2022 MBPC 46, 2022 MBPC 46

Citation: 2022 MBPC 46 THE PROVINCIAL COURT OF MANITOBA THE PAS COURT CENTRE IN THE MATTER OF: THE FATALITY INQUIRIES ACT C.C.S.M. c. F52 AND IN THE MATTER OF: KEVIN ANDERSON, Deceased (DATE OF DEATH: SEPTEMBER 16, 2018) Decision on Setting the Scope of the Inquest Judge Timothy Killeen Issued this 7 th day of September, 2022 T. Killeen, PJ Introduction [ 1 ] In February 2020, the Chief Medical Examiner (CME) of Manitoba directed that an inquest into the death of Kevin Anderson should be held.

His letter to the Chief Judge set out the reasons for his determination, together with the relevant sections of The Fatality Inquiries Act C.C.S.M. c.F52 ( FIA ). [ 2 ] McDonald, ACJ was assigned as the inquest judge. A hearing to determine which parties should have standing was held. Later, in August 2021, McDonald, ACJ determined the scope of the inquest. Hearing dates were set.

The inquest was to be heard in The Pas, commencing in December 2021 and continuing over six weeks into February 2022. [ 3 ] For reasons that follow, the inquest was adjourned to allow the parties to obtain further information and to deal with a motion. New hearing dates have been set for five weeks in the fall 2022. The Present Motion [ 4 ] The City of Thompson (Thompson) and Thompson Fire and Emergency Services (TFES) filed a motion, asking that the scope of this inquest be modified from the scope as set on August 31, 2021. They ask: 1.

Whether the original scope of this Inquest, as set by then presiding Judge McDonald in his August 31, 2021 decision, should be revised to remove the issue of determining whether or not Mr. Anderson’s death was preventable had there been more timely medical intervention, including the establishment of an intravenous line. 2. Whether the original scope of this Inquest, as set by then presiding Judge McDonald in his August 31, 2021 decision, should be revised and have the following primary focus:

(1) To review the coordination of a multi-agency response to a serious incident in a remote setting in Manitoba; and,

(2) To determine what changes, if any, can be made to the medical system to prevent similar deaths from occurring in a remote setting in Manitoba. [ 5 ] Thompson and TFES were joined by Shared Health, The Northern Regional Health Authority, OmniTRAX, and Hudson Bay Railway. The motion was opposed by the Anderson family and the Teamsters Canada Rail Conference. Other parties, including the Office of the Fire Commissioner of Manitoba and the Attorney General of Canada, on behalf of the Royal Canadian Mounted Police and Transport Canada, took no position. Background

[ 6 ] On September 15, 2018, a freight train operated by the Hudson Bay Railway Company left The Pas, headed to Thompson. The crew consisted of the engineer, Christopher Rushton and the conductor, Kevin Anderson. The rail line traverses an area of central Manitoba that is largely uninhabited. With limited exceptions, the rail line is not easily accessible by road. [ 7 ] As the train was travelling at a reduced speed through the Wekusko Subdivision, it derailed. The rail bed under the rail line had been washed out. The three locomotives and four rail cars at the head end left the tracks.

The lead locomotive, containing Mr. Rushton and Mr. Anderson, struck the opposite bank of the washout. It folded to about a forty-five degree angle because of the force involved. Both men were pinned in the cab by a generator and electrical cabinet that was pushed into the cab by the derailment. [ 8 ] The railway was not immediately aware of the derailment. The area is remote, has poor cell phone coverage and the power required for communication by the two men had been lost. A helicopter pilot who was travelling near the area, saw the scene and soon after landed nearby to assist.

A helicopter crewmember tried to call 911 but was unable to speak to an operator as the calls kept dropping. The crewmember was able to reach a member of a nearby RCMP detachment. RCMP were able to notify the railway’s dispatch. [ 9 ] Although the derailment had occurred at about 16:40 hours, the railway did not know of the event until notified by others after 18:00. Thompson Fire and Emergency Services were also notified but were not initially told that the crewmembers were trapped inside. The presence of hazardous goods was not initially reported.

Members of a local RCMP detachment were taken to the scene by the helicopter pilot but were unable to extricate the men. They reported that heavy equipment would be needed for that task. The officers reported the presence of hazardous goods. Diesel fuel was leaking and gas might be leaking from two derailed cars of liquid petroleum gas (LPG). [ 10 ] The helicopter was forced to leave as it was not equipped to fly after dark. Eventually, emergency services arrived at a staging area. The railway dispatched equipment. A hazardous goods team arrived.

