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 10th, 2005 25

2
  1                        Appearances
  2  Derry Millar      )             Commission Counsel
  3  Susan Vella        )
  4  Donald Worme, Q. C )    (np)
  5  Katherine Hensel  )    (np)
  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    )              The Honourable Michael
  6  Bill Hourigan    )              Harris
  7  Jennifer McAleer )
  8  
  9  Ian Smith        )   (Np)       Robert Runciman
 10  Alice Mrozek     )   (np)
 11  Harvey Stosberg  )   (np)       Charles Harnick
 12  Jacqueline Horvat )   (np)
 13  Douglas Sulman, Q.C. )           Marcel Beaubien
 14  Trevor Hinnegan     ) (np)
 15  
 16  Mark Sandler       )            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  )              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   )              Chiefs of Ontario
 13  Matthew Horner   )
 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   )
 23  Danya Cohen-Nehemia ) (np)
 24  
 25

1 TABLE OF CONTENTS 2 Page 3 Exhibits 6 4 5 ANDREW LEMAY MCCALLUM, Affirmed 6 Voir Dire Commences 7 Examination-in-Chief by Ms. Susan Vella 9 8 Voir Dire Concluded 9 10 Examination-In-Chief by Ms. Susan Vella 18 11 Cross-Examination by Mr. Andrew Orkin 84 12 Cross-Examination by Mr. Peter Rosenthal 90 13 Cross-Examination by Mr. William Henderson 104 14 Cross-Examination by Mr. Julian Falconer 116 15 Cross-Examination by Ms. Karen Jones 123 16 Cross-Examination by Mr. Al O'Marra 131 17 Re-Direct Examination by Ms. Susan Vella 140 18 19 JOHN FREDERICK CARSON, Sworn: 20 Examination-In-Chief by Mr. Derry Millar 143 21 22 Certificate of Transcript 280 23 24 25

1 LIST OF EXHIBITS 2 No. Description Page 3 P-390 Curriculum Vitae of Dr. Andrew Lemay 4 McCallum. 11 5 P-391 Document Number 5000004, Coroner's 6 Investigation Report into the death of 7 Anthony "Dudley" George, Feb 17/03. 20 8 P-392 PowerPoint presentation of Dr. Andrew 9 McCallum. 29 10 P-393 NAEMSP Guidelines for resuscitation in 11 penetrating TCPA (Traumatic Cardiopulmonary 12 Arrest), published in 2002. 52 13 P-394 "Minimal Volume Resuscitation", Bickell NEJM 14 1994:331:17:1105-1109. 60 15 P-395 Two (2) page Addendum to Document Number 16 5000004, page 391, by Dr. Andrew McCallum. 76 17 P-396: Curriculum vitae of Deputy Commission John 18 Frederick Carson. 144 19 P-397 Book of handwritten notes by Deputy 20 Commissioner John Carson, 1990, 1993 21 and 1994. 167 22 P-398 Document Number 2000658, Land dispute 23 Kettle and Stony Point First Nations 24 and Ipperwash Beach cottage owners. 187 25

1 LIST OF EXHIBITS (cont'd) 2 Exhibit No. Description Page No. 3 P-399 Document Number 2001062 MSGSC Briefing 4 Note, May 19/93 Re: Native demonstration 5 Camp Ipperwash. 221 6 P-400 Document Number 2002678 OPP Number 1 7 District Operational Plan, Occupation 8 of Canadian Forces Base, Ipperwash, 9 Revised 28 May, 93. 271 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

1 --- Upon convening at 9:00 a.m. 2 3 THE REGISTRAR: This Public Inquiry is 4 now in session. The Honourable Mr. Justice Linden 5 presiding. Please be seated. 6 MS. SUSAN VELLA: Good morning, 7 Commissioner. 8 COMMISSIONER SIDNEY LINDEN: Good 9 morning. 10 MS. SUSAN VELLA: The Commission calls as 11 its next witness, Dr. Andrew McCallum. 12 THE REGISTRAR: Good morning, Dr. 13 McCallum. 14 THE WITNESS: Good morning. 15 THE REGISTRAR: You can have a seat 16 there, sir, if you like. Do you prefer to swear on the 17 Bible, sir, or affirm. 18 THE WITNESS: I'll affirm. 19 THE REGISTRAR: Very good, sir. Could 20 you state your name in full for us please, for the 21 record? 22 THE WITNESS: Andrew Lemay McCallum. 23 M-C-C-A-L-L-U-M. 24 25 ANDREW LEMAY MCCALLUM, Affirmed:

1 (VOIR DIRE COMMENCES) 2 3 EXAMINATION-IN-CHIEF BY MS. SUSAN VELLA. 4 Q: Good morning, Dr. McCallum. 5 A: Good morning. 6 Q: I want to thank you for driving the 7 six (6) hours to be with us today. 8 A: You're welcome. 9 Q: Dr. McCallum, I understand that you 10 are currently in the Regional Supervisor Coroner for 11 Eastern Ontario. 12 A: That's correct. 13 Q: And have you produced a curriculum 14 vitae which accurately sets out your qualifications of 15 your professional background? 16 A: I have. 17 Q: And I wonder if you could get that 18 document. Do you have it in front of you? 19 A: I -- I don't have it with me. I 20 provided it in advance. 21 22 (BRIEF PAUSE) 23 24 COMMISSIONER SIDNEY LINDEN: Okay. 25 MS. SUSAN VELLA: I thought I didn't hear

1 an echo. 2 3 (BRIEF PAUSE) 4 5 COMMISSIONER SIDNEY LINDEN: Do you want 6 to try it again? 7 8 CONTINUED BY MS. SUSAN VELLA. 9 Q: All right. I apologize for that, Dr. 10 McCallum. I'll just start over again. 11 I understand that you are currently the 12 Regional Supervising Coroner for Eastern Ontario? 13 A: That's correct. 14 Q: And you have been since September 15 2003? 16 A: That's also correct. 17 Q: Now have you produced to the 18 Commission, a curriculum vitae which accurately reflects 19 your qualifications and background experience? 20 A: I have. I sent it electronically, in 21 advance. 22 Q: All right. And, Commissioner, I 23 wonder if you have a copy of that before you? I'd like 24 to make the curriculum vitae of Andrew Lemay McCallum the 25 first exhibit of the morning.

1 THE REGISTRAR: Exhibit P-390, Your 2 Honour. 3 COMMISSIONER SIDNEY LINDEN: P-390. 4 5 --- EXHIBIT NO. P-390: Curriculum vitae of Dr. 6 Andrew Lemay McCallum. 7 8 CONTINUED BY MS. SUSAN VELLA. 9 Q: And I understand that you obtained 10 your M.D. from McMaster University in 1980? 11 A: Correct. 12 Q: You then received -- is it the 13 F.R.C.P.C. in emergency medicine? Perhaps you could just 14 tell us what that is? 15 A: It's a higher degree in medicine 16 conferred by the Royal College of Physicians and Surgeons 17 of Canada in the specialty of emergency medicine. 18 Q: And you received that in 1987? 19 A: Correct. 20 Q: I understand that you also in 1988 21 received the diploma of the American Board of Emergency 22 Medicine? 23 A: Yes. 24 Q: Since July of 2000 you have been an 25 associate professor with the Department of Medicine at

1 McMaster University? 2 A: Yes. 3 Q: And since October 2003, you have also 4 been an associate professor, Department of Emergency 5 Medicine at Queen's University? 6 A: Correct. 7 Q: You are a member of a number of 8 professional organizations including the Royal College of 9 Physicians and Surgeons of Canada? 10 A: Yes. 11 Q: The American Academy of Forensic 12 Sciences? 13 A: That's correct. 14 Q: -- and the Canadian Association of 15 Emergency Physicians and you have held the science -- 16 scientific Co-Chair of that organization since 2002? 17 A: Actually, that was a -- that was a 18 self-limited appointment for a conference that was -- 19 that I assisted in organizing. 20 Q: Thank you. From July 2001 to August 21 2003 you were Chief of Staff at Hamilton Health Sciences 22 Corporation? 23 A: Yes. 24 Q: From 1998 to July 2001 you were the 25 Chief of Emergency Medicine at Hamilton Health Sciences

1 Corporation? 2 A: That's correct 3 Q: And the Medical Director of the 4 Emergency Program at that organization? 5 A: That's correct 6 Q: You were also the Vice-Chair of the 7 Medical Advisory Committee of the Hamilton Health 8 Sciences Corporation? 9 A: Yes. 10 Q: From December 2000 to January 2002, 11 you were the Regional Medical Liaison? 12 A: That's correct. 13 Q: And from November 2000 to the present 14 you have been a coroner for the Province of Ontario, 15 Ministry of the Solicitor General. 16 A: That's right. 17 Q: As well, over the course of your 18 career you have been a consultant in varying capacities 19 with respect to emergency medical services? 20 A: That's correct. 21 Q: That includes, for example, having 22 been the Consultant to the Minister of Health in the 23 state of Kerala, India in association with their med and 24 -- sorry, in -- in connection with designing an emergency 25 medical services system for that state?

1 A: That's right. 2 Q: In February of 2000 you were a 3 consultant in Mount Sinai Hospital in their utilization 4 of ambulance diversion? 5 A: Yes. 6 Q: In February of 2001 you were a 7 consultant to the University Health Network to provide an 8 external review of their Emergency Department? 9 A: That's correct. 10 Q: And to provide a review of the 11 University Health Network's emergency services? 12 A: That's right. 13 Q: You have conducted numerous reviews 14 of care -- medical care -- conducted for the Chief 15 Coroner for Ontario in -- in various Emergency 16 Departments? 17 A: That's right. 18 Q: From 1993 to 1998 you were the 19 Director for the Department of Emergency Services for 20 Sunnybrook Health -- Health Science Centre? 21 A: Yes. 22 Q: You were also a Medical Director for 23 the Advanced Cardiac Life Support Instructional Program 24 at Sunnybrook? 25 A: That's correct.

1 Q: Prior to that from 1990 to '93 you 2 were the Chief of Emergency Medicine for St. Joseph's 3 Community Health Centre in Hamilton? 4 A: That's right. 5 Q: And prior to that, an emergency 6 physician at St. Joseph's Hospital? 7 A: Yes. 8 Q: And before that, an emergency 9 physician for the Toronto General Hospital? 10 A: That's right. 11 Q: You've also received various honours 12 from your colleagues from time to time -- 13 A: Yes. 14 Q: -- as listed at page 6 of your 15 curriculum vitae? 16 A: That's -- that's correct. 17 Q: You've also held and been engaged in 18 many professional development activities outlined at 19 pages 7 to 8 of your curriculum vitae, including the 20 Chair of the Board of Examiners in Emergency Medicine of 21 the Royal College of Physicians and Surgeons of Canada 22 from 1994 to 1996? 23 A: That's right. 24 Q: A member of the Board of Examiners in 25 Emergency Medicine of the Royal College of Physicians and

1 Surgeons of Canada from 1989 to 1984 -- to '94? 2 A: Yes. 3 Q: And a member of the Specialty 4 Committee in Emergency Medicine for the Royal College of 5 Physicians and Surgeons in Canada from 2001 to the 6 present? 7 A: Actually, that terminated in 2003; 8 that's -- that's -- yes. 9 Q: Thank you -- thank you very much. As 10 well, you have been a member from time to time of various 11 university committees? 12 A: Yes. 13 Q: That's listed at page 8 of your 14 Curriculum vitae and that would include from 1990 to 1993 15 being a member of the Emergency Medicine Post Graduate 16 Education Committee for McMaster University? 17 A: That's right. 18 Q: And as well, you've been on a number 19 of hospital committees listed at pages 8 through 10 of 20 your curriculum vitae including from 2001 to 2003 the 21 Chair of the Medical Advisory Committee for Hamilton 22 Health Services? 23 A: That's correct 24 Q: From 1993 to 1998 you were a member 25 of the Trauma Physician Management Group for Sunnybrook?

1 A: Yes. 2 Q: And from 1988 to 1993 you were a 3 member of the Acute Care Committee for St. Joseph's 4 Hospital in Hamilton? 5 A: Also correct 6 Q: You are also the recipient of 7 research awards, which are -- are listed at page 10 of 8 your curriculum vitae? 9 A: Yes. 10 Q: And you are the author or a co-author 11 of a number of peer reviewed publications listed at pages 12 10 to 11 of your curriculum vitae? 13 A: Yes. 14 Q: That would include, for example, the 15 author of -- of a article in the Canadian Association of 16 Emergency Physicians Review entitled "Negative Diagnostic 17 Lavage in Blunt Abdominal Trauma"? 18 A: Yes. 19 Q: And in 19 -- the 1991 Canadian 20 Medical Association Journal, co-author of a comment 21 called "A Survey of resuscitation Training in Canadian 22 Undergraduate Medical Programs"? 23 A: That's correct. 24 Q: As well in 1996, you were co-author 25 of an article entitled "Pre Hospital Interventions:

1 Critical Resuscitation's Number 1"? 2 A: That's correct. 3 Q: And also the author of a -- editor of 4 a non-peer reviewed document entitled: "The Road to 5 Survival: A Review and Recommendations for Enhancement 6 of Emergency Medical Services System in the State of 7 Kerala, India"? 8 A: Correct. 9 MS. SUSAN VELLA: Commissioner, I would 10 like to at this time, tender Dr. McCallum as an expert in 11 emergency medicine, including emergency procedures and 12 pre-hospital and in-hospital assessment and treatment of 13 penetrating trauma to the torso. 14 COMMISSIONER SIDNEY LINDEN: Does anybody 15 have any comment or question? That's fine. 16 MS. SUSAN VELLA: Thank you. 17 18 (VOIR DIRE CONCLUDES) 19 20 EXAMINATION-IN-CHIEF BY MS. SUSAN VELLA: 21 Q: Dr. McCallum, were you asked by the 22 office of the Chief Coroner to undertake a project in 23 relation to the circumstances relating to the death of 24 Anthony O'Brien George, also known as Dudley George? 25 A: I was.

1 Q: What were you asked to do? 2 A: I was asked specifically to review 3 the -- Mr. Commissioner, may I refer to my -- my report? 4 Q: Certainly. 5 6 (BRIEF PAUSE) 7 8 A: I was asked specifically to review 9 the -- the circumstances surrounding the care that Mr. 10 George received after he had been shot. 11 Q: So from the point of the gunshot 12 wound to the -- to the moment he was pronounced? 13 A: Correct. 14 Q: Thank you. And did you write a 15 report which sets out your key factual findings, 16 conclusions, and opinions in that regard? 17 A: I did. 18 Q: Is your report dated February 17, 19 2003? 20 A: That's correct. 21 Q: And it accurately sets out all of 22 your factual findings, conclusions and opinions? 23 A: There is -- there are a couple of 24 minor typographical errors but, yes, it does. 25 Q: Thank you. Commissioner, I'd like to

1 tender the expert report of Dr. Andrew McCallum, dated 2 February 17, 2003, as the next exhibit. 3 THE REGISTRAR: P-391. 4 COMMISSIONER SIDNEY LINDEN: P-391. 5 6 --- EXHIBIT NO. P-391: Document Number 5000004, 7 Coroner's investigation 8 report into the death of 9 Anthony "Dudley" George, 10 February 17/03 11 12 CONTINUED BY MS. SUSAN VELLA: 13 Q: For the record, that's Inquiry 14 Document Number 5000004. 15 Now, in preparation of your report, did 16 you review certain documents? 17 A: Yes, I did. 18 Q: Can you advise the Commission as to 19 what documents you reviewed in preparation of your 20 report? 21 A: I reviewed the medical chart for Mr. 22 George. I reviewed the repot of the post-mortem that was 23 done after the -- after his death. I -- I had some 24 information as well from the investigator who 25 investigated on behalf of the office of the Chief

1 Coroner. 2 I had the toxicology report that was done 3 -- report of the toxicologic examination, I should say. 4 And there were some other documents, I don't have the 5 list of them here with me, but there were other documents 6 as well. 7 Q: And you indicated you relied on 8 interviews conducted by an investigator on behalf of the 9 Chief Coroner. Was that Detective Armstrong? 10 A: That's correct. 11 Q: Did you also bring to bear your 12 general expertise in developing your findings, 13 conclusions, and opinions? 14 A: I did. 15 Q: Did you make any key assumptions 16 underlying your -- your opinion? 17 A: No. 18 Q: And are there any important 19 limitations to your opinion? 20 A: Well, the obvious limitation is that 21 I wasn't there for the events and therefore wasn't a 22 direct observer. 23 Q: All right. 24 A: And all of what I received was after 25 the fact recording and/or account by the detective

1 involved with the witnesses statements. 2 Q: As a result of your review, did you 3 form any factual findings underlying your conclusions and 4 opinions? 5 A: Well, obviously the -- the -- the key 6 fact was that Mr. George had been shot and that his -- 7 that -- that the gunshot that caused his death had 8 entered his chest, the -- the bullet had entered the 9 chest and had severely lacerated -- or, I should say 10 lacerated the pulmonary arteries on the left side. 11 And it was my opinion after viewing the 12 documents that that was what caused Mr. George's death. 13 Q: And did you set out the -- your key 14 factual findings under the heading "Review of Events" in 15 your expert report? 16 A: I did. 17 Q: Can you summarize your key findings 18 in relation to the means and timing of Dudley George's 19 transport from the Ipperwash Provincial Park to the 20 Strathroy Middlesex General Hospital on the evening of 21 September 6th, 1995? 22 A: My understanding is that he was, 23 after being shot, was loaded into a car and driven to the 24 actual Army Base itself. And at that point he was 25 transferred to another private vehicle.

1 The private vehicle was -- I think he was 2 accompanied by three (3) individuals at that time. My 3 information was that he was accompanied by three (3) -- 4 three (3) individuals. And the vehicle left the Army 5 Camp and drove -- and I think in my original report I 6 said drove north, but in fact, I understand because of 7 later information I received that the car was taken 8 almost directly south immediately, and then drove -- 9 driven on back country roads towards Strathroy. 10 I believe that the occupants of the car 11 were -- were very aware that -- how seriously injured Mr. 12 George was, and felt that they needed to get him to 13 hospital, based on the information provided to the -- to 14 -- to Detective Armstrong. 15 It proceeded along the back country roads, 16 and at a point stopped, and assistance was sought from 17 the occupants of a nearby farmhouse. 18 And the reason I gather that this -- that 19 the car was stopped is because they had a flat tire, and 20 they were concerned whether or not they'd be able to 21 continue on. And an ambulance was called at that point, 22 according to the information I received. 23 They waited some period of time, several 24 minutes I understand, but I -- I gather became concerned 25 that further waiting would be harmful to Mr. George and

1 therefore elected to proceed in their car again towards 2 Strathroy. And that they did, even though my information 3 was that the tire had burned back to the rim. They 4 proceeded southbound. 5 The information I received was that during 6 the first part of the trip, Mr. George was making some 7 movements. But that by the time they got to the 8 farmhouse, and -- and this time is difficult to estimate 9 but I gather it was some ten (10) or fifteen (15) 10 minutes, he had stopped making any kind of movement. 11 The occupants -- the -- the rear seat 12 occupant who was sitting next to him felt that there was 13 still some -- some heartbeat that -- that could be heard, 14 but I -- the information I have on that was not clear to 15 me. 16 They did ask for assistance at the 17 farmhouse in the form of some bandages, and I believe 18 they received some clean cloth and attempted to continue 19 to apply pressure to the wound around Mr. George's 20 collarbone area. 21 The vehicle continued southbound, and my 22 information was that it reached Strathroy, and the 23 Strathroy Middlesex Hospital some minutes after midnight 24 -- several minutes after midnight. 25 At that point, Mr. George -- the -- the --

1 the car stopped in the parking lot and my understanding 2 is that the other occupants of the car were taken into 3 custody. 4 Mr. George was removed. I believe there 5 may have been several minutes delay into the hospital 6 where resuscitation was commenced. 7 The -- as it happened, my understanding is 8 that by coincidence there was a general surgeon in the 9 hospital as well as the physician on duty in the 10 emergency department. And together they attempted to 11 resuscitate Mr. George using what would, in my opinion, 12 be conventional means of resuscitation -- 13 Q: All right, can we just -- 14 A: Certainly. 15 Q: -- back up, and I'll just stop you 16 there for a moment, thank you. Now, is it your 17 understanding that -- or, did you form an understanding 18 as to whether any medical intervention or first aid 19 intervention was attempted en route to the hospital, 20 aside from the application of pressure to the wound and 21 the application of the clean cloth in that respect? 22 A: I understand that was the limit of 23 the first aid at the time. 24 Q: All right, and now can you summarize 25 your key findings concerning what medical care was

1 provided to Dudley George once he arrived at the 2 Strathroy Middlesex General Hospital, including the -- 3 the -- at the time of arrival to the time of 4 pronouncement? 5 A: My understanding is that he was 6 brought into their resuscitation area in the Emergency 7 Department. It was discovered that he had no vital 8 signs, and -- and that means that he had no respiratory 9 movements, no -- no breathing; he had no audible heart or 10 pulse, that could be palpated. 11 Further, he had a rhythm, on the 12 electrocardiograph, when the monitor leads were 13 connected, that's known as a systole, which means cardiac 14 standstill. There was no electro-cardiographic activity 15 of the heart at all. 16 The first therapy was that he had a tube 17 inserted into his trachea, or his windpipe, to assist in 18 breathing. And he had what's known as positive pressure 19 ventilation, with a bag, to insufflate, or force air into 20 the lungs to allow for oxygenation. 21 Q: This is where you have a mask put 22 onto the -- the face of the subject, and an air bag 23 that's squeezed to force oxygen? 24 A: Well, when the tube is placed in the 25 trachea, the mask is no longer necessary.

1 Q: Okay. 2 A: You can connect the bag directly to 3 the tube. 4 Q: Okay. 5 A: It's a -- you get a better seal, and 6 -- and better air insufflation into the lungs when that's 7 done. As well, he had two (2) large bore, which means 8 large-sized IV catheters inserted. And that's important 9 because larger catheters can infuse fluid faster, just -- 10 the basic laws of physics allow that; and so that was 11 done. 12 It's not, based on the records that I had 13 available to review, clear how much liquid was actually 14 infused during the resuscitation attempts. He had chest 15 compressions, or CPR as well, as I mentioned positive 16 pressure ventilation started, and the cardiac rhythm 17 remained a systole throughout. 18 Q: Meaning that there was absolutely no 19 -- no functioning of the heart at that time? 20 A: That's correct. 21 Q: And lastly, would you summarize, 22 then, your factual findings with respect to the -- the 23 cause of death and impact of the gunshot wound on the 24 various bodily functions and parts of Dudley George? 25 A: Mr. -- Mr. George died because of

1 severe intrathoracic haemorrhage caused by laceration of 2 the pulmonary arteries on the left side, due to the 3 bullet, which entered his chest above the left clavicle 4 or left collarbone. 5 Q: Can you -- can you explain in 6 layperson's language what -- what that means, please? 7 A: What happened was that Mr. -- Mr. 8 George suffered a significant amount of blood loss, into 9 the cavity of his chest, as a consequence of laceration 10 of the pulmonary arteries. 11 The pulmonary arteries -- the heart, 12 you'll remember, has two (2) sides; it has a right side 13 and a left side. The right -- 14 Q: I'm wondering -- I'm sorry, just 15 before you carry on, would it be helpful to go to any of 16 your slides in this respect? 17 A: I think it may be useful to go to 18 Slide 14. 19 Q: All right. And just before we do 20 that, Dr. McCallum, I understand that you have prepared a 21 PowerPoint presentation to assist in your testimony 22 today? 23 A: That's correct. 24 Q: And you did that at our request? 25 A: I did.

1 Q: And I'd like to make the PowerPoint 2 presentation of Dr. Andrew McCallum the next exhibit, 3 please? 4 THE REGISTRAR: P-392, Your Honour. 5 COMMISSIONER SIDNEY LINDEN: P-392. 6 7 --- EXHIBIT NO. P-392: PowerPoint presentation of 8 Dr. Andrew McCallum 9 10 THE WITNESS: If you just punch in "14" 11 and enter, it'll go to the... 12 13 (BRIEF PAUSE) 14 15 THE WITNESS: I think you can just page 16 up to it -- to slide one (1). There we go. And then if 17 you just put it back in the slide show that will -- the 18 bottom left -- the bottom left little slide icon there, 19 on the bottom left of the... 20 MS. SUSAN VELLA: Right. 21 THE WITNESS: Just above your arrow. 22 Right there. Just go one (1) -- there you go, that's the 23 one. Thank you. 24 This -- this is a schematic diagram of the 25 thorax, and I apologize in advance, I recognize that

1 these may be difficult images for -- for some in the room 2 to see so I want to -- I want to acknowledge that. 3 But these -- this schematic diagram shows 4 the -- 5 COMMISSIONER SIDNEY LINDEN: Excuse me. 6 Is the sound -- some folks are having difficulty hearing 7 you. 8 MS. SUSAN VELLA: Perhaps you would use-- 9 COMMISSIONER SIDNEY LINDEN: There is a 10 microphone. 11 MS. SUSAN VELLA: -- the hand microphone 12 there -- 13 THE WITNESS: Oh, certainly. 14 MS. SUSAN VELLA: -- that would be a 15 little bit easier. Thank you. 16 THE WITNESS: Is that better? 17 COMMISSIONER SIDNEY LINDEN: I don't 18 know, we'll see. I'm not sure if it is. Is the hand mic 19 working? 20 MS. SUSAN VELLA: Could you just test it 21 again? 22 THE WITNESS: Test, test. 23 24 CONTINUED BY MS. SUSAN VELLA. 25 Q: Thank you.

1 A: This schematic diagram shows the -- 2 the anatomy of the chest in very simplified terms, but 3 the key things to look at are the -- the blue and the red 4 vessels that emerge from the heart. 5 The red side is the arterial side, the 6 high pressure, oxygenated blood that is pumped from the 7 left side of the heart. The blue side is the venous 8 system. The -- the blue vessels here bring blood back to 9 the right side of the heart, to the right atrium, where 10 it is then transmitted through into the right ventricle. 11 And the right ventricle pumps the blood 12 through the pulmonary arteries into the lungs where it's 13 oxygenated. 14 15 (BRIEF PAUSE) 16 17 Q: Which slide would you like next? 18 A: Slide 15, please. That's great. You 19 can see, in this slide, that I've -- that I've inserted 20 an arrow which schematically represents the path of the 21 bullet that -- that entered Mr. George's chest. 22 And where the arrowhead is situated, one 23 can see where the pulmonary arteries would have been 24 injured. And that again, this -- this is not an exact 25 representation, but more of a conceptual one, to assist

1 the Commission in understanding the injury. 2 Next slide please. 3 4 (BRIEF PAUSE) 5 6 Q: Which number; 16? 7 A: That would be 16. 8 Q: Yeah, thank you. 9 A: Mr. O'Marra, if you just type in 10 sixteen (16) it'll go automatically to it -- sixteen (16) 11 enter. 12 MR. AL O'MARRA: No. I'm not sure we can 13 get it. 14 MS. SUSAN VELLA: For some reason my 15 numbering isn't -- isn't working. 16 THE WITNESS: Maybe your number lock is 17 on. I suspect that's what it is. 18 19 CONTINUED BY MS. SUSAN VELLA. 20 Q: There you go. 21 A: This is another diagrammatic 22 representation of the chest itself, and this one has 23 obviously a lot more vessels evident in it. It's less 24 schematic, and this is probably closer to the true -- I 25 know it's closer to the true anatomy of the -- of the

1 chest itself. Next slide please. 2 What happened, in Mr. George's case, was 3 that as a consequence of the bullet entering his chest, 4 and damaging the pulmonary arteries here. He had 5 bleeding in the amount of about one (1) litre of blood 6 that was found at autopsy. 7 And the critical thing is that in a -- in 8 a normal sized individual, which Mr. George was, a person 9 of average stature, a male, there are some five and a 10 half (5 1/2) to six (6) litres of blood in the total 11 blood volume that's circulating, ordinarily. 12 Mr. George lost a litre of blood, but the 13 key thing, in his case, was the speed with which it was 14 shed. And that resulted in a number of deleterious 15 physiologic affects, in my opinion. 16 So although the amount of blood shed was 17 only about a litre, and that, though a significant amount 18 of blood, would -- would not ordinarily -- if it was shed 19 slowly, had been fatal in his case. Because it was shed 20 quickly, I believe that this led to the fatal outcome. 21 Q: And what were the physiological 22 results of the rapidity of the blood loss here? 23 A: If we could go to, just bear with me 24 a second here, if we could go to slide 2. If it would be 25 all right, I'll outline that. In order to understand

1 that, one has to understand some basic physiology and I 2 apologize to -- to those of you who have left science a 3 long time ago. 4 To understand this, you need to understand 5 that the major force, it affects all this, and the body 6 is osmosis. And osmosis is defined as the -- is the 7 passage of water from a region of high water 8 concentration through a semi-permeable, meaning it's only 9 partly permeable to the passage of either water or 10 solutes, to a region of low water concentration. 11 All body fluids are solutions, all of them 12 have dissolved substances, so therefore osmosis is always 13 working in the body. 14 The strength and concentration, or 15 concentration of a solution, is inversely proportional to 16 the water concentration. The higher the salt 17 concentration in any water, for example, the lower the 18 water concentration; it just makes -- they're both 19 opposites. 20 And we know that the cell membrane 21 permeability isn't constant, it's not always the same, 22 like in the old experiments we used to with sugar and the 23 potato in the classroom, it changes. And it changes in 24 the body due to a number of factors, but one (1) -- the 25 most important one is energy.

1 And energy in the body is supplied through 2 the provision of substances like sugars, proteins, to the 3 cells. The blood supplies that, and so when the blood is 4 not pumping normally, those energy stores and -- and 5 supplies are significantly affected. And therefore the 6 cell membrane -- cell membrane is affected as well, and 7 its permeability changes. 8 If you look at the composition of the 9 body, I'll just try to represent this diagrammatically. 10 Next slide, please. The body is 60 percent water, 11 ordinarily, and of that water -- next slide, please. 12 Q: And for the record, this is now slide 13 4. 14 A: Yes. The body fluid is about one 15 third (1/3) found outside the cells. These are the 16 fluids that bathe the cells, and this includes the fluid 17 that's found in the bloodstream itself. 18 Two-thirds (2/3) of the body's water is 19 found inside the cells of the body. 20 Next slide, please. 21 Q: Slide 5. 22 A: A quarter of the fluid that's found 23 in the extra cellular, or outside the cells, is actually 24 inside the blood vessels. And that's important when one 25 considers how one resuscitates a person from shock,

1 because whatever fluid ones gives to this -- to the 2 person will equilibrate, because of osmosis, throughout 3 the entire fluid outside the cells. 4 The fluid inside the cells is largely 5 unaffected by resuscitation, at least in the early stages 6 of care. 7 Next slide, please. And go one (1) more, 8 please. 9 The major solute found in the extra 10 cellular fluid, the fluid outside the cells, is sodium 11 chloride and that's why the -- all the substances that we 12 use to resuscitate people are based on that salt. 13 Standard -- normal saline, Ringer's Lactate, they're all 14 based on that -- on those salts. 15 Inside the cells the major solute is 16 different. It's potassium phosphate. We don't use -- we 17 use very little phosphate in acute resuscitation, and the 18 reason is that we're not really worried about this fluid 19 at the early stage of our resuscitation. We're really 20 worried about this fluid, the extra cellular fluid, and 21 in particular, the fluid that's found inside the blood 22 vessels. 23 Q: All right, which is the one-quarter 24 (1/4) mark that you've got there. 25 A: That's correct.

