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Coroner's inquest: Emergency services dispatch a 'work in progress'

Day 5 wraps up in Sudbury, inquest continues next week in Ottawa
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Stephanie Bertrand, Matthew Humeniuk and Michael Kritz died as a result of a boating crash on Lake Wanapitei in July, 2013. An inquest into their deaths is probing the role problems with the 911 system and dispatch may have had in the incident. (File)

Keeping the city's emergency dispatch services current is like building an aircraft while it's in the air, said a Greater Sudbury Police inspector on Day 5 of a coroner’s inquest into a deadly boating tragedy.

The inquest is looking into the incident that killed Matthew Humeniuk, 33, and Michael Kritz, 34, the early morning of June 30, 2013, and Stephanie Bertrand, 25, who died of her injuries on July 7, 2013.

The question of adequate resources at emergency services call centres has been a recurring theme throughout the inquest. It was the focus on Friday when Police Insp. John Valtonen was joined by Greater Sudbury Fire Services Deputy Chief Jesse O'Shell and Central Ambulance Communications Centre (CACC) Manager Josée Lafleur on a panel to discuss possible inefficiencies within the system.

None of the managers were there to help with the rescue in 2013, but they said they spoke with their call takers and dispatchers prior to their questioning at the inquest.

Valtonen is manager of police and fire dispatch. Greater Sudbury Fire Services has a contract with Sudbury police to have its call takers and dispatchers also dispatch fire calls. 

The 911 call centre receives between 400 and 600 calls every day, with between 150 to 200 of those calls being 911 calls. The CACC receives on average 100 calls a day for ambulance dispatch, but rescue calls such as the boat accident are not common. 

Greater Sudbury Police Service is always looking at different initiatives to improve efficiency, said Valtonen, adding there are many “pilot projects” the service initiates. 

“We throw it up against a wall and see if it sticks,” he said. “All of this is a work in progress.”

For example, Sudbury police has a pilot program that allows someone who is lost to send an email to police, and officers can track them through that message to their location.

Staffing levels at the 911 call centre have remained the same since 2013, Valtonen said. That is currently under review, but just adding personnel is easier said than done. 

“We have to be responsible stewards of public money,” he said. “We can't hire more people just because we're busy.”

In questioning the three, the Crown said it wasn't an exercise in blame, but evidence suggests there were some problems in communication in dealing with the fatality, and that's what the discussion was about. 

The inquest is being held to examine the circumstances of each of the deaths, and to provide an opportunity to enhance understanding of the 911 system and the co-ordination of emergency responders. The five-member jury will make recommendations aimed at preventing similar deaths.

Robert Dorzek is the lone survivor of the crash. He called 911 and stayed on the line with the operator for about an hour. The dispatcher that took Dorzek's call had trouble locating the crash location, despite having been sent a map.

Dorzek was instructed to light a signal fire to help first responders locate the site of the crash by the same dispatcher. Kritz died when the signal fire spread to ignite the crashed boat.

On Sept. 3 the following year, Kathryn Missen of Casselman (near Ottawa) died as the result of a medical condition after calling 911. Emergency personnel did not respond to Missen's call.

As per the ministry's statement, “...the commonality shared among the four deaths concerns Ontario's 911 response system; section 25(2) of the Coroners Act permits a joint inquest where two or more deaths appear to have occurred in the same event or from a common cause.”

Dr. David Cameron is presiding as inquest coroner. The inquest will continue next week in Ottawa and will be live-streamed beginning at 9 a.m. from Oct. 22 to Nov. 2.


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Arron Pickard

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