Transportation problems and then confusion over the location of the derailment prevented assistance from arriving at the scene until just before midnight. [ 11 ] Both men were badly injured and trapped. Mr. Anderson succumbed to his injuries at the scene, more than seven hours after the derailment. The emergency responders used specialized equipment to extract Mr. Rushton. He was evacuated for treatment for his severe injuries. [ 12 ] The Transportation Safety Accident Investigation Board (TSB) investigated the derailment, in accordance with the Federal regulation of railroads.

A report of the derailment was completed and circulated. Calling the Inquest [ 13 ] On February 13, 2000, the Chief Medical Examiner (CME) sent a letter to the Chief Judge, calling for an inquest into the death of Mr. Anderson. The CME was aware of the TSB investigation. [ 14 ] Part of his letter stated: An autopsy documented that Mr. Anderson had suffered multiple fractures of ribs and long bones, as well as multiple lacerations of his skin. No significant injuries were identified to his head or internal organs. Death was due to cumulative blood loss resulting from the fractures and lacerations.

It is my opinion that the provision of medical intervention, including establishment of an intravenous line, would have dramatically improved Mr. Anderson’s chances of surviving this event. [ 15 ] His letter directing the Inquest stated: Thus, I feel the scope of this inquest should encompass the Provincial response to this incident. Mr. Anderson’s death was preventable. Therefore in accordance with s. 19(1) and s. 19(2) of the Fatality Inquiries Act , I direct that an inquest be held into the death of Kevin Anderson for the following reasons: 1) To determine the circumstances relating to Mr.

Anderson’s death; 2) To review the coordination of a multi-agency response to a serious incident in a remote setting; 3) To examine policies and protocols used by police, paramedics, and other first responders regarding operation in a potentially dangerous setting; and, 4) To determine what if, if anything, can be done to prevent similar deaths from occurring in the future. The First Scope Hearing [ 16 ] The inquest judge held a standing hearing, resulting in several parties, including the family of Mr. Anderson, receiving standing. Later, a hearing was held to determine the scope of the Inquest.

Broadly, certain parties took the position that the Inquest was required to consider the circumstances of the derailment, including consideration of maintenance issues with the rail bed. Other parties took the position that the TSB investigation had dealt with those issues. There was no basis to inquire into matters that had been investigated, particularly where any recommendations made pursuant to the provincial Fatality Inquiries Act C.C.S.M. c.

F52 could not infringe on the federal jurisdiction over railroads. [ 17 ] In August 2021, McDonald, ACJ released a decision limiting the scope to exclude the areas previously investigated during the TSB investigation. The decision determined that the CME did not set the scope of any Inquest. After calling the inquest, the presiding Judge is required to determine what the scope will be.

The judge considered the provisions of the FIA , including s. 26(1) : An inquest is a non-adversarial proceeding held for the sole purpose of establishing the facts necessary to enable the presiding provincial judge to prepare a report under

section 33.

[ 18 ] He also noted that the legislation requires a fair and expeditious hearing. [ 19 ] McDonald, ACJ also noted the opinion in the letter from the CME to the Chief Judge, indicating that Mr. Anderson might have survived had there been earlier medical intervention. He noted: [50] The facts surrounding the rescue effort and the timeliness of medical attention or lack thereof, to the injured persons are set out in the background facts at the beginning of this decision.

The lengthy recitation of facts from the TSB report is important to put the derailment in context when considering its materiality and proximity to Mr. Anderson’s death. The heartbreaking fact is that Mr. Anderson’s injuries, had there been appropriate medical intervention, were probably survivable in the opinion of the CME. [51] All parties agree the primary focus of this Inquest should be the apparently flawed response to the derailment and the delay in giving medical attention to Mr. Anderson and his co-worker Mr. Rushton. Although the derailment was certainly a circumstance of the death of Mr.

Anderson, the considerable body of facts available to the Court suggest it was not the proximate cause. Reassignment of the Inquest [ 20 ] Dates were set for hearing evidence. The dates totalled six weeks, spread over a period starting in December 2021 and continuing through the winter. In November, McDonald, ACJ gave notice of his retirement from the bench. A case management conference was held, with a new presiding judge. Counsel for the family of the deceased raised the issue of an adjournment. They had provided information to the police that they said was relevant to the cause of the derailment.