1 Q: One-quarter (1/4) of sodium chloride 2 is within the blood? 3 A: That's right. One-quarter (1/4) of 4 the total sodium chloride found in the extra cellular 5 fluid, yes. 6 What keeps the fluid inside the blood, and 7 inside the cells, is the presence of large proteins which 8 exert osmotic pressure, and they keep fluid inside those 9 cells, ordinarily. 10 Next slide, please. 11 Now shock -- and this is quite important; 12 colloquially, shock is often referred to the state that 13 happens after a traumatic event, the stunned, or kind of 14 numb feeling that one gets. 15 But, in fact, physiologically, shock is 16 something quite specific. And it is the presence of 17 inadequate tissue blood flow, leading to irreversible 18 tissue damage and death, if not treated. 19 Next -- next, please. 20 Clinically, this is observed by 21 physicians, and nurses, and ambulance people, as the 22 presence of low blood pressure, high heart rate, 23 confusion, blue extremities, and death. I've put 24 confusion in twice. Next slide, please. 25 Now ordinarily, a person can respond to

1 haemorrhage or shock, physiologically, by the -- by a 2 number of mechanisms. The presence of clotting, clotting 3 is an important means of stopping the flow of blood, 4 obviously. 5 It would not have been very effective in 6 Mr. George's case, because he had a large vessel injury 7 in the right side -- low pressure circulation and 8 bleeding would have occurred quite quickly in that 9 situation. 10 Second is the ability of blood vessels to 11 constrict. They're not hoses like the garden hose, they 12 can actually vary their calibre and constrict down. And 13 the benefit of this is that, of course, at the site of 14 the bleeding can stop the bleeding, but also the 15 constriction occurs selectively to divert blood to what 16 are called the noble organs, the -- the organs that are 17 critical to life. The heart, kidneys, liver, and brain. 18 And that's why the extremities become 19 blue, because the blood flow to the extremities is shut 20 down; those areas are non-essential. Next please. 21 Also, shock hormones are released and the 22 heart and breathing rate increase. Shock hormones 23 include things like adrenaline -- adrenaline, which 24 causes further constriction of the blood vessels, speeds 25 up the heart and allows for the body to -- to compensate

1 to some degree. 2 Cortisol is hydrocortisone; it's a -- it's 3 a -- it's a beneficial substance in shock. What one 4 sees clinically again is an increase in the heart and 5 breathing rate; blood pressure falling. And the reason 6 blood pressure falls is because the blood -- blood 7 vessels are constricted maximally; and fluid shift. And 8 this is beneficial because it allows fluid to shift into 9 the blood vessels and augment or replace in part at 10 least, the blood that's been shed. 11 Q: All right. So, -- so just before we 12 get to the next shot, just so that I understand, perhaps 13 we go back, these are -- these -- these are bodily 14 responses which will occur as soon as, or should occur, 15 as soon as there is unusual blood -- blood loss from a 16 blood vessel? 17 A: That's correct. 18 Q: And the -- the point of these 19 interactions or interventions is to slow down -- 1. Slow 20 down the rate of blood loss because the vessels are being 21 constricted. 22 2. Divert existing blood supplies to the 23 most important organs. 24 And 3. The heart beats faster in order to 25 more effectively pump or circulate a restricted or a

1 limited volume of blood? 2 A: That's correct. 3 Q: Is that essentially what happens? 4 A: That's -- that's essentially it. 5 Q: And that's the -- that's the natural 6 bodily process without any medical -- 7 A: Right. 8 Q: -- intervention? 9 A: That's correct. And that occurs 10 within seconds to minutes of the injury actually 11 occurring. 12 For example, clotting is essentially 13 complete within eight (8) minutes after -- after one gets 14 cut, and you know that if you cut your finger. 15 And so that -- that -- that occurs even in 16 major injuries. Unfortunately, with large holes in 17 vessels, clotting's not enough to stop the bleeding. 18 Q: All right. And that's because the -- 19 the blood loss is just too quick -- 20 A: Well, the hole -- 21 Q: -- for the clotting to function? 22 A: -- the hole is too big. 23 Q: Okay? 24 A: So, a clot can -- clotting is most 25 effective at the capillary or very small blood vessel --

1 blood vessel level. 2 Constriction, on the other hand, is more 3 effective in bigger blood vessels so it's a -- it's a -- 4 very much a -- a complex interplay between all the 5 factors that -- that come to bear. 6 Now, unfortunately in some people if the 7 shock proceeds far enough, the massive dead or dying 8 cells reaches a critical point, and at that point shock 9 can not be recovered from. There are too many cells that 10 have been damaged. 11 Next please. Salvage, unfortunately, at 12 that point is impossible. 13 Q: In other words, notwithstanding any 14 intervention, any resuscitation events, no matter how 15 much fluid you pump into the system, it's too late? 16 A: That's correct. This -- one (1) of 17 the markers of this is the presence of cardiac arrest, 18 and it's well known among the group of people who 19 resuscitate trauma victims that cardiac arrest is 20 something to be avoided at all costs, because once it's 21 occurred it's -- it's a -- it's a very important marker 22 of a dismal prognosis. 23 Q: In other words -- 24 A: So, that if one -- when resuscitating 25 someone has someone who is very, very ill during trauma

1 resuscitation, the key thing is to keep that person's 2 heart going, and -- and this is obviously, intuitively, 3 would -- would seem to make sense. 4 But, in fact, it makes physiologic sense 5 as well, because if it occurs, if arrest occurs even if 6 one is able to resuscitate the person from that cardiac 7 arrest, it's likely that down the road that death will 8 still occur -- 9 Q: All right. 10 A: -- because it's an important marker 11 that there's been irreversible shock. 12 Q: And just to ensure that, for the 13 record, cardiac arrest is when the heart stops? 14 A: That's correct. 15 Q: Okay. 16 A: Next please. Obviously the goal in 17 shock resuscitation then is to restore adequate tissue 18 blood flow and oxygenation. 19 It's -- contrary to what one might think 20 watching the television shows, it's not just to give IV 21 fluid and -- and to get the blood pressure up to where 22 it's in the normal range. 23 It's, in fact, to get proper blood flow to 24 the organs, and there are many ways to measure that 25 beyond just taking blood pressure, that go beyond the

1 scope of this discussion. 2 Q: All right. And just blood flow means 3 not -- not necessarily the volume of blood, but getting 4 blood from point A to point B, that process? 5 A: That's correct. 6 Q: And oxygenation is ensuring there's 7 sufficient oxygen in the blood cells in order to be 8 functional? 9 A: That's right, and if -- the next 10 slide will I think make that clear. 11 How's this done? Well, the heart is a 12 pump, and like any pump the heart needs to be primed. So 13 having an appropriate amount of blood coming back to the 14 heart through the venous system is almost as important as 15 having enough blood in the -- in the system itself, 16 because the heart responds to the -- the fluid that's 17 presented to it; it will pump more if more fluid is 18 there. 19 So that's the first thing. And that's 20 what the IV fluids do, they prime the pump. 21 However, in very severe shock, there may 22 be too many red blood cells lost to allow for oxygenation 23 to occur normally and in those cases it's necessary to 24 give transfused blood, to give red blood cells from 25 outside the body in order to restore and ensure adequate

1 tissue oxygen delivery. 2 The oxygen delivered to tissues actually 3 varies with the -- we've heard already about the 4 haemoglobin level, but also the cardiac output, which is 5 why the heart beats faster, because the heart rate and 6 the amount of blood pumped with each contraction of the 7 heart are the two (2) major determinants of cardiac 8 output. 9 And then finally, the oxygenation of the 10 blood. It's why oxygen is given to all people who are in 11 extremis, especially from trauma, to ensure that there's 12 no deficit of oxygen going to the haemoglobin. 13 Q: And what is, "extremis"? 14 A: Extremis means somebody who's near 15 death. Next, please? 16 How is this done, then? Practically 17 speaking, there are a series of steps which are followed 18 in almost every case, in logical order and this is what 19 people learn in -- they're very much akin to what learn - 20 - people learn in basic cardiac life support, so it's A, 21 B, C. 22 The airway's opened and in very severely 23 old people the trachea would be intubated; this was done 24 in Mr. George's case. Respirations need -- are assisted 25 using the bag valve mask or bag valve tube device.

1 Oxygenation is ensured by giving extra oxygen at that 2 point. Haemorrhage is controlled with external pressure 3 where possible. 4 Unfortunately, in Mr. George's case, 5 despite the best efforts of the people who were with him, 6 that wasn't possible because the bleeding was internal, 7 inside the chest cavity. 8 The chest cavity, itself, is a large 9 space, in the normal person it's between five (5) and 10 seven (7) litres volume, so one could literally bleed an 11 entire blood volume in there with no pressure possible 12 and that's -- that's an important factor here. 13 Q: So, in other words, the individuals, 14 no matter how they press on the skin surface, they're not 15 going to be able to stop that bleeding? 16 A: Correct. The -- the bleeding source 17 was deep inside his chest. Internal control is possible 18 in some circumstances and we'll come to that later on. 19 Q: Yes. 20 A: Priming the heart, as I mentioned 21 before, by giving intravenous fluid is important as well 22 in -- in managing shock. And finally, replacement of 23 shed blood by giving transfusions if the haemoglobin 24 count has gotten too low to provide normal oxygen 25 transport. Next slide, please.

1 You'll -- you'll remember from the 2 schematic diagram of the body fluid composition that I 3 emphasize that only a quarter of the extracellular fluid 4 is inside the blood vessels and fully three-quarters 5 (3/4) is in fluid bathing the tissues; that's important 6 when one's giving crystalloid because we've heard that 7 it's the same composition as the extracellular fluid. 8 So, it equilibrates throughout the 9 entirety of the extracellular fluid, meaning one has to 10 give significantly more IV, normal saline for example, to 11 replace a blood volume than if one was replacing that 12 bloodshed with whole blood. 13 So, for example, if a litre is lost, one 14 has to give three (3) litres of normal saline to 15 satisfactorily prime the pump and replace that fluid. 16 In very severe shock, and this is what's 17 known -- there's a classification of shock, Class 3 and 18 Class 4 shock means that there's been between 35 and 50 19 percent of the entire blood volume lost. In those cases, 20 the convention is that one gives whole -- gives 21 transfused blood -- 22 Q: Hmm hmm. 23 A: -- packed blood -- red blood cells, 24 plus the IV that I've mentioned earlier. 25 Q: And -- and did the -- the blood loss

1 for Dudley George reach that level? 2 A: It did not and -- and the reason it 3 didn't was because -- in my view was that the rapidity of 4 the bloodshed was the critical factor in Mr. George's 5 case; it simply overwhelmed his ability to compensate for 6 that blood loss and therefore he couldn't -- he couldn't 7 cope with that. 8 Q: In other words, for the natural 9 bodily response to shock that we've outlined -- 10 A: Correct. 11 Q: -- constriction of the veins, the 12 blood clotting, et cetera; that just couldn't happen at a 13 quick enough rate here because of the rapidity of the 14 blood loss? 15 A: That's correct. 16 Q: Okay. 17 A: And the other factor -- one -- just 18 to put it slightly differently, the rate of blood loss 19 can be as important as the amount of blood loss. So, if 20 the blood is shed very quickly, that may be a critical 21 factor and that's what I believe happened in Mr. George's 22 case, because he lost about a fifth or 20 percent of his 23 blood volume, which is in the -- which, in some cases, 24 would be survivable, but I believe the rate at which it 25 was lost was critical.

1 The other factor that may have been 2 important in Mr. George's case was his -- his pre- 3 existing cardiac situation. 4 Q: What was it about his pre-existing 5 medical situation that -- that was a negative? 6 A: At -- at autopsy he was found to have 7 75 percent blockage of his left anterior descending 8 coronary artery, one (1) of the three (3) main arteries 9 that supplies the heart. 10 If we've heard that the ability of the 11 heart to compensate is really critical in compensating 12 for the first stages of shock, someone who has some heart 13 disease will not be as able to do, for example, as a high 14 endurance athlete, a highly -- a highly trained athlete. 15 So, younger people, particularly children, 16 compensate for shock very well, whereas older people who 17 may have coronary disease, do not so as well and that may 18 have been a factor in Mr. George's case. 19 Q: All right. Thank you. 20 A: I think that concludes the -- the 21 section of slides on that. 22 Q: I appreciate that. Now, based on 23 your review of this matter then, and your expertise, did 24 you form an opinion that had Mr. George been transported 25 to the Strathroy Middlesex General Hospital by ambulance

1 in the care of paramedics and provided with paramedic 2 intervention en route, whether his chance of survival 3 would have been materially improved? 4 A: I don't believe so. 5 Q: And what is the basis of your 6 opinion? 7 A: Well, the -- the total time, and I 8 recognize that it's hard to ascertain this with 9 precision, but the total time from the initial wound to 10 arrival at hospital in Strathroy was fifty (50) to fifty- 11 five (55) minutes. 12 The transport method to the hospital was 13 not relevant in my view. I think, in fact, that the 14 decision of Mr. George's companions to load him in the 15 car and go was probably the correct one. 16 Q: Why is that? Why -- why would you 17 not recommend or why would the paramedic intervention not 18 likely improve his chance of survivability? 19 A: That's based on studies that have 20 been done throughout the world which have showed that the 21 most important determinant of outcome from pre-hospital 22 arrest, is time of arrival at the hospital. 23 So, despite the fact that one might 24 intuitively believe that the intervention of paramedics 25 in these cases wold make a tremendous difference, the

1 evidence doesn't support that. 2 In fact, it seems to be that those who are 3 going to survive are those who arrive at hospital in a 4 very short time. 5 Unfortunately the proximity of Mr. George 6 at the time of the gunshot wound to hospital was not -- 7 wasn't close and he had some distance to be transported. 8 The provision of all the advance life 9 support manoeuvrers that are done in the pre-hospital 10 setting, in this particular group, in terms of its 11 benefit, is highly controversial, but the evidence to 12 support benefit is lacking. 13 Q: And do you have any -- so what I'm 14 understanding -- if I'm understanding you then, your 15 evidence, the -- the nature and extent of this particular 16 injury, which was a penetrative trauma, was such that the 17 usual medical interventions such as supply of intravenous 18 fluid for example, would not likely have -- have enhanced 19 his chance of survival? 20 A: That's correct. 21 Q: And do you have any studies which 22 support this position? 23 A: Well, there are two (2) -- there are 24 two (2) that are, I think, important to refer to and they 25 are in the PowerPoint presentation as well, at Slide 18.

1 I could ask you to go to that. 2 3 (BRIEF PAUSE) 4 5 Q: Now, just before we go to your 6 PowerPoint presentation, the article that you're 7 referring to is a position paper by the National 8 Association of -- of EMS physicians -- 9 A: That's correct. 10 Q: -- from the United States, and it's a 11 document which was published in 2002? 12 A: That's correct. 13 Q: All right. And did you -- is this 14 document or is this study an authoritative study in your 15 field of expertise? 16 A: It is. It's actually a guideline 17 based -- it's a position paper based on a review and 18 analysis of the literature in this area. 19 Q: And did you -- do you adopt this 20 position paper as part of your opinion? 21 A: Yes. 22 Q: Commissioner, I'd like to make the 23 position paper entitled, Guidelines for Withholding or 24 Termination of Resuscitation in Pre-Hospital Traumatic 25 Cardio-Pulmonary Arrest, the next exhibit.

1 THE REGISTRAR: P-393, your Honour. 2 COMMISSIONER SIDNEY LINDEN: P-393. 3 4 --- EXHIBIT NO. P-393: NAEMSP Guidelines for 5 resuscitation in penetrating 6 TCPA (Traumatic 7 Cardiopulmonary Arrest), 8 Published in 2002 9 10 CONTINUED BY MS. SUSAN VELLA: 11 Q: Perhaps you can explain what this 12 position paper sets out and how it applies, in your 13 opinion, to Dudley George's situation? 14 A: Certainly. The paper was prepared by 15 the National Association of Emergency Medical Services 16 Physicians, which is a group in the United States of -- 17 professional group, composed of physicians who provide 18 medical direction and guidance to ambulance personnel 19 working in large or small systems in the United States. 20 There are Canadian members as well. And 21 it is an authoritative group in this field. The paper 22 was put together based on the review of a series of 23 research studies that had been in this area looking at 24 whether -- whether or not one should continue or 25 terminate resuscitation of people who have suffered

1 cardiac arrest in the pre-hospital setting and in fact 2 due to trauma. 3 So specific -- this is not this is not a 4 group of people who have had cardiac based ventricular 5 fibrillation or sudden cardiac arrest. It's people who 6 have been injured and who have an arrest. 7 And based on their review of the 8 literature, they've come to a number important 9 conclusions. The first is that when one is going to 10 attempt advance life support manoeuver such as putting in 11 an endotracheal tube into the trachea or putting an 12 intravenous infusion in. 13 This should be done during transport. In 14 other words, transport should not be delayed because 15 transport is the key benefit that's offered to these 16 people. 17 The next slide, please. The next is that 18 where arrest has occurred in the pre-hospital setting due 19 to trauma, one should consider termination of 20 resuscitation attempts when the arrest has persisted for 21 more than fifteen (15) minutes. 22 The reason for that is that the chance of 23 resuscitating the person is virtually zero. The chance 24 of -- 25 Q: So -- so once the -- sorry, once the

1 heart has stopped -- 2 A: Correct. 3 Q: -- and there's no activity -- 4 A: Correct. 5 Q: -- and that's happened for fifteen 6 (15) minutes, then there's no chance of resuscitation 7 successfully? 8 A: That's -- that's the virtual 9 situation. 10 Q: Thank you. 11 A: The other thing is that when one is 12 being transported in that circumstance, of course the 13 ambulance is proceeding at breakneck speed with lights 14 and sirens on and there is a risk to public safety and to 15 the occupants of the ambulance. 16 So, one has to consider that balanced 17 against the needs of the person inside the vehicle, the 18 patient. 19 Next please. If the person has arrested 20 and the transport time is known to be fifteen (15) 21 minutes or greater, then the ambulance personnel should 22 consider that individual non-salvageable. 23 And again the same logic applies; that 24 fifteen (15) minute window is really the maximum time at 25 which someone could be -- could be hoped to be

1 resuscitated. 2 Next please. If the person has no vital 3 signs, no blood pressure, no pulse, no respiratory 4 effort, and also has no signs of life, and those are 5 distinct entities as you may have heard previously in 6 testimony, the signs of life would include pupillary 7 response, gasping, movements or evidence of the 8 electrocardiogram activity, resuscitation should not be 9 started at all. 10 And again, the reasoning is that there's 11 no hope of meaningful resuscitation. Meaningful 12 resuscitation refers to the fact that the person will 13 leave hospital with their cognition, their -- their 14 faculties intact with -- 15 Q: And just for clarification, over what 16 period of time or what's the -- the maximum period of 17 time for which a person can be absent vital signs and -- 18 A: And survive? 19 Q: -- and then still be resuscitated? 20 A: That fifteen (15) minute window is 21 really the maximum time. The physiologic time for brain 22 death is between six (6) and ten (10) minutes, but there 23 are recorded instances of people surviving as long as 24 fifteen (15) minutes. There are other factors that don't 25 apply in Mr. George's case such as hypothermia which can

1 prolong survival time, but again, that's usually not the 2 case. 3 Finally, if there are clear signs of 4 death, an injury that's incompatible of life, then 5 resuscitation obviously shouldn't be attempted and that's 6 part of a position statement. 7 The reason that the NAEMSP put forward 8 these position statements is that -- next slide, please - 9 - the reality is that the presence of traumatic 10 cardiopulmonary arrest is associated with a dismal 11 prognosis. 12 There really is even in the best of hands, 13 close to trauma centres, a very, very grim outlook for 14 someone who has an arrest due to trauma in the pre- 15 hospital setting. 16 Q: So, even if the person arrives at a 17 trauma centre within less than fifteen (15) minutes or 18 less than ten (10) minutes even, the survival rate is 19 between point eight (.8) and 4 percent? 20 A: That's correct; that's under optimal 21 circumstances. And the reason I say that is that these 22 studies of course are done next to trauma centres. 23 They're done by academic physicians who are interested in 24 the outcome of what happens. 25 In the United States, of course, in large

1 urban areas penetrating trauma is not rare, in quite -- 2 in distinct contrast to Canada, and therefore they have a 3 good deal of experience with it. They're used to doing 4 the manoeuvres that need to be done. 5 For example, one (1) of the things that 6 can be done for people who have penetrating trauma to the 7 chest is an Emergency Department thoracotomy, which is an 8 operation where the chest is entered through a large 9 incision that's made very rapidly in the left side of the 10 chest, and a variety of manoeuvres may be tried. 11 So, for example, if there's a hole in the 12 heart, they might literally put a plug there, either a 13 finger or a catheter, such as a urinary catheter and blow 14 the balloon up and try and stop the bleeding. 15 They may clamp the aorta, the large vessel 16 that comes off the left side of the heart, to try and 17 staunch the blood flow. 18 A manoeuvre, incidentally, which would not 19 have worked for Mr. George, because he had a pulmonary 20 artery laceration, so therefore it wouldn't have been -- 21 wouldn't have been helped at all by that. 22 Q: Hmm hmm. 23 A: And bleeding can be a -- bleeding 24 control can be attempted. the problem with the procedure 25 is that it requires a great deal of experience and skill.

1 It would not be found, typically, in a place like 2 Strathroy, for example. 3 Although there was a general surgeon 4 there, general surgeons who work in smaller community 5 settings wouldn't have to do a procedure like this, 6 virtually ever, in their careers. And so the chance of 7 them being able to do something useful in the time that's 8 required is very, very small. 9 Q: All right. And we'll certainly 10 explore that procedure a little bit -- a little bit 11 later, but as I understand, then, the penetrating trauma 12 to the chest, that would include, of course, a gunshot 13 wound to -- to the -- to the clavicle area such as -- 14 A: That's correct. 15 Q: -- Mr. George suffered? 16 All right. And do you have any other 17 studies which support your opinion that paramedic 18 intervention would not have materially enhanced Mr. 19 George's rate of survivability? 20 A: Well, there's another study known as 21 the -- there's a study done by Bickell in Houston, which 22 is the next slide, please. 23 24 (BRIEF PAUSE) 25

1 A: And Bickell studied -- and this is 2 rare in this field, because I should emphasise for the 3 Commission that the research that's been in this area is 4 not randomised control trials, such as one would see in 5 the evaluation of a new medicine. 6 Because of the ethical concerns, one can't 7 generally do that kind of research in victims of trauma. 8 They're already injured, and one can't control when 9 they're going to be injured, typically. 10 Q: And just for our information, this is 11 a article entitled, "Immediate Versus Delayed Fluid 12 Resuscitation for Hypotensive Patients with Penetrating 13 Torso Injuries," co-authored, led by William Bickell, and 14 it's published in 1994 in the New England Journal of 15 Medicine. 16 Is that right? 17 A: That's correct. 18 Q: And do you consider this study to be 19 authoritative in your field? 20 A: Yes. 21 Q: Do you adopt it as part of your 22 opinion? 23 A: Yes, I do. 24 Q: Commissioner, I'd like to make this 25 article the next exhibit, please.

1 THE REGISTRAR: P-394, your Honour. 2 COMMISSIONER SIDNEY LINDEN: P-394. 3 4 --- EXHIBIT NO. P-394: "Minimal Volume 5 Resuscitation," Bickell Nejm 6 1994:331:17:1105-1109 7 8 CONTINUED BY MS. SUSAN VELLA: 9 Q: Perhaps you can just explain what the 10 thesis was here, and what the -- the result was and apply 11 that to Dudley George's situation. 12 A: Well, the hypothesis was one that 13 might be counterintuitive to the average person, and that 14 is that the provision of IV therapy, fluid therapy to a 15 person who's bleeding might actually be detrimental to 16 them. 17 Q: How so? 18 A: Well, the concern was that, if one 19 gets -- one gives IV fluid, that may cause dilation of 20 the blood vessels, or raising of the blood pressure and, 21 in fact, lead to increase in bleeding. He -- 22 Q: So in other words, instead of 23 constricting the blood vessel which would normally be the 24 function, you put in more fluid and it expands the blood 25 vessel --

1 A: That's correct. 2 Q: -- and that increases, of course, the 3 -- the loss of blood. 4 A: Correct. And the authors who are 5 surgeons, believe that, or hypothesised, that so doing, 6 might lead to an increase in blood loss if one did it 7 before surgical control of the bleeding had been 8 achieved. 9 It wasn't that they weren't going to give 10 the blood or give the fluid to expand the blood vessels; 11 their belief, though, was that one should -- should gain 12 surgical control of the vessels that were damaged -- 13 Q: So stop -- 14 A: -- before doing it. 15 Q: -- stop the bleeding first? 16 A: Exactly. 17 Q: Okay. 18 A: So, they put together a study where 19 they aimed to get their patients to the operating room 20 very quickly. And if one looks at the study, the time 21 that the -- from the time of injury to actual arrival in 22 the operating room was about forty-five (45) minutes. 23 Now, it's very important to compare that 24 to the time that Mr. George had before he arrived at the 25 Strathroy Hospital, for example.

1 He had some fifty (50) to fifty-five (55) 2 minutes, and that's just the time to arrive at hospital. 3 In my experience, working in two (2) large trauma 4 centres, three (3) actually, it's virtually impossible to 5 get somebody off the the street into the operating room 6 in anything less than fifteen (15) to twenty (20) 7 minutes. 8 It is virtually impossible and the reason 9 is that the -- the portering through the hospital, 10 getting the necessary equipment set up, et cetera, et 11 cetera, just leads to an obligate time period before one 12 can get that person to the operating room. 13 So, these times, it's recognized 14 throughout the trauma -- trauma world, are exceedingly 15 short times to actually achieve; it's very difficult. 16 In any case, Bickell and his group 17 randomized almost six hundred (600) patients to either 18 receive minimal fluid resuscitation in the field; in 19 other words, an IV was started, but almost no fluid was 20 given, or to receive a conventional fluid resuscitation 21 and then being rushed to the operating room. 22 And what they found was that there is a 23 benefit to not giving fluid to these people in the pre- 24 hospital setting; 70 percent of the people who received 25 their minimal volume resuscitation survived, versus 62

1 percent who received conventional treatment. 2 That's important because although it's not 3 a significant increase, it actually runs counter to what 4 one might believe intuitively would be the -- the way 5 things should go. 6 Next slide, please. Now, in order to 7 properly evaluate this study in the -- in the context of 8 the matter we're dealing with today, one has to remember 9 this is study done in Houston, Texas, a large urban 10 setting, significant rate of penetrating trauma, highly 11 skilled surgeons because they see it all the time, they 12 had short transport times to the hospital, all under 13 twenty (20) minutes. 14 These were -- although they were 15 penetrating trauma victims, they were not in cardiac 16 arrest, these people had -- were excluded because they 17 didn't -- they -- they had cardiac arrest, they were 18 excluded. 19 Q: Why -- 20 A: And the reason for that was because 21 there's no hope of survival. 22 Q: And -- and this is -- 23 A: No meaningful hope. 24 Q: -- this is the situation of Dudley 25 George in the sense --

1 A: Right. 2 Q: -- it was a penetrating trauma and he 3 was in cardiac arrest by the time he got to the hospital? 4 A: Correct. I think what it does 5 illustrate that's useful is, the Commission decides what 6 are the appropriate recommendations to follow from the 7 Inquiry, is that this is a controversial issue. It is 8 not a slam-dunk that IV fluid is better. 9 It is not clearly beneficial in all 10 circumstances, but we don't know, for example, in a 11 patient who has vital signs whether or not, if the 12 transport time is long, and this is the situation in much 13 of rural Canada, whether or not we should be giving IV 14 fluids to these patients. This is being studied, but the 15 answers are not clear yet. 16 Q: And so, in other words, it may or may 17 not improve the recoverability, if you will, or 18 survivability of someone with this type of a penetrating 19 trauma? 20 A: Well, I -- with one (1) important 21 caveat, who has not had a cardiac arrest. 22 Q: Who has not had a cardiac arrest. 23 Thank you. 24 25 (BRIEF PAUSE)

1 Q: All right. And, just for the record, 2 I note that the survival rate outcome is at page 1107 of 3 the article and -- and the rationale, if you will, 4 underlying what you've just talked about, is outlined on 5 page 1108 under 'Discussion.' 6 A: That's correct. 7 Q: Thank you. Now, we have heard 8 evidence from the treating healthcare professionals in 9 this case that providing oxygen to Dudley George while 10 en-route would have been advisable. Do you agree or 11 disagree with that? 12 A: It would have been advisable, but not 13 clearly beneficial. 14 Q: And the reasons why it would not 15 clearly have been beneficial? 16 A: Because the research evidence to 17 support that the provision of extra oxygen resulting in a 18 better outcome is lacking. 19 Q: And similarly, I take it from your 20 opinion that providing intravenous fluid while the -- the 21 treating healthcare professionals also testified that 22 providing intravenous fluid en-route would have been a 23 prudent measure. Do you agree or disagree? 24 A: I can't answer that with a simple yes 25 or no. If I might be permitted to digress --

1 Q: Certainly. 2 A: -- I'll tell you why. 3 It would be beneficial to start an 4 intravenous early on because we've heard that 5 constriction of the blood vessels proceeds as one (1) of 6 the compensatory mechanisms and therefore, later on in 7 the course of the patient's care, it may be harder to 8 start an intravenous because there's more constriction of 9 the blood vessels including the veins. 10 So, starting an IV early is a beneficial 11 thing, however, and this is why I can't give you a simple 12 yes or no, there isn't good evidence that starting IV's 13 in the pre-hospital setting results in a better outcome 14 regarding survivability. 15 Q: At the end of the day? 16 A: Yes. So, it would be advisable, yes, 17 generally helpful to start it earlier on, but would it 18 have made a difference to the ultimate outcome, I don't 19 think that can be said. 20 Q: And those are for the reasons you've 21 just outlined? 22 A: Correct. 23 Q: So, in the end, then, Pierre and 24 Caroline George's instincts in getting Dudley George to 25 the hospital as quickly as possible, were the right

1 instincts to follow, given the nature and severity of the 2 brother's injuries? 3 A: I believe so. 4 Q: Now, we have heard evidence that J.T. 5 Cousins, the young man who sat in the back seat with 6 Dudley George and applied pressure to the wound area, 7 believes that he continued to hear a heart beat after 8 they left the Veen farmhouse on Nauvoo Road, right up to 9 the hospital. 10 In your view, is it likely that J.T. 11 Cousins continued to hear a heart beat beyond the Veen 12 residence? 13 A: Well, I stress in answering that I 14 wasn't there -- 15 Q: Yes. 16 A: -- but I have experience in trying to 17 assess patient's vital signs with actually fairly 18 sophisticated equipment, in the back of ambulances and 19 helicopters, both of which are noisy environments. And I 20 believe that it would have been very, very difficult to 21 actually hear a heartbeat in that setting, especially 22 when there was a flat tire and there was the noise of 23 travelling along back roads. 24 And I think it's likely that Mr. Cousins, 25 certainly in good faith, heard something, but I believe

1 he may have been hearing his own heartbeat, for example; 2 that's a -- that's a common -- common illusion that one 3 has. And similarly, when one's feeling a pulse, it's 4 fairly common to feel one's own pulse. 5 So, those two (2) things, I believe, would 6 have -- I believe it would have been very difficult to 7 hear Mr. George's heart in that car. 8 Q: Hmm hmm. And based on your review 9 and your expertise, did you form any conclusion as to 10 whether or not it is likely that Dudley George was absent 11 all vital signs, prior to his arrival at the Strathroy 12 Middlesex General Hospital? 13 A: Well, there was several -- I believe 14 that Mr. George had been absent vital signs for twenty 15 (20) to thirty (30) minutes prior to arrival at the 16 hospital and I base that on several things. 17 The first is that the -- the absence of 18 movement prior to the time that the car actually reached 19 the farmhouse which is recorded by Mr. Cousins, I 20 believe, and that's the information I received. 21 The second is that the -- at the hospital, 22 I read a later addendum and I should have alluded to this 23 earlier in my testimony, that I did receive an addendum 24 from a nurse who was at the scene -- 25 Q: Yes.

1 A: -- who, when Mr. George was turned, 2 observed that he had lividity, what -- what sounds like 3 lividity to me, based on the description of the fixed, 4 bluish discolouration of the skin that she gives. 5 Lividity takes somewhere between thirty 6 (30) minutes and two (2) hours to appear after death. 7 And lividity as you may have heard already, is the 8 pooling of blood in the dependant portion of the body 9 after death, which is a normal phenomenon after death, 10 but it can be of some assistance in timing death. 11 Q: And nurse Derbyshire, by the way, did 12 testify that she viewed Dudley George's skin to be 13 mottled in the back of the car at the hospital ramp and 14 that there was blood swelling, I guess, at -- in the jowl 15 and neck and area. 16 Is that what you're referring to? 17 A: I was referring to the posterior 18 portion of Mr. George, but if that were present as well, 19 that would be important. 20 Q: Okay. Thank you. And so, then, in 21 your opinion, it is likely that he was absent vital signs 22 at a minimum of thirty (30) minutes prior to his arrival 23 at the hospital? 24 A: That's correct. 25 Q: And did you further -- all right.

1 And just to be clear, this conclusion is based on -- on 2 statistical -- the statistical course of this type of -- 3 of lividity? 4 A: That's correct. 5 Q: And given the nature and severity of 6 Dudley George's gunshot wound, what emergency medical 7 procedures would have constituted optimal in-hospital 8 medical care? 9 So, we'll move now from the enroute care 10 to the hospital care. 11 Q: Well, I think what the physicians did 12 was appropriate in the setting that they were working, 13 and that is in a community hospital in a smaller town and 14 with the experience and skills that were present there, 15 and I don't mean in any way to suggest that they weren't 16 appropriate, because I think they were, that is the 17 skills and experience of the physicians who were present. 18 Q: You mean given that this wasn't a 19 full trauma centre? 20 A: Correct. They're not working in a 21 trauma centre and they -- their role would have been, if 22 possible, to stabilise and minimise further damage and 23 evacuate or cause the evacuation of Mr. George, if that 24 were possible. 25 If Mr. George had arrived at a trauma

1 centre, then the appropriate thing would have been to 2 undertake exactly the same treatment that was started at 3 the Strathroy Middlesex Hospital, but in addition to give 4 consideration to an Emergency Department thoracotomy. 5 And that, as I mentioned earlier, is the 6 operation where one enters the chest and controls the 7 bleeding directly using internal methods as opposed to 8 the external pressure that was alluded to earlier. 9 Q: And what was the -- the name of that 10 procedure again? 11 A: Emergency Department thoracotomy. 12 Q: Thoracotomy. 13 A: Yes. 14 Q: And can you just explain in a little 15 more detail what -- what the objective of that procedure 16 is and -- and what it -- what it takes to do it? 17 A: Well, the -- the objective is to gain 18 control of haemorrhage inside the chest. The procedure 19 involves making a semi-circular incision between the 20 fourth and fifth ribs on the left side of the chest 21 following the space between the ribs and then inserting a 22 rib spreader, which is an instrument, to force those ribs 23 apart and thus allowing the visualization of the interior 24 of the chest. 25 And then one follows a fairly -- fairly

1 stereotyped approach, looking first at the heart to see 2 whether or not there's a hole in the heart. And -- and, 3 of course, that wouldn't have been known because it 4 couldn't be known at the time, looking then to see if the 5 covering of the heart, the pericardium, is tense with 6 blood, because that can actually impede the pumping of 7 blood. 8 And then finally, looking for other 9 sources of haemorrhage such as from the great vessels of 10 the chest and then hopefully applying a clamp or putting 11 in something to occlude or stop the -- the flow of blood 12 from those areas. 13 Q: All right. And did you form an 14 opinion as to whether or not the performance of a 15 thoractomy here, emergency thoractomy, assuming of 16 course, that Mr. George was brought to the trauma centre 17 in time, whether -- what the chances were of -- of his 18 survivability? 19 A: Well, the -- the -- again, going back 20 to the document that's been introduced in evidence and 21 that is the position paper of the National Association of 22 Emergency Service -- Medical Services Physicians, on 23 page -- 24 Q: Exhibit P-393. 25 A: Right.

