RELEASE DATE: June 22, 2011 Manitoba THE PROVINCIAL COURT OF MANITOBA IN THE MATTER OF: The Fatality Inquiries Act C.C.S.M. c. F52 AND IN THE MATTER OF: An Inquest into the death of: Andrew Szabo Report on Inquest and Recommendations of Judge Mary Kate Harvie Issued this 17th day of June 2011 APPEARANCES: Ms Mandy Ambrose, Counsel to the Inquest Mr. Gavin Wood, Counsel for Criti Care EMS, Inc. Mr. Robert Sokalski, Counsel for Winnipeg Football Club and Canadian Football League Mr. William Olson, Q.C., and Ms. Catherine Tolton, Counsel for Winnipeg Regional Health Authority, The Grace General Hospital and the Health Sciences Centre Mr. Michael Jack, Counsel for Winnipeg Fire Paramedic Service and The City of Winnipeg Mr. Thor Hansell and Mr. Tyler Kochanski, Counsel for Dr. T. Bergmann, Dr. E. Smith and Dr. G. Pierce Mr. Robert Tapper, Q.C., Counsel for Mrs. Szabo Ms. Betty Owen, Inquest Co-ordinator Manitoba THE FATALITY INQUIRIES ACT, C.C.S.M. c. F52 REPORT BY PROVINCIAL JUDGE ON AN INQUEST INTO THE DEATH OF: ANDREW SZABO Dated at the City of Winnipeg, in Manitoba, this 17th day of June, 2011. “Original Signed by:” Judge Mary Kate Harvie Copies to: Chief Judge Ken Champagne, Provincial Court of Manitoba The Honourable Andrew Swan, Minister of Justice Dr. A. Thambirajah Balachandra, Chief Medical Examiner Inquest: Andrew Szabo Page: 1 A Brief Summary of Events Leading to the Death of Andrew Szabo [1] On August 4, 2006 Andrew Szabo and his wife Barbara Szabo attended a Winnipeg Blue Bomber football game at the Canad Inns Stadium in Winnipeg, Manitoba. They were accompanied by Randy Gustafson, a friend who was visiting from out of town. Although earlier that day Mr. Szabo had consumed some alcohol, he was showing no signs of impairment. Mr. Szabo and Mr. Gustafson purchased and consumed some beer prior to the commencement of the game. Mr. Szabo and his wife then proceeded to their seats in section K, row 13, seats 1 and 2 in the stadium’s north end zone. Mr. Gustafson also sat in the north end zone but in a seat at the opposite end of the same row as Mr. and Mrs. Szabo, as they were unable to purchase tickets together. [2] At approximately 7:25 P.M. Mr. Szabo motioned to Mr. Gustafson that they should go down and meet at ground level of the stadium. As Mr. Szabo stood up he appeared to catch his foot under the bench seat in front of him. He began to fall forward but was caught by Mrs. Szabo and a man seated in row 12 and was able to right himself. Mr. Szabo then started down the stadium stairs. It appeared to eye witnesses that he gained speed as he proceeded down the stairs, losing his balance as his upper body accelerated faster than his lower body. Before reaching the horizontal walkway at the base of the seats, he appeared to catch one foot on the other, causing him to fall. The forward momentum propelled him across the platform, causing him to strike his head on the guard rail running in front of sections J and K. His body became limp and he fell through the railings onto the concrete surface below. [3] Bystanders rushed to his side and observed that he was lying flat on his back, apparently unconscious. He was attended to almost immediately by paramedics from “Criti Care”, a private paramedic company retained by the Winnipeg Football Club to provide services to patrons attending the game. A 911 call was immediately placed and Mr. Szabo was triaged by the Criti Care paramedics. Mr. Szabo’s care was transferred to the care of the Winnipeg Fire Paramedic Service (“WFPS”) at 7:45 P.M., who eventually decided that he was to be transported to the Grace General Hospital. [4] Mr. Szabo arrived at the Grace General Hospital at 8:12 P.M. He was triaged and his injuries were assessed as a “CTAS No. 2”. He was treated and remained in the Emergency Department for a number of hours. As he was being prepared for discharge, he was observed to be unwell. As his condition began to deteriorate, he was moved to the resuscitation room where he underwent extensive interventions. [5] On August 5, 2006 at 3:06 a.m. Mr. Szabo was transferred by ambulance to the Emergency Department at the Health Sciences Centre (“HSC”) where his care was assumed by their “gold team.” Despite aggressive attempts Inquest: Andrew Szabo Page: 2 at resuscitation at the HSC, Mr. Szabo succumbed to his injuries and was pronounced dead at 6:22 a.m. on August 5, 2006. [6] A medico-legal autopsy confirmed the cause of death was “multiple injuries due to fall from height”. The manner of death was deemed “accidental”. The Mandate of the Inquest [7] In Manitoba, Inquest proceedings are governed by both common law and by the