Nov. 30, 2000

Anthany Dawson Inquest

Notes by Laura Fraser

Witness Tom Breiter

He is a head administrator for ambulance service. Questioned on currency of ambulance policy last issue produced July 1996. Ambulance policy is subject to change because of the changes in the Mental Health Act. Current policy issues are entered as evidence. Every ambulance administrator has access to a policy manual. Policyholders are responsible for notifying all staff of changes. In January 2000 a memo was sent out about restraints and belts. He informed us that a patient must not be transported in a prone position. Briker was questioned to clarify what "transport of a patient" means. Briker had to refer to the manual and search for a definition. He could find no definition and stated that a definition "would be helpful". Does the transport of a patient begin when they are on a stretcher or is a transport when the ambulance vehicle is on route to hospital? The first suggestion that was given by Breiter to implement change in policy is when a situation arises. The next suggestion is the lack of resources in order to provide knowledge training to field workers. He was asked if this is "reactive". Breiter could not deny that policy implementation is reactive. The only way information has been distributed is by being posted on a notice board. Does everyone read these boards? There is no way to know if members have become aware of changes. Members are not tested on new material and are not required anywhere to sign off.

Device Designed For Only Face Up

A new device that is going to be added on to stretchers is a shoulder belt. This is intended to safe guard patients from injury if in an accident. This belt is intended for only a face up position. Juror questioned when policy changed about not transporting a patient in the prone position, was it reactive or proactive? Breiter stated that it was "reactive" due to a case from a patient transported in prone position. The next revisions that are going to be published on policy according to Breiter "will not be published" until a section on training of new policy occurs to field staff. Next he was asked by juror did ambulance attendants not have the power to say to the police officers that the patient must be secured face up? Breiter confirmed that the ambulance attendants have that kind of power. Why did the ambulance attendants secure Anthany face down? Especially if they knew ambulance policy on transportation.

Witness Drew Burgwin

Ambulance administrator: There is no information according to Burgwin to say which unit is more effective. Referring to ALS or BLS vehicles. The medical system is in support of the ALS vehicles and demands in Victoria. However, the day Anthany went into Cardiac arrest an ALS vehicle was not available. Burgin is sure that the attendants were appropriate in not waiting for an ALS vehicle. He was questioned about the congestion of transfers in Victoria. This refers to non-emergency patients in ambulance vehicles. These transfers occur by appointment and take away from availability of these vehicles to emergencies. Victoria is able to staff three full time ALS units. This EMA 3 service the day Anthany went into Cardiac arrest could have treated him with an intravenous line. Burgwin was asked his opinion about the service that is provided in Victoria. He believes that the service of ALS patients is good. ALS vehicles get to most ALS patients. Burgwin was asked, was Anthany Dawson an ALS patient? He agreed that Anthany was an ALS patient. He claims that it was appropriate to send an EMA 2 vehicle to Anthany. He was asked by Ms. Brown, Is there any time when a patient will be transported in the prone position? He could not find one reason why that would be appropriate. It is occurrence reports; medical field concerns or attendants concerns that determine when further EMA 3 people trained are needed. This reactive system is the only device to determine when the system is lacking ASL vehicles or EMA 3s.

Witness Sgt. Mark Albrecht testifying in place of Ron Brain

The investigation was handed over to the R.C.M.P. to regain public confidence. The Chief of police received this file and it was accessed whether or not this was a criminal case. Deputy Lane reviewed the case and then Bob Gillian. Gillian recommended that no charges be laid. This was an internal investigation though. He is asked to explain the complaints process. He explains the Police Act regulates professional conduct. Referring to twelve disciplinary results. The whole office is held in office in Vancouver. The Police Act is "corrective not punitive". When a form one is signed then a complaint is considered a lodged complaint. When a complaint is over the phone it is dealt with informally. The receiver of the complaint must notify the person to fill a form one. A Public Trust complaint was made by the Victoria Police Department. If there had been a recommendation of a charge then disciplinary action would have been taken.

Complaint Suspended

A complaint was lodged from Nancy Dawson in May of this year. The conduct complaint at this stage has been "suspended pending the inquest outcome"- Orr. He suggests that the only complaint is the disclosure of investigation by Farrell. To date there was no disciplinary action internally. There has been no review of internal information "to substantiate an investigation". He claims that the only information that came from Sheldan striking Anthany was only from the media according to his testimony. He cannot answer if a Critical Incident Review has been done. He stated he was willing to find out. When an officer is issued a notebook it is their discretion if they take notes or not. In an order the notebook is the property of Police Department. It would be an incident report that would be more required then taking notes. A statement or Will Say is only required as a request. Brooks asks the witness is it not more beneficial to do an investigation closer to the date of incident. He claims the initial involvement with R.C.M.P. involvement had occurred as the result of Anthany’s Death in occurrence with Police and Ambulance attendants.

Someone Was Aware of Concern: Police Conduct

If there is a third party complaint what is the process? A third party can complain on a form one. In Dr. Gleason evidence there was awareness that the family had a complaint of conduct of police. Albrecht says that if was aware of that he would have followed up with an investigation. It is in evidence the door-to-door inquiries were at only a few places. This part of the investigation was not extensive. At one of the interviews there is a note that an inquest was going to be held this was on notes of Aug. 17, 2000. The police did not put out a news release for two weeks requesting people to come forward if they witnessed Anthany Dawson. Albrecht was reminded that Atherton had given a statement that he witnessed Sheldan striking Anthany. *Yet earlier he testified this was only known through the media. Albrecht remembers training at Justice Institute regarding note taking is instructed to note specific things and this is used to recall memory. If a critical incident review were done it would have assisted in this setting of Inquest. A Critical Incident Review was not done because of Investigation by the R.M.C.P.. Albrecht says that he would have written notes. He is in agreement with juror that notice be put in papers to ask for witnesses to come forward immediately would be helpful policy. The recommendation made for no charges could not be based on without a reasonable doubt.

Albrecht agrees critical incident report would have been useful.

Anthany Dawson’s Death is considered an incident that fits into Critical Incident Review.

Albrecht brought in policy dealing with Critical Incident Review. Pecknold gives evidence without going to the stand he objects that his client has not brought current policy as evidence. Pecknold argues with Orr that he did not notify him that this was going to be an issue today. A break has occurred for Pecknold to find current policy. Document has been withdrawn as evidence. It has been learned that this particular policy is subject for review. It is only considered as a guideline at this time for training. The only thing preventing Critical Incident Review according to Albrecht is the outcome of the inquest. Albrecht says that he would make note of serial numbers of handcuffs. To this date no police witness will say whom the cuffs were returned to. Sgt. Excused from stand. No further witnesses are being called for this Inquest. Adjourned to Dec. 1, 2000 for charge to the jury, deliberation and verdict.