1 Q: Yes. 2 A: On page 144 there's a table which 3 summarizes major studies of emergency thoracotomy. And 4 if one looks at that, one realizes that the survival 5 rate, and going down to the bottom of the chart where it 6 says, "Totals," survival rate from penetrating trauma 7 from a compilation of these studies is 16 percent. 8 So, again, that 's under optimal 9 circumstances, going to a trauma centre with a skilled 10 surgeon and a skilled team, because it's not just the 11 surgeon, it's the team who assists who's -- which is 12 important, the survival rate is 16 percent. 13 So, juxtaposing that against the 0.8 to 4 14 percent versus 16 percent and emphasizing that these 15 individuals were not in cardiac arrest. 16 Q: All right. The -- 17 A: So, the best one could hope for is 18 about 16 percent survival if the person arrives with some 19 vital signs, but is in extremis; near death. If somebody 20 arrives in cardiac arrest, the survival rate is 21 significantly lower. 22 Q: Much lower? 23 A: Yes. 24 Q: 0.8 percent to 4 percent? 25 A: Correct.

1 Q: And in the event that the cardiac 2 arrest has been persisting for fifteen (15) minutes or 3 longer, then there is no chance of recovery? 4 A: That's correct. So, I think that, if 5 I -- I might just say this, that at -- to the Hamilton 6 General or Sunnybrook the chances would not have been 7 better in this circumstance at that time. 8 Q: All right. 9 10 (BRIEF PAUSE) 11 12 Q: Now, had Dudley George arrived at the 13 hospital, the Strathroy Middlesex General Hospital, 14 within thirty (30) minutes from the point of the bullet 15 entering into his body, do you have an opinion as to 16 whether or not a thoractomy would have saved his life? 17 A: The -- again, it's difficult to 18 answer with a simple yes or no, because the critical 19 feature would be if he were in cardiac arrest or not. 20 Q: Right. 21 A: If he's not in cardiac arrest within 22 thirty (30) minutes, then there's -- then there's a 23 chance, but the chance that you see is 16 percent. 24 Q: Do you know where the closest trauma 25 centre capable of performing an emergency thoractomy was

1 to the Ipperwash Provincial Park? 2 A: Well, there are two (2) trauma 3 centres, Windsor and London. I'm not exactly sure which, 4 geographically, is closer, but London is a university 5 centre and would be more likely to have a surgeon onsite 6 because it's a teaching centre, so there would be 7 residents in-house and the ability to mount the trauma 8 response would be faster there than, say, in Windsor. 9 Q: And then, in the -- in the 10 circumstances presented to the Emergency Department at 11 the Strathroy Medical General Hospital shortly after 12 midnight on September the 7th, 1995, did the health care 13 professionals present provide competent emergency medical 14 care to Dudley George recognizing the limitations faced 15 by that department as you have described? 16 A: I think they did. 17 Q: Now I understand that you received 18 information relevant to your task after you wrote your 19 report? 20 A: I did. 21 Q: And can -- the new information you 22 received, can you please describe what that information 23 was? 24 A: Well, I was -- I mentioned earlier 25 that I received a statement of Jacqueline Derbyshire

1 regarding her observations of Mr. George's body. I also 2 was able to review the transcript evidence of Dr. Marr 3 and Dr. Saettler. 4 Q: And as a result of receiving that new 5 information, have you, in any way, altered any of the 6 opinions or conclusions or findings which you have 7 testified to today? 8 A: I did not. 9 Q: All right. And with respect to the 10 information received through the interview of nurse 11 Derbyshire by Detective Armstrong I believe, did you -- 12 did you write an addendum to your report? 13 A: I did. 14 Q: And this is a two (2) page addendum? 15 A: That's correct. 16 Q: I'd like to make the addendum to the 17 report of Dr. McCallum the next exhibit please. 18 THE REGISTRAR: P-395, Your Honour. 19 COMMISSIONER SIDNEY LINDEN: P-395. 20 21 --- EXHIBIT NO. P-395: Two (2) page Addendum to 22 Document Number 5000004, page 23 391 by Dr. Andrew McCallum 24 25 CONTINUED BY MS. SUSAN VELLA:

1 Q: In conclusion, Dr. McCallum, assuming 2 that even under the optimal circumstances you have 3 described, that is arrival at a full trauma centre within 4 fifteen (15) minutes from point of injury, whether or not 5 pre-hospital medical intervention occurred, had all the 6 emergency procedures been followed, including an 7 emergency thoracotomy, Dudley George would likely have 8 not survived his gunshot wound based on the statistics 9 that you have reviewed today; is that right? 10 A: That's correct. 11 Q: Now, Dr. McCallum, part of the 12 mandate of the Commission is to make recommendations 13 aimed at ensuring such casualties as Dr. -- as Mr. Dudley 14 George, do not happen in the future; based on your expert 15 review of the delivery of emergency medical services to 16 Dudley George, do you have any recommendations which 17 might assist the Commission? 18 A: I have -- I do. 19 Q: Could you advise us? 20 A: Certainly. The first is that this -- 21 the events that are being examined here occurred nearly 22 ten (10) years ago. And the importance of transport has 23 been emphasized I think in -- in my testimony this 24 morning, transport time or minimizing transport time. 25 And therefore one recommendation I would

1 make is that the -- there be a better link with pre- 2 hospital care providers and in particular air ambulance 3 providers, because since the time of Mr. George's death, 4 the air ambulance system in Ontario has evolved 5 significantly. 6 There are now I'm told, some fourteen (14) 7 air ambulances available. At that time there was one 8 (1). And furthermore, these air ambulances are capable 9 of doing what are scene calls. 10 In other words landing near the -- the 11 scene of an injury, picking up the person, en route 12 providing advance life support and taking them directly 13 to a trauma centre. 14 And that is something that has been shown 15 in several studies to be beneficial -- beneficial 16 intervention. So, that's one (1) recommendation I would 17 make. 18 Q: And -- and just for our further 19 information, are you aware as to whether any of these air 20 ambulances are stationed anywhere close to -- to the 21 London General Hospital for example? 22 A: There is one (1) stationed in London, 23 to my understanding. 24 Q: Right in London? 25 A: Yes.

1 Q: Is there one (1) also in Windsor? 2 A: I'm not 100 per cent certain about 3 that. I -- I don't know that for sure. 4 Q: All right, thank you. 5 A: But I do know there's one (1) in 6 London. And the flying time from London to Ipperwash 7 would be twenty (20) minutes at most. 8 Q: Now would it be feasible to pre- 9 assign an air ambulance given the number of resources 10 that we have in the Province, to pre -- to have 11 preassigned an air ambulance to a scene of potential 12 multiple casualties? 13 A: It probably would -- it would be 14 conceivable but probably not advisable. 15 Q: Why is that? 16 A: And the reason is that the ambulances 17 have many tasks and -- and duties and they're flying 18 critically ill patients around the province constantly. 19 So, it would be I think not reasonable to remove one (1) 20 of those ambulances from somebody in -- in -- for an -- a 21 foreseeable but not yet seen eventuality. 22 Q: All right. 23 A: However, the system is such now that 24 I believe that the availability of the ambulances is -- 25 is -- is much better, and therefore one could obtain one

1 much more easily than at that time. 2 Q: All right. Thank you. And what is 3 your second recommendation? 4 A: My second recommendation is that it 5 probably, despite my testimony regarding the lack of 6 clear benefit of having advanced life support 7 interventions, it would be useful to have that available 8 because, for example, airway interventions early on, 9 opening the airway providing effective ventilation to the 10 patient, effective respirations, are associated with 11 better neurologic outcomes. 12 And furthermore, as -- and I think I gave 13 a rationale for this in earlier testimony, starting an 14 intravenous earlier, even though it's not clearly 15 beneficial, at least provides a conduit for the later 16 installation of IV fluids. 17 Q: So, in other words, the availability 18 of advanced care, paramedics and ambulances obviously -- 19 A: Correct, and that -- 20 Q: -- to -- 21 A: -- that's something that can be pre- 22 arranged in my view, ground ambulances. 23 There are now, in Windsor and in Sarnia, 24 advanced care paramedics. This is a phased-in 25 implementation that's gone on over the last five (5) to

1 seven (7) years and so that now is -- is -- would be 2 available. It wasn't at the time. 3 Q: Do you know whether or not there were 4 any advanced ambulance care paramedics in Sarnia in 1995? 5 A: I don't believe so, and the reason I 6 say that is there was a study done called the Ontario 7 Pre-hospital Advanced Life Support Study, or OPALS, which 8 resulted in a gradual introduction in communities like 9 Sarnia and Windsor of advanced care paramedics. 10 And I don't believe that it had been 11 implemented at that time there, but I might be wrong. I 12 can't be 100 percent certain. 13 Q: All right. Thank you. And do you 14 have any third recommendation? 15 A: I do. Based on the information that 16 I received, and on review of the transcripts of Dr. Marr 17 and Saettler I gather that there wasn't clear 18 communication between the officers who were involved in 19 the incident and the -- and the hospital staff. 20 And that's something I believe should be 21 emphasized for any future incident, that it's important 22 that the -- that the personnel at the scene or -- and 23 that would include the relatives who came with Mr. 24 George, be allowed to or -- and in fact encouraged to 25 give their information to the hospital staff so it's

1 clear what happened, when. 2 Now, that's quite important, and it's one 3 (1) of the things I stress when I used -- I did stress 4 when I was teaching residents and -- and -- and 5 paramedics is that that communication can be missed and 6 it's -- can give -- there can be very valuable 7 information relayed. 8 Q: Hmm hmm? 9 A: So, that's something that's -- that 10 should be emphasized to police and to paramedics, and to 11 hospital staff. 12 Q: And to family members? 13 A: And -- and to family members who 14 accompany a person. 15 Q: All right. And they should be 16 encouraged by whatever professionals have accompanied 17 them? 18 A: Correct. 19 Q: Do you have any further 20 recommendations for the Commission? 21 A: I think those would constitute my 22 recommendations. 23 Q: Dr. McCallum, thank you very much, 24 that concludes my examination-in-chief. 25 Perhaps we can canvas Counsel for possible

1 cross-examination, Commissioner? 2 COMMISSIONER SIDNEY LINDEN: Let's do 3 that now. Does anybody wish to ask Dr. McCallum any 4 questions? 5 Yes, Mr. Orkin...? 6 MR. ANDREW ORKIN: Ten (10) minutes. 7 COMMISSIONER SIDNEY LINDEN: Mr. 8 Rosenthal...? 9 MR. PETER ROSENTHAL: Twenty (20) minutes 10 to a half an hour, sir. 11 COMMISSIONER SIDNEY LINDEN: Mr. 12 Henderson...? 13 MR. WILLIAM HENDERSON: Perhaps five (5) 14 minutes. 15 COMMISSIONER SIDNEY LINDEN: Ms. 16 Jones...? 17 MS. KAREN JONES: Fifteen (15) minutes. 18 COMMISSIONER SIDNEY LINDEN: Mr. 19 O'Marra...? 20 MR. AL O'MARRA: Reserve five (5) to ten 21 (10) minutes, sir. 22 COMMISSIONER SIDNEY LINDEN: Mr. 23 Falconer...? 24 MR. JULIAN FALCONER: Ten (10) to fifteen 25 (15) minutes.

1 COMMISSIONER SIDNEY LINDEN: We will take 2 a morning break now, and we'll do cross-examination right 3 after. 4 THE REGISTRAR: This Inquiry will recess 5 for fifteen (15) minutes. 6 7 --- Upon recessing at 10:25 a.m. 8 --- Upon resuming at 10:45 a.m. 9 10 COMMISSIONER SIDNEY LINDEN: Yes, Mr. 11 Orkin? 12 13 (BRIEF PAUSE) 14 15 MR. ANDREW ORKIN: Good morning, 16 Commissioner. 17 COMMISSIONER SIDNEY LINDEN: Good 18 morning. 19 20 CROSS-EXAMINATION BY MR. ANDREW ORKIN: 21 Q: Good morning, Dr. McCallum. 22 A: Good morning. 23 Q: My name is Andrew Orkin, I'm co- 24 counsel to the estate of the late Dudley George and of 25 the Sam George group of family members.

1 A: Good morning. 2 Q: And I have just a few questions from 3 you, as you saw from the grow -- the go-around. 4 You indicated a moment ago in your 5 testimony concerning the -- the report that you prepared 6 at the request of the -- the commission -- of the -- of 7 the Coroner, that your report was February 17, 2003; is 8 that correct? 9 A: That's correct. 10 Q: Could you tell us, please, when you 11 were requested or when you were commissioned to undertake 12 that report? 13 A: My recollection is that it was 14 several weeks before that. Usually it would take me two 15 (2) to three (3) weeks, but I don't have a precise date. 16 Q: So, it's accurate to say that early 17 in 2003 -- 18 A: Correct. 19 Q: -- you were approached by the Coroner 20 to undertake this review of the various reports that had 21 -- and -- and documents that you referred us to? 22 A: Correct. 23 Q: Now, Dudley George was shot and 24 killed in 1995, so this would be some seven (7) years or 25 more after the shooting in September --

1 A: That's right. 2 Q: -- of 1995? 3 Is there any significance to you in being 4 requested some years after an event like this, which is 5 something or was something at the time, something of a 6 cause celebre, to be reviewing the various factors that 7 you were asked to review so many years after that event? 8 A: It's unusual to be asked that long 9 afterwards, yes. 10 Q: Could you elaborate as to why you 11 find that unusual? 12 A: Well, my experience having prepared 13 other expert reports is that one (1) to two (2) years 14 wouldn't be unusual for the -- for the -- for a delay 15 postmortem for that kind of report to be requested, but 16 seven and a half (7 1/2) years is -- is much longer than 17 I would have seen in other cases. 18 Q: Was it indicated to you in -- in any 19 terms as to why you were being asked so late after the 20 shooting to be examining the factors that you were asked 21 to examine? 22 A: There wasn't any specific information 23 given to me in that regard, no. 24 Q: No. You indicated quite frankly, and 25 this is quite obvious, that your examination of the

1 issues that you examined was very much after the fact, 2 and that's by definition, the case with your having been 3 approached. 4 I'd like to ask you some questions going 5 back to the period of time, the mid-'90's, when Dudley 6 George was shot. 7 Your testimony was -- was very clear and 8 compelling about the -- the lack of difference that there 9 might have been had certain circumstances been more 10 optimal in Dudley George being transported, based on the 11 clinical evidence from the United States and elsewhere; 12 is that correct? 13 A: That's correct. 14 Q: That conclusion is very much based on 15 the pon -- the specific injuries that were suffered by 16 Dudley George and -- and in particular, their severity; 17 is that correct? 18 A: Difficult to answer yes or no, and 19 the reason is that it is partly based on that, but also 20 on the general experience with persons who suffer 21 traumatic cardiopulmonary arrests before getting to 22 hospital. 23 So, broadly -- so that population of 24 patients who have that, so, yes. He had devastating 25 injuries, but in addition he had this -- he had a cardiac

1 arrest and that unfortunately was -- is correlated with a 2 very poor outcome. 3 Q: Now -- thank you. And now building 4 on that answer, can you envisage circumstances involving 5 trauma of various kinds and serious trauma occurring in 6 circumstances such as took place at Ipperwash Park -- 7 Park, resulting in the shooting of Dudley George, and 8 serious trauma to at least one (1) other person. 9 Can you envisage circumstances in which 10 improved conditions of transport and communication might 11 have made a significant difference to the survival or 12 outcome that occurred with respect to injured people? 13 A: The -- the answer is a qualified yes. 14 Q: Could you expand why -- 15 A: Certainly. 16 Q: -- why you're giving us a qualified 17 yes? 18 A: This -- well, the -- the best analogy 19 that we have is Military operations. And we know that 20 from Military medicine, that the provision of it, early 21 and advanced surgical care, near the battlefield, can 22 result in improvements in survival. 23 And that's been demonstrated in every war, 24 which sadly continue to happen, throughout the twentieth 25 century; and in every conflict -- major conflict -- that

1 occurred from World War I, World War II and so on, the 2 survival rate of individuals wounded in battle improved. 3 However, there are -- this is why it's a 4 qualified yes, there are certain injuries which have not 5 benefited tremendously from that kind of care, and one 6 (1) of them is major penetrating thoracic injury. So, if 7 you're asking about penetrating trauma to the torso, the 8 answer is probably not a significant difference, even 9 having advanced people there, but other injuries, yes. 10 So, major injuries to limbs and vessels 11 outside the chest can benefit from that kind of care. 12 So, in the specific of Mr. George's injuries, I don't 13 think things could have been dramatically different, but 14 there would be a benefit overall to having appropriate 15 medical care, at the scene of a conflict, where injury 16 might be likely to occur. 17 Q: Now, you've referred to a body of 18 knowledge arising out of scenes of conflict. This body 19 of knowledge is not as -- as you indicated a new body of 20 knowledge? 21 A: That's correct. 22 Q: Now, where one was preparing, in a 23 given context, with the assembly of armed personnel and 24 the machinery of the infliction of injury, it would not 25 be unreasonable to expect, in your view would it not, to

1 anticipate that injuries of a variety might occur that 2 would -- would benefit from the kind of attention that 3 you've just talked about? 4 A: I would agree with that. 5 Q: Thank you, those are all of my 6 questions, Commissioner. 7 COMMISSIONER SIDNEY LINDEN: Thank you. 8 MR. ANDREW ORKIN: Thank you, Dr. 9 McCallum. 10 COMMISSIONER SIDNEY LINDEN: Yes, Mr. 11 Rosenthal? 12 13 (BRIEF PAUSE) 14 15 CROSS-EXAMINATION BY MR. PETER ROSENTHAL: 16 Q: Good morning, Dr. McCallum. 17 A: Good morning. 18 Q: My name is Peter Rosenthal, I'm the 19 Counsel for some people from the Stoney Point First 20 Nation of the name Aazhoodena, and George Family Group. 21 I'd like to ask you about several areas, briefly. 22 One (1) issue that's arisen in the course 23 of this inquiry, is the fact that, on the scene, or near 24 the scene of the shooting, there was a St. John's 25 Ambulance vehicle, labelled as such, but that was being

1 used by the police as a command centre, as a 2 communication centre; and that -- we've heard evidence 3 that some of the First Nations people resented that fact 4 when they found out about it afterward. 5 You have background as a -- a physician 6 associated with the Military, as well as other areas, 7 according to your CV. It's my understanding that in 8 Military situations, there's a notion that ambulances -- 9 Red Cross and so on -- should be labelled separately, and 10 should never participate in Military operations, so that 11 everybody knows they're medical not Military people; is 12 that fair to say? 13 A: That really -- I -- I don't know a 14 lot about that in this particular context, it goes beyond 15 the scope of my expert review. 16 Q: I see. So, you can't assist us as to 17 whether -- do you have a personal view as to whether a 18 vehicle labelled medically, like an ambulance, should be 19 used for pure police operation? 20 COMMISSIONER SIDNEY LINDEN: Yes, just a 21 minute, Mr. Rosenthal, Ms. Vella and Ms. Tuck-Jackson -- 22 MS. SUSAN VELLA: Commissioner, this 23 Witness has been qualified as an expert witness to assist 24 the Commission with respect to scientific issues that 25 would be beyond the realm of a layperson's knowledge.

1 In my respectful submission, it is not 2 appropriate to ask this witness for his personal views, 3 in that they will not assist the Commission in making its 4 findings of facts in that regard. 5 COMMISSIONER SIDNEY LINDEN: Do you have 6 any other -- 7 MR. PETER ROSENTHAL: We can move on. 8 COMMISSIONER SIDNEY LINDEN: Yeah, that's 9 fine. 10 11 CONTINUED BY MR. PETER ROSENTHAL: 12 Q: Let's move to some of the medical 13 details that you've discussed. 14 As you indicated, the total amount of 15 blood loss, that Mr. Dudley lost, was not so much that 16 one would have necessarily expected death from it; is 17 that fair to say? 18 A: Yes, due to the amount or volume. 19 Q: Yes. And you indicated that perhaps 20 one (1) explanation for his death in spite of, normally, 21 not such a huge amount of blood loss, was that it might 22 have been lost very quickly. 23 But could another aspect of it be the fact 24 that it was the pulmonary artery that was injured, and 25 the pulmonary artery plays a very important role in

1 delivering oxygen to the body? 2 A: I don't think that would have been a 3 plausible explanation from my -- in my respectful view 4 because the -- the pulmonary -- there was only one -- 5 there were two (2), I gather, two (2) injuries to the 6 pulmonary arteries. 7 There were still two (2) other pulmonary 8 arteries which were not injured, and they would have been 9 perfusing the -- the lung, if that's what you're getting 10 at. 11 However, one can't -- this is -- this is a 12 system, it's not -- you can't take in isolation. So yes, 13 it would have been a factor. 14 Q: Yes. Yes, as you indicated in spite 15 of the knowledge that we do have in the human body, 16 there's a lot that we don't know, and there's a lot 17 that's quite speculative in these areas, right? 18 A: Very true. 19 Q: Now with respect to the lividity that 20 was reported by the nurse, it doesn't appear to have been 21 reported by either of the doctors, as far as I 22 understand, is that correct? 23 A: Nothing that I saw or -- or read 24 indicated that they took note of it. 25 Q: And so she indicated that she based

1 that on her observation of Mr. George as she was taking 2 him -- helping to take him from the car in which he was 3 delivered to the hospital. She may or may not have been 4 accurate in that, is that fair to say? 5 A: I -- I couldn't venture an opinion in 6 that respect. 7 Q: Now the question of the left 8 descending artery being 75 percent occluded? 9 A: Yes. 10 Q: As I understood your evidence, you 11 indicated that might have played a role, but would you 12 agree that the pathologist who did the autopsy determined 13 that, in his view, it was not relevant to the cause of 14 death? 15 A: I think that's true and I believe 16 that he was basing -- pathologists are applied 17 anatomists; they're not physiologists. And so, 18 therefore, he would have been in a position only to 19 comment on what he actually saw in front of him. 20 Q: Yes. 21 A: Whereas, my role is to look at it 22 both from the standpoint of what was found at postmortem, 23 but also what one would be able to reasonable deduce 24 based on the evidence before us. 25 Q: Yes.

1 A: So my view is that the -- Mr. 2 George's heart was, by virtue of this narrowing in his 3 heart, not capable of producing the intense effort that 4 an athlete's heart, for example, would be. 5 And therefore his ability to withstand 6 this tremendous physiologic insult wouldn't be good as 7 someone who is in say -- 8 Q: But would it not have been the case, 9 that if the occlusion of the coronary artery played a 10 role, in the way that you're suggesting, the role that it 11 would've played would have been to have induce 12 thrombosis, a heart attack, right? 13 A: No. That's not how it would have 14 worked. 15 Q: Isn't the fact of occlusion of 16 coronary arteries, the danger from that in general is 17 heart attack, right? 18 A: The danger from the cardiovascular 19 standpoint is, but it also reduces the capacity of the 20 heart to respond to increased physiologic demand; that's 21 why people for example who have coronary disease get 22 angina when they exert themselves; this is a form of 23 exertion, the response to shock is a form of exertion, 24 and that's what I was alluding to. 25 Q: A very large number of -- a very

1 large percentage of people have 75 percent occlusion of 2 the left coronal artery, isn't that correct? 3 A: It's not rare. That's correct. 4 Q: A very large number of people, even 5 Dudley George's age, there was -- 6 A: Absolutely. 7 Q: -- a veteran study and so on? 8 A: Yes. 9 Q: But no -- no obvious symptoms of any 10 kind? 11 A: But this is not a normal situation, 12 of course. This is a situation where there's profound 13 physiologic effect occurring, and that's the difference. 14 And I -- I wouldn't want anybody on the Commission to 15 misinterpret me as saying that Dudley George died of a 16 heart attack. He did not. 17 Q: No. 18 A: And I hope that that's not the 19 conclusion that's been drawn. 20 Q: Yes. 21 A: It's simply to say, that the 22 physiologic effect of the -- of the haemorrhage would 23 have been more deleterious in him than it might have been 24 in someone had no coronary disease. 25 Q: I see, okay. So it might have played

1 a small role, is that fair to say? 2 A: Assessing the contribu -- degree of 3 contribution, I think, is impossible. 4 Q: Yes. Now you've made a 5 recommendation that advance paramedics with life support 6 capabilities should be available in such circumstances. 7 A: That's correct. 8 Q: And in particular they would have -- 9 such medics would have available IV possibilities, and 10 oxygen possibilities, but you've told us that you don't 11 think, in this particular case, that it wouldn't have 12 made a difference. 13 And if I understood your evidence 14 correctly, that's because of the fact that he suffered 15 cardiac arrest. 16 But would you not agree that it's 17 possible, it's hard to quantify the probabilities, but 18 it's possible, that if he had received such advance 19 paramedic care, soon after he was shot, from an 20 ambulance, that he might not have gone into cardiac 21 arrest as quickly as he did, and he might have arrived at 22 the hospital before cardiac arrest? 23 A: The answer to that is no. And the 24 reason is that the type of injury that Mr. George had 25 suffered was one that was devastating and -- and if one

1 believes Bickell's work, providing increased blood flow 2 to it would increased his haemorrhage, and would have 3 been ultimately harmful. 4 And there certainly wouldn't have been a 5 clear benefit. And this is again -- I recognize that 6 there will be experts that could testify here who might 7 give an opposite opinion, and the reason is that it's 8 controversial. 9 I think the important message is, one 10 can't be sure that provision of IV fluids, for example, 11 would have resulted in a benefit to Mr. George; I can't 12 conclude that. 13 Q: No, you can't be sure of anything in 14 this matter, but in Bickell's study, it was a statistical 15 study, of course, of a large number of patients -- 16 A: Correct. 17 Q: -- as I understand it. And as I 18 understand it, they speculate, at least, that one (1) of 19 the reasons, that in some cases inserting extra fluid 20 might have deleterious effects, rather than beneficial 21 effects, is because it could stop the clotting that would 22 take place and -- and therefore increase the blood loss, 23 is that correct? 24 A: That's correct, yes. 25 Q: However, we know for -- of course, it

1 wouldn't have been known until autopsy, but we know from 2 the autopsy, that in Dudley George's case, the wound was 3 such that there wouldn't have been any beneficial effect 4 from clotting in any event, right? 5 A: Oh, I don't think we can conclude 6 that. 7 Q: We can't conclude that? 8 A: No, we cannot. 9 Q: I -- I thought you said that earlier 10 in your testimony... 11 A: No, I think that the -- the effect of 12 clotting in large holes in vessels is significantly bene 13 -- is significantly less. 14 Q: Significantly less? 15 A: But there's also true -- it's also 16 true, that you're looking at the clotting in isolation, 17 you have to look at the constriction of vessels as well, 18 and the -- and the potential for increasing bleeding as a 19 result of dilating the vessels when giving the fluid. 20 So that's the -- that also must be 21 considered. 22 Q: Yes. But isn't it reasonable to say, 23 that it's likely that, given the nature of his wound, of 24 Dudley George's wound, that at least some of the negative 25 effects of infusion of fluids, that Bickell was talking

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1 about, might not have been present in that case? 2 A: No, I don't think so because those -- 3 those -- those victims, in his study, had injuries that 4 were not dissimilar to Mr. George's; they had penetrating 5 injuries to the chest. It would have involved the 6 pulmonary arteries and I can't say how many would have -- 7 Q: Yes. 8 A: But broadly speaking, the injuries -- 9 there's no discrimination in a projectile that traverses 10 the chest, obviously. 11 Q: Yes -- 12 A: So they would have had the same kinds 13 of injuries, and therefore I think that one couldn't 14 conclude that your hypothesis -- 15 Q: Among the -- 16 A: -- is correct. 17 Q: Well, let me just pursue that a bit 18 further. Do -- wouldn't you agree that among the 19 patients studied by Dr. Bickell, there were likely some 20 with wounds similar to Dudley George's in the sense of 21 similar blood vessels, and other -- other blood vessels; 22 we don't know the distribution, as you indicated. 23 Is that correct? 24 A: Yes, I would agree with that. 25 Q: And therefore, it could be,

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1 conceivably, a further statistical breakdown of Dr. 2 Bickell's patients and a further discrimination as to 3 which ones did benefit and which ones did not benefit by 4 IV infusion? 5 A: Well, we -- unfortunately we don't 6 have that information -- 7 Q: Yeah. 8 A: -- and -- and the other problem, one 9 would get into, is the smaller the sample size, the less 10 one can conclude about it, as you know. 11 Q: Absolutely. Now, Mr. Orkin was 12 asking you about the fact of your -- doing your 13 investigation in the year 2003, of events that had 14 happened in September of 1995. 15 And we've, of course, had many witnesses 16 at this inquiry about those events, and they all have the 17 problem that it's ten (10) years later. 18 Were you told, when you began your 19 investigation in 2003, why the Coroner's Office had not 20 done an investigation many years earlier? 21 A: I wasn't privy to that information. 22 Q: Now, you're a regional Coroner among 23 other -- 24 A: Other -- 25 Q: -- many other responsibilities you

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  1  have, and one of your responsibilities is determining
  2  whether or not to call an inquest in various situations;
  3  is that fair?
  4                 A:   That's correct. 
  5                 Q:   Now the -- my understanding is that
  6  the origins of the coroner system, hundreds of years ago
  7  in England, were that -- with the notion that if someone
  8  dies at the hands of the authorities, there should be a
  9  public investigation into that death.  
 10                 Is that the -- fair and accurate
 11  description?
 12                 A:   That's correct, yes.
 13                 Q:   And it was clear from news reports,
 14  on September 7, 1995, that Dudley George had died at the
 15  hands of public authorities; is that fair?
 16                 A:   That's fair.
 17                 Q:   And can you give us any explanation
 18  as to why the Coroner's Office did not do it, a proper
 19  investigation, and decide to hold an inquest prior to
 20  2003?
 21                 COMMISSIONER SIDNEY LINDEN:   Just a
 22  minute, before you answer the question, Mr. O'Marra has a
 23  objection. 
 24  
 25                        (BRIEF PAUSE)

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1 MR. AL O'MARRA: As I think My Friend 2 will see, from Dr. McCallum's curriculum vitae, that he 3 was not a coroner until 2000, and not a regional 4 supervising coroner until 2003, so he wouldn't have been 5 part of the Office of the Chief Coroner when any 6 decisions were made, or review of this particular 7 fatality. 8 MR. PETER ROSENTHAL: Yes, he may -- may 9 not, nonetheless, be able to answer my question from what 10 he's learned, but -- 11 COMMISSIONER SIDNEY LINDEN: You can ask 12 him if he knows anything about it, but I assume -- 13 MR. PETER ROSENTHAL: Excuse me, sir? 14 COMMISSIONER SIDNEY LINDEN: -- I'm 15 assuming that he doesn't, but you better ask him the 16 question. 17 18 CONTINUED BY MR. PETER ROSENTHAL: 19 Q: Yes, so in spite of your Counsel's 20 interjection, do -- do you have any information that 21 would assist us in understanding that? 22 A: No. 23 Q: Now, in the Coroner's Act, are there 24 still mandatory inquests? 25 A: There are.

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1 Q: And is it mandatory that there be an 2 inquest into a death that occurs while the person is 3 detained or in actual custody of a police officer? 4 A: There is; that is mandatory, yes. 5 6 (BRIEF PAUSE) 7 8 Q: Thank you very much, sir. Thank you. 9 COMMISSIONER SIDNEY LINDEN: Thank you, 10 Mr. Rosenthal. I think Mr. Henderson is up next? 11 12 (BRIEF PAUSE) 13 14 CROSS-EXAMINATION BY MR. WILLIAM HENDERSON: 15 Q: Good morning, Dr. McCallum. 16 A: Good morning. 17 Q: My name is Bill Henderson and Mr. 18 John George and I represent the Chippewas of Kettle and 19 Stony Point. 20 Just a few questions in -- in relation to 21 your findings and I apologize to the members of the 22 George Family who are here who've probably heard all too 23 much about this, but when you did your assessment in 24 relying on the -- the autopsy that was done, you -- you 25 found that there was one (1) litre of blood in the left

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1 chest cavity? 2 A: That is what I -- what was related to 3 me in the report of the autopsy, correct 4 Q: And, it doesn't seem like -- and I 5 believe you -- you pointed this out, it doesn't seem like 6 a large amount of blood, for example, if one were to 7 donate blood, what used to be called a pint of blood, 8 that would be roughly half of that volume? 9 A: That's right. 10 Q: And, you indicated that the -- your 11 advice in that connection was that it was the rate of 12 loss and not the quantity of loss? 13 A: That's correct. 14 Q: The -- there was, as you -- as you 15 pointed out, a penetrating wound to the thoracic cavity, 16 would pneumothorax have been a factor in this at all? 17 A: Well, my -- my -- it -- it could have 18 been and it's one (1) of the concerns in an injury like 19 this, but my understanding was that when Mr. George's -- 20 at autopsy was not found in the pneumothorax and it 21 would have been one (1) of the potential causes, but it 22 wasn't found in this case to my knowledge. 23 Q: And the indicator of that would have 24 been a collapsed lung? 25 A: Either a collapsed lung and/or when

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1 the chest was opened the -- the escape of air, which is - 2 - the pneumothorax by itself is not the problem, it's a 3 tension pneumothorax or pressure -- air under pressure. 4 Q: Hmm hmm. 5 A: That's, incidently, much more common 6 with a stab wound than it is with a gunshot wound, but 7 that -- that wasn't found in any case. 8 Q: Thank you. And so the presence of 9 the fluid in -- in the chest itself wouldn't have been a 10 contributing factor, it's the fact that the fluid came 11 out of the -- 12 A: Correct. 13 Q: -- circulatory system? 14 A: That's right. The -- the circulatory 15 effect was the more important one. 16 Q: You indicated that it would have 17 been, of course at the outset, seeing a penetrating 18 wound, the compression that was in fact, applied, would 19 have been relevant to a pneumothorax if that was a 20 factor. 21 So, in that sense, it was a proper thing 22 to do? 23 A: I may have misstated if I said that. 24 It was a proper thing to do, first of all -- 25 Q: Yes.