As any criminal charges would prevent the inquest from continuing until the charges were resolved, they took the position that the inquest should not commence until that issue was determined. The request for an adjournment was not granted. Most parties opposed the adjournment. All parties were preparing to attend The Pas for evidence starting in early December. The Update from the CME [ 21 ] The matter then became more complicated.

On the Friday prior to the scheduled date to start the inquest, the CME provided some further information to Inquest Counsel, including that he had changed his opinion that “provision of medical intervention, including establishment of an intravenous line, would have dramatically improved Mr. Anderson’s chances of surviving this event”. He was no longer of the opinion that more timely medical intervention could have altered the outcome. [ 22 ] The information was shared with all counsel.

As a result, a case management conference was held on Saturday, December 4, 2021. [ 23 ] At that conference, a number of counsel indicated that they would require instructions from their clients on what action, if any, they should take. The difficulty of getting instructions on a weekend when everyone was scheduled to travel to The Pas led to a decision to cancel the first two weeks of evidence. [ 24 ] Further information from the CME indicated that the opinion on the potential to survive these injuries had come from a colleague.

The colleague indicated that he had not understood that a casual conversation between colleagues would be given such weight. In any event, it was clear that the CME no longer held the opinion that Mr. Anderson was likely to have survived had he received treatment earlier. [ 25 ] Several counsel indicated that they might argue that the change in opinion should lead to a change in the scope of the inquiry. There was also discussion about the ability of the CME to provide further opinions. [ 26 ] The CME provided further information on December 17.

He indicated that the issue of survivability was a complicated medical issue, best addressed by others with expertise in the field of first aid and emergency medicine. [ 27 ] The issue and the need for instructions on changing the scope of the inquest led to a further case management conference on January 25, 2022. The remaining hearing dates had been cancelled. There was further discussion about the issue of the opinion of the CME. Counsel for the Inquest sought further information on the issue of survivability.

An independent physician, with expertise in the subject, was asked to provide an opinion. [ 28 ] On April 2, 2022, Dr. Brodie Nolan, a physician with expertise in severe trauma, provided a report. His opinion was that earlier introduction of an intravenous line would not have had an impact. The injuries were likely not survivable even with earlier medical intervention. [ 29 ] The Court scheduled a further case management conference to determine if any party was bringing a motion to limit the scope of the inquest.

As counsel for the inquest was told that at least one party would bring such a motion, the case management conference was cancelled. The parties were told that any motion, together with supporting material, was to be filed by June 1, 2022. Any responses were to be filed by June 15. Those who did not wish to be included were not required to file material. Others could simply state their position. [ 30 ] This motion to limit the scope and the supporting material was filed before the filing date. Other parties filed briefs indicating their position.

Thompson and Thompson Fire and Emergency Services (TFES) advanced the positions: Should the scope of this inquest be revised to remove the issue of determining whether or not Mr. Anderson’s death was preventable had there been more timely provision of medical intervention, including the establishment of an intravenous line? Should the scope of this inquest now have as a primary focus the following issues: 1) To review the coordination of a multi-agency response to a serious incident in a remote setting in Manitoba; and,

2) To determine what changes, if any, can be made to the medical system to prevent similar deaths from occurring in a remote setting in Manitoba. [ 31 ] Counsel for the Anderson family advised the court just prior to June 15 that they needed additional time to obtain an expert opinion on whether the opinion of Dr. Nolan was going to be challenged. Others objected and a Case management conference was scheduled to deal with the filing timelines. In the interim, the timeline was suspended. The case management was set for June 24.

Counsel for the Anderson family had indicated that they needed until July 22 to obtain the expert report. [ 32 ] In response, Thompson and TFES took the position that extending the timelines to allow such a report to be filed could make the argument on the motion moot. The response to their motion should deal with the substance of the motion, not what evidence might be relevant if the motion were dismissed. [ 33 ] A further issue was whether extending the timelines to allow for provision of another medical opinion on survivability would result in further delays and procedural wrangling.

Would there be cross-examination on the opinions on the motion? If so, when would that be done? The motion could not be decided unless the evidence on the motion was ready. The position of the family appeared to be that an expert report would address the potential that the death could have been prevented. [ 34 ] Ultimately, an extension of time to file material in response was granted. Everyone was reminded that an inquest is not an examination for discovery or preliminary inquiry. [ 35 ] The evidence ultimately filed came from Dr.

