review, and an update of all the latest treatments and 10 interventions. 11 Q: Were you on duty at the Emergency 12 Department of the Strathroy Middlesex General Hospital on 13 the evening of September the 6th, 1995? 14 A: Yes, I was. 15 Q: What time did you come on duty? 16 A: 11:00 p.m., 23:00. 17 Q: Did you arrive early that evening? 18 A: I may have. Usually we try to be 19 there ten (10) minutes or so early. 20 Q: I understand that you were the charge 21 nurse in the Emergency Department that evening? 22 A: Yes. 23 Q: What are the key duties of the charge 24 nurse? 25 A: A charge nurse, on any shift, acts as

1 a coordinator. Patient care is -- is her uppermost 2 concern and standards of practice for patient care being 3 maintained. She also may assign other nurses specific 4 duties. 5 She's available to Administration, if 6 there were to be any questions that they wanted answered 7 throughout the department. She may -- may be requested 8 to deal with the public. She may be requested to deal 9 with any outside matters, and generally, she runs the 10 place. 11 Q: Now, were there any other Emergency 12 nurses on duty that evening? 13 A: No, there's -- there -- at that time 14 there was only one (1) -- one (1) RN on the night shift. 15 Q: For the -- 16 A: In the -- in the Emergency 17 Department, yes. 18 Q: Is that the same now? 19 A: No, now there's two (2), just due to 20 volume. 21 Q: Had you been the charge nurse before? 22 A: Oh, yes. 23 Q: Basically, every shift that you would 24 take, would you be the charge nurse for the Emergency 25 Department?

1 A: Not necessarily. The charge nurse -- 2 the -- the nurse that is in charge is actually based on 3 seniority, seniority is based on -- it goes up by hours 4 of work. 5 So, even though I'd been there a long 6 time, I may not necessarily, because being a job share, 7 of course, I wouldn't have the hours. So, there's --it's 8 always the senior nurse, in hours, that will be the 9 charge nurse, except on days, and then there is a charge 10 nurse who works days. 11 Q: Okay. In a nutshell, you were 12 responsible for the administration of the Emergency 13 Department that evening from the nursing perspective? 14 A: Yes. 15 Q: Prior to coming onto your shift that 16 night, were you aware of the Ipperwash Park occupation by 17 Aboriginal people? 18 A: I was aware of it through the news 19 media. 20 Q: Were there any contingency plans, 21 made in advance, specific to possible Emergency services 22 that might be required with respect to the Park 23 occupation at the hospital? 24 A: When? 25 Q: Prior to September the 6th, to your

1 knowledge? 2 A: No. No, you mean was there sort of a 3 plan if -- if there should be -- no, not that I was aware 4 of. 5 Q: All right. So, when you came on for 6 your shift that evening, as far as you were concerned, 7 this was just another night? 8 A: Hmm hmm. Yes, just another night. 9 Q: did that change? 10 A: It certainly did. 11 Q: When? 12 A: When -- actually, when I came on 13 duty, and there's usually the nurse going off of duty, 14 will give you a report on any patients that are left for 15 your shift or anything that is pertinent that she wishes 16 you to know. 17 And -- and one (1) of the nurses that 18 evening told me that -- that she had received a phone 19 call and that several ambulances had been dispersed to 20 the Ipperwash area. 21 Q: Who was that nurse? 22 A: Lisa Seeley. 23 Q: And, you would have received this 24 information, then, around 23:00 hours -- 25 A: Yes.

1 Q: -- at the switch-over? 2 A: Yes. 3 Q: Did she advise you who she received 4 the call from with respect to the dispatch of ambulances? 5 A: She had received it from Wallaceburg. 6 Q: All right. Did you often receive 7 calls from the Wallaceburg Ambulance Dispatch? 8 A: No. No, they're not in our 9 jurisdiction. 10 Q: Now, at this time were you provided 11 with any specific details of specific casualties? 12 A: No. 13 Q: So, this was essentially a -- a 14 warning or a notice that there might be -- 15 A: Hmm hmm. 16 Q: -- casualties that evening? 17 A: Yes, we really still had no knowledge 18 of anything specific. 19 Q: Was there any indication provided 20 through Lisa Seeley, that the casualties, the possible 21 casualties, could include gunshot wounds? 22 A: No. I -- at least I don't 23 remember her saying that. 24 Q: Or that there could be multiple 25 serious casualties?

1 A: No. 2 Q: Do you recall how many nurses were on 3 duty at the hospital for that evening shift? 4 A: I -- I really wouldn't have any idea 5 of how many were in the hospital, like, I think some of 6 the floors, it varies on the number of patients as to how 7 many they staff with per -- per evening and per night 8 shift, so I wouldn't be aware of the total number, but it 9 certainly -- it certainly is bare bones. 10 Q: Bare bones staff? 11 A: Yeah, on the night shift. 12 Q: Okay. Were there any doctors on duty 13 that night? 14 A: Yes. 15 Q: Do you know how many? 16 A: Two, (2) that I know of. 17 Q: And who were they? 18 A: Dr. Marr, she was the doctor on call 19 in the Emergency Department, and Dr. Saettler was the 20 surgeon on call that evening -- or, that night. 21 Q: Did you take any preparative -- 22 preparation steps for the Emergency Room Department as a 23 result of the call from Wallaceburg? 24 A: Just to make the -- just to make the 25 supervisor aware that there was something.

1 Q: And who was the supervisor who you 2 spoke with? 3 A: Marlene Bergman. 4 Q: Did you communicate any requests of 5 Marlene Bergman with respect to precautionary steps or 6 requirements that should be taken? 7 A: Well, I said to her that we -- we had 8 to think about staffing, as to who we may be able to pull 9 from the other floors, if we were to need them, but I 10 really had no idea -- I couldn't ask for anything 11 specific because I didn't know myself. 12 Q: All right. Did -- did that standby 13 situation change at some point? 14 A: Yes. 15 Q: Do you recall when? 16 A: I think it was maybe a half an hour 17 or so later. Just -- now, it was getting on toward 18 midnight, maybe twenty (20) to or a quarter to, then we 19 did get -- I did get a call from the London Dispatch -- 20 Q: Hmm hmm. 21 A: -- which is -- which is our area. 22 Q: All right. Is this the London 23 Am