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1 A: -- but it wouldn't have been a factor 2 in pneumothorax. 3 Q: It wouldn't? 4 A: It would not have any negative affect 5 on a pneumothorax or any positive affect, for that 6 matter. 7 Q: Okay. I -- I apologize for my 8 confusion on that, I thought that if there was -- if 9 there is an open chest wound that controlling it was a 10 first aid measure or -- 11 A: You're -- you're thinking of a 12 sucking chest wound or a wound where -- where air is 13 being entrained through the wound with respiration -- 14 Q: Yes. 15 A: -- and -- and which is not the 16 situation here as I understood what -- what had happened. 17 Q: And again, you would distinguish 18 between a projectile and a stab wound or something of 19 that nature? 20 A: Actually, in -- in -- a sucking chest 21 wound is typically -- it's evident to everybody that -- 22 that air is being sucked in; one can hear it. It's quite 23 -- it's quite audible, although again, this was in a very 24 loud environment, obviously, the back of a car. 25 Q: Thank you, Doctor. In relation to

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1 ventilation, you had indicated that is important, but not 2 necessarily oxygen? 3 A: No, the -- the -- I wouldn't want -- 4 again, I may -- I may have been misinterpreted. 5 Ventilation is important, the provision of 6 adequate oxygen is also important. The addition of 7 supplemental oxygen is thought to be, and it's 8 intuitively obvious that that's a good thing to do, but 9 in fact, one cannot over-saturate haemoglobin. 10 In other words, if you -- if you provide 11 oxygen up to 100 percent, the haemoglobin only gets so 12 saturated with oxygen; it doesn't go beyond that point. 13 So, the more important phenomenon is replacing lost red 14 cells -- red blood cells. He's going to need more of 15 them, fully saturated with oxygen. 16 Full saturation of oxygen occurs at room 17 air, at the haemoglobin level. 18 Q: Yes, so when you -- if I remembered 19 your words, you said the -- the studies have not shown 20 the beneficial aspects of supplemental oxygen, but 21 ventilation is important because ambient air contains 22 sufficient oxygen. 23 A: It is standard procedure to give 24 supplemental oxygen, but it is now impossible to evaluate 25 whether it makes a difference or not, because one

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1 couldn't ethically withhold it from a person at this 2 point. 3 Q: So, ventilation in the sense of 4 assisted respiration -- 5 A: Correct -- 6 Q: -- from ambient air is just as 7 essential? 8 A: -- essential, that is right. 9 Q: And, it's -- it's more effectively 10 done if it can be done through an endotracheal tube? 11 A: That's right. 12 Q: Now, we've heard evidence that the 13 ambulance attendants who were on duty that night were not 14 trained to put in an endotracheal tube. 15 Is that a -- a normal situation as you 16 understand it in rural parts of Ontario? 17 A: It certainly was in 1995. It is 18 still the norm in many parts of Ontario. There are, 19 however, increasingly paramedics who have those skills 20 deployed in smaller communities and even in rural 21 settings now in 2005. 22 Q: Thank you. I -- I believe there was 23 evidence to that effect as well, Commissioner, and also 24 in relation to the administration of an intravenous, even 25 starting a saline solution; I believe the evidence was

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1 that the ambulance attendants in this area would not 2 introduce an intravenous line into any patient that they 3 were transporting? 4 A: That's my understanding as well. And 5 if I might, just for the benefit of -- of the Commission, 6 just outline that putting in endotracheal tubes and 7 starting intravenous infusions are both kinesthetic 8 skills. In other words, they involve manual dexterity 9 and they also involve intellectual knowledge of what 10 needs to be done. They are perishable skills. 11 In other words, unless used regularly, the 12 ability to do it declines and the problem with volunteer 13 ambulance services in smaller community settings is the 14 maintenance of skills. 15 One can teach paramedics to do this, but 16 maintaining their skills and -- and being able to 17 continue to do it can be very problematic because they 18 simply don't get the opportunity to do it enough and that 19 continues to be a challenge across much of rural Ontario. 20 And it's an important consideration when one considers 21 the rural setting and -- and recommendations that should 22 be made for rural settings. 23 Q: I think that is helpful, Doctor, 24 because the -- the attendants who testified who were on 25 duty at that time indicated it is a training problem, but

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1 it's also, as you say, a perishability problem in terms 2 of those skills. 3 A: Correct. 4 Q: And that would be particularly the 5 case, if I understand it, in the case of the endotracheal 6 tube? 7 A: Correct. 8 Q: Which is a difficult procedure? 9 A: It can be challenging, yes. 10 Q: Thank you. We've been looking, this 11 morning, at the whole incident somewhat retrospectively 12 knowing -- having the benefit of your advice as to 13 various causes and factors and assuming that Mr. George 14 might have arrived where he did at Strathroy Middlesex 15 Hospital or even at a trauma centre. 16 If you were at the scene when the incident 17 occurred, or someone with advanced training for the 18 purpose, what procedures would you have carried out at 19 the scene? 20 A: I wouldn't have carried anything out 21 at the scene, I would have loaded him in the most 22 appropriate vehicle, ideally an ambulance, but -- 23 Q: Yes? 24 A: -- a vehicle and anything I would 25 have attempted to do would have been done en route.

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1 Q: And that would have been? 2 A: And that would have been to institute 3 an intravenous infusion. I would not have given large 4 amounts of fluid presuming I could arrive at the hospital 5 within a reasonable period of time. In my ideal 6 setting -- 7 Q: Yes. 8 A: -- that would have been by air 9 ambulance to a trauma centre. An -- an oral endotracheal 10 tube would have been inserted. In the reverse order, you 11 can do that first, then the IV. 12 As I mentioned in my earlier testimony 13 the reason you put the IV in is two (2); one is to secure 14 a vein -- a venous access, a way, ideally; two (2) would 15 be put in with large bore catheters and then fluid would 16 be infused. And that decision would be based on how long 17 it was going to take us to get to the hospital. 18 And the reason -- that's based on 19 Bickell's work and Bickell's work only applies, as we've 20 heard, to urban short transits. This is -- this was not 21 the case in this circumstance, obviously. 22 Q: And with respect to ventilation? 23 A: Assisting the ventilation is actually 24 a useful thing to do, because there is some evidence from 25 a -- from a variety of sources that that can improve

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1 survival outcomes broadly speaking, not just in this 2 group. 3 Q: So, you would do -- 4 A: But it would not be -- and this is 5 again, I want to stress, it's no panacea; it wouldn't 6 solve the problem if somebody's had a cardiac arrest. 7 Q: No, no. I'm not suggesting that, I'm 8 just asking -- 9 A: I just want to make sure. 10 Q: -- the procedures that you would 11 follow and, of course, if the situation were sufficiently 12 stable, you would -- you would go as far as an 13 endotracheal tube? 14 A: Yes. 15 Q: To -- to ensure adequate ventilation? 16 A: Yes. 17 Q: And would you do -- were there any 18 other therapies or measures you might take? 19 A: Well, the control of external 20 haemorrhage where possible -- 21 Q: Yes. 22 A: -- and of course that couldn't be 23 attained in Mr. George's case, but pressure over the area 24 where the bullet had entered was prudent and reasonable. 25 Stabilization on -- along a firm surface,

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1 ideally not a board, but that's what's used commonly now. 2 Q: Yes. 3 A: And again, I can't over-emphasize the 4 importance of rapid transport. 5 Q: All right, and maintaining body 6 temperature and other standard -- 7 A: Well, that's difficult to do. One 8 would like to think one could do that, but in fact it's 9 not very easy to do in the pre-hospital setting. 10 Q: Right. Again indicating that the 11 faster you can get to the trauma centre, the -- 12 A: I -- I became something of a 13 minimalist towards the end of my clinical career in pre- 14 hospital care. I believe that transport is the -- is 15 really the critical thing. 16 Q: With all speed essential? 17 A: Yes. 18 Q: In your supplementary report, I 19 believe you said that the suggestion of mottling or 20 lividity might have indicated an actual time of cardiac 21 arrest as much as thirty (30) minutes before arrival at-- 22 A: That's correct. 23 Q: -- the hospital? Was that the sole 24 factor that -- that suggested the minimal number of 25 thirty (30) minutes to you?

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1 A: No, the -- the absence of spontaneous 2 movement was important as well, prior to Mr. George's 3 vehicle arriving at the farmhouse, and I believe that 4 would also correlate with cessation of blood flow -- 5 Q: I see. 6 A: - and profusion of the brain. 7 Q: And again, if my memory serves me, 8 the advantage of having so many lawyers is that if my 9 memory is wrong, somebody will tell me. 10 I believe when the -- when the doctors 11 testified, they indicated that the -- the condition of 12 the pupils on arrival at the hospital was also an 13 indicator to them. 14 A: That was a -- that would -- the 15 absence of pupillary responses is a -- is important in 16 determining whether or not there were signs of life. 17 Q: Yes. 18 A: And as I -- I do believe, having read 19 -- I think it was Dr. Marr's transcript -- 20 Q: I believe it was, yes. 21 A: -- there -- that is, I agree with her 22 opinion that pupillary -- pupillary response persists for 23 some six (6) to ten (10) minutes after cessation of 24 circulation. 25 So that can establish a minimum period of

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1 time, but of course, pupillary response or fixation of 2 the pupils persists long after that as well, so that just 3 gives you the minimum time. 4 Q: All right, so in -- are there any 5 other factors? If I take that correctly, we would be 6 talking possibly a period of as little as six (6) perhaps 7 twelve (12), to thirty (30) minutes. 8 Are there any other factors -- 9 A: Well, I think that my opinion -- 10 Q: -- that might -- 11 A: -- is that it's closer to thirty (30) 12 minutes based on the -- based on the presence of the 13 mottling and based on the absence of movement at the 14 front of the farmhouse. So that -- that's my view. 15 Q: Fine, thank you doctor. Those are my 16 questions. 17 COMMISSIONER SIDNEY LINDEN: Thank you, 18 Mr. Henderson. 19 I think Mr. Falconer is next. 20 21 (BRIEF PAUSE) 22 23 CROSS-EXAMINATION BY MR. JULIAN FALCONER: 24 Q: Good morning, Dr. McCallum. Dr. 25 McCallum, my name is Julian Falconer and I act on behalf

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1 of Aboriginal Legal Services. 2 A: Good morning. 3 Q: Dr. McCallum, in answer to -- to 4 questions by Ms. Vella, you testified that the heart 5 condition or the condition the heart was found in, quote: 6 "May have been a factor in Mr. George's 7 case." 8 Do you remember giving that -- 9 A: That's correct, yeah. 10 Q: Now, you'd agree with me that a 11 forensic pathologist, when they do their work on a case 12 such as Dr. Shkrum in this case, one (1) of their jobs is 13 to analyse and opine on various aspects of the patient's 14 condition, and what factors may or may not have led to 15 death; yes? 16 A: That's correct. 17 Q: And I take it there may be a 18 constellation of factors that can lead to a death, and 19 it's the job of the forensic pathologist to identify 20 those; is that fair? 21 A: Yes. 22 Q: You, yourself, in doing the report 23 you did in February 2003 did not have access, of course, 24 to the -- the body of Mr. George or to any organs that a 25 person doing an autopsy would have access to; correct?

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1 A: That's correct. 2 Q: The forensic pathologist in this 3 case, Dr. Shkrum, he had those advantages of access to 4 the body; is that fair? 5 A: He did. 6 Q: And you'd agree with me that those 7 are very significant advantages, assuming the forensic 8 pathologist involved is qualified; correct? 9 A: I'm not sure I'd agree with that. 10 Q: All right, would you agree with this, 11 that Dr. Shkrum in his work in this case is not something 12 you'd question? 13 A: No. I would agree with that, yes. 14 Q: Right, and it's fair to say that in 15 terms of the information you learned in February 2003, 16 that Dr. Shkrum was of the view that in terms of any pre- 17 existing heart conditions, that he did not believe that 18 the cardiac findings contributed to the death; correct? 19 A: That's correct. 20 Q: And you -- all your comments aside 21 about the advantages of being an athlete et cetera, you'd 22 agree with me that you don't dispute Dr. Shkrum's 23 finding, do you? 24 A: I do not. 25 Q: All right. Mr. Rosenthal and his

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1 questions of you pointed out that since September 2003 2 you've been the Regional Supervising Coroner for Eastern 3 Ontario; is that right? 4 A: That's right. 5 Q: And your job in terms of the 2003 6 investigation by the Chief Coroner involved actually 7 receiving information from investigators that were 8 working on behalf of the Chief Coroner; yes? 9 A: That's right. 10 Q: And the investigators in this case 11 included an acting Detective Mark Armstrong and a 12 Detective Sergeant Roselli; is that right? 13 A: I -- I only met with Detective 14 Armstrong. 15 Q: All right. And you had access to 16 their statements and their reports? 17 A: Yes. 18 Q: And I take it's not unusual for a -- 19 for a coroner's investigation to proceed that way and 20 relying on police officers as coroner's constables? 21 A: Again, investigating officers, yes. 22 Q: And it's fair to say that that's 23 actually statutorily legislated under the Coroner's Act? 24 A: It is. 25 Q: And whether it's a -- the Peel

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1 Regional Police Service as it was in this case or another 2 municipal service or the Ontario Provincial Police; 3 that's standard, isn't it? 4 A: It is. 5 Q: And I take it it's fair to say that 6 for example in this case, because it involved the 7 shooting by the OPP, it's preferable that the 8 investigating officers assisting the coroner's 9 investigation be from another service; correct? 10 A: That's right. 11 Q: But having said that, it's not 12 unusual for the Coroner's office to rely on the Ontario 13 Provincial Police in the conduct of their investigations; 14 correct? 15 A: That's right. 16 Q: You'd agree with me that it's a 17 necessary part of the work that coroners do to actually 18 rely and develop good working relationships with the OPP; 19 isn't that right? 20 A: That's right. 21 Q: And in developing those good working 22 relationships with the OPP, it's essential that you trust 23 the work they do; right? 24 A: Yes. 25 Q: And so, routinely, you will rely on

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1 an investigator's work as a professional from the Ontario 2 Provincial Police; yes? 3 A: That's true. 4 Q: And as far as you're concerned, you 5 respect their work and you expect them to respect your 6 work; correct? 7 A: Yes. 8 Q: And would it be fair to describe 9 without overstating, that the OPP represents in -- in 10 many cases for investigations that the Office of the 11 Chief Coroner does, that the OPP represents a fundamental 12 piece of the puzzle in coroner's investigations? 13 A: They do. 14 Q: Thank you, sir, those are my 15 questions. 16 COMMISSIONER SIDNEY LINDEN: Thank you, 17 Mr. Falconer. 18 Ms. Jones...? 19 MR. JULIAN FALCONER: Oh, I'm sorry, 20 there's one (1) more. I apologize. 21 COMMISSIONER SIDNEY LINDEN: Oops. 22 MR. JULIAN FALCONER: Sorry, it's like 23 that Paul Drake thing in Perry Mason, you know. There's 24 just one more question. 25

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1 CONTINUED BY MR. JULIAN FALCONER. 2 Q: Mr. Orkin had asked you a question 3 about why -- what information you had for the length of 4 time between 1995 and 2003, the delay. 5 Do you remember he'd asked you about that? 6 A: Yes. 7 Q: And you said, I have -- I had no 8 specific reasons for the delay, do you remember saying 9 that? 10 A: Yes. 11 Q: I can't help myself. I have to ask 12 you, accepting you have no specific reasons, what about 13 general reasons? What was your general sense? 14 A: It was a -- it was a -- it was an 15 improper syntactical construction. I had no -- I had no 16 indication why I -- 17 Q: That's a pretty impressive phrase, 18 improper syntactical construction. I'm going to remember 19 it. 20 A: Some big words, I apologize. 21 Q: I appreciate that. So the bottom 22 line is at no time did you determine for yourself or 23 develop an opinion for yourself in your own mind as to 24 why the investigation would have been triggered at that 25 time?

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1 I don't mean a conclusive opinion, just 2 simply as an investigator you didn't determine in your 3 mind why it was -- 4 A: I -- I wasn't an investigator. I 5 think it's important to emphasize. I was an expert 6 witness asked to comment particularly on this aspect of 7 the medical care Mr. George received, and I did that. I 8 didn't have any other information. 9 Q: Fair enough. I appreciate your 10 assistance. 11 COMMISSIONER SIDNEY LINDEN: Thank you. 12 Ms. Jones...? 13 14 (BRIEF PAUSE) 15 16 MS. KAREN JONES: Good morning, 17 Commissioner. 18 COMMISSIONER SIDNEY LINDEN: Good 19 morning. 20 21 CROSS-EXAMINATION BY MS. KAREN JONES: 22 Q: Good morning, Dr. McCallum, my name 23 is Karen Jones and I'm one (1) of the lawyers for the 24 Ontario Provincial Police Association. 25 A: Good morning.

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1 Q: And, Dr. McCallum, I wanted to ask 2 you some questions that are in a bit of a different area 3 from what you've been dealing with in terms of Mr. 4 George. 5 You've talked about his resuscitation and 6 your views about resuscitation, but one (1) of the other 7 things that we know from Dr. Shkrum's report was that Mr. 8 George, through the course of his injury, had suffered a 9 broken clavicle, were you -- were you aware of that? 10 A: Yes. 11 Q: Yeah. And, Dr. Shkrum, when he was 12 giving evidence, had suggested that someone who had some 13 experience and expertise in emergency metal -- medical 14 care could be more appropriate than he in terms of 15 talking about that injury and what it means. And so I 16 wanted to take this opportunity to ask you a few 17 questions about that if you can help us with it. 18 And so, in terms of a broken clavicle, Dr. 19 Shkrum talked about the purpose a little bit of a 20 clavicle as -- as being the bone that connects the 21 shoulder to the body by way of -- by an attachment at the 22 sternum of the chest? 23 A: That's correct. 24 Q: And the purpose of the clavicle being 25 to keep the shoulder up and back?

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1 A: That's correct. 2 Q: Okay. And can you tell us, in your 3 experience, when someone presents in, for example, an 4 emergency department with a broken clavicle, what kind of 5 things might you see? 6 A: The -- the individual would complain 7 of pain in the collarbone area, typically -- 8 Q: Yeah. 9 A: -- giving an account usually related 10 to a fall -- 11 Q: Yeah. 12 A: -- often on the outstretched hand 13 and, on examination, one would observe that there's a 14 deformity typically of the -- of the collarbone, usually 15 manifesting as a hump or bump. Sometimes the shoulder, 16 itself, will be thrust forward because the strut of the 17 collarbone -- 18 Q: Right. 19 A: -- has been disrupted. 20 Q: But sometimes I take it, all you 21 could do is feel a bump in the area? 22 A: Yes, sometimes the -- the crack -- 23 Q: Yeah. 24 A: -- is not -- the -- the two (2) parts 25 of the bone are normally positioned.

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1 Q: Right. 2 A: The person would complain of 3 tenderness on palpation, often you may feel bony crepitus 4 or crackling when -- when palpating the area. Usually, 5 there is no associated injury, but there can be injury to 6 the great vessels or to the nerves underlying the 7 collarbone and one has to do an examination of the -- the 8 upper limb to determine whether or not those are present. 9 There's -- rarely, one can see a puncture 10 of the -- of the covering of the lung, the pleura and 11 pneumothorax, but that's very rare. And then the x-ray 12 that's taken usually, or ordered, it confirms the 13 presence of the -- of the injury. 14 Q: Okay. You've talked about people 15 coming in with -- with complaints of pain or discomfort 16 and I take it in your experience that the complaints can 17 range from not a lot of pain or discomfort to quite a 18 bit; it's really an individual response? 19 A: Usually, the -- usually, there's 20 quite a bit. 21 Q: Pardon me? 22 A: Usually, there is quite a bit of 23 discomfort associated with it. This is an injury that's 24 far more common in -- in children than in adults. 25 Q: Yeah.

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1 A: And usually the child will let you 2 know pretty quickly that it hurts a lot. 3 Q: Okay. And in terms of the effect of 4 a broken clavicle on range of movement, I understand that 5 one (1) movement that someone with a broken clavicle 6 would be restricted in, and I think it's sometimes called 7 "the suitcase sign" -- 8 A: Hmm hmm. 9 Q: -- is picking up a heavy object off 10 the floor with the affected arm or the arm on the 11 affected side? 12 A: Yes. Yes, that's -- 13 Q: The classic? 14 A: -- described. It's, to be frank, not 15 very useful clinically, but it does describe -- 16 Q: Yeah. 17 A: -- because we rarely ask people to do 18 that. 19 Q: I understand that. 20 A: They usually don't want to cooperate. 21 Q: Outside of that, I take it that so 22 long as there's no damage to the shoulder, itself, or to 23 the back, that -- that someone who had a broken clavicle 24 would have range of movement in their arm? 25 They would be able to, for example, move

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1 their arm away from their body -- 2 A: No. 3 Q: -- or towards their body? 4 A: No. They would -- they would have a 5 great deal of discomfort with any movement of the arm. 6 Q: Okay. 7 A: In fact, the -- the early treatment, 8 the first aid treatment is to put a sling on it and -- 9 and -- 10 Q: Okay. 11 A: -- by -- by so, immobilizing it. 12 Q: Okay. The restriction, though, as I 13 understand it, would be pain or discomfort not because, 14 for example, anatomically you weren't able to move your 15 arm? 16 A: It depends on what -- what's 17 happening with the fragments of bone -- 18 Q: Hmm hmm. 19 A: -- remember I said that the collar 20 bone acts as a strut -- 21 Q: Right. 22 A: -- so that when one is lifting one's 23 arm, there's a natural tendency for the shoulder to move 24 medially or towards the centre of the body -- 25 Q: Right.

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1 A: And if the collar bone is disrupted 2 and the two (2) ends are moving, that can happen. The 3 muscular attachments usually keep it in place, though. 4 Q: Right. 5 A: But there's a -- to do this for 6 someone with a fractured collar bone would be exquisitely 7 painful. 8 Q: Right. And -- and I -- so you're 9 talking about the movement that you're talking would be 10 painful would be raising an arm up with the elbow up? 11 A: Or -- or abducting or adducting -- 12 Q: Okay. 13 A: -- would be painful. Rotation would 14 not be so painful, but the fact is that it's difficult to 15 move the shoulder at all, make any range of movement with 16 the shoulder without moving and affecting the collar 17 bone. 18 Q: Okay. And again, in terms of pain, 19 one (1) of the things that Dr. Shkrum had talked about is 20 not only is there a range of sensation that different 21 people feel. So, for example, a person could have an 22 injury and report little or no pain with it, where 23 another person could have the same injury and experience 24 a lot of pain -- 25 A: That's correct.

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1 Q: -- so we talked about the experience 2 of pain as being very variable? 3 A: It is very variable. 4 Q: And he also talked about an 5 individual's response to pain as being variable as well, 6 depending on the circumstances. 7 A: Yes. 8 Q: For example, he said that there are 9 circumstances, and he said sports is one (1) example, 10 where people can have injuries and because of the 11 circumstances and the adrenaline and -- and what's going 12 on, they can move and act in a way that is much different 13 than they would in other circumstances? 14 A: That's true. 15 Q: And I take it that's something that 16 you've seen as well? 17 A: Oh, yes. 18 Q: Yeah, okay. Those are my questions, 19 thank you. 20 COMMISSIONER SIDNEY LINDEN: Thank you 21 very much, Ms. Jones. 22 Mr. O'Marra...? 23 24 (BRIEF PAUSE) 25

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1 MR. AL O'MARRA: Thank you, Commissioner, 2 just a few questions. 3 4 CROSS-EXAMINATION BY MR. AL O'MARRA: 5 Q: Dr. McCallum, just some questions of 6 you in your role as a coroner and as a regional 7 supervising coroner. 8 A little earlier in the Inquest, questions 9 were raised of Dr. Shkrum about the availability of his 10 postmortem report and when that becomes available, either 11 to family or to -- to public. 12 And in your role as a Regional Supervising 13 Coroner, can you advise us to as to your understanding of 14 the initial distribution of a -- of a postmortem report? 15 A: Well, the initial distribution is to 16 qualified persons as named under the Coroner's Act and 17 they broadly speaking, are the relatives of the deceased 18 person and the person's spouse, and they're made 19 available under the Coroner's Act, specifically to those 20 people. 21 Q: Okay. Now, in terms of the 22 postmortem report, when it's prepared as I understand it, 23 under Section 28 of the Coroner's Act, it goes to the 24 coroner, it goes to the Regional Supervising Coroner, 25 being the person in your position, the Crown Attorney and

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1 the Chief Coroner. 2 A: That's correct. 3 Q: Okay. And when you've indicated that 4 the distribution is to the family, am I correct in my 5 understanding that that's under Section 18(2) of the 6 Coroner's Act when it's been determined that an Inquest 7 is unnecessary? 8 A: That's correct. 9 Q: All right, and -- now I just want to 10 -- to turn to the question of -- of inquests. 11 You were asked as to whether they're 12 mandatory and the other form -- or discretionary 13 inquests? 14 A: That's correct. 15 Q: Okay, and what is your understanding, 16 if there is a -- a criminal offence charged arising out 17 of -- of -- out of the death? 18 Is the inquest called to a -- in a -- time 19 proceeding that being dealt with or after that's been 20 dealt with? 21 A: The inquest is called after -- after 22 the charges have been dealt with. 23 Q: I see. And in -- in this particular 24 -- and just dealing with the issues of investigation, 25 while the Coroner's Act provides for the assistance of

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1 either the local police or at the request of the Chief 2 Coroner, the Ontario Provincial Police to assist in the 3 investigation, you've experienced that in -- in 4 investigating cases as a coroner? 5 A: Yes. 6 Q: Okay. And what are those incidences 7 that involves fatalities and -- and the police are 8 involved; special investigations unit becomes involved 9 in the investigation? 10 A: That's -- that's correct. 11 Q: Okay. And you've been involved in 12 those investigations? 13 A: I have. 14 Q: Now with respect to the relationship 15 between the coroner and the special investigations unit, 16 do you direct their investigation; are they acting 17 investigators for you? 18 A: No. There's -- there's no statutory 19 relationship. 20 Q: No. And when they've completed -- or 21 when they're conducting their relationship do they -- or 22 investigation, do they report to you? 23 A: They do not. 24 Q: And if charges arise in those 25 circumstances, dealt with through the normal criminal

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1 proceedings, are -- are -- is there a reporting to you as 2 the coroner of -- of that process? 3 A: No. 4 Q: And once the criminal charges have 5 been dealt with -- well let's take it a step earlier. If 6 there's a SIU investigation and no criminal charges 7 result, do you have the benefit of the information 8 obtained during the course of that investigation? 9 A: For the purpose of investigating, yes 10 I do at that point. 11 Q: Once they've completed their 12 investigation? 13 A: Once the investigation's completed 14 and it's been deemed that there's no criminal 15 responsibility. 16 Q: And then that information is provided 17 to you so that you, in turn, can complete your 18 investigation into answering the five (5) questions with 19 respect to a person's death? 20 A: That's correct. 21 Q: Okay. And -- and perhaps even making 22 use of it for the benefit of determining whether an 23 inquest is to be called? 24 A: That's correct. 25 Q: Okay. And I take it that that's the

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1 same when the SIU investigation results in a criminal 2 charge and proceedings, we have -- 3 A: After the proceedings have concluded, 4 that's correct. 5 Q: So, it's only after those proceedings 6 are concluded that you get access to that information? 7 A: Yes. 8 Q: Okay. And are you aware of that 9 occurring in this particular instance? 10 A: I don't have any knowledge of what 11 happened prior to my -- 12 Q: Prior to your being asked? 13 A: -- asked to review the records. 14 Q: And so you had no knowledge of the -- 15 the coroner obtaining the SIU records after the trials 16 and appeals of Kenneth Deane? 17 A: That's not something I was privy to. 18 Q: Okay. But, you did have contact with 19 Detective Mark Armstrong? 20 A: Yes, I did. 21 Q: And he was -- were you aware that he 22 was a seconded police officer to the Office of the Chief 23 Coroner? 24 A: I was. 25 Q: Okay. And -- and he was assisting a

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1 regional supervising coroner in examining the 2 circumstances from the time of Mr. George's shooting to 3 his pronouncement of death? 4 A: That was my understanding, right. 5 Q: And Detective Armstrong was a member 6 of the Peel Regional Police Service. 7 A: That was my understanding, yes. 8 Q: And did you in -- in terms of any 9 information that you were provided with, have contact 10 with any members of the Ontario Provincial Police? 11 A: No. 12 Q: Now, just a couple -- just one (1) 13 further -- question in the area of -- of your 14 recommendations that you -- that you provided to the -- 15 the Commission. 16 You made reference to one (1) aspect about 17 rapid evacuation and -- and very use of air ambulances. 18 A: Yes. 19 Q: Okay. And I know that you've spoken 20 with me about this but perhaps we should canvas this as 21 well with the Commission; is there some limitation to the 22 use of -- of air ambulances? 23 A: There is. 24 Q: And can you just outline that just so 25 that --

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1 A: Sure. 2 Q: -- we're all aware of it. 3 A: Air ambulance is operated under what 4 are know as visual flight rules. They are not instrument 5 -- well they do have instrument capability but for the 6 purposes of responding to a scene, they would have to fly 7 under visual flight rules. 8 And of course they can't land at a scene 9 after dark unless they can see where they're landing. So 10 any scene call done by an air ambulance would have to be 11 done during either at an approved heliport under 12 Transport Canada's regulations or during daylight hours. 13 Q: I guess that -- that's the important 14 part; during daylight hours? 15 A: Correct. 16 Q: Now, again, with respect to your 17 recommendations, in your role as -- as heading up 18 Emergency Department and being chief at a -- at a major 19 medical centre, did you ever engage in emergency 20 planning? 21 A: Yes, I did. 22 Q: Okay. And is that outside of the 23 hospital and with other agencies? 24 A: Yes, I did. 25 Q: Okay. And did you ever engage in

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1 emergency planning with police services who may have been 2 involved or expected to be involved in -- in public order 3 events? 4 A: I did, in 1995, with the Metropolitan 5 Toronto Police. 6 Q: Just tell us a little bit about that, 7 if you would. 8 A: The -- there was a joint initiative 9 to link paramedics to emergency tactical units, or the 10 emergency tactical unit with the -- with the Metropolitan 11 Toronto Police, because that arose pursuant to an 12 incident where there was felt to be not ideal medical 13 support to a shooting incident that occurred in downtown 14 Toronto. 15 And as a consequence of that meeting, a 16 program was developed where certain paramedics who met 17 the certain requirements, particularly physical fitness 18 requirements, were trained to operate in close proximity 19 to the emergency tactical force and to provide medical 20 support to operations that they were undertaking. 21 Q: Okay. Now, I take it that with 22 respect to that kind of program that the expectation 23 would be that these would be highly trained paramedics 24 who would be on call on an ongoing basis? 25 A: That's correct. They would be --

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1 they would have regular duties as paramedics, but in 2 addition, they would be available to support the ETF when 3 needed. 4 Q: Okay. Aside from that particular 5 specialized program, do you have any views as to benefit 6 of -- of police services engaging in, sort of, pre-event 7 planning with their local medical centres or emergency 8 responders if they have advance knowledge that they're 9 going to be involved with some form of event that could 10 result in a confrontation where there may be injuries? 11 A: I think it's sensible to do that. 12 Q: And is there any reason why that 13 could not take place in -- in a rural environment as 14 opposed to an urban environment. 15 A: No, there's no reason why it can't be 16 generalized to the rural environment. 17 Q: Okay. Thank you very much, Dr. 18 McCallum. 19 COMMISSIONER SIDNEY LINDEN: Thank you, 20 Mr. O'Marra. 21 Yes, Ms. Vella...? 22 MS. SUSAN VELLA: Just a couple of 23 questions in reply -- re-examination, I should say. 24 25 RE-DIRECT-EXAMINATION BY MS. SUSAN VELLA:

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1 Q: Mr. Falconer suggested to you that -- 2 that you accepted Dr. Shkrum's opinion in full as to the 3 causes of death or the cause of death of Dudley George, 4 and you agreed with that. 5 I believe you indicated earlier in your 6 testimony, however, that Dr. Shkrum's scope of assessment 7 was restricted by his field of expertise, by what he 8 could see; is that correct? 9 A: That's correct. 10 Q: And so -- and, of course, you brought 11 a different discipline to the examination of the 12 potential contributory causes of death when you looked at 13 this matter? 14 A: That's what I attempted to do. 15 Q: And therefore, by suggesting as you 16 have, that a possible contributing factor to the cause of 17 death may have been, essentially, a clogging of arteries? 18 A: Yeah. And to state it plainly, the 19 cause of death was a gunshot wound. 20 Q: Yes. 21 A: However, Mr. George's ability to cope 22 with that physiologic insult might have been affected by 23 his cardiac status. 24 Q: In other words, this might have been 25 an aggravating factor?