statutory provision of The Fatality Inquiries Act, C.C.S.M. c.F52. The primary purpose of an inquest, as set out in The Fatality Inquiries Act section 33(1), is to determine the identity of the deceased, the facts surrounding the death, and whether the death was preventable. The Inquest Judge can make recommendations for changes to “the programs, policies or practices of the government and the relevant public agencies or institutions or the laws of the province” where the Judge is of the opinion that such changes “would reduce the likelihood of death in similar circumstances.” [8] In this instance, the Chief Medical Examiner (“CME”) for the Province of Manitoba called an Inquest on March 6, 2008, and identified the following issues to be addressed: 1. To determine the circumstances under which Mr. Szabo’s death occurred; and 2. To determine what, if anything, can be done to prevent similar deaths from occurring in the future with regard to, but not limited to, the following: a. prevention of falls from spectator stands at the stadium; b. appropriateness of taking seriously injured patients to hospitals other than the major trauma centre in Winnipeg; and c. management of the patient at the Grace General Hospital. [9] In an effort to address the matters identified by the Chief Medical Examiner, 50 witnesses were called (and some recalled) over a period of 35 days, and extensive documentary evidence was filed. As the evidence was called, a broad and complex range of related issues were touched upon, many of which could have easily been the subject of extensive examination. It became clear during the course of the proceedings that certain topics were simply too complex in nature and too collateral to the central issues to be the subject of extensive review. During the course of this report, those matters may be identified, but will not necessarily be the subject of specific recommendations. To do otherwise would be unfair to those who have knowledge about and a specific interest in those issues. Inquest: Andrew Szabo Page: 3 [10] Having said that, it is often the case that a series of problems, rather than a limited number of discreet issues, culminate to create a “perfect storm” that results in a tragic death. It is important for the Court to consider the individual factors which may have contributed to the death, as well as any “systemic” issues which may have played a role, and, where appropriate, to address both through recommendations. Culpability- Balancing Statutory Constraints with Factual Findings [11] It is important at the outset to recognize the unique nature of an Inquest hearing and to respect both the limitations and the responsibilities placed upon the Judge assigned to conduct an Inquest and make recommendations. This is particularly the case where the facts are at issue and the circumstances of the death are contentious. The provisions of The Fatality Inquiries Act place specific limitations on findings to be made by an Inquest Judge on issues of culpability. Section 33(2) states: In making a report under subsection (1), a Provincial Judge a) …….. b) Shall not express an opinion on, or make a determination with respect to, culpability in such a manner that a person is or could be reasonably identified as a culpable party in respect of the death that is the subject of the Inquest. [12] The extent to which an Inquest Judge can receive evidence and make factual findings on contentious issues which might be necessary for accurate conclusions and appropriate recommendations arose in Swan v. Harris (1992), 79 Man. R. (2d) 188 (Q.B.). An Inquest was called after two brothers died within several months of each other of self-inflicted gun shot wounds. The Inquest Judge heard evidence suggesting that the father of the two deceased had been abusive towards them. While the presiding Judge commented upon the evidence, he did not conclude that the deaths were related to any allegations of abuse. The father brought an application for a declaration that the Inquest Judge had acted without jurisdiction and applied to quash those parts of the report that referred to allegations of abusive conduct. Upon review, Jewers J. denied the application, concluding that the Inquest Judge had “inquired into a subject that was potentially relevant, and then reported on it” (paragraph 16). Had the Inquest Judge delved into a subject that was “utterly remote and made that part of the report”, a jurisdictional argument might have successfully been argued. [13] A similar conclusion was earlier reached in Head and Head v. Trudel PJC (1988), 54 Man. R. (2d) 145 (Q.B.); affirmed at (1989), 57 Man.R.