Tien, whose expertise was also in treatment of significant trauma, including on the battlefield. Notably, Dr. Tien did not opine that earlier medical intervention could have prevented Mr. Anderson’s death. His report was extensive, but dealt with the cause or causes of death and methods for treating some of the issues. The Law Concerning the Scope of the Inquest [ 36 ] The CME is governed by the FIA . The court is required to act within the parameters established by the FIA . The CME does not establish the scope of the inquest; that is the responsibility of the Court.

That responsibility must be read in the context of the FIA . The Chief Judge has no power to direct that a court hold an inquest in the absence of a determination by the CME that an inquest should be held. The relevant sections of the FIA include: Decision to ho ld inquest 19(1) Following a review of the investigation report of a death, the chief medical examiner must determine if an inquest into the death should be held. Considerations 19(2) The chief medical examiner may determine that an inquest should be held if he or she is of the opinion that (

a) an inquest is necessary to determine the cause or manner of death or the exact circumstances in which the death occurred; or (

b) an inquest may enable the presiding provincial judge to recommend changes to provincial laws or the programs, policies and practices of the provincial government or of public agencies or institutions to prevent deaths in similar circumstances. Discretion if Other Review being Conducted 19(3) The chief medical examiner may determine that an inquest should not be held if (

a) the cause and manner of death and the circumstances in which a death occurred are already known; and (

b) a review into the death has been or will be conducted under another Act that will result in recommendations to prevent deaths in similar circumstances. CME may Make Recommendations 19(4) The chief medical examiner may determine that an inquest into a death should not be held if (

a) the cause and manner of death and the circumstances in which the death occurred are already known; and (

b) he or she has made recommendations to the minister and any other person he or she considers appropriate on measures to prevent deaths in similar circumstances. [ 37 ] The process starts with the administrative decision of the CME, following his investigation. The CME is not granted the statutory authority to set the scope of the inquest. In this inquest, the scope was originally set by McDonald ACJ, but was based on the context existing at the time. That included the opinion, then existing, that the death of Mr. Anderson might have been prevented if there had been earlier and effective medical intervention.

I will not duplicate the legal analysis contained in the August 2021 decision of McDonald ACJ, but simply follow it. The First Determination of Scope

[ 38 ] By August, 2021, the investigation into the cause of the derailment by the TSB had been completed and distributed. That Federal agency had looked at the causes of the derailment, as required pursuant to the federal regulation of railways. The CME made reference to this in calling for an inquest to look at the response to a serious incident in a remote setting. [ 39 ] The issue for the first hearing on the scope of the inquest was whether the FIA required an inquest look at the cause of the derailment that in turn caused the death of Kevin Anderson.

Essentially, that would have required the inquest to cover the same topics already covered by the TSB. The issue of whether the death of Kevin Anderson was preventable was not the subject of the motion. At that point, the letter setting out the opinion of the CME was not contradicted. The issue of preventability would presumably have arisen from a review of all of the evidence of the response, including the timeliness, the treatment and the potential for extrication from the crushing force. The issue of preventability of Mr.

Anderson’s death was going to require the evidence of all of the first responders, as well as anyone associated with the difficulties in getting to the scene in an expeditious manner. [ 40 ] McDonald, ACJ stated, in part: [50] The facts surrounding the rescue effort and the timeliness of medical attention or lack thereof, to the injured persons are set out in the background facts at the beginning of this decision. The lengthy recitation of facts from the TSB report is important to put the derailment in context when considering its materiality and proximity to Mr. Anderson’s death.

The heartbreaking fact is that Mr. Anderson’s injuries, had there been appropriate medical intervention, were probably survivable in the opinion of the CME. [51] All parties agree the primary focus of this Inquest should be the apparently flawed response to the derailment and the delay in giving medical attention to Mr. Anderson and his co-worker Mr. Rushton. Although the derailment was certainly a circumstance of the death of Mr.

Anderson the considerable body of facts available to the Court suggest it was not the proximate cause. [ 41 ] After a review of the arguments concerning expanding the scope of the inquest to include consideration of the reasons why the rail bed had been destroyed, McDonald ACJ concluded that expanding the scope beyond what had been included in the letter from the CME calling the inquest would not be appropriate.

He concluded: [63] In weighing the arguments of counsel, I conclude that I am able to incorporate into my eventual findings a treatment of the circumstances of the derailment which incorporate the investigation of the TSB and of Transport Canada to satisfy the requirement of section 33(1) of the FIA .