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1 A: Yes. 2 Q: And in so identifying this as a 3 potential aggravating factor, you are not in any way 4 disputing Dr. Shkrum's conclusions or opinions; is that 5 fair? 6 A: That's correct. 7 Q: And Ms. Jones asked you some 8 questions concerning the capabilities of individuals with 9 broken clavicles and I wonder if you are able to provide 10 us with any opinion concerning -- given the nature and 11 extent of Dudley George's broken clavicle whether someone 12 with that type of injury would likely be able to pick up 13 a rifle from the ground? 14 A: I -- I think it -- I'm not sure I 15 could comment on that, to be honest. 16 Q: All right. Fair enough. You 17 indicated that, in any event, this type of injury would 18 likely generate some degree of pain? 19 A: Yes, I believe it would. 20 Q: And in your experience, would the 21 degree of pain in typical situations constitute an 22 effective barrier restricting the movement of that 23 person's arm? 24 A: I believe it would after the fact. I 25 think, though, it's important to bear in mind the fact

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1 that in warfare and in sports it's known that there -- 2 there are people who can carry on relatively normal 3 activities in the face of injuries that should cause 4 great pain, but aren't perceived immediately. 5 Q: All right. Thank you. That 6 concludes my re-examination. I want to thank you very 7 much, Dr. McCallum, for coming today and sharing your 8 opinion and evidence with the Commission. 9 COMMISSIONER SIDNEY LINDEN: Thank you 10 very much, Dr. McCallum. 11 12 (WITNESS STANDS DOWN) 13 14 COMMISSIONER SIDNEY LINDEN: I think 15 we're going to take an early lunch, right? 16 MS. SUSAN VELLA: Yes, Commissioner. As 17 is the plan to commence with the examination-in-chief of 18 Deputy Commissioner Carson after lunch today. 19 COMMISSIONER SIDNEY LINDEN: Should we 20 adjourn to 1:00 or 1:15? Does it make a difference? 21 MS. SUSAN VELLA: I would suggest 1:15. 22 COMMISSIONER SIDNEY LINDEN: Okay. We'll 23 adjourn now for lunch until 1:15. 24 THE REGISTRAR: This Inquiry stands 25 adjourned until 1:15.

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1 --- Upon recessing at 11:45 a.m. 2 --- Upon resuming at 1:16 p.m. 3 4 THE REGISTRAR: This Inquiry is now 5 resumed. Please be seated. 6 MR. DERRY MILLAR: Good afternoon, 7 Commissioner. The Commission's next witness is Deputy 8 Commissioner John Carson. 9 COMMISSIONER SIDNEY LINDEN: Good 10 afternoon, Deputy Commissioner. 11 THE REGISTRAR: Good afternoon, Mr. 12 Carson. Do you prefer to swear on the Bible, sir, or 13 affirm? 14 DEPUTY COMMISSIONER CARSON: Yes, please. 15 THE REGISTRAR: The Bible. Take it in you 16 right hand please, and would you give us your full name 17 for the record please? 18 DEPUTY COMMISSIONER CARSON: John 19 Frederick Carson. 20 THE REGISTRAR: Thank you, sir. 21 22 JOHN FREDERICK CARSON, Sworn: 23 24 EXAMINATION-IN-CHIEF BY MR. DERRY MILLAR. 25 Q: Deputy Carson, I understand that you

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1 joined the Ontario Provincial Police in 1978, is that -- 2 A: That's correct. 3 Q: And you're assigned to the Manotick 4 Detachment? 5 A: Correct. 6 Q: And you were conducting general 7 police duties in the Manotick Detachment? 8 A: Yes, sir. 9 Q: And at -- Commissioner, at Book 2, 10 there's a number of books, the black book in front of 11 you, Book 2, Tab 38. There's a curriculum vitae, and 12 that's your curriculum vitae, Deputy Carson? 13 A: Yes, sir. 14 Q: And perhaps we could mark that as the 15 next exhibit. 16 THE REGISTRAR: P-396, Your Honour. 17 COMMISSIONER SIDNEY LINDEN: P-396. 18 19 --- EXHIBIT NO. P-396: Curriculum vitae of Deputy 20 Commission John Frederick 21 Carson. 22 23 CONTINUED BY MR. DERRY MILLAR: 24 Q: And from 19 -- December 1982, to 25 August 1985, you were with the White River Detachment; is

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1 that correct? 2 A: That's right. 3 Q: And can you tell us a little bit 4 about what you did in White River, and the nature of your 5 duties in White River? 6 A: I was a Provincial Constable General 7 Law Enforcement Officer at White River doing general 8 routine police duties for the Town of White River, and 9 the surrounding area, and the Trans Canada Highway. 10 Q: And as a constable at the White River 11 Detachment, did you have any interaction with the First 12 Nations? 13 A: Yes. In White River, a large segment 14 of the population was First Nations, as well as, just 15 beyond the limits of White River, was a First Nations 16 territory of Pickmovert (phonetic) and it was rather 17 customary that we would be working with First Nations 18 people as a matter of course. 19 Q: And I wonder if you could pull that 20 mic a little closer to you because I -- people may be 21 having trouble picking it up. Thank you. And then from 22 1985 to 1989 you were a Corporal and Shift Supervisor at 23 the Chatham Detachment? 24 A: Yes, sir. 25 Q: And can you just tell us a little bit

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1 about your duties as a corporal in Chatham? 2 A: I was a Shift Supervisor, in Chatham, 3 responsible for a platoon of officers. And as a 4 supervisor, I would be responsible for the overall 5 operations of a particular shift, at any given time, and 6 responsible for the policing duties, for the most part, 7 across Kent County, not within the municipal 8 jurisdictions of Chatham, Wallaceburg, or Tilbury. 9 Q: And as part of your duties, at the 10 Chatham Detachment, did you interact with the 11 Moraviantown of First Nation? 12 A: Yes, the Moravian First Nation's 13 territory was within our jurisdiction and we had one (1) 14 First Nations constable, who was assigned specifically 15 for the territory. But it was a OPP administrated type of 16 arrangement. 17 Q: So that the OPP were the police that 18 policed the First Nation? 19 A: We -- we supervised the policing of - 20 - of Moraviantown. Being as there was only one (1) 21 constable, much of -- of the work, because of the hours 22 of work, clearly, many of our officers responded to calls 23 for service, and did patrol on Moraviantown. 24 Q: So, there was one (1) Aboriginal 25 officer, and then when he was unavailable, or support was

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1 needed, the -- the OPP from Chatham provided that 2 support? 3 A: That's correct. 4 Q: And then, from May 1989 to September 5 1989, I understand you were the Acting Staff Sergeant of 6 the Grand Bend Detachment? 7 A: Yes, for the summer operations. 8 Q: And that's -- is there a separate 9 detachment for the summer and the -- the balance of the 10 year? 11 A: Yes, at that time what we would do is 12 post approximately twenty (20) to twenty-two (2) 13 constables, plus several sergeants, and a staff sergeant, 14 at Grand Bend, which would look after the summer business 15 in the village of Grand Bend, itself. 16 Q: And you were then promoted in -- to 17 Staff Sergeant in September 1989, is that correct? 18 A: That's right, sir. 19 Q: And you were made the Detachment 20 Commander of the Forest Detachment? 21 A: That's right. 22 Q: And I'll come back to that in a 23 moment, but in 1983 -- '93, you were promoted to 24 Inspector? 25 A: Yes, sir.

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1 Q: And you were posted to London as an 2 Inspector? 3 A: Yes, to the London District 4 Headquarters. 5 Q: And then you were an Inspector in the 6 London District Headquarters until 1995 -- December 1995 7 when, as part of reorganization, you became an Inspector 8 in the Western Region? 9 A: That's correct. 10 Q: And we'll come back to that as we go 11 along. The -- as well, from July 1994 to October 1995, 12 you were Acting -- an Acting Superintendent with the 13 London District? 14 A: Yes, at that particular time the 15 Superintendent, who had been a District Commander, 16 retired in 1994 and I was appointed Acting Superintendent 17 Responsible for District Command until '95 when the 18 restructuring took place. 19 Q: And what were your duties as District 20 Commander? 21 A: I was the overall commander of the 22 three (3) counties of Middlesex, Elgin, and Oxford 23 Counties for all OPP operations. 24 Q: And then from December 1995 to 25 January 2000, you were an Inspector in the Western

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1 Region? 2 A: Yes, sir. 3 Q: And then, were promoted in January 4 2000 to Superintendent, and were Superintendent from 5 September -- January 2000 to September 2001; is that 6 correct? 7 A: That's correct. 8 Q: And you served as Force Adjudicator? 9 A: Yes, sir. 10 Q: And can you tell us what is the role 11 of the Force Adjudicator? 12 A: The Force Adjudicator is the Hearings 13 Officer to preside over Police Service Act hearings. 14 Q: And that's hearings with respect to 15 charges -- internal charges against police officers? 16 A: That's correct. 17 Q: And then in September 2001 you were 18 promoted to Chief Superintendent? 19 A: Yes, sir. 20 Q: And you were again located at the 21 general headquarters, that's in Orillia? 22 A: Yes, sir. 23 Q: And you remained a Chief 24 Superintendent, until November 2004, at which time you 25 were promoted to Deputy Commissioner?

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1 A: That's right. 2 Q: And as a Deputy Commissioner, you're 3 in charge of field and traffic services? 4 A: Yes, sir, I am. 5 Q: Now, if I could take you back over to 6 page 3 of Exhibit 396; I note that you've taken a 7 substantial number of courses, and the courses that I 8 would like to ask you a bit about are the courses prior 9 to 1995. 10 And I note that you took a Crisis 11 Negotiator's Course from the OPP Academy in 1987; is that 12 correct? 13 A: Yes, sir. 14 Q: And what did that involve, sir? 15 A: A Crisis Negotiator Course is a 16 course that's provided to train members in crisis 17 negotiation procedures. Crisis Negotiators are used 18 where there are barricaded subjects, or hostage taking 19 type situations, and the negotiator would be the 20 individual who actually makes contact with the individual 21 who is subject of the barricade, or hostage taking, and 22 try to negotiate a release of the hostages, or a 23 surrender of the barricaded gun person. 24 Q: And between 1987 and September 4th, 25 1995, did you participate as a Crisis Negotiator?

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1 A: Yes, on many occasions. 2 Q: And was that with respect to what 3 type of incident? 4 A: Actually, I -- I worked on several -- 5 some that were suicidal people, threatening to take their 6 own life; some were barricaded, with persons in the 7 residence, almost always with a weapon, normally -- or 8 most often, certainly nothing normal about it, with 9 firearms or with other weapons, such as a knife, 10 etcetera. 11 Q: And prior to May of 1993, had you 12 been involved in an occupation, or a blockade? 13 A: No, sir. 14 Q: Then -- I note that in 1990, you took 15 the Incident Commander's course from the OPP Academy? 16 A: Correct. 17 Q: And can you tell us what that 18 involved? 19 A: Yes, the Incident Commanders course, 20 was a course that was designed for the person who would 21 be in charge of major incidents. 22 Q: Yes. 23 A: In particular, things like the 24 barricaded person, the suicidal people, hostage 25 situations, crowd management, anything where it was

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1 required to assemble a number of officers and -- and 2 there would be a requirement for a senior officer to -- 3 to -- to take command. 4 And normally, those are, for the most 5 part, incidents where there has been threat to life. 6 Q: And I take it as a -- an Incident 7 Commander, you would not perform the negotiator's role, 8 they were two (2) separate roles? 9 A: Correct, and the reason the Incident 10 Commanders course came later, because in 19 -- sorry -- 11 Q: It's 1990. 12 A: 1990, of course. Actually, I took 13 two (2) incident command courses. There's another 14 Incident Commander course later on -- 15 Q: Yeah, we'll get to that too -- 16 A: Okay. So, anyway it was -- it was a 17 course that, you know, most Detachment commanders would 18 take at that time. 19 Q: Then, I note in 1993, there was a 20 course: First Nations Awareness, and in brackets, Curve 21 Lake, by the First Nations branch. 22 Could you tell us what that involved? 23 A: That was a one (1) week seminar, held 24 at Curve Lake, to provide First Nations awareness. We -- 25 we stayed at Curve Lake, and there was a week of -- of

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1 exposure to cultural and First Nations issues. 2 Q: And how many people participated when 3 you participated in the course? 4 A: Probably in the area of twenty (20) 5 candidates would have been there as well. Included in 6 that was one of the First Nations -- First Nation 7 officers from Kettle Point, Constable Duff (phonetic) 8 Bressette, his first name isn't Duff but... 9 Q: Carmen? 10 A: No. 11 Q: Murray Bressette? 12 A: Murray Bressette, yes, I think that's 13 right -- I'm sorry. 14 Q: And did you take this course, the 15 First Nations Awareness course, before or after you 16 became Detachment Commander in Forest? 17 I mean, excuse me, before or after May of 18 1993? 19 A: Oh, when -- it -- it was while I was 20 Detachment Commander here in Forest. 21 Q: And when in 1993 did you take it? 22 A: It was in the spring of the year, it 23 would have been, in all likelihood, March, early April. 24 Q: Okay. Then, in 1994, you took a 25 course, Exercise Square Deal: Canadian Land Forces Staff

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1 College. Can you tell us about that? 2 A: Yes, that's a course provided by the 3 Canadian Forces at their training college in Kingston to 4 provide an opportunity for civil authority to work 5 through scenarios where there may be a requirement for 6 aid to civil power, by the National Defence. 7 And so it's a -- well, it's a one (1) week 8 course. It really focuses on the familiarity and the 9 processes of how the -- the civil authority interacts 10 with the Armed Forces. 11 Q: And, in that year as well, you took 12 the Commander's Course Barricaded Persons from the 13 Canadian Police College and can you describe that course, 14 sir? 15 A: Yes, it's a course for commanders, 16 usually at the commissioned officer or senior officer 17 rank, who will be in charge of barricaded persons-type 18 incidents and there was a number of commanders from 19 across Canada who attended and that's a scenario-based 20 type of training whether there is some classroom training 21 and then there's some practical exercises to -- to test 22 your skills. 23 Q: And, this involved police officers 24 from across the country, not just from the Ontario 25 Provincial Police?

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1 A: From all across Canada. 2 Q: And then, in 1994 you took two (2) 3 additional incident commander's course -- Incident 4 Commander Course Level II at the OPP Academy and the 5 Incident Commander Course Level I. 6 Firstly, what is the Incident Commander 7 Level II? 8 A: The difference between the Level I 9 and Level II is, Level I is for command of situations, 10 for instance, a flood or other natural type of disaster 11 where it is, for the most part, commanding resources and 12 deploying resources. Tornado is another example where 13 there's -- there's been some sort of a natural disaster. 14 The Level II is when you get into the -- 15 the threat to life type situations where there's 16 barricade persons; where there are hostage takings, those 17 kinds -- the ones where there's an escalated threat 18 level. 19 And what happened in and around that time, 20 the course I had taken earlier, the Incident Command 21 Course, basically was being revamped and this was a -- a 22 new structure to how we managed those types of incidents. 23 Q: And what kind of -- in these Levels I 24 and II, can you tell us what kind of issues you dealt 25 with?

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1 A: Well -- 2 Q: Other than barricaded persons and... 3 A: That -- that's the main focus, but 4 it's also to familiarize the commanders with the tools 5 that are available to the commanders, so you have 6 exposure to what -- in my case, I -- I certainly knew 7 what a crisis negotiator would do, but there was crisis 8 negotiation familiarization, there was ERT 9 familiarization, there was TRU familiarization, because 10 some of the commanders had had no experience necessarily 11 in some of those disciplines. 12 And so the tactical teams, for instance, 13 would demonstrate their skills and their capabilities so 14 that the commanders would have an understanding of what 15 tools were available to them. 16 Q: And how long were these two (2) 17 courses, approximately? 18 A: I believe it was two (2) weeks. 19 Q: And, you use the name, "ERT" and can 20 you tell us, that's E-R-T? 21 A: That's correct, it's Emergency 22 Response Team. 23 Q: And what was the function of an 24 Emergency Response Team back in 1994 and 1995? 25 A: And Emergency Response Team would be

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1 a team made up of -- normally of fifteen (15) constables 2 who would be trained in search and rescue, containment, 3 canine backup support, those types of skills. 4 Q: And of the fifteen (15) constables, 5 were there fifteen (15) constables plus a sergeant? Was 6 it led by a sergeant -- 7 A: Normally, there would be a -- a 8 supervisor; at least one (1) and sometimes two (2) 9 depending on the -- the area. 10 Q: And was that in addition to the 11 fifteen (15) constables? 12 A: Usually it would be in addition. 13 Q: And the canine unit is a -- a dog 14 unit? 15 A: That's right, a dog handler and a 16 constable. The dog handler is a constable with a -- with 17 his German Shepherd dog as a normal course. 18 Q: And would the canine unit be part of 19 -- be one (1) of the constables part of the fifteen (15) 20 or would he be an addition? 21 A: No. No, that's a separate unit. 22 Q: Okay. That's a separate unit? 23 A: But it would not be uncommon, for 24 instance, if a canine unit was requested to do a track of 25 an armed person that ERT would be required to work with

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1 the canine handler in order to provide support. 2 Q: And then, you used the acronym "TRU" 3 and I take it that's T-R-U? 4 A: Correct. 5 Q: And can you tell us what TRU stands 6 for? 7 A: That's Tactics and Rescue Unit. 8 Q: And what is the -- back in 1994 and 9 1995, what was the role of the TRU unit? 10 A: TRU is available for the deployment 11 of containment in the instance of a hostage taking or 12 barricaded gunman. They're trained in canine backup for 13 the high risk type calls. They are trained in special 14 rescue, for instance, rappelling down rock cliffs or 15 whatever to provide rescue capability in -- in extreme 16 terrain and they're also trained in hostage rescue. 17 Q: And as -- what is the -- back in 1994 18 and 1995, what was the typical size of a TRU team? 19 A: It would be twelve (12) constables, 20 one (1) sergeant, one (1) staff sergeant. 21 Q: And so there would be fourteen (14) 22 people in all? 23 A: Right. 24 Q: And where did some -- did different 25 members of the TRU team have specialized training?

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1 A: Yes, there was different disciplines 2 within the team. 3 Q: And can you tell us what they were in 4 1994 and 1995? 5 A: Well, for example, some would be unit 6 leaders who would be responsible for several members of - 7 - of the unit. Some are special firearms experts, who 8 would provide supervision at firearms training. Some 9 were identified and trained as rappel masters who would 10 provide the training expertise in rappelling, for 11 example, and special -- special assistance in a rescue. 12 Some were trained in, for instance, each 13 team would have at least two (2) snipers who were highly 14 trained, those types of disciplines. 15 Q: All right, and the -- we'll come to 16 hear more of it later, but in 1994 and 1995, there was 17 also a crowd management unit, is that correct? 18 A: Right. That's within the ERT 19 capability. 20 Q: And can you tell us what -- when you 21 say it was in -- "within the ERT capability", what do you 22 mean by that? 23 A: Well, a crowd management team is made 24 up of two (2) ERT teams. At that point in time, as I was 25 explaining in my earlier comments, that we had districts,

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1 so the Chatham District was responsible for three (3) 2 counties. You'd have an ERT team in that district. 3 The London area would have an ERT team. 4 So, if you required a crowd management team, you would 5 have to deploy two (2) ERT teams from two (2) districts 6 to mobilize a crowd management operation. 7 Q: So a crowd management team would be 8 basically made up of two (2) ERT teams, so it would be 9 approximately thirty (30) constables? 10 A: Correct. 11 Q: And back in 1993, the -- excuse me, 12 back 1993 to 1995, there was a re-organization going on 13 in the OPP and the district teams, as you said, number 3 14 district was part of the old system? 15 A: Yes, sir. 16 Q: But it was still in place in 1995? 17 A: Yes, it was. And the number 3 18 district was -- was the old Burlington district 19 headquarters, just for geography. 20 Q: For -- oh, thank you. Now when you - 21 - in 1989, September 1989, when you were assigned as 22 Detachment Commander at Forest, can you tell us back then 23 what the territorial jurisdiction of the Forest 24 Detachment was? 25 A: Yes, the Forest Detachment had that

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1 part of Bosanquet Township that includes the town of 2 Forest, Raven's Wood, Arcona, Watford, the 402 down to 3 County Road 26, I believe it was at that time, the 4 village of Camlachie and the lakeshore back up to and 5 around Kettle Point to Highway 21 at the Military Base, 6 CFB Ipperwash, but not including the Military Base. 7 Q: So that the territorial limit on the 8 east would have stopped at Army Camp Road, just on the 9 western side of Camp Ipperwash? 10 A: That's right. 11 Q: And in 1989, you were responsible for 12 policing in the town of Forest as well? 13 A: Yes, sir. 14 Q: And with respect to the Kettle and 15 Stony Point First Nation in 1989, what was your 16 relationship with the police officers at Kettle and Stony 17 Point First Nation? 18 A: At that time they had, I believe it 19 was, four (4) constables and a supervisor. 20 Q: Yes. 21 A: And it was at that time similar to -- 22 to the Moraviantown example. It was an OPP administered 23 First Nations policing agreement. One (1) of the 24 sergeants, Mike Hudson from Forest was the liaison 25 officer at that time working directly with the supervisor

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1 from Kettle Point, providing oversight assistance if you 2 -- if you will to the Kettle Point officers. 3 And when they required assistance or 4 backup, the officers from Forest would provide that. 5 Q: And in 1989 was Mr. Myles Bressette 6 the supervisor of the Kettle and Stony Point First Nation 7 police? 8 A: Yes, he was. 9 Q: And -- now when you attended in -- 10 were made Detachment Commander in Forest, would you have 11 within your territory the Kettle and Stony Point First 12 Nation? 13 A: Yes, sir. 14 Q: And what, if anything, had you done 15 either at the time you became Detachment Commander or 16 before to learn more about Aboriginal issues? 17 A: When I was first appointed to Forest, 18 it was brought to my attention by my superiors from the 19 district headquarters of a concern at that time in 20 regards to the relationship between the officers at 21 Forest and the officers at Kettle Point. 22 The resulted in a meeting actually before 23 I even reported to Forest, with one (1) of the inspectors 24 from the district headquarters with Chief Tom Bressette 25 and with Myles Bressette.

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1 And it was made clear to me that there was 2 some issues around the working relationship. And as a 3 result of that as I quickly learned who the staff were at 4 Forest Detachment, I realized very quickly that I had two 5 (2) First Nations officers in the Detachment, that being, 6 Luke George and Vince George. 7 Throughout my time there I certainly 8 sought out their perspective on the issues in Kettle 9 Point and you know, how we deal with some of the issues 10 there. And some of the concern that had been raised with 11 me by Miles Bressette and Chief Bressette in the initial 12 meeting I had, we had some discussion of how we work 13 through the concerns that were being raised. 14 Q: And that meeting as you -- you said 15 that took place before you became appointed Detachment 16 Commander, it was in the summer of 1989? 17 A: Yes. I -- I believe the way that the 18 dynamics of that was, that meeting would have taken 19 place, I can check my notes, but it was either Tuesday or 20 Wednesday after Labour Day '89, and I was reporting for 21 duty in Forest the following Monday. 22 Q: And what were some of the issues that 23 -- can you recall what some of the issues that were 24 raised at that meeting? 25 A: The issue was really the relationship

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1 between the officers and that some of the OPP officers 2 were going onto Kettle Point taking enforcement action 3 and there was a strong sense that they shouldn't be doing 4 that. 5 They shouldn't be spending their lunch 6 hours visiting people on Kettle Point, that they should 7 only go there to -- when they had permission from the -- 8 the First Nations officers who were working. 9 Q: And did some of the officers that 10 were in your Detachment, Vince George and Luke George, 11 did they live on Kettle and Stony Point? 12 A: No. One (1) lived in the town of 13 Forest and the other lived in Sarnia and however, they 14 had family that lived on Kettle Point. In fact, Luke and 15 Vince's parents lived within eyesight of Highway 21 16 junction. 17 Q: And their father was Mr. Robert 18 George Sr.? 19 A: Yes, sir. 20 Q: And he's also known as, "Nobby," I 21 think? 22 A: That's correct. 23 Q: And as a result -- what, if anything 24 occurred as a result of that meeting with you and Chief 25 Tom Bressette and Mr. Miles Bressette?

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1 A: Later in September after I had a bit 2 of time to get situated at Forest, I had a general 3 meeting at the Detachment where all the members attended. 4 And I outlined the concerns that were 5 raised with me and the need for us to -- to work with the 6 officers at Kettle Point and the need to have 7 understanding of, you know, what the concerns were and to 8 work -- work with them to do the business we needed to 9 do. 10 Q: And if I could take you -- we've been 11 provided with a number of your notes and you'll find in 12 one (1) of the books that's in the... 13 There's a book called, "Ipperwash Inquiry 14 Handwritten Notes, Deputy Commissioner John Carson, 1990, 15 1993, and 1994." And at Tab 1 there's a note, "October 16 16, 1990," do you see that? 17 A: Yes. 18 Q: And that appears halfway down the 19 page at 13:00, which would be one o'clock? 20 A: Correct. 21 Q: And there's a reference: 22 "Kettle Point Police Meeting, Admin 23 Building, Chief Bressette, 24 Administrator; C. Shawkence." 25 And then, I can't read the next line, can

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1 you read that, sir? 2 A: Yes. 3 "Discussed several concerns of M.C. 4 Bressette." 5 Q: And, is that Miles Bressette? 6 A: That's right. 7 Q: And can you tell us what the concerns 8 that were raised at this meeting were? Were they similar 9 concerns? 10 A: I -- I can't recollect exactly, but I 11 would suspect it would be similar to what I just 12 outlined. 13 Q: And, Commissioner, perhaps we could 14 just stop for a moment. These notes include a number of 15 notes over 1990 -- 1990, 1993 and 1994 and the -- this 16 booklet was taken from your notes, Deputy Commissioner? 17 A: Yeah, yes. 18 Q: And for some of these notes you 19 actually have the originals with you? 20 A: I have them with me, yes. 21 Q: And they're in the blue binder that 22 you have there, or at least some of them are? 23 A: Or in my briefcase, here. 24 Q: And perhaps we could mark as the next 25 exhibit, I think it would be 397 --

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1 THE REGISTRAR: Yes. 2 MR. DERRY MILLAR: The binder -- the 3 booklet of notes for 1990, 1993, and 1994? 4 5 --- EXHIBIT NO. P-397: Book of handwritten notes by 6 Deputy Commissioner John 7 Carson, 1990, 1993 and 1994. 8 9 CONTINUED BY MR. DERRY MILLAR: 10 Q: Now, the -- you were beginning to 11 tell us when we got into the issues about the 12 relationship with the Kettle and Stony Point First 13 Nations Police Force about things that you had done to 14 learn about various issues in -- Aboriginal issues. 15 Can you tell us a little bit more about 16 what you did? 17 A: Well, during my tenure as Detachment 18 Commander, there were a number of occasions where, you 19 know, we would have been in situations where -- 20 COMMISSIONER SIDNEY LINDEN: Excuse me, 21 do you have an observation? 22 MR. JULIAN FALCONER: I'm sorry, 23 Commissioner, it's probably me being more -- than 24 necessary, but I was wondering -- I was wondering, in 25 terms of entering the Officer's Notes as exhibits, I have

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1 to readily concede that while I've looked at many 2 transcripts, I haven't been here for a lot of entries of 3 notes. 4 Is there any possibility that the standard 5 foundation for entering the notes could accompany 6 entering them as exhibits, because they've simply gone in 7 bolus bolus without any foundation. And I'm not 8 questioning that these are the officer's notes or their 9 authenticity, I simply am respectfully suggesting that 10 there ought to be a bare minimum foundation for them 11 going in. 12 I'm not questioning My Friend or being 13 critical, I'm simply respectfully requesting that, 14 because they -- they may well become relevant as we go 15 down the road, in terms of questioning on the notes. 16 COMMISSIONER SIDNEY LINDEN: Well, I want 17 to remind you Mr. -- 18 19 CONTINUED BY MR. DERRY MILLAR: 20 Q: Inspector Carson, with respect to the 21 notes and the notes, in particular, that are in Exhibit 22 397, what -- when were these -- I know that they cover 23 many years, but when were these notes made in relation 24 to, for example, the first note? And we can do this the 25 hard way or we can do it the easy way.

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1 In October 6th, the first note October 2 16th, 1990. When would you have made that note, sir? 3 A: They would have been made that day, 4 sir. 5 Q: And was that your practice to that, 6 sir? 7 A: Yes, sir. 8 Q: And perhaps we will -- so that when 9 you made your -- during the course of this period, 1990, 10 1993, and 1994, the period covered by this book, was it 11 your normal practice to make the notes on the day of, or 12 shortly after the event? 13 A: For the most part, my notes are made 14 during the tour of duty and almost without exception, 15 prior to the completion of the tour of duty. 16 Q: And when you say the "tour of duty", 17 that means the -- the day that you were working? 18 A: Yes, and so -- and I use the term 19 "tour of duty" because if I happen to be working late or 20 on overtime, heaven forbid, they would be done during 21 that time period as opposed to waiting a day to do them 22 later. 23 Q: So that your practice was to try to 24 make the notes as quickly as you could after the event? 25 A: That's right, sir.

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1 Q: And at times it would be 2 contemporaneous with the event? 3 A: Yes. 4 COMMISSIONER SIDNEY LINDEN: I want to 5 remind Mr. Falconer and others, this isn't a criminal 6 trial and the rules are a little more relaxed, but that 7 doesn't prevent you from raising an objection when you 8 think it's appropriate. 9 But, if possible, I'd like to try to do 10 this before the event occurs, so we don't need to do it, 11 as Mr. Millar says, the hard way. 12 But, of course, it's open to you to object 13 to what you think is appropriate at any time. Are the 14 notes now -- is that a sufficient foundation for you, Mr. 15 Falconer, at this point? 16 MR. JULIAN FALCONER: I'm very grateful, 17 Mr. Commissioner, for that. 18 COMMISSIONER SIDNEY LINDEN: Thank you. 19 MR. JULIAN FALCONER: And I have no -- no 20 confusion that this is a criminal trial and I certainly - 21 - from the point of view of the foundation -- 22 COMMISSIONER SIDNEY LINDEN: That's not 23 going to be picked up on the -- what you're saying isn't 24 going to be picked up. 25 MR. DERRY MILLAR: You better come up

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1 here, Mr. Falconer. 2 COMMISSIONER SIDNEY LINDEN: I'm sorry, 3 Mr. Falconer, but we don't have a mic at every desk. I 4 wish we did, but... 5 MR. JULIAN FALCONER: I -- I appreciate 6 that, Mr. Commissioner, and I really underhand that this 7 is not a criminal trial. It's simply a matter of whether 8 or not this officer's comfortable that these notes 9 reflect an accurate version and a contemporaneous version 10 of the events as he transcribed them. And obviously from 11 a foundational point of view, I thought that ought to be 12 relevant. 13 COMMISSIONER SIDNEY LINDEN: Thank you 14 very much, Mr. Falconer. Let's carry on. 15 16 CONTINUED BY MR. DERRY MILLAR: 17 Q: You indicated that you had, as part 18 of your Detachment, Luke and Vince George back in 1989? 19 A: Yes, sir. 20 Q: And I think you indicated that you'd 21 had discussions with them with respect to Kettle and 22 Stony Point First Nation concerns? 23 A: Yes. 24 Q: And can you tell us what that 25 included?

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1 A: Well, I certainly had some, I would 2 suggest, specific discussions with them because, quite 3 frankly, it appeared that they were the target of the 4 concern by Miles Bressette, in particular. 5 So, just trying to come to some sense of 6 balance that met their personal desires to, for instance, 7 going to their parents for lunch breaks or coffee break. 8 And at the same time, working with the -- the wishes of 9 the First Nations Officer, in particular with Miles 10 Bressette. 11 I mean, I wanted to -- I wanted them to be 12 able to work together in a harmonious fashion and achieve 13 that as easily as possible. 14 Q: And at the time, back in 1989, what 15 was the relationship between Forest -- the Forest 16 Detachment and the Kettle and Stony Point First Nation? 17 You supervised the police force, what was 18 the -- was that what your role was, as Detachment 19 Commander? 20 A: Technically, it would be, and that's 21 why we had a sergeant who was the liaison officer who 22 worked very closely with Miles Bressette in particular. 23 Q: And you said that was Sergeant Mike 24 Hudson? 25 A: That's right.