I see no persuasive evidence that material unanswered questions about the derailment remain outstanding. [64] I am persuaded that my duty to provide findings to the Minister and make orders that are fair and expeditious in pursuit of a determination of the issues in this Inquest require that this Inquest remain limited to the recommended areas of inquiry set out in the CME’s letter with the clarification that the response of all federal agencies or federally regulated actors such as HBR and the RCMP during the rescue effort, in conjunction with the provincial actors, will be a subject of inquiry.

Likewise, the safety practices and protocols of HBR and the safety and communications equipment on-board the freight train, in the view of this Court, intersect with and would have affected the response of various provincial agencies and will be the subject of evidence heard at this Inquest. Any recommendations arising from the Inquest will not include recommendations respecting Federal departments, agencies or federally regulated actors. [ 42 ] The issue of the preventability of Mr. Anderson’s death was not at issue on the first scope hearing. It was clear at that time that it must form part of the inquest.

Can the Scope be Changed? [ 43 ] Whether the scope of the inquest is a preliminary or an interim issue, McDonald ACJ had clearly determined what the scope should be. Absent a compelling reason to do so, a decision of a court should not be revisited or varied. To allow otherwise would risk a never ending series of procedural issues. [ 44 ] The opinion of the CME changed after the inquest was called. Although there was comment on this, the reason was that he had relied on comments from a colleague and it appears that the colleague did not view the comments as a fully considered opinion on a complex issue.

Properly, the CME notified counsel for the inquest as soon as he became aware of the issue. All parties knew about it within a short time, leading to the adjournment and subsequent motion. The opinion about Mr. Anderson’s death being preventable was clearly an important part of the scope of the inquest at the time of the first scope hearing. It appears to have been clear that the opinion of the CME was going to be an important part of the evidence. Then, it changed. [ 45 ] In my view, this is a material change. The issue of preventing of Mr.

Anderson’s death, despite the profound injuries and the need to extricate him from crushing force, was the opinion of the CME, which no longer exists. However, the basis for calling the Inquest was much broader than consideration of whether more timely medical treatment, including the introduction of an intravenous line, would have prevented Mr. Anderson’s death. As such, an Inquest is still appropriate and required. [ 46 ] In my view, the scope must be revisited based upon this material change.

The reasons for the change in the opinion of the CME and the timeliness of the change are not relevant for this analysis. Should the Scope be Changed? [ 47 ] It would be inappropriate to include the preventability of Mr. Anderson’s death as part of the inquest, if the only reason for doing so was based on a now retracted opinion. That would lead to a situation that was likely to be highly contentious in this non- adversarial process.

If the issue of preventability of his death is examined, it becomes practically impossible to limit the scope of questioning of witnesses who were involved in this attempt to save Mr. Anderson, and were successful in saving the life of Mr. Rushton. It would be difficult to limit the witnesses called, as each one could have something to add on what else might have been done. The delays would have to be analyzed on the basis of whether each delay contributed to his death, as well as what should be recommended for future events. In my view, the issue of fault would hang over the inquest.

A question of whether there was fault, or who may have been at fault is relevant in a civil action or a prosecution. It is not necessary in an inquest. The purpose of an inquest is as set out in the

FIA . Purpose of inquest 26.2(1) An inquest is a non-adversarial proceeding held for the sole purpose of establishing the facts necessary to enable the presiding provincial judge to prepare a report into the death under

section 33 . Inquest not a civil or criminal proceeding 26.2(2) An inquest is not subject to the same rules of procedure and evidence that apply in civil or criminal proceedings. … Inquest report 33(1) After completion of an inquest, the presiding provincial judge must provide the minister with a written report that sets out his or her findings respecting the following: (

a) the identity of the deceased; (

b) the date, time and place of death; (

c) the cause of death; (

d) the manner of death; (

e) the circumstances in which the death occurred. Recommendations in inquest report 33(1.1) The report under subsection (1) may contain recommendations on changes to provincial laws or the programs, policies and practices of the provincial government or of public agencies or institutions to prevent deaths in similar circumstances. [ 48 ] There may be some circumstances where the court must consider the issue of fault. If so, there are provisions for in camera evidence and a

section dealing with how the court is to report on that. In camera evidence and culpability 33

(2) In a report made under subsection (1), a provincial judge (

a) may disclose in camera evidence that is received during the inquest where the judge is satisfied that disclosure of the evidence (

i) is essential to setting forth when, where and by what means the deceased person died, the cause of death and the material circumstances of the death, and (ii) is in the public interest; (

b) shall not express an opinion on, or make a determination with respect to, culpability in such 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. [ 49 ] These sections do not require a consideration of the preventability of the death. In my view, an inquiry into whether the death of Mr.