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1 Q: And what types of things would Mr. -- 2 Sergeant Hudson deal with as liaison officer? I'm trying 3 to understand the relationship, Deputy Commissioner. 4 A: He would monitor the administration, 5 because the administration was reported through Forest. 6 For instance, when -- when they investigated incidents, 7 occurrences, criminal events, they would have to be 8 reported at month end, for example. 9 He would monitor the -- the reporting that 10 the investigations, where -- where there was a 11 requirement for some assistance, say, for some expertise, 12 or some way he could help or identify training needs, 13 those types of things he -- he worked very closely with 14 the supervisor. 15 Q: And during the period of time that 16 you were Detachment Commander, did the relationship 17 change between the Forest Detachment and the Kettle and 18 Stony Point First Nation? 19 A: Well, I would suggest the 20 relationship with the officers, generally, was very 21 positive that the -- that the constables themselves got 22 along pretty well. And there was certainly mutual 23 understanding and respect for their work and there was no 24 hesitation for either the OPP officers or the First 25 Nations officers to help one another.

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1 The big issue seemed to be OPP officers 2 going onto the First Nations territory and -- and that 3 seemed really to cause some distress for Miles Bressette 4 in particular. 5 Q: And did the relationship of the OPP 6 supervising the Kettle and Stony Point First Nation 7 police force change at all during the period of time you 8 were Detachment Commander? 9 A: It didn't change. It -- it continued 10 -- Sergeant Hudson, I believe, continued those duties the 11 whole time I was at Forest, if I'm not mistaken. 12 But there was a couple of incidents where 13 there were complaints about his -- his work and resulted 14 in some meetings with the Chief and Council, as a result 15 of the concerns being raised. 16 Q: And the arrangement between -- the 17 legal arrangement between the OPP and the First Nation in 18 -- between 1989 and 1993 was -- was a result of the First 19 Nation Policing Agreement; is that correct? 20 A: That's right. 21 Q: And what, if anything, did you learn 22 about the history of this area when you moved to Forest? 23 A: Well, I -- I certainly learned fairly 24 quickly about the relationship of the Stoney Point and 25 Kettle Point Bands and the issue of the displacement from

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1 what's now CFB Ipperwash in the 1940's under the War 2 Measures Act. 3 That was certainly something, not 4 necessarily came to my attention but certainly something 5 I learned about and I asked, you know, many questions 6 about. And certainly, through Vince and Luke George, was 7 able to learn a fair bit about the history of that 8 particular incident. 9 Q: And did you participate in any 10 seminars presented by members of the OPP or others? 11 You've told us about the later one, but in the early 12 years? 13 A: Yes. Actually one (1) particular 14 seminar we had, it was actually conducted at Walpole 15 Island. At that time Ron George was an inspector with 16 the OPP and Ron gave an overview of the land -- the whole 17 issue of reserves across Southern Ontario. 18 But in particular Sarnia, Kettle Point, 19 Ipperwash, and Walpole, the Lambton County experience 20 mostly. But he explained it as he knew it from his 21 university studies, and -- and how all that came to be 22 and the meetings of some of the treaties, and the 23 interpretations that were drawn from those. 24 Q: And so he spoke of the Treaty of 25 1827?

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1 A: Yes. 2 Q: And did he speak of the surrenders in 3 1927 and 1928? 4 A: I -- I can't speak specifically to 5 the surrenders of '27, '28, you're referring to the Park 6 itself with Park today? 7 Q: The Park and the beach. 8 A: I don't -- I don't recall off the top 9 of my head if there was any discussion about that. But 10 there certainly was some discussion around the 1942 War 11 Measures Act. 12 Q: And did you spend time reading about 13 the issues? 14 A: Yes. Well, more so later on. I did 15 acquire some publications that talked about treaties, and 16 did some reading on them. 17 Q: And why did you do that, sir? 18 A: I thought it was relevant given the 19 area that I was responsible for. 20 Q: And Mr. Ron George is the brother of 21 Luke and Vince George? 22 A: That's correct. 23 Q: And during this period of time 1989 24 to 1993, did you meet, from time to time, with Chief Tom 25 Bressette?

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1 A: Yes. 2 Q: And did you have discussions about 3 the history of the area with them -- with him? 4 A: Well, most meetings with Tom usually 5 began with a bit of a history lesson. So he was 6 certainly not shy about sharing his views on -- on those 7 types of issues. 8 Q: And from time to time did you meet 9 Bonni Bressette? 10 A: Yes, I had met Bonni Bressette. 11 Q: And Bonni Bressette was a councillor, 12 I think, at the time, or was she -- perhaps she wasn't at 13 that time. 14 A: She -- I'm not sure if she was a 15 councillor; she had been a past Chief, I believe, at that 16 point. 17 Q: And when you met Bonni Bressette, did 18 you discuss the history of the area too? 19 A: I don't recall if I did or didn't. I 20 believe -- I believe I met Bonni, particularly through 21 Mike Hudson, who knew her fairly well, from his liaison 22 duties. 23 Q: And, in the early years, did you have 24 a Sergeant George Allison on the Forest Detachment? 25 A: Yes.

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1 Q: And what was his role? 2 A: George was one (1) of my sergeants, 3 who was a first line supervisor, responsible for one of 4 the platoons. He was one of four (4) sergeants posted 5 here, at Forest. He had been posted here for all the 6 time that he had been sergeant, I believe. 7 He had been here for several years, lived 8 in the area, and was very active in the area. He was in 9 service clubs, and he -- he knew or knows many of the 10 local people in the Forest community as well as Kettle 11 Point. 12 Q: And were a number of -- when you 13 arrived in Forest in 1989, were a number of your officers 14 -- had they been posted in Forest for some period of 15 time? 16 A: Yes, there was a number of Members 17 who had been here pretty much their whole career. 18 Q: And in 1989, when you arrived, how 19 many officers were there in the Forest Detachment, 20 approximate? 21 A: Between twenty (20) and twenty-five 22 (25) constables. 23 Q: Plus four (4) sergeants? 24 A: Four (4) sergeants. 25 Q: And you as a Staff Sergeant?

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1 A: Correct. 2 Q: And now during the period 1989 to 3 1993, did you have any contact with local politicians? 4 A: Had some, yes. In particular, it was 5 customary that we would have contact with the mayors, or 6 reeves, of the municipalities that we policed. 7 Q: And so the -- that would include the 8 Mayor of the Township of Bosanquet or a Reeve I guess? 9 A: Yes. 10 Q: And who was that? 11 A: That was -- at that time, it was 12 Mayor Thomas -- Fred Thomas. 13 Q: Fred Thomas? And, as well, did you 14 meet with the Mayor of Forest? 15 A: Yes. And his name escapes me. 16 Q: Mr. Gord McNeilly? 17 A: Gord McNeilly. Yes, he was a manager 18 at Hydro at that time, I believe. 19 Q: And did you meet with the -- on an 20 annual basis with the Mayor of Watford? 21 A: I know I've met the Mayor of Watford, 22 but I can't recall how many times I met with the Mayor. 23 But we -- we had a muni -- we had a community policing 24 committee over there. I know I met with representatives 25 from that community on numerous occasions.

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1 Q: And what about provincial 2 politicians, members of the provincial parliament? 3 A: The only -- 4 Q: 1989 to 1993. 5 A: Well, in -- in '93ish, I'm just 6 trying to think. When the issue of the civil suit with 7 West Ipperwash was taking place, at some point in time in 8 '93, I'm not sure if it was during my tenure in Forest, 9 or after I'd already left, but I certainly knew the MPP, 10 Marcel Beaubien. 11 Q: And when did Mr. Beaubien first get 12 elected? 13 A: That would be in the -- 14 Q: In 1995? 15 A: The '95 election I believe, because 16 he had been previously the Mayor of Petrolia. 17 Q: And had you met him as Mayor of 18 Petrolia? 19 A: I don't believe so. 20 Q: And the local MPP, prior to the 21 election of Mr. Beaubien, in the -- in June of 1995, had 22 you met the previous MPP? 23 A: I'm not sure who that was, sir. 24 Q: Okay. What about the federal member 25 of parliament?

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1 A: I met Rosemarie Ur, but I don't 2 believe it was before '93. 3 Q: Not before? Thank you. Now, I 4 understand that one of the issues that you dealt with was 5 an issue with respect to the beach along West Ipperwash 6 road; is that correct? 7 A: Yes. 8 Q: And West Ipperwash -- can you tell us 9 where West Ipperwash Road runs? 10 A: Are you talking about the beachfront 11 incidents? 12 Q: Beachfront -- I'm trying to describe 13 the beachfront without pulling up a map, I can do that. 14 A: Well, technically -- technically it 15 runs from the -- from Kettle Point to the -- to, I 16 believe, West Ipperwash Road, where you can actually 17 drive down the beach from one end to the other. 18 Q: And West -- 19 A: Anyways... 20 Q: -- Ipperwash Road, is it the road 21 that runs past the Kettle and Stony Point Mall? 22 A: I'm talking about the road that runs 23 in from Raven's Wood to the lake. 24 Q: Ravenswood to the lake, that's Centre 25 Ipperwash Road.

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1 A: That's correct. Thank you. 2 Q: And the beach issue, however, dealt 3 with a piece of land that was -- had formerly been part 4 of the Kettle and Stony Point First Nation; is that 5 correct? 6 A: That's my understanding, yes. 7 Q: And there was a -- can you tell us 8 what the issue was when -- about the -- the beachfront 9 when you first went to Forest? I take it it was in 10 existence when you arrived in Forest? 11 A: Yes. Well, a couple of things were 12 happening. One (1) was the civil suit launched by the 13 Kettle Point Band in regards to the surrender of the 14 property of the cottages that, as you pointed out, had 15 previously been part of the Kettle Point Reserve. 16 Q: And that, I understand, came later, 17 1992, 1993? 18 A: Yes. But there was an issue around 19 access through the beach front. Historically, as I 20 understand it, long before I arrived in Lambton County, 21 it had been customary that people could go to Ipperwash 22 Beach and could travel that whole distance from one end 23 to the other, unfettered. And that had been a practice, 24 basically as I understood, like time immemorial, where 25 people would do that.

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1 Q: And when you say "Ipperwash Beach, 2 from one (1) end to the other", one (1) end was Kettle 3 and Stony Point First Nation? 4 A: Yes. 5 Q: And what was the other end, as you 6 understood it? 7 A: Where the road comes in from 8 Ravenswood, Centre -- Centre Road. 9 Q: Centre Ipperwash Road? 10 11 (BRIEF PAUSE) 12 13 Q: And the issue, with respect to the 14 beachfront east of Kettle Point, revolved around access 15 to the beach? 16 A: Yes. Some of the cottagers, during 17 that time frame, had attempted to erect posts, or 18 obstructions, to limit people travelling through that 19 area. 20 Basically, it was some cottagers who felt 21 that their property line went straight down to the 22 water's edge and they -- they were trying to prevent 23 vehicular access up and down the beach. 24 Q: As well as pedestrian access? Did it 25 involve pedestrian access as well?

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1 A: The big issue wasn't pedestrian 2 access so much as vehicles travelling through. 3 Q: And if I could take you to a document 4 -- there's a document in front of you. It's Inquiry 5 Document 2000658, which is right on the pile straight 6 ahead. Yes. 7 Is this a document that you've seen 8 before? 9 10 (BRIEF PAUSE) 11 12 A: Yes, I believe so. 13 Q: And it's a -- do you know who 14 prepared this document and why this document was 15 prepared? 16 17 (BRIEF PAUSE) 18 19 A: I can't tell you for sure if I 20 directed it to be assembled, but it certainly was part of 21 a package that was put together, at some point in time, 22 during my tenure there, I believe, and part of that was 23 the capturing of all of the incidents that were related 24 to that area. 25 Q: And it reports on a number of

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1 incidents with respect to the beachfront and problems 2 along the beachfront? 3 A: Yes. 4 Q: And there's an executive summary 5 that's the first five (5) pages? 6 A: Yes. 7 Q: And I take it -- I note on page 4 -- 8 page 3 that there's a reference to some charges that were 9 laid in 1991 and then were withdrawn in 1992? 10 A: Yes. 11 Q: And the author of the document 12 indicates at the bottom of page 3 and at the top of page 13 4 that it was his understanding they were withdrawn for 14 two (2) reasons; one (1) colour of a right by the 15 Natives, that they were acting on behalf of council, who 16 believe they own the property, as per the Temagami 17 incident; and secondly, the length of time it took to 18 bring the defendants before the courts. 19 A: Right. 20 Q: And was that your understanding as to 21 why the charges were withdrawn? 22 A: As I recall, yes. 23 Q: And the last two (2) pages of this 24 document, there's a letter dated March 2nd, 1993 and it's 25 signed by you.

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1 Is that your signature on page 2? 2 A: Where? Where? On the back? 3 Q: The very last -- the last two (2) 4 pages of the document, Deputy Carson? 5 A: Yes, that's my signature. 6 Q: And why did you write this letter of 7 March 2, 1993? 8 A: Well, the whole issue of colour of 9 right, and how the Crown Attorney was going to respond, 10 if charges were laid, was important so that I could give 11 the appropriate direction to the officers at our 12 detachment, to understand, and be prepared for dealing 13 with further issues of a like nature. 14 Q: And I understand from the document, 15 that there was just a small number of people who took the 16 position that they did, with respect to the beachfront? 17 A: For the most part, yes. 18 Q: And the -- this document simply 19 collects some of the issues -- some of the documents 20 within your detachment that relate to this issue? 21 A: Right. 22 Q: And perhaps we could mark that the 23 next exhibit; it would be Exhibit 390... 24 THE REGISTRAR: P-398. 25

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1 --- EXHIBIT NO. P-398: Document Number 2000658, Land 2 dispute Kettle and Stony 3 Point First Nations and 4 Ipperwash Beach cottage 5 owners. 6 7 CONTINUED BY MR. DERRY MILLAR: 8 Q: And I note that there's -- somebody's 9 written in handwriting, "22 July/'93". It's: 10 "Acting Staff Sergeant Beacock advises 11 no reply ever received." 12 Have I read that correctly? 13 A: That's correct. 14 Q: And is that accurate? Did you ever - 15 - do you recall receiving a reply before you left as 16 detachment -- 17 A: I don't believe I ever received an 18 answer. 19 Q: Thank you. 20 A: I'm still waiting. 21 Q: Now, I understand as well, that in 22 nineteen (19), -- the early '90s, the OPP used the rifle 23 ranges at Camp Ipperwash for training; is that correct? 24 A: Yes, we conducted firearms training 25 there.

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1 Q: And did that involve just the Forest 2 Detachment or other Detachments? 3 A: For the most part it was the Lambton 4 County Detachments, and at that time that would be 5 Sombra, Petrolia, Forest, and Pinery. 6 Q: There was a separate -- in the early 7 '90s there was a separate Detachment at Forest -- at 8 Pinery Park? 9 A: Yes. 10 Q: And the -- at some point in the early 11 '90s you stopped using Camp Ipperwash for training; is 12 that correct? 13 A: Correct. 14 Q: Can you tell us how that came about? 15 A: Yes. We had a meeting at Kettle 16 Point. Chief Bressette was there. And one (1) of the 17 issues he raised, and I can get you the date from my 18 notes if you like, but one of the -- one of the issues he 19 raised was the fact that the OPP was using the base for 20 training was validating the Military or Department of 21 National Defence's, the Federal Government's position 22 that the military base was still required. 23 As a result of that, there was certainly 24 some discussion within the Ontario Provincial Police and 25 the decision was made that we would no longer use it as a

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1 training facility in that we didn't want that perception 2 that our use or requirement for a firearms facility had 3 any bearing on a federal decision in regards to the 4 return of the base. 5 Q: And so all OPP Detachments stopped 6 using it for training? 7 A: That's correct. 8 Q: And that -- was that in 1992? 9 A: I believe it's '92, but I can check 10 my notes to confirm that, but I know it was in the fall 11 of the year, and Inspector Hutton (phonetic) from the 12 First Nations branch had attended that meeting as well. 13 Q: Okay. And just before we leave the 14 beach issue along West Ipperwash, the -- can you tell us 15 what the relationship was during the early '90's between 16 the OPP and some of the cottagers and the people who 17 lived at Kettle Point? 18 A: Well, as -- as a result of the issues 19 around the charges, particularly charges getting 20 withdrawn and some incidents where we didn't have 21 reasonable grounds to lay the appropriate charges, we 22 were getting into a very difficult situation where, quite 23 rankly, I believe some of the cottagers were losing faith 24 in our ability to do our job, in their view. 25 They -- they certainly seemed to think we

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1 should be laying more charges in certain incidents, but 2 clearly in many cases, it just wasn't possible or there 3 wasn't the appropriate evidence required to lay charges. 4 And as a result of that, we were certainly 5 -- I had more than one (1) occasion where that 6 displeasure was voiced to me. 7 Q: By some of the cottagers? 8 A: Yes. 9 Q: Now during the period of time when 10 you were the Detachment Commander, did you perceive any 11 issues with respect to racism, in your command? 12 A: Did I perceive any issues? 13 Q: Yes. 14 A: No, sir. 15 Q: And the -- did you have any -- did 16 you receive any complaints with respect to racism during 17 the period of time you were Detachment Commander? 18 A: No, sir. 19 Q: Now, in May of 1990 -- oh, before I 20 leave that, the -- Mr. Miles Bressette has testified that 21 you and he did not get along that well, that -- I don't 22 think he put it that words, but it's clear from his -- 23 from some of the things he said that there was some 24 friction between you and he. 25 Is that --

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1 A: I'm not sure I'd categorize it that 2 way. I think I'd categorize it more that he certainly 3 made it clear that he didn't want me meddling in what he 4 thought was his business. 5 Q: And he indicated that at one (1) 6 time, he wanted to add more officers to the Kettle and 7 Stony Point police -- First Nations police department and 8 he had sought five (5) additional officers and you would 9 only support one (1) additional officer. 10 Do you recall that? 11 A: No, not particularly, no sir. 12 Q: Okay. And he also indicated that at 13 one (1) point in time, that there was a situation where 14 he says that you told him that if his police officers 15 were charging people outside the First Nation and issuing 16 tickets, that you would charge people within the First 17 Nation. Do you recall that? 18 A: I don't believe that ever occurred, 19 sir. 20 Q: Did you have any problem with respect 21 to charges being laid either by your officers or Kettle 22 and Stony Point officers in each other's, for the want of 23 a better word, territorial jurisdiction? 24 A: I have no issue with that whatsoever. 25 In fact I encouraged the supervisor, Miles Bressette, to

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1 allow his officers to work with the OPP officers from a 2 training perspective to -- to give them additional 3 experience to -- to help them. 4 Quite frankly, I ran into roadblocks with 5 him being amendable to anything like that whatsoever. I 6 got the -- the clear sense that he wanted nothing to do 7 with having Kettle Point officers working with OPP 8 officers at all. 9 My view, the OPP officers and the First 10 Nations officers have had the clear authority to take 11 appropriate action where they encounter it. Whether it's 12 on or off the reserve and I would expect them to do 13 exactly that. 14 Q: And the -- so you encouraged training 15 between -- training of the Kettle and Stony Point 16 officers by your OPP officers? 17 A: I certainly encouraged it but I can't 18 say I was very successful at it. 19 Q: Okay. Now if we could turn to May of 20 1993, in May of 1993 you were promoted to Inspector? 21 A: Yes, sir. 22 Q: And when was that? 23 A: May the 10th, 1993. 24 Q: And before we get to May the 10th, 25 the -- on May the 6th, 1993 there was, as I understand

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1 it, the first occupation of the Army Camp by members of - 2 - of the Kettle and Stony Point First Nation? 3 A: Yes, sir. 4 Q: And can you tell us what happened on 5 May the 6th, from your perspective? 6 A: Yes. May I refer to my notes? 7 Q: Certainly. And those, again, were 8 notes that were made at or about the time that the events 9 took place? 10 A: They were. 11 Q: And for the benefit of My Friends, 12 it's page 2, Tab 2, Exhibit 397. 13 A: At 9:30 in the morning, Carl George 14 attended the office in Forest and indicated that he was 15 the Chief of Stoney Point, and that about twelve (12) 16 natives will occupy CFB Ipperwash until the land claim is 17 settled. 18 He told me that he was going to proceed to 19 the base, that there would be peaceful entry was expected 20 and that there would be a peaceful occupation and that no 21 outside involvement was expected. 22 Q: And did he leave you with any pieces 23 of paper? 24 A: Yes, he did leave me a document. 25 Q: And if I could take you to the --

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1 there's a little book -- I'm sorry you've got so many 2 books there, Deputy Carson. But there's a book entitled 3 "Documents For --" it's right in the upper -- at the very 4 corner of this paper underneath. 5 And at Tab 1 there's a document that's 6 been marked P-36. 7 A: Yes, sir. 8 Q: And is that the document that Chief 9 Carl George left with you? 10 A: Yes, it is. 11 Q: And Carl George is now known as Carl 12 Tolsma? 13 A: Apparently so. I wasn't aware of 14 that until I read it in transcripts from this Hearing. 15 Q: You -- you always knew him as Carl 16 George? 17 A: Correct. 18 Q: And Mr. -- Chief George left you with 19 Exhibit P-36. What did you do? 20 A: I notified my superiors at district 21 headquarters in Chatham. 22 Q: And what else, if anything, did you 23 do? Did you send any officers down to Kettle -- to the 24 Camp Ipperwash? 25 A: I believe, and I'm going by memory

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1 here, but if my memory serves me correctly, I sent 2 Sergeant Mike Beacock down to the gate at that point in 3 time. 4 Q: To the gate to the army -- to the 5 Army Camp? 6 A: To the point where they were going to 7 make the entrance into the -- the firing ranges. 8 Q: And was that where they were going to 9 make their entrance, was into the firing ranges? 10 A: Right. 11 Q: And was -- can you -- do you recall 12 what part of the army camp it was -- they were going to 13 enter along Highway 21? 14 A: Yes, along Highway 21 there's a -- 15 two (2) or three (3) locations where there would be a 16 typical farm gate, for lack of a better term, that would 17 be chained shut. 18 Q: Yes. 19 A: And it's my understanding the chain 20 was cut with a pair of bolt cutters and they continued to 21 enter into the military base. 22 Q: And you as well provided -- sent a 23 letter to -- dated May 6th, to the Superintendent in 24 Number 1 District headquarters in Chatham, and if I could 25 take you to Book 1, Tab 1, it's Inquiry document number

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1 2002643. 2 It's the big, black book. It'll be Tab 1. 3 4 (BRIEF PAUSE) 5 6 Q: It should be Tab 1. 7 8 (BRIEF PAUSE) 9 10 Q: Is that a letter signed by you, sir? 11 A: Yes, it is. 12 Q: And it refers to the -- in paragraph 13 2, the statements from Stoney Point First Nation 14 outlining their objectives and concerns and that that 15 referred to what has been marked as Exhibit P-36, you 16 sent that on? 17 A: Correct. 18 Q: And at the next tab in the book, the 19 small book, there's a document -- it's straight ahead of 20 you, yes. 21 It's document P-167, could I just take you 22 to that. 23 24 (BRIEF PAUSE) 25

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1 Q: It's at Tab 2, and this is a briefing 2 note. Have you seen that before, sir? 3 4 (BRIEF PAUSE) 5 6 A: I don't believe I have. 7 Q: You haven't seen it? Well, is it 8 normal for a note such as this to be distributed in 9 number 1 district? 10 A: Well, this -- this is a typical 11 briefing note that would have been raised by the district 12 headquarters. As it notes, it was -- it was prepared by 13 Inspector Tom McKenna and it was forwarded to the "A" 14 Division, which is -- at that time, it -- well, at that 15 time the "A" Division commander was -- was still posted, 16 I believe, at general headquarters. 17 I'm not sure they'd moved to London yet. 18 Q: Pardon me? 19 A: I'm not sure they had moved to London 20 at that time, in '93. 21 Q: And -- 22 A: But it's -- but it's a report up by 23 the district to the division commander. The division 24 commander would have been responsible for the districts, 25 Chatham, London, Mount Forest and Burlington and

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1 Downsview at that time. 2 Q: And the division commander then was 3 Chief Superintendent Coles? 4 A: It could have been Coles or it may 5 have been his predecessor. 6 Q: Tom Wall (phonetic)? 7 A: No, it would -- no that was the Chief 8 Superintendent. 9 Q: In any event, he was based in London? 10 A: Well, he would have likely have still 11 been in general headquarters in Toronto at that point. 12 Q: Now, at or about this time, there was 13 a re-organization taking place in the OPP? 14 A: Yeah, that occurred particularly 15 through 1995. 16 Q: '95? 17 A: Yes, there was a -- a project 18 underway through '94 and into '95, but the actual 19 restructuring took place throughout '95. 20 Q: We'll come back to that then. Now, I 21 note that on May the 10th in Exhibit 397 at page 3, it's 22 this book here, sir. 23 24 (BRIEF PAUSE) 25

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1 Q: I think it's the notes, 1993 and '94. 2 A: Okay. 3 4 (BRIEF PAUSE) 5 6 A: Which tab, sir? 7 Q: Tab 2, page 2 and 3. At the bottom 8 of page 2 there's a note: 9 "Monday, May 10th/'93, 08:00 report to 10 Number 2 District Headquarters, 11 promotion to Inspector. Meet 12 Superintendent..." 13 A: Formsby. 14 Q: No further entries. So, that was the 15 day that you were officially promoted? 16 A: Yes, sir. 17 Q: And, as an inspector, what were your 18 duties to be? 19 A: My duties were to assist the District 20 Commander in -- in the command of the district in London, 21 which included Oxford, Middlesex and Elgin Counties. And 22 part of my duties, we -- myself and another inspector 23 would have literally split up the District 24 responsibilities so that each of us would have 50 percent 25 of the day-to-day operations to monitor and supervise.

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1 Q: Okay. And, in the book, Exhibit 397 2 at page 3, there's a note that has on it, "May 7/'93." I 3 take it this is your note? 4 A: No, I believe that's Sergeant Mike 5 Beacock's note. 6 Q: This is not -- oh. 7 A: It looks like his writing, anyway. 8 Q: Pardon me? 9 A: It looks like his writing. 10 Q: So, it's not your note? 11 A: No, sir. 12 Q: Okay. And, the next page, May the 13 4th -- May the 8th, page 4? 14 A: Same thing. 15 Q: That's Sergeant Beacock's note? 16 A: I believe so. 17 Q: In any event, it's not yours? 18 A: Correct. 19 Q: And May the 10th, page 5? 20 21 (BRIEF PAUSE) 22 23 A: I believe these are Beacock's notes 24 again. 25 Q: Okay. And page 6, May 18th, 1993?

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1 A: Those don't look like my notes. 2 Q: Okay. And, page 7? 3 A: If I could just check my originals? 4 Q: Sure. 5 6 (BRIEF PAUSE) 7 8 A: I -- I don't see any notes of mine 9 that reflect this. 10 Q: When is the next -- when did you 11 become appointed Incident Commander with respect to 12 Ipperwash? 13 A: About Wednesday of that week, around 14 the 12th. 15 Q: And who appointed you Incident 16 Commander? 17 A: Chief Superintendent Coles. 18 Q: And what's the next note that you 19 have with respect to the events at Ipperwash in 1993? 20 A: I'm still out of order here. 21 22 (BRIEF PAUSE) 23 24 Q: Perhaps we could have the afternoon 25 break, Commissioner, and then we'll sort this out.

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1 COMMISSIONER SIDNEY LINDEN: We'll have 2 an afternoon break now. 3 THE REGISTRAR: This Inquiry will recess 4 for fifteen (15) minutes. 5 6 --- Upon recessing at 2:35 p.m. 7 --- Upon resuming at 2:56 p.m. 8 9 THE REGISTRAR: This Inquiry is now 10 resumed, please be seated. 11 MR. DERRY MILLAR: Commissioner, before 12 we begin, we've had a request from all of My Friends. I 13 understand it's -- they would all like to have a slight 14 adjustment in the schedule, simply with respect to the -- 15 Deputy Carson, and the request is to run from ten o'clock 16 to 4:30 for the days that Deputy Carson's in the box, and 17 I have no objection to that. 18 It's -- as long as it's understood it's 19 just for this witness and I -- My Friends tell me -- 20 their spokespersons tell me that that's agreeable, so. 21 COMMISSIONER SIDNEY LINDEN: Well, we 22 have a certain number of days set aside for the Deputy 23 Commissioner. 24 Is it still likely that we'll finish him 25 in those days?

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1 MR. DERRY MILLAR: I don't know. 2 COMMISSIONER SIDNEY LINDEN: You don't 3 know? 4 MR. DERRY MILLAR: It may -- if we cut 5 off an hour a day, it -- 6 COMMISSIONER SIDNEY LINDEN: Well, 7 presumably if they're better prepared, they'll be able to 8 move more quickly, right? That's the idea. 9 MR. DERRY MILLAR: I think that's the 10 idea, sir. 11 COMMISSIONER SIDNEY LINDEN: Let's try 12 and keep to our schedule, if we can. 13 MR. DERRY MILLAR: Yeah, no, if we can, 14 we will. 15 COMMISSIONER SIDNEY LINDEN: Yes, that's 16 fine. 17 MR. DERRY MILLAR: But -- 18 COMMISSIONER SIDNEY LINDEN: I 19 understand. There's a lot of documents, there's a lot of 20 material and that time in the morning is very important. 21 So I think we should accommodate Counsel. 22 MR. DERRY MILLAR: Now, the one thing I 23 haven't thought about was Thursday we normally start at 24 9:00 and stop at 3:30 and I suggest we do the same thing 25 on Thursday, so we would just do this for Tuesday and

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1 Wednesday of this week and then... 2 COMMISSIONER SIDNEY LINDEN: Well... 3 MR. DERRY MILLAR: I think that's 4 agreeable because I think everyone would rather stop at 5 3:30 on Thursday. 6 COMMISSIONER SIDNEY LINDEN: Okay, so -- 7 MR. DERRY MILLAR: So, on Tuesday we'll 8 start at 10:00 and go to 4:30, and Wednesday we'll 9 start... 10 11 (BRIEF PAUSE) 12 13 COMMISSIONER SIDNEY LINDEN: No, it's -- 14 today it's -- 15 MR. DERRY MILLAR: It's Tuesday already, 16 excuse me. Tomorrow is Wednesday. We'll start at 10:00 17 and go to 4:30, Thursday we'll start at 9:00 and go to 18 3:30. 19 COMMISSIONER SIDNEY LINDEN: And next 20 week, we'll start at 10:00 on Tuesday and Wednesday? 21 MR. DERRY MILLAR: Tuesday and Wednesday, 22 yes. 23 COMMISSIONER SIDNEY LINDEN: Is that all 24 right? It looks like everybody's nodding approval. All 25 right, let's continue.

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1 MR. DERRY MILLAR: I'm losing the days, 2 you see. 3 4 CONTINUED BY MR. DERRY MILLAR: 5 Q: Now, can you tell us, when you were 6 appointed incident commander of -- on May the 12th, what 7 were your instructions? 8 A: I was going to be responsible for the 9 OPP response in conjunction with the events involving any 10 of the occurrences with the occupation of CFB Ipperwash. 11 Q: And in the scheme of things in the 12 OPP back in 1993, you would not normally would you -- you 13 would not normally have been serving in this area as an 14 inspector attached to the London District Headquarters, 15 is that correct? 16 A: That's correct, it's in a different 17 district. 18 Q: And the -- this district is -- back 19 then was Chatham? 20 A: Yeah, it was Chatham, Number 1 21 District out of Chatham. 22 Q: And so were you -- the gentleman that 23 appointed you Incident Commander, were you told why you 24 were chosen as Incident Commander? 25 A: I was assigned because I had been the

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1 Detachment Commander for the four (4) years previous and 2 had some understanding and knowledge of the issues and 3 also some of the people involved and also the -- the 4 geography where CFB Ipperwash actually resides at that 5 time was within Pinery Park Detachment, and it was a very 6 small Detachment; it had probably a maximum nine (9) 7 constables maybe. 8 And so there was a desire that I manage 9 the issue with CFB Ipperwash in conjunction with the 10 resources from both Forest and Pinery and work with the 11 Detachment commanders involved. 12 Q: And what was your next involvement. 13 I take it you have a note of May 19th, 1993, that's at 14 page 9 of Exhibit 397? 15 A: Which page, sorry? 16 Q: Page 9 at Tab 2. 17 A: Yes, that's correct. 18 Q: Now perhaps you could just describe 19 for us, Deputy Carson, the -- how you made your notes 20 starting in May of 1993. I see you have in front of you 21 a number of blue binders that have original notes in them 22 and -- you're not using a traditional police notebook. 23 Can you explain how this came about? 24 A: When I was promoted to Inspector, the 25 note taking requirements are slightly different. Our

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1 non-commissioned officers are required to use the small 2 notebook as I have been referring to here earlier. 3 And as a commissioned officer you have the 4 -- I guess, for lack of a better term, the freedom to -- 5 to choose how you want to make your notes. I chose to do 6 them in a 3 ring binder style note from that point on and 7 keep track of it on a monthly -- a monthly note taking 8 basis. 9 Q: And did you separate your Ipperwash 10 notes from your other notes or did they all -- were they 11 all made together in your binders as you went along? 12 A: I -- I eventually split them up so 13 the Ipperwash notes were independent of my day to day 14 notes because it was becoming so many notes regarding 15 Ipperwash that it was being mixed in. 16 Q: But initially they're -- 17 A: Initially they were mixed. It was 18 just whatever I happened to be doing that day, it just 19 went on in chronological order for the date. 20 Q: And you have a note here, it's May 21 19th, 1993, and I take it you received a telephone call 22 from Detective Superintendent Tom Wall, is that correct? 23 A: That's right. 24 Q: And can you briefly tell us what that 25 call was about?

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1 A: The note says: 2 "We discussed the CFB Ipperwash native 3 encampment. Confirmed the assignment 4 of myself as the Incident Commander. 5 Further, Colonel Boyd has requested 6 that responsibility for enforcement of 7 law be turned over to the OPP. 8 Department of National Defence advises 9 they have documentation to prove 10 ownership. They expect the appropriate 11 law enforcement. There's a thousand 12 (1000) cadets coming in the near future 13 and they may not be sensitive to the 14 native issue." 15 Q: And then there's a note of 16 Superintendent Wall's telephone numbers and there's a 17 note: 18 "Request contact of the Crown Attorney 19 Don Vale, position re: Charges on 20 Base." 21 What does that refer to? 22 A: That refers to some discussion we had 23 where I believe I undertook to contacting the Crown 24 Attorney in Sarnia to discuss the issue of potential 25 charges on CFB Ipperwash.

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1 Q: And in 1993, what was the position of 2 the Ontario Provincial Police if there was a 3 position with respect to Aboriginal occupations of land? 4 A: Occupations were normally handled 5 through the use of court injunctions. 6 Q: And did that apply to any occupation 7 or simply occupations involving First Nations? 8 A: Well, I can't recall other 9 occupations, but in particular, two (2) of the ones in, I 10 guess recent history it would have been around Native 11 occupations throughout Ontario. 12 Q: And so, was this a formal written 13 down policy or simply the policy of the -- the Force? 14 A: I suspect it was a general policy, 15 but I'm not sure if there was written policy to that 16 effect. I -- quite frankly, I doubt it. 17 Q: But it was your understanding as the 18 Incident Commander in May of 1993 that the Ontario 19 Provincial Police before it would require and injunction 20 to do what? 21 A: Before there was any overt action to 22 remove anyone from an occupied territory. I think it's 23 worthwhile noting that Chief Coles had been the Incident 24 Commander or had been involved in the incident command in 25 regards to some of the issues that were present in the

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1 Akwesasne area years previous. 2 He had been a Division Commander in that 3 area, so he brought with him some experience and 4 understanding of that issue and certainly he shared some 5 of those issues in regards to how we approach this type 6 of incident. 7 Q: And so, would it be the Ontario 8 Provincial Police that would seek the injunction or 9 someone else? 10 A: No, whoever was the owner or the 11 landlord, whatever -- however you want to position it, of 12 -- of the property in question would be required to 13 demonstrate to the Court that they, in fact, had 14 ownership and apply for the appropriate injunction. 15 Q: And then, that injunction 16 hypothetically might order the Ontario Provincial Police 17 to do something, in which case the Ontario Provincial 18 Police would do what was required by the injunction? 19 A: We would do as directed by the Court. 20 Q: And, the -- the book that's in front 21 of you, the small book straight ahead, at Tab 5 there's a 22 copy of a letter dated May 18th, 1993, written by Staff 23 Sergeant Beacock. It was marked Exhibit P-170, it's 24 Inquiry Document 2000667. 25 Did you see a -- or receive a copy of this

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1 letter back in 1993 on or about it's date, do you recall? 2 A: This particular note or -- or memo is 3 indicative of a daily report that was produced by the 4 Forest Detachment. That particular document each day was 5 forwarded to the District Headquarters in Chatham, the 6 District Headquarters to London to my attention, and also 7 to the Chief Superintendent's office at the Division 8 Office. 9 Q: So, this letter is simply one of a 10 series that were sent on a daily or reasonably regular 11 basis? 12 A: Yes. 13 Q: And this refers to an incident at 14 10:35 hours on May 18th with respect to the service of a 15 notice by a Mr. Scott Ewart with respect to the Army 16 Camp, is that correct? 17 A: Yes. 18 Q: And, at Tab 6 -- excuse me, at Tab 4 19 of that book there's a copy of Exhibit P-35, a fax from a 20 Captain Dodson to Superintendent Randall with a document 21 dated May 18th, 1993 signed by Carl George, and with what 22 appears to be the signature of a Mr. Scott Ewert as -- as 23 bailiff. 24 Did you see this document on or about its 25 date in May of 1993?

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1 A: Yes, I would have been provided a 2 copy of that. 3 Q: And Captain Dodson was from the 4 London detachment of -- 5 A: I believe he would have been in -- he 6 was either at London or -- well, it was faxed from the 7 London -- London detachment of the CFB London, so he 8 would have -- he would have been at the Wolseley Barracks 9 in London. 10 Q: And this is the document that's being 11 referred to by Mr. Beacock in Exhibit P-170, the letter 12 dated May 18, 1993, is that your understanding? 13 A: I believe so, yes. 14 Q: And then there's a note at the bottom 15 of page 9, you've got a telephone -- 1021 refers to a 16 telephone call? 17 A: Yes, sir. 18 Q: And with Staff Sergeant Beacock? 19 A: Yes. 20 Q: And he advised you of -- further of: 21 "Possible camping on Provincial Park 22 Ipperwash this weekend." 23 Then: 24 "Ministry of Natural Resources 25 Enforcement Specialist Brett Hodson has

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1 been in contact with Atkins Sergeant 2 Beacock." 3 Have I read that correctly? 4 A: That's correct. 5 Q: And he's advising you that there 6 might be something happening at the Ipperwash Provincial 7 Park? 8 A: Correct. 9 Q: And do you recall anything more 10 beyond this note? 11 A: Not off the top of my head, no. 12 Q: And then it's -- the -- there's a 13 note -- message left for Crown Attorney Steve Vale (sic) 14 to return the call, and what does that refer to; does 15 that refer to the note of -- just immediately above it 16 with respect to charges? 17 A: Yes, that's what it appears. 18 Q: And then, on the next page, page 10, 19 there's a note. Is this your note? 20 A: Yes, it is. 21 Q: And it's on a yellow sticky on -- in 22 your blue binder? 23 A: That's correct. 24 Q: And it's on the back page of the note 25 of -- and can you tell us what this note refers to, sir?

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1 A: The -- the yellow notes I have? 2 Q: Yes, which, for the benefit of My 3 Friends, is page 10 of exhibit 397? 4 A: The note says: 5 "Authority to arrest, OPP authority." 6 And it looks like I've marked down the 7 time as 12:20: 8 "Checked with Sol Gen? Don Vale..." 9 And comment is: 10 "Advocates general.' 11 I'm not sure what that means. 12 "Documentation, Trespass to Property 13 Act does not apply, provide act in 14 section." 15 Just... 16 Q: And what did you take this -- can you 17 tell us what you understood that to mean back in 1993, if 18 you recall? 19 A: Well, if you refer to the next note 20 at 12:20 -- 21 Q: And that's at May 19th, 1999, 12:20, 22 a telephone call from Don Vale, Lambton County Crown 23 Attorney? 24 A: Correct, and -- and it shows that: 25 "We discussed the Ipperwash Kettle

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1 Point issue, advises to obtain 2 regulations to transfer authority, 3 review statutes, Federal, re: trespass, 4 Trespass to Property Act does not 5 apply, is there authority to arrest, 6 consider advice of Sol Gen." 7 Q: So, I take it from that he was 8 telling you to seek advise from the Solicitor General? 9 A: Yes. 10 Q: And did you do that? 11 A: I called Detective Superintendent 12 Wall and apprised him of that discussion. 13 Q: And that's a note at 13:40? 14 A: Right, and he was going to take the 15 issue up with legal services. 16 Q: So that -- you're -- just so I 17 understand, the chain of command; a request such as that 18 would have been made to your superior to take up with 19 legal services? 20 A: Correct. 21 Q: And then you had a discussion at 22 13:50 on May 19th, with Superintendent Randall? 23 A: Yes, I did. 24 Q: And Superintendent Randall was in 25 first -- first district?

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1 A: Number 1 district, Chatham. 2 Q: And what was the conversation with 3 him about? 4 A: Well there was just -- again, 5 discussion around the applicable statutes and he was 6 going to assign his detective staff sergeant to look into 7 the necessary legislation that we needed to understand. 8 Q: Then there's a note: 9 "Acting Staff Sergeant Beacock will 10 contact and ask to meet Carl George re: 11 occupation of Provincial Park and range 12 area presence." 13 Can you tell me what that says after 14 "range area"? 15 A: "Presence is working, request no 16 interference with military operations." 17 Q: And so was this a call by you to 18 acting Sergeant Beacock or was Superintendent Randall 19 asking you to do that? 20 A: I think it was a discussion the two 21 (2) of us had and I undertook to make that phone call. 22 Q: And is it fair to say that you more 23 or less had two (2) bosses here? You had Mr. -- 24 Superintendent Randall was from number 1 district and 25 Superintendent Wall was from the London head -- London

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1 district headquarters? 2 A: No, Wall -- Detective Superintendent 3 Wall was at the division headquarters with Chief 4 Superintendent Coles, and that didn't take into 5 consideration I was reporting to Superintendent Ormsby 6 still at this time, who was in charge of Number 2 7 district. 8 So, I had several bosses, quite frankly. 9 Q: So you were reporting to a number of 10 different people? 11 A: Yes, sir. 12 Q: All of whom were interested -- 13 Superintendent Randall was interested in this issue 14 because this area fell within his area of -- of 15 authority, Number 1 district. 16 A: That's correct. 17 Q: Then there's a note at 14:03, you 18 called acting Superintendent Beacock and you request him 19 to: 20 "Meet Carl George and discuss concerns 21 this afternoon and will call back." 22 Is that -- have I read that correctly? 23 A: That's accurate. 24 Q: And then what's the balance of the 25 note?

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1 (BRIEF PAUSE) 2 3 Q: "1. Provincial Park [something] 4 alcohol. Campers not sympathetic. 5 2. Interfering at base." 6 A: That's right. 7 Q: And what does that refer to? 8 A: I believe the discussion was to have 9 some dialogue with Carl and express the concerns and -- 10 with the anticipated outcome that he would be able to 11 ensure, as was alluded to earlier, that -- that the 12 occupation not interfere with the day to day operations 13 of the military base. 14 Q: Okay. And then: 15 "Beacock advises that Detective Staff 16 Sergeant Matthews is preparing a plan 17 with command posts at [something] MTO"? 18 A: Northville MTO. 19 Q: And that would be at the Northville 20 lot -- the MTO -- 21 A: Yeah -- 22 Q: -- lot in -- 23 A: Port Franks. 24 Q: In Port Franks? 25 A: Yes.

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1 Q: Then if I could take you to Book 2, 2 Tab 39 which is the second of the big, black books. Yes 3 -- at Tab 39 is a -- 4 A: There's no Tab 39. 5 6 (BRIEF PAUSE) 7 8 A: Perhaps I have it here. 9 Q: No. 10 11 (BRIEF PAUSE) 12 13 A: Yes, sir. 14 Q: This is a briefing note from -- it's 15 MSGCS, it's Ministry of Solicitor General and 16 Correctional Services briefing note, is that correct? 17 A: That's correct. 18 Q: And this is another routine note put 19 out by the Office of the Commissioner? 20 A: That's correct. 21 Q: And do you know where these notes go 22 to, for example, this note? 23 MR. JULIAN FALCONER: Can we have a 24 location for that document? I'm -- I'm not following 25 that last document.

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1 MR. DERRY MILLAR: Sure, it's Inquiry 2 Document 2001062. 3 MR. JULIAN FALCONER: Thank you. 4 5 CONTINUED BY MR. DERRY MILLAR. 6 Q: Where -- what -- how does this -- the 7 notes such as this get generated and what happens to it? 8 A: Well, the note would be generated by, 9 in this particular case, the commissioner's office, some 10 of his staff, and it would be forwarded to the Ministry 11 and -- and in all likelihood to the deputy minister 12 staff. 13 Q: And what is the purpose of the note? 14 A: It's just to apprise them of the 15 status of this incident. 16 Q: And the information in the note would 17 be provided to the office of the commissioner by who? 18 A: Well, it could come from a number of 19 sources. It could come from the division commander, it 20 could come from a district commander or one of the 21 district inspectors. But it would usually be generated 22 by command staff in the districts. 23 Q: So either in Chatham or in London, in 24 this case, because of your involvement based in London? 25 A: Yes.

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1 Q: And perhaps we could mark this as the 2 next exhibit, Commissioner? 3 THE REGISTRAR: P-399. 4 COMMISSIONER SIDNEY LINDEN: P-399. 5 6 --- EXHIBIT NO. P-399: Document Number 2001062 MSGCS 7 Briefing Note, May 19/93 Re: 8 Native Demonstration- Camp 9 Ipperwash. 10 11 COMMISSIONER SIDNEY LINDEN: Just one (1) 12 page? 13 MR. DERRY MILLAR: It's one (1) page. 14 15 CONTINUED BY MR. DERRY MILLAR. 16 Q: Now this note indicates that the 17 issue with the Native demonstration Camp Ipperwash, 18 Ministry position, OPP role is continuing to keep the 19 peace. And then there's a background piece and the first 20 paragraph of which reads: 21 "A peaceful occupation of Camp 22 Ipperwash took place on May 6th, 1993 23 at 10:00 hours pursuant to ongoing 24 Native claims return of this land to 25 them. Camp Ipperwash is presently the

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1 property of and occupied by the 2 Department of National Defence." 3 It goes on to indicate that: 4 "The occupation continues and is 5 peaceful and civil obedience is being 6 maintained. Occupation will continue 7 until negotiations with the federal 8 government are concluded." 9 And that was information provided to you 10 by Mr. -- Chief Carl George? 11 A: Basically, yes. 12 Q: And the Base Commander had advised 13 the OPP that camp personnel will co-operate to the extent 14 possible. 15 Had you at this point had a discussion 16 with the Base Commander? 17 A: Yes. 18 Q: And had that -- you'd been given that 19 advice by the Base Commander? 20 A: Yes we -- we had an ongoing liaison 21 with the Base staff but in particular the Base Commander. 22 Q: And do you recall who was the Base 23 Commander back in May of 1993? 24 A: I believe it was Fred White. 25 Q: And he was a sergeant major?

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1 A: I believe so, yes. 2 Q: And then there's an indication on May 3 18th, 1993: 4 "Stoney Point band member advised the 5 Forest OPP Detachment that the Stoney 6 Point First Nations people would be 7 serving notice on Camp Ipperwash 8 personnel that structures would be 9 moved onto Camp Ipperwash property." 10 And that's the notice that we referred to 11 earlier? 12 A: Correct. 13 Q: "And OPP personnel met on the site 14 with the Chief was provided with a copy 15 of the notes which was tacked to the 16 wall of the main gate building. A 17 similar notice was to be served on an 18 MNR employee. Such service did occur. 19 However, no attempt was made to move 20 structures onto Provincial Park 21 property." 22 So there was a -- at the same time were 23 you aware that there was going to be a claim with respect 24 to the Provincial Park? You had been concerned about it 25 from a note we just saw about the Camp --

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1 A: I'm just trying to refer in my memory 2 when -- when I learned of it, if it was through the 3 original note that was served earlier or if there was 4 some other discussion. But -- but I was aware that -- 5 that the Ipperwash Park was certainly potential of an 6 occupation. 7 Q: And then the note goes on to say 8 that: 9 "At 11:52 hours on May 18th, 1993 the 10 Chief cut a lock from a chain that 11 secured a gate into Camp Ipperwash and 12 opened the gate. Numerous vehicles and 13 a small structure were moved onto the 14 Base property. No military personnel 15 were present and no incidents 16 occurred." 17 And that would be the second lock that was 18 cut along Highway 21? 19 A: Right. 20 Q: And that was along Highway 21 near 21 the rifle ranges? 22 A: Yes, sir. 23 Q: Then if I could take you to page 12 24 of your notes, May 19th. And there's a -- and the page 25 12 is our numbering of Exhibit 397, May 19th you got a

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1 telephone call from Detective Superintendent Wall; is 2 that correct? 3 A: Yes, sir. 4 Q: And it goes on to say: 5 "Is this advice being given to you by 6 Detective Superintendent Wall? Doug 7 Scott will discuss issue with Attorney 8 General. He will be attending in a 9 Ministerial meeting Friday, 21 May, 10 '93, 10:00 hours." 11 Who was Doug Scott, do you recall? 12 A: Doug Scott was an inspector who was 13 providing liaison duties to the Ministry. 14 Q: And had you dealt with Mr. Scott -- 15 Inspector Scott before? 16 A: I don't believe I'd ever met him. 17 Q: And then, there's a note: 18 "Updated re: Acting Staff Sergeant 19 Beacock meeting Carl George." 20 A: Yes? 21 Q: What's that refer to? The meeting 22 between -- 23 A: Between Beacock and Carl George. 24 That was just apprising him of the -- of that meeting. 25 Q: Then there's a note:

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1 "May require three (3) contingency 2 plans." 3 Have I read that correctly? 4 A: That's correct. 5 Q: And the three (3) contingency plans 6 are, "1) the status quo; 2)..." 7 A: "Turn over to OPP enforcement on 8 Base, 3) Military action against 9 Natives." 10 Q: And then, it goes on to say... 11 A: "Will update when Beacock calls back. 12 Update by Friday 09:00 for Doug Scott." 13 Q: And what were these -- why were you 14 discussing these three (3) contingencies? 15 A: Well, there's a -- a number of 16 different issues. And at this point I had done or had 17 requested some research to be done in regards to the 18 ownership of CFB Ipperwash and I had had some discussion 19 or was certainly aware of some discussion with Military 20 officials. And there were a number of different 21 approaches that were discussed. 22 The Military, it would have been their 23 preference that we simply go in and enforce trespass. 24 The OPP felt that wasn't the appropriate approach. 25 I ended up receiving the documentation

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1 around the 1942 War Measures issue and reviewed that. 2 And one (1) of the -- the Military would have liked to 3 turn over the -- the policing responsibility to the OPP 4 and simply go in and take whatever necessary action that 5 they felt we should. 6 And the other part, or the potential was 7 that the Military could take the action they deemed 8 appropriate pursuant to being responsible for that 9 Military Base, the security of the Base itself. They 10 have a -- 11 Q: Have defence regulations? 12 A: Yes, they -- they have authority 13 under what they call, "DCARS," the Defence Controlled 14 Access Regulations and they clearly had the authority if 15 they so felt appropriate to remove any trespasser from a 16 Military Base. That -- that applies to all Military 17 Bases nationwide. 18 Q: And when you say that you had 19 requested research and had obtained research with respect 20 to the War Measures Act 1942 Appropriation, what did you 21 get and what did you look at? 22 A: I -- I received copies of the actual 23 documentation that was developed back in 1942 around the 24 -- the actual -- get the right terminology -- of 25 expropriation of the property from the -- from the First

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1 Nations territory. 2 Q: They called it, actually, 3 appropriation back then under the War Measures Act, but 4 it has the same affect but, yes? 5 A: And so, I -- I received a copy of the 6 original documents and -- and certainly had the 7 opportunity to review those. 8 Q: And, as a result of reviewing those, 9 did you form any opinion with respect to the issue of 10 ownership at Camp Ipperwash? 11 A: It was -- it was fairly easy to -- to 12 read into that document that there was good reason to 13 understand how the Stoney Point people would have a 14 strong belief that -- or a strong expectation that the 15 property be returned to them at some point in time, 16 subsequent to the needs of the Military, pursuant to the 17 1942 Appropriation. 18 Q: And what, if any, effect did that 19 have on your thinking with respect to the issues at Camp 20 Ipperwash? 21 A: Well, to me, one (1) of the issues 22 that was -- was discussed, in particular with Detective 23 Superintendent Wall and Chief Coles, became the issue of 24 colour of right, and, in fact, that was subsequent 25 discussion between ourselves, and Military officials as

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1 well. 2 Q: And you were concerned, or the issue 3 for you was that the occupiers might very well, have a 4 colour of right, to be on the property? 5 A: Correct. 6 Q: In which case they were not 7 trespassing? 8 A: Well, I certainly felt there was lots 9 of room for debate on that issue. 10 Q: And the position of -- your position, 11 and the position of the OPP, was the Military, if they 12 wanted you to do something, had to get an injunction? 13 A: Well, that was one (1) of the options 14 that they could do, was to get an injunction, but they 15 could also enforce their controlled access regulations of 16 -- make an arrest, turn them over to us, where we would 17 continue the arrest and proceed with the judicial 18 process. 19 Q: So that if the Military took steps 20 under the Defence Controlled Access Regulations, they 21 would make any arrests, they would take the people they 22 arrested to the gate of Camp Ipperwash, and then turn 23 them over to the OPP? 24 A: That's it in a nutshell, yes. 25 Q: The OPP would not go in and -- into

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1 the -- the Army Camp and take possession of the people 2 they arrested on the Army Camp? 3 A: No, and we were very clear that our 4 preferred approach would have been an injunction. 5 Q: And I think we'll see that in some of 6 these notes as we go along. 7 Now, I note at 14:37 on May 19th, you had 8 called the Ministry of Natural Resources District Office 9 in Aylmer and spoke to Ron Baldwin, the district manager. 10 Is that correct? 11 A: That's right. 12 Q: And there's, "Advised meeting with 13 Carl and..." 14 A: "John and Maynard George". 15 Q: And who -- who's John? 16 A: I'm not sure, quite frankly. 17 Q: And is that a -- can you tell us what 18 else this note refers to, Deputy Commissioner? 19 A: "The moving an eight (8) by eight (8) 20 structure onto Ipperwash Park, this 21 date, agreed to the location. 22 Information and crafts to campers -- 23 Intend to work with native people. 24 Natives may attempt to charge campers 25 for use of the beach. Ministry of

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1 Natural Resources intend to prepare a 2 message to the campers requesting a 3 tolerance of the issues et cetera. 4 MNR, seeking legal opinion -- Aware of 5 Friday inter-ministerial meeting." 6 Q: And so I take it this is advice 7 you're getting from -- actually from Mr. Baldwin? 8 A: Yeah, it was a conversation we had. 9 Q: And they had no objection to the 10 moving, onto Ipperwash Provincial Park, of this small 11 structure? 12 A: Right. It was like a small trailer 13 type piece of equipment. 14 Q: Then there's a note at the top of 15 page 13 of the bound Exhibit 397. You are requested to 16 attend at Chief Superintendent's Cole -- Chief 17 Superintendent Cole's office, and on page 14 of Exhibit 18 397, there's a note that you did attend at Chief 19 Superintendent Cole's office. 20 Is that correct? 21 A: That's right. 22 Q: And then there's a referenced 23 chronology of events: 24 "Historically break down into factions 25 -- 1942, 1985 payment -- splinter

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1 groups." 2 What does that refer to, Deputy 3 Commissioner Carson? 4 A: Well, this refers to the chronology 5 of events, starting to document, you know, how this issue 6 arrives where it's at today, so we have some documents 7 for ourselves to refer to, and some understanding of it. 8 Historically, the issues is in regards to 9 the -- issues under the War Measures Act when Stoney 10 Point people were displaced to Kettle Point, and the 11 ongoing issues in regards to the descendants of the 12 Stoney Point people, and the Kettle Point people who were 13 there. 14 That's what it refers to in regards to 15 factions and in the 1980s, some payment that was made by 16 the Federal Government, to Kettle Point Band; and then 17 the splinter groups reflects that people that were on the 18 -- actually the occupiers were a splinter group of -- of 19 Kettle Point Band. 20 Q: And then, there's a heading -- and 21 there's a line, "Date, Event, Source," what's that 22 referring to? 23 A: Oh, we're just developing some 24 documentation around how we were going to -- to capture 25 some of the information as people were assigned to do

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1 some work. 2 Q: And then a constable was going to be 3 -- assist with respect to day-to-day administration; is 4 that correct? 5 A: Yes, he was assigned to me. He was 6 sent to the Forest Detachment where he would prepare, on 7 a daily basis, updates of the activities that were 8 occurring in regards to this. 9 Q: And then, there's a note, "prepare 10 daily updates," is that correct? 11 A: Right. And that's what -- that would 12 be his assignment. 13 Q: His assignment? And he was to assist 14 regarding intelligence? 15 A: Correct. 16 Q: And when you say, "intelligence," 17 what are you referring to there, identifying people, or 18 what's being referred to in intelligence? 19 A: That's part of it, and Neil Morris 20 would be someone from our intelligence branch, and he 21 would be someone who would be in contact with our members 22 at Forest, or myself, and just be coordinating some of 23 that information. 24 Q: And what kind of information was Neil 25 Morris -- what's the name of the constable, I didn't...

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1 A: Bill Watkins. 2 Q: Watkins -- the -- other than 3 identifying who was on the -- on the Base, what other 4 intelligence were they to -- to be dealing with? 5 A: Well, it would be a matter, of 6 course, of trying to just determine, you know, what the 7 intentions were, and any strategies that may be 8 developing, or if any visitors were coming from beyond 9 the area, just to have some understanding of what the 10 connections were, and who was coming and going. 11 Q: Then, there's a note, "Maintain local 12 involvement." 13 A: That's correct. That refers to 14 trying to maintain lines of communication, with the likes 15 of Staff Sergeant Mike Beacock, Mike Hudson, other 16 Members who know the occupiers, on a first name basis, so 17 there would be rapport maintained. 18 Q: Then, a note says: 19 "Detective Superintendent Wall, deal 20 with political issues." 21 What does that refer to? 22 A: Well, he would deal with the issues 23 within the Ministry, all the legal issues, and the 24 briefing notes and those types of things. 25 Q: And then, there's a note, "Research

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1 into legal issues by AG." 2 A: Correct. 3 Q: Then -- 4 A: I think that's something that had 5 been requested already by Detective Superintendent Wall; 6 I just made note of that was talked about in our 7 discussion. 8 Q: And those legal issues were the 9 Trespass to Property Act and -- 10 A: Yeah, ownership of the property, the 11 -- the whole historical issue around the Military Base. 12 I think it was around this time that I actually received 13 the document -- copies of the documents of the 1942 14 Appropriation. 15 Q: So, you were personally doing this as 16 well as getting advice from the -- the Attorney General's 17 Department? 18 A: Well, they -- they were providing the 19 documentation; I was certainly asking for that kind of 20 information, and it was being forwarded to me as it 21 became available. 22 Q: Then, there's a line: 23 "Who was involved splinter group?" 24 There's a question mark, splinter group, 25 and what's that refer to, the splinter group above?

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1 A: "Who was involved in the splinter 2 group?" 3 Q: Okay. 4 A: Yes, the actual occupiers. 5 Q: And then, I can't read the next line. 6 A: "Develop liaison with demonstrators", 7 I believe. 8 Q: And -- 9 A: And then: 10 "Develop liaison with Military." 11 It's just a couple -- ditto. 12 Q: So, what you're trying -- what you 13 were discussing is you wanted to have a contact with both 14 the demonstrators, and with the Military? 15 A: Correct. And the next -- 16 Q: And the next -- 17 A: The next line refers to researching 18 the issues of ownership and researching issues of legal 19 issues. 20 Then: 21 "Analysis of the consequences, develop 22 intelligence of unrecognized third 23 group." 24 Q: And what does that refer to? 25 A: I'm not sure what I was referring in

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1 that particular point. 2 Q: And then there's a note, "map"? 3 A: Map. Get a map. 4 Q: Just simply a map of the area? 5 A: Correct. We wanted something that 6 was substantial. 7 Q: And the -- at the top of the next 8 page, page 15 of 397, you spoke to Acting Superintendent 9 Beacock on -- or met with him at 13:00 hours on May 20th; 10 is that correct? 11 A: Correct. 12 Q: And can you read that note, that 13 first note? 14 A: Review objectives? 15 Q: Yes. 16 A: Then continue on? 17 Q: Yes. 18 A: "Patrol Highway 21. Observe activity 19 on base. Three (3) groups camping at 20 north end of base. Viewed Ipperwash 21 Provincial Park. Meet with Sergeant 22 Major Fred Wright. Discuss Native 23 issues. 24 Military, business as usual with cadets 25 this weekend."

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1 Q: And does this refer to a meeting that 2 Acting Superintendent Beacock had with Sergeant Major 3 Fred Wright? 4 A: I believe I -- this was a meeting I 5 had myself. 6 Q: Oh so, you and Beacock met with -- 7 A: Yeah, I think we met with Wright 8 together. 9 Q: And the next note. 10 A: "At 2:45 I returned to the Forest 11 Detachment. Called Inspector Turner. 12 Requested assistance of Sergeant 13 Wright. Assist re: the Native issues. 14 Prepare a chronology of events. 15 Assisted by Provincial Constable Luke 16 George Speck and Acting Staff Sergeant 17 Beacock." 18 Q: And the Sergeant Wright that's 19 referred in this note is Mark Wright? 20 A: Correct. 21 Q: And you were ask -- seeking his 22 assistance with respect to this assignment? 23 A: Yes, I was. 24 Q: And had you worked with -- with ins - 25 - Sergeant Mark Wright before?

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1 A: Yes, I'd known him for several years. 2 Q: And had you worked together at -- at 3 Chatham or in -- 4 A: He -- he had been a sergeant at 5 Sombra Detachment, I believe -- either when I was a 6 Sergeant at Chatham or while I was a Staff Sergeant at 7 Forest. But in -- in and around the mid to late '80's. 8 Q: And it refers -- you refer in this 9 note to the prepared chronology of events, and if I could 10 ask you to look at the small black binder directly in 11 front of you? 12 And if you would go to Tab 8, you will 13 find Exhibit P-208. And that's a letter dated May 20th, 14 1993, it's Inquiry Document 2000665. And that's a letter 15 signed by you? 16 A: It is, yes. 17 Q: And attached to it is a two (2) page 18 chronology that starts back in 1927, or prior to 1927, it 19 deals with 1927, and the sale of Ipperwash, surrender of 20 Ipperwash Beach. Then 1942 to 1980 and then 1993 and -- 21 was this a chronology that you put together with 22 Constable Luke George and Constable, I take it's George 23 Speck? 24 A: No, I'm sorry. If I said Luke George 25 it should have been Vince George.

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1 Q: Vince George. Excuse me that may 2 have been me. 3 A: And also, in regards to 1927, it's 4 the track of land -- 5 Q: Commonly known as Ipperwash Beach. 6 A: Right. I -- I'm sorry. I'm -- I was 7 confused. 8 Q: That's with respect to the West 9 Ipperwash area? 10 A: Right. 11 Q: And that was -- what did you -- what 12 did you use to create this chronology of events? 13 A: I have no idea. 14 Q: But it -- by this time you had -- you 15 had taken a look at the 1942 War Measures Act material, 16 and you got advice from Vince George and Constable Speck, 17 it's George Speck? 18 A: Correct. 19 Q: And George Speck had been a constable 20 in Forest in 1993, for a long time? 21 A: Well, George Speck has almost forty 22 (40) years on -- I think he's served his whole career 23 here. 24 Q: So -- and -- so back in '93 he had a 25 long period of service --

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1 A: Yeah, I think he only had a short 2 stint down in the Burlington area prior to coming here, 3 so he spent most of his adult life here, I believe. 4 Q: And this chronology was forwarded to 5 Chief Superintendent Coles, and why was this chronology 6 created, Deputy Carson? 7 A: Well, it was to -- to help us 8 understand that the events that we were dealing with, and 9 try to develop understanding of -- at the division level, 10 and to help with communication, with general 11 headquarters, in regards to the -- the issues around how 12 this occupation came to be. 13 And I'm not sure exactly the date I 14 received the documents, like, I'd have to check, but 15 certainly it was in and around this time that I was 16 getting the documents in regards to the 1942 removal. 17 Q: Then, at the bottom of the page, or 18 at 17:15 it says: 19 "Report facts to Division 'A' and 20 number one (1) district headquarters." 21 I take it that's referring to Exhibit P- 22 208? 23 A: Correct. 24 Q: And then you went off duty at 5:30 25 and at 7:45 you got a telephone call from Acting

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1 Superintendent -- Acting Sergeant L. Parks? 2 A: Correct. 3 Q: And he's telling you about a cell 4 phone call he received from Maynard George? 5 A: That's right. 6 Q: And it goes on to say: 7 "George advises that Military 8 installing a heavy chain across a 9 roadway and demands OPP have Military 10 remove it." 11 Then a note, 12 "I advised Parks that we would not 13 interfere with Military operations. 14 Park advises that George threatened 15 obstruction charges for not taking..." 16 A: Action. 17 Q: "-- action now". 18 A: Well, just for not taking action. 19 Q: Okay. And: 20 "Park was advised that we, OPP, will 21 not interfere with Military action." 22 A: Correct. 23 Q: And then the next day, page 16, on 24 May 21st, '93, there was a meeting at the district 25 headquarters boardroom in London?

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1 A: That's right. 2 Q: And it would appear that this is a 3 planning meeting? 4 5 (BRIEF PAUSE) 6 7 A: Yes. 8 Q: And there's a reference, 9 "Command tailor -- trailer available 10 from transport branch, photographic 11 surveillance, cell phones". 12 And I take it that one (1) thing you were 13 -- you were considering was getting a command trailer; 14 you wanted photographic surveillance and cell phones for 15 people? 16 A: Correct. 17 Q: And then the next line, the first 18 word I can't read. 19 A: I'm not sure what it is. 20 Q: And -- 21 A: Oh, maybe uniform. 22 Q: And then, "info to Forest for 23 intelligence"; is that correct? 24 A: From intelligence? 25 Q: From intelligence. And then there

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1 are a number of officers identified; what were the roles 2 of these officers? 3 A: The list here? Detective -- 4 Q: Yes. 5 A: -- Inspector Connors and Wall and 6 Matthews? 7 Q: Yes. 8 A: They all had various roles, I -- I'm 9 not sure where -- Connors may have worked in intelligence 10 back then, perhaps, it's my best guess. 11 Q: Yeah. 12 A: And these other officers, Detective 13 Superintendent Wall was the Superintendent In Charge of 14 Criminal Operations for the region, and Matthews was 15 Detective Sergeant -- Detective Staff Sergeant out of 16 Chatham. 17 Detective Constable Hernandez (phonetic) 18 was an Intelligence Officer out of Chatham. Sergeant 19 Bell was an Intelligence Officer out of the London Joint 20 Forces operation, and John Fuller worked for our 21 Technical Support Bureau at that time. 22 Q: Military SIU, what's that mean? 23 A: That would be a Military Special 24 Investigations Officer; it's the Military -- Military 25 Police.