Anderson was preventable would be necessary if it was capable of producing recommendations which might save lives in the future, and there was a reasonable basis in the evidence or anticipated evidence to establish that other or more timely actions could have saved his life. However, there is no evidence or anticipated evidence before the court of this nature, despite the fact that dozens of witnesses have been interviewed and independent experts in emergency medicine have offered their opinions. Nonetheless, there are still lessons that can be learned from the tragic death of Mr.

Anderson that may allow the Court to make recommendations to effect changes to the current Provincial system of responding to incidents of major trauma in remote locations of the province. The Opinion Evidence [ 50 ] The expert opinion received from Dr. Nolan was obtained for the purpose of assisting the court in dealing with the question of whether the inquest should continue to examine whether earlier or other medical intervention could have prevented the death of Mr. Anderson. I see no need to comment on what lead to inquest counsel obtaining this opinion.

No allegation of bias has been raised with respect to Dr. Nolan. He has no connection with the office of the CME or any of the parties to this matter. His qualifications and his

opinion can be tested later when he testifies. At this point, the

summary of his opinion is relevant. Mr. Anderson’s death is very tragic. However, given the remoteness of the derailment, the resources available to him at the time, the necessity of hazmat scene assessment, and the delays that would have resulted to perform a field amputation, I do not believe that he would have survived if first responders had arrived sooner. Additionally, as per the reasons outlined above, I would respectfully disagree with the initial opinion of Dr. Younes that establishment of an IV would have dramatically improved the chances of Mr.

Anderson’s survival. [ 51 ] Counsel for the TCRC and the Anderson family provided an opinion from Dr. Homer Tien. There do not appear to be any concerns with the qualifications or opinion of that doctor, but again, these will be tested when he testifies. Dr. Tien did not express an opinion that Mr. Anderson’s death might have been prevented. His report focuses on the reasons for his death and the proposed recommendations to deal with the various medical problems caused by a crushing injury, with hypothermia, an absence of pain management and extrication only through amputation. Mr.

Anderson must have suffered for hours before his death. Dr. Tien’s recommendations, concurred with by Dr. Nolan, might assist first responders in dealing with this type of tragedy in the future. [ 52 ] The issues which were of concern when the timeline to obtain Dr. Tien’s report was extended did not arise in the event. There is no apparent contest of experts. The risk of the inquest becoming an examination for discovery or preliminary inquiry has not been realized.

Instead of a contest between two experts, there is close concurrence between them concerning the tragic events and potential recommendations for changes in response. Conclusion [ 53 ] Neither the circumstances of the event, nor the opinion of the experts leads to a reasonable conclusion that earlier or different medical treatment at the scene in September 2018 would have prevented the death of Mr. Anderson. Accordingly, it will not remain within the scope of the inquest.

Consideration of the preventability of his death would lead to a protracted, contentious exercise that would not assist the court in any of the required functions. [ 54 ] Accordingly, I do not expect evidence from each of the responders. However, the delay in arriving at the scene, combined with communication issues will still require evidence to explain what happened as a basis to recommend what should happen in the future. TFES suggested that the inquest should look at a multi -agency response to such an event.

It is important to determine what can be done to speed the response. [ 55 ] I also note one of the issues contained in the original letter from the CME. 3) To examine policies and protocols used by police, paramedics, and other first responders regarding operation in a potentially dangerous setting; [ 56 ] The response was delayed because of issues regarding the hazardous goods in railcars. The RCMP officers who attended made observations about that. This issue needs to be considered. [ 57 ] Even though there is no basis to conclude that Mr.

Anderson’s death might have been prevented, there is still a need to consider the issues that caused his death. Drs. Nolan and Tien have both provided information setting out the challenges of treating a patient suffering from crushing forces from which extrication is difficult. [ 58 ] The nature of this event, a derailment, may not be common, but crushing forces may arise in motor vehicle or aviation collisions as well as industrial or construction accidents. It is important to understand the problems and potential treatment.

Accordingly, we will deal with the issue of how a life might be saved in a similar event in the future. I understand that some suggestions might carry a significant cost, which may make recommendations impractical. Still, policy makers should know of the options. “Original Signed” KILLEEN, P.J.