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1 Q: That was a Military Police Officer? 2 A: Correct. 3 Q: And in these notes we see SIU in a 4 number of places, is that -- that's referring to the 5 Military Police? 6 A: Yeah, the Military have a special 7 investigations -- special investigations unit within 8 their police structure. 9 Q: And then, there's a note: 10 "Intelligence [something] will monitor 11 movements and photo." 12 A: "An intelligence unit" -- 13 Q: Okay. 14 A: "-- will monitor movements and photo, 15 supply info through Acting Staff 16 Sergeant Beacock. Check on Windsor 17 tactical training." 18 Q: And what's that refer to? 19 A: While we had ceased using the 20 Military Base for training purposes, some of our 21 municipal counterparts, in fact, still used it for -- for 22 their training and Windsor had been one (1) of them. 23 Q: And so, were -- what was the -- 24 what's the purpose of the note "Check with Windsor 25 Tactical Training"; was it to get them to stop using it?

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1 A: Well, we wanted to make them aware of 2 the occupation and that it may not be a place they would 3 want to be conducting training. 4 Q: Okay. Then, on the next page, page 5 17, there's a note, 16:20 you had a telephone call from 6 Chief Superintendent Coles and it says: 7 "Discussed inter-Ministerial meeting. 8 Inspector Doug Scott attended, support 9 of direction to-date Chief 10 Superintendent reaffirms direct 11 reporting to Superintendent Randall." 12 A: That's correct. 13 Q: And can you tell me a little bit more 14 about that? What did you talk about, if you can recall, 15 with respect to the inter Ministerial meeting? 16 A: All I can tell you is he must have 17 updated me on whatever feedback he received from 18 Inspector Scott. 19 Q: And the supportive direction to-date, 20 is that the support of Chief Superintendent Coles or 21 someone else? 22 A: I'm assuming it's Coles. 23 Q: Then, at Tab 10 -- excuse me, at Tab 24 9, there's a letter dated May 20th, 1993; it's Exhibit P- 25 174 Inquiry Document 2002549 and you're shown as having

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1 received a copy of this letter. 2 Do you recall seeing this letter back in 3 May of 1993? 4 A: It would have been one (1) of the 5 standard daily updates. 6 Q: And this reports on a meeting, the -- 7 the May 19th issue with respect to Chief Carl George and 8 Maynard George is referred to as Historian, meeting with 9 the Park superintendent, Les Kobayashi and others from 10 MNR? 11 A: Correct. 12 Q: And the agreement with respect to 13 moving a small building onto the Provincial Park for the 14 weekend? 15 A: Correct. It was kind of a -- an 16 information booth. 17 Q: An information booth? 18 A: For lack of a better description. 19 Q: And then, at Tab 10 of this book 20 there's Exhibit P-175, it's Document 2002607 and it's a 21 letter dated May 22nd, 1993 from W.C. Watkins to the 22 Superintendent and I take it that this, again, is one (1) 23 of the daily reports? 24 A: Correct. 25 Q: And Watkins was the constable that

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1 was assigned to assist you? 2 A: Right. He raised the document for 3 me. 4 Q: And this notes at three (3) -- 5 additional three (3) tents have been erected on the 6 occupying land, two (2) on two (2) firing ranges fronting 7 on Highway 21 and it's simply bringing everyone up-to- 8 date? 9 A: Correct. 10 Q: And then, there's a note, the second 11 last paragraph: 12 "Of interest is a statement made by 13 Carl George to MNR officials on May 20, 14 1993, that they, 'haven't occupied any 15 buildings yet.'" 16 And did you have any discussion with 17 respect to that quote with either Constable Watkins or 18 Acting Staff Sergeant Beacock? 19 A: I don't recall specific discussion. 20 Q: And then at the next tab, Tab 11, 21 this is a document that's Exhibit P-176, Inquiry Document 22 2002603. And this is a letter from you dated May 23, 23 1993 to the Superintendent. 24 And this refers again -- this refers to -- 25 on May 22nd you had received a telephone call or Forest

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1 Detachment had received a telephone call from Captain 2 Dodson in London that a notice had been served on the 3 Military at CFB Ipperwash by a bailiff that indicated 4 First Nation people would be setting up checkpoints. 5 Checkpoints are to be set up around the 6 parade square and the barracks and it notes that: 7 " For [the] Victoria weekend, there are 8 about nine hundred (900) cadets and 9 militia using the Base." 10 And there's a note, Acting Staff Sergeant 11 E.B. Beacock attended CFB Ipperwash and obtained a copy 12 of the notice. It is apparent that the notice is 13 basically a letter delivered by the licensed bailiff. 14 There's no reason to believe that it holds 15 any substance in law and Beacock -- you report that 16 Beacock and yourself went to this -- the camp and spoke 17 to Chief Carl George; is that correct? 18 A: That's right. 19 Q: And we saw that note earlier on, was 20 that referring to that? Where's -- is there a note with 21 respect to your meeting with Carl George; was it on May 22 22nd? 23 It is, page 18, May 22nd? "Eleven 24 o'clock, attend Camp. Spoke to --" 25 A: That's correct.

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1 Q: "-- Carl George. [something] Carl 2 George not available. All quiet." 3 Did you eventually have a discussion with 4 Carl George that day? 5 A: Just a -- 6 Q: There's a note on page 19, May 22nd 7 as well: 8 "19:50 called Acting Sergeant Staff -- 9 Staff Sergeant Beacock and you 10 discussed, it's call with Dodson, the 11 Bailiff Scott Ewart with respect to the 12 checkpoints and ask him to contact Carl 13 George." 14 A: On the -- on page 20 -- 15 Q: Yes? 16 A: You will see that I met Acting Staff 17 Sergeant Beacock at campsite with Carl George. So that's 18 21:10 hours. 19 Q: So that's at 9:10? 20 A: Correct. 21 Q: And that note says: 22 "Met Acting Sergeant Beacock at 23 campsite with Carl George. George ..." 24 A: "Sitting in his vehicle talking to 25 Beacock. Lengthy discussion re: return

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1 of lands. George advises feds coming 2 to Kettle Point Tuesday, community 3 centre. They would have to come to 4 Camp to see Carl. 5 During discussion asked what was the 6 major issue. Carl stated that that 7 they must be recognized as a separate 8 Band and Tom Bressette was not helping. 9 When asked about camper setting up 10 along shooting range he advised that 11 people need privacy and they had no 12 control to stop them from camping where 13 they want. Carl advised that the 14 Stoney Point Band was recognized. They 15 would start building on the property." 16 Q: They would then start building on the 17 property? 18 A: Correct. 19 "It is apparent that Stoney Point 20 people do not intend to leave even if 21 negotiations at a federal level are 22 commenced." 23 Q: And then there's a note on the next 24 page at 22:40, you called Detective Superintendent Wall 25 and you report on the meeting of Carl George and staff --

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1 acting Staff Sergeant Beacock; is that correct? 2 A: That's right. 3 Q: And you refer to the licenced 4 bailiff. Then you -- there's a note: 5 "We were not prepared to assist 6 Military police and cause confrontation 7 at this time. I would further attempt 8 -- I would attempt to further [discuss] 9 -- discussion with Bob George , 10 hyphen." 11 You know what the next word -- Sunday 12 morning? 13 A: Sunday morning. 14 Q: "Superintendent Wall advised we can 15 [something] legal branch ascertain 16 validity of documents served on 17 Military." 18 A: Correct. 19 Q: So the position of the OPP on May 20 22nd is, or at least your position was that you were not 21 going to assist the Military? 22 A: Correct. 23 Q: And I understand that there were no 24 checkpoints set up around the -- were there any 25 checkpoints set up around the --

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1 A: No. 2 Q: -- built-up area? 3 A: No, no. 4 Q: So that issue -- Maynard George did 5 not carry through with -- with what he had indicated he 6 was going to do? 7 A: No, he did not. 8 Q: And again, at page 22 on May 23rd, 9 1993, it's Sunday. There's -- you're at the Base? 10 A: I started at 7:30 at the Forest 11 Detachment preparing a briefing for the superintendent. 12 Q: Yes. Then "tour of Ipperwash base 13 area"? 14 A: Yes. 15 "A few people milling about. 16 Checked rear Base near the beach. 1:10 17 no persons observed. Met with Sergeant 18 Major White on the roadway. Discussed 19 events to date. Sergeant Major feels 20 the natives are attempting to 21 antagonize Military. He is clear that 22 the tactics will not provoke a Military 23 response. Returned to the office in 24 Forest at eleven o'clock." 25 Q: And then there's a note of a meeting

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1 at 13:15 with acting Staff Sergeant Beacock and Neil 2 Morris. 3 A: Yes. 4 "Morris advises that information 5 re: warriors. Half day, which is 6 individual male married to a woman from 7 Oneida warrior affiliation. 8 Information that he would have been at 9 Ipperwash on the 22nd May and supplied 10 information to locals as to support 11 that could be afforded to Ipperwash. 12 Information is that fifty (50) people 13 could be assembled within one (1) hour 14 and five hundred (500) within one (1) 15 day. 16 Network exists to Akwesasne and 17 Kanesatake." 18 Q: And that was -- that was information 19 provided to you by Mr. Morris? 20 A: Yes. 21 Q: Then there's a sticky, I guess, on 22 the back of that page. The next page says: 23 "First Nation OPP officers video cars." 24 What's that referring to? 25 A: I'm not sure, but I -- I don't have

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1 that sticky note, but -- oh, here it is. Actually it's 2 in regards to the 24th. 3 Q: Okay. 4 A: It's a First Nations OPP officer, so 5 that would be referring to the -- Luke George, Vince 6 George, oh, and there was Phil George, I believe, was 7 working in the Sombra area at that time. 8 Video cars, we had, I believe one (1) or 9 two (2) vehicles. One (1) in the Sombra area that was 10 equipped with in-car video, VHS tape recording 11 capability. So that was just a note of -- of resources 12 that were available. 13 Q: Available. Then at page 24 then 14 there's the note, May 23rd. Is that a continuation of 15 the note that we saw before? 16 A: Yes, I believe so. 17 Q: And it says: "Warriors could supply 18 food [something] and other logistics"? 19 A: "Food, arms, and any other logistics 20 required. Informant suggests that at 21 this time no plans for warrior 22 involvement. However, if Military took 23 an offensive action, warriors would 24 come out of the woodwork. 25 Morris also advises that there are

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1 legal proceedings being prepared 2 through lawyers in London. At this 3 time, no information to what that might 4 be. 5 Morris advised to contact Constable 6 Winston Williams and discuss any other 7 information that he may have. Advised 8 Morris to be conscious of 9 counterintelligence. 10 Beacock and Morris both advised that 11 this information would not be 12 disseminated to anyone and I 13 would advise Detective Superintendent 14 Wall." 15 Q: And then Captain Dodson attended? 16 A: Yes, he: 17 "Attended Forest Detachment, discussed 18 the issues with Acting Staff Sergeant 19 Beacock. Copies of Military Updates 20 received." 21 Q: And if I could take you to Tab 11 of 22 -- we were looking at P-176. You wrote this letter of 23 May 23rd on May 23rd after these -- the meeting that you 24 had with Carl George? 25 A: Correct.

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1 Q: Then, at the next Tab, Tab 12, 2 there's Exhibit P-178, it's Inquiry Document 2002612. 3 And is this a document that you're familiar with, sir? 4 It refers to you, but... 5 6 (BRIEF PAUSE) 7 8 MR. MARK SANDLER: What is the tab 9 number? 10 MR. DERRY MILLAR: It's -- well, it's -- 11 we've got a different set of tabs here, but this is -- 12 what we did is, we created just for My Friends, a 13 document book based on the exhibits that have been 14 already marked, but it's Inquiry Document 2002612. 15 MS. ANDREA TUCK-JACKSON: Could you 16 please repeat the number? 17 MR. DERRY MILLAR: P-178. 18 MS. ANDREA TUCK-JACKSON: Thank you. 19 THE WITNESS: It appears to be a document 20 we produced, but I can't put a finger on it. 21 22 CONTINUED BY MR. DERRY MILLAR: 23 Q: It's simply a listing of some of the 24 issues and some of the events. 25 A: Well, it's just -- well, it's just an

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1 update of the chronology. 2 Q: Yeah. Then, at the next tab in the 3 book that's in front of you and My Friends don't have it, 4 but it's Exhibit P-216, Inquiry Document 1007625. 5 A: Correct. 6 Q: And that's the minutes of a 7 ministerial meeting : 8 "Inter-ministerial Officials Committee 9 on Aboriginal Emergencies Working Group 10 Meeting re: Camp Ipperwash and 11 Ipperwash Provincial Park." 12 It's dated Tuesday, May 25, 1993 and 13 prior to these Proceedings, have you seen this document 14 before? Did you get these minutes? 15 MR. JULIAN FALCONER: What's the document 16 number again? 17 MR. DERRY MILLAR: It's 1007625. 18 MR. JULIAN FALCONER: Thank you. 19 THE WITNESS: I'm sorry, sir. 20 21 CONTINUED BY MR. DERRY MILLAR: 22 Q: Did you get these minutes of these 23 inter-ministerial meetings? Have you seen this document 24 before, P-216? 25 A: No, I believe I only have -- became

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1 aware of it in a recent disclosure. 2 Q: So that back in 1993 you did not 3 receive the minutes of any inter-ministerial meetings? 4 A: No, I -- I was only briefed by 5 Detective Superintendent Wall. 6 Q: Or Superintendent Coles? 7 A: Well, usually it would be -- 8 Q: Wall? 9 A: -- Wall, he -- he was the contact 10 more often than not with Doug Scott. 11 Q: Okay. Then there's a note, May 24th, 12 it's simply a note of what you did on that date with 13 respect to the issues at Ipperwash? 14 A: Page 25? 15 Q: Page 25, yes. 16 A: Correct. 17 Q: And if I could take you to page 27 of 18 Exhibit 397, there's a note, which I take it is a sticky 19 on one (1) of the notes in your blue book: 20 "Maynard [an arrow] Dolan MNR." 21 Can you tell us what that referred to? 22 23 (BRIEF PAUSE) 24 25 A: If you refer to May 26th notes --

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1 Q: Yes? 2 A: -- on page 28 -- 3 Q: Yes. 4 A: -- you'll see: 5 "At 10:45, call from Bill Watkins 6 advises Ministry of Natural Resources 7 Dodson, Aylmer received a call from 8 Maynard George. Stoney Pointers will 9 be painting the trailer at Ipperwash, 10 Thursday, the 27th of May, 0900 to 11 10:00 hours. Prepared to pass out 12 information. Maynard commented that 13 he's having difficulty maintaining 14 control over his people." 15 So I think that's the note when the phone 16 call came in. 17 Q: Then there's a note actually before 18 that at 9:20, Chief's office -- can you read that note 19 and tell us what that refers to on page 28? 20 A: Yeah, that's correct. I believe 21 that's: 22 "Bill, the Chief's office, MNR research 23 Ipperwash issue. MNR Ipperwash contact 24 Chief Bressette. Research issue of 25 bailiff serving notice. Another

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1 meeting Thursday on the 27th of May." 2 Q: And on the 27th of May, the next day, 3 there's a note that you had a telephone call with 4 Detective Sergeant Bell and he advised you of activity at 5 the Base. Camp -- 6 A: Nearest the barracks -- 7 Q: -- barracks and Maynard George 8 location? 9 A: Correct. 10 Q: And then there's a note with respect 11 to munitions that the Army was receiving; is that 12 correct? 13 A: Yeah. The Military were receiving 14 some munitions and this was an inventory of what they 15 were expecting to arrive. 16 Q: Then there's a note: 17 "Checking re: detailed aerial photos 18 from Military." 19 What's that refer to? 20 A: Military were going to provide me 21 with some aerial photos of the Military Base. 22 Q: And then "Members off for ..." 23 A: Weekend. 24 Q: Weekend and then "update next Tuesday 25 unless..."

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1 A: Heightened activity. 2 Q: Okay. And then you reported to -- 3 called Superintendent Wall, updated and then there's a 4 note: 5 " Tuesday meeting. Military declined 6 to attend..." 7 A: Busy. 8 Q: Okay. 9 A: Meeting 13:30 this date. 10 Q: Letter -- 11 A: "Letter from ADM of ONAS to the 12 federal rep. for Ontario to express 13 concern regarding the events. 14 Negotiate to Indian Affairs rep, 15 negotiations controlled by DND. Bruce 16 Long updated to discuss with Vale." 17 Q: And I take it that this -- you were 18 advised by Superintendent Wall that the Ontario 19 Government was going to write the Federal Government to 20 express their concern regarding the negotiations that -- 21 with respect to Camp Ipperwash? 22 A: Correct. 23 Q: And then on the next page, page 30, 24 again on May 27th you had: 25 " A call with Chief Superintendent

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1 Coles and discussed Native issues. No 2 major changes. Discussed Chief 3 Bressette not, [something] with 4 Military. Suggested he may support 5 Stoney Point." 6 What's that referring to? 7 A: "Chief Bressette not happy with the 8 Military. Suggested he may support Stoney 9 Point." 10 Q: And if I could take you to the black 11 book, Tab 14, you will see Exhibit P-257 which is Inquiry 12 Document Number -- I regret that I don't have it. 13 THE REGISTRAR: P-257? 14 MR. DERRY MILLAR: Yes. Can you look -- 15 THE REGISTRAR: Document Number 2001217. 16 MR. DERRY MILLAR: 20012 -- 17 THE REGISTRAR: 17. 18 19 CONTINUED BY MR. DERRY MILLAR: 20 Q: And this is a letter from Sergeant 21 McDonald acting -- on behalf of Acting Staff Sergeant 22 Beacock and you received a copy, is that correct? 23 A: That's right. 24 Q: And it reports on a meeting on May 25 26th between Terry Humberstone on behalf of the Ministry

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1 of Natural Resources and Chief Tom Bressette? 2 A: Correct. 3 Q: And this refers to the fact that 4 Chief Bressette's not happy with the Ministry of National 5 Defence and Mr. Humberstone reports that he was 6 considering joining with the occupation. 7 A: Correct. 8 Q: Then: 9 "Chief -- Mr. Humberstone reported that 10 Chief Bressette also indicated that the 11 Band doesn't believe there is a 12 legitimate land claim in relation to 13 Ipperwash Provincial Park and feels 14 that the MNR should be throwing out 15 those persons who occupy the Park." 16 A: Correct. 17 Q: "In addition, Bressette made mention 18 that peacekeepers from Oneida and 19 Moraviantown had visited the area 20 recently." 21 A: That's right. 22 Q: Now, this is a report from Mr. 23 Humberstone to Mr. -- 24 A: Steve -- 25 Q: -- McDonald and Mr. Beacock is that--

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1 A: Steve McDonald accepted it, yes. 2 Q: And in May of 1993, did you have any 3 discussions with Chief Tom Bressette with respect to the 4 Provincial Park, do you recall? 5 A: I couldn't tell you off-hand, to be 6 100 percent sure. I'd be surprised if we didn't. I 7 mean, we discussed, certainly, the -- the whole issue of 8 the Ipperwash Military Base and I'd be greatly surprised 9 if we didn't have discussions about the Park as well. 10 Q: And at the next tab -- you can't 11 recall any discussions? 12 A: Not specifically, no. 13 Q: The next tab in this book there's a 14 document, it's Inquiry Document 2002678; it's entitled, 15 "Ontario Provincial Police Number 1 District Operational 16 Plan, occupation of Canadian Forces Base Ipperwash" and 17 this document is dated -- on the third last page it says, 18 "Revised May 28, 1993 -- May -- 28th May, '93." 19 What is this document, sir? 20 A: It's a -- a plan, an operational 21 plan, in regards to the occupation of CFB Ipperwash. 22 Q: Yes? 23 A: So it was developed given the issues 24 that we were facing in regards to the occupation and 25 potential action that may be taken by minister -- or the

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1 Department of National Defence. 2 Q: And it indicates on page 1 that 3 you're going to be in the short-term, the Incident 4 Commander and if it's going to be longer, they would get 5 an Incident Commander from Number 1 District Command; is 6 that correct? 7 A: Correct. 8 Q: And what role did you play in 9 developing this document? 10 A: I was basically the, for lack of a 11 better term, responsible for having it made. 12 Q: And I note that the -- it sets out at 13 page 2 the role of the OPP with respect to defence 14 establishments? 15 A: Correct. That's the OPP policy 16 that's -- that is part of our police order in -- in 17 relation to defence establishment. 18 Q: And, it says in 42.2: 19 "In addition to Federal statutes and 20 regulations, specifically it's 21 responsibility, the Military Police 22 enforces on defence establishments, 23 within the limits of its authority, the 24 Criminal Code and provincial traffic 25 statues and regulations. For the

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1 purpose of prosecuting any such matters 2 the Military Police may deal directly 3 with the Crown Attorney." 4 And then in 42.3: 5 "An offence under the Criminal Code of 6 Canada that is serious in nature and, 7 in particular, due to limitations 8 imposed by the National Defence Act, 9 the offences of murder or manslaughter 10 or any serious sexual assault occurring 11 on a defence establishment lying within 12 Force jurisdiction will be reported by 13 the military police to the nearest 14 Force location." 15 So I take it from this that for less 16 serious offences, the Military deals with it themselves. 17 For more serious offences, they call in the OPP? 18 A: Correct. That was a protocol that 19 was developed and in particularly, with Military Bases as 20 you can well appreciate, the safety hazards around the 21 operation of a Military Base and the fact that they had 22 their own police. 23 Technically, we have the authority to 24 enforce the law within the Military Base but due to the 25 protocols and the fact that they had Military police

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1 there that were certainly very able to handle the day to 2 day operations, it was only those serious offences where 3 we go in and either take the investigation or assist them 4 with their investigation if they needed expertise. 5 Q: Then I note on the next page, page 3 6 the OPP action is some of the things that we've already 7 discussed. 8 "In addition to maintaining the peace, 9 monitoring demonstrative movement and 10 facilitating peaceful negotiations. We 11 will develop a chronology on the 12 issues. Develop liaison with Kettle 13 and Stony Point officials, Military 14 officials, RCMP officials -- " 15 And somebody's written in, "MNR". Then, 16 "Research ownership of land or legal 17 title if control issue. Research legal 18 resource issues. Federal legislation, 19 provincial legislation, police 20 authority. Develop intelligence 21 information on other groups attending. 22 Monitor all activities, actions and 23 movements to gather evidence for 24 possible future prosecutions. Request 25 and assist with discussions of issues

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1 at the inter-ministerial committee 2 meetings. Further police action will 3 be decided and this area updated after 4 review, the aforementioned and after 5 consultation with all parties 6 involved." 7 So, the plan provided for some of the 8 things that we've already discussed this afternoon? 9 A: Correct. 10 Q: And then on the top of page 4, 11 there's a reference to: 12 Chief Superintendent C. Coles and 13 Detective Superintendent T. Wall met 14 with Major General Vernon and Colonel 15 Boyd, May 20, '93. The Military will 16 continue a non-confrontational position 17 and encourage senior staff to get more 18 involved in negotiations with the First 19 Nations people." 20 Then there's a note, 21 "Friday. Commander..." 22 A: Stan Blythe. 23 Q: "Ottawa policing position." 28 May, 24 I take it? 25 A: Correct.

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1 Q: Do you know what that's referring to? 2 A: I suspect that would be the position 3 that the Military police are going to take in regards to 4 their role. 5 Q: And then there's a section on the 6 command post communications, and then on page 5 7 identification. 8 "Number 1 District Technical 9 Identification Unit will supply and 10 train a member of Forest Detachment to 11 operate a video camera, record any 12 incidents that may occur." 13 And then on page 6: 14 "Negotiations. If the need arises to 15 take all the above steps, it will be 16 necessary to have negotiators in place 17 to talk to the individuals involved. 18 It will be necessary to supply the 19 occupants of the Base with a field 20 telephone that would be connected to 21 negotiators at the command centre. 22 The police do not have the power to 23 negotiate with the First Nation people 24 regarding land, but if any criminal 25 acts do occur, then we must be in a

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1 position to negotiate." 2 So that you were constrained because you 3 couldn't negotiate with respect to the land issues, but 4 you were preparing to negotiate if there were any 5 criminal issues that arose; I take it? 6 A: Correct. 7 Q: And this plan, although it was in 8 place, was never used because it wasn't needed to be 9 used; is that correct? 10 A: That's right. 11 Q: And the command post was never moved 12 to Port Franks and it was simply -- had been developed in 13 case it was necessary? 14 A: That's right. 15 Q: And there are two (2) maps that are 16 at the last -- the last two (2) pages of exhibit -- of 17 Document 2002678 and we should mark this the next 18 exhibit, Commissioner. 19 THE REGISTRAR: P-400. 20 21 --- EXHIBIT NO. P-400: Document Number 2002678 OPP 22 Number 1 District Operational 23 Plan, Occupation of Canadian 24 Forces Base, Ipperwash, 25 Revised 28 May, 93.

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1 CONTINUED BY MR. DERRY MILLAR: 2 Q: And can you tell us, those maps 3 appear to be -- what do they -- what are they maps of? 4 A: Well, it appears to be Kettle Point 5 and the waterfront. 6 Q: Yes, and the -- and the second one? 7 A: I believe it's the waterfront 8 adjacent to Kettle Point, but I can't be 100 percent 9 sure; the map is quite unclear. 10 Q: And -- but at this point -- even the 11 map may be of Kettle Point, Kettle Point was not the 12 issue, was it? 13 A: Oh, no. Not -- not at all. 14 Q: Then... 15 16 (BRIEF PAUSE) 17 18 Q: Page 31, May 28th, '93, at 14:55 you 19 had, again, a discussion -- a telephone call from 20 Detective Superintendent Walls -- Wall, excuse me, and it 21 indicates that there was calls from Military re: Read Le 22 -- Lead Agency. 23 "Captain Dodson asked direction re: 24 intervention military would require to 25 obtain injunction. His opinion, Dodson

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1 short-term pain D/Campbell advised, 2 asked for plan for Temagami something 3 scenarios?" 4 A: Review scenarios? 5 Q: "Review scenarios. D/Campbell looked 6 for more detailed plan. Staff to 7 Forest Detective Superintendent Wall 8 that will be discussed with 9 Superintendent Randall. Meeting 10 reference plan, 08:00 May -- Monday, 31 11 May, '93" 12 A: Correct. 13 Q: Now, this is referring to the -- the 14 reference military would require to obtain injunction, 15 was that something that Superintendent Wall, you 16 understood, had told Captain Dodson? 17 A: Correct. There had been ongoing 18 discussions with the Military that Tom Wall had 19 facilitated; and it was made very clear that if they 20 wanted to remove the parties from the Military Base, 21 they'd require an injunction. 22 Q: And then they would -- they'd be 23 required to get an injunction? 24 Then, the next page, are these your notes, 25 May 31/93, page 32?

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1 A: Correct. Yes, they are. 2 Q: And that's a meeting where? What's 3 this refer to, sir? 4 A: I was trying to figure that out. It 5 looks like it was a brainstorming session to look at 6 various scenarios that could be potentially developed, 7 and logistics that would be attached to that. 8 Q: And the first sentence says: 9 "Security of Military Base. Then 10 Interim until invoking the injunction." 11 Is that correct? 12 A: Yes. 13 "Security Military Base regarding 14 notice until invoking the injunction. 15 Prevent support of First Nations." 16 Q: That's assuming the Military got an 17 injunction? 18 A: Right. One (1) of the -- one (1) of 19 the points that we had to deal with was, if the Military 20 told us they had an injunction, or were preparing to get 21 an injunction, that we secure the area to prevent 22 additional occupiers from coming into the area. 23 Q: If they had got an -- oh, I see. If 24 they had got an injunction, then you -- one (1) of the 25 jobs the OPP would have had, would be to cordon off the

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1 area around the Army Camp? 2 A: Well, and -- and one (1) of the 3 concerns that went along with that was that if there was 4 notice served, that an injunction was being sought that 5 there's a period of time from the notice of filing, and 6 the actual injunction taking place, could be a 7 significant period of time, but would require security of 8 the base, in the interim, until that injunction was 9 actually delivered. 10 Q: And then, there's a note: 11 "Discuss Ip with Sergeant Major." 12 Is that Superintendent -- what's -- how 13 does that -- what's the next sentence read? 14 A: Oh: 15 "Discuss Ipperwash with Superintendent, 16 Ministry of Natural Resources." 17 Q: And is that referring to -- 18 A: That would be -- 19 Q: -- Mr. Kobayashi? 20 A: Correct. 21 Q: Then this is simply things that you 22 are thinking about you would have to do? 23 A: This was scenario development. 24 25 (BRIEF PAUSE)

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1 Q: Then, at the top of the next page, 2 it's -- is a continuation of the scenario development? 3 A: Correct. 4 Q: And then on May 31st, page 34, you 5 got a telephone call from someone; Sergeant McDonald? 6 A: That's right. 7 "Advises Constable Shaun Johnstone was 8 talking to a male native, brown Buick 9 at Ravenswood." 10 Question mark if it was Carl George. 11 "Subject advised that bailiff is going 12 to serve Military and caterers, 13 suppliers not to supply the Base. 14 Prohibit delivery. Publish in the 15 London Free Press. McDonald advised to 16 send update through channels." 17 Q: Okay. And then on page 35, there's a 18 -- on May 31st at 08:00, at the Chatham district 19 headquarters, there's a meeting with Superintendent 20 Randall, Detective Superintendent Wall, Staff 21 Superintendent Matthews, Inspector Turner, McKenna, and 22 yourself, I take it? 23 A: Correct. 24 Q: And this relates to a planning -- I 25 take it, just planning?

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1 A: Well, it's really an update to that 2 point in time, and a review of the various scenarios that 3 may develop. 4 Q: And step 1 was the action to date, 5 and notification of both parties re: application for 6 injunction? 7 A: Correct. 8 Q: If that, in fact, had taken place, 9 but that had not taken place? 10 A: Correct. 11 Q: What's that refer to? 12 A: Well, that -- the things that would 13 set the scenario in motion would be the -- would be 14 serving notice of the application for an injunction. 15 Q: All right. Then there's three (3) 16 scenarios: 17 "Injunction obtained by the Military- 18 OPP, that's scenario 1." 19 Scenario 2, move on to -- move -- 20 A: Onto the Base alone or Military. 21 Q: And then 3? 22 A: No injunction, the Military clears 23 the base. Problem on exterior of Base, and Base cleared 24 moved -- moves to Crown land. Occupation of Provincial 25 Park Ipperwash. Closure of roads.

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1 Q: And those were -- that was a scenario 2 that you were concerned about? 3 A: Right, those are some of the issues 4 that we realized that we'd be facing should something 5 like this proceed. 6 Q: Okay. And then step 2? 7 A: "Upon application of Military, 8 regarding the injunction, the OPP 9 communicate the OPP role to all the 10 parties. If we are named in 11 injunction, control the base access, 12 establish a perimeter. Ministry of 13 Natural Resources would close the Park. 14 Negotiate a peaceful evac -- evacuation 15 and resolution subject to the 16 conditions of the injunction. 17 Logistics, children's aid re: 18 children. Same as step 2. Returning 19 to scene." 20 Q: And what's -- what, if anything, 21 occurred as a result of this meeting. This was simply a 22 planning meeting to consider different alternatives if... 23 A: None of it was put into effect. 24 Q: None -- yeah, the -- no injunction 25 was got -- or was obtained. None of these scenarios took

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1 place. 2 A: That's right. 3 Q: Then there's a note at page 38, June 4 the 1st, '93 -- 5 COMMISSIONER SIDNEY LINDEN: Mr. Millar, 6 you said you wanted to adjourn at 4:30. 7 MR. DERRY MILLAR: I don't want to, 8 but... 9 COMMISSIONER SIDNEY LINDEN: But you 10 said -- 11 MR. DERRY MILLAR: Anyway, that's fine. 12 COMMISSIONER SIDNEY LINDEN: Did we agree 13 to adjourn at 4:30? 14 MR. DERRY MILLAR: We did. 15 COMMISSIONER SIDNEY LINDEN: Okay, then I 16 think we should. We will adjourn now. It is past 4:30, 17 until tomorrow morning -- 18 MR. DERRY MILLAR: At ten o'clock. 19 COMMISSIONER SIDNEY LINDEN: -- at ten 20 o'clock. 21 MR. DERRY MILLAR: Thank you, sir, thank 22 you. 23 24 (WITNESS RETIRES) 25

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1 THE REGISTRAR: This Public Inquiry is 2 adjourned until tomorrow, Wednesday, May the 11th at 3 10:00 a.m. 4 5 --- Upon adjourning at 4:34 p.m. 6 7 8 9 Certified Correct 10 11 12 13 ______________________ 14 Carol Geehan, Ms. 15 16 17 18 19 20 21 22 23 24 25