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HomeMy WebLinkAbout1994-2624.Montogmery.97-07-28 ONTARIO EMPLOYES DE LA COURONNE CROWN EMPLOYEES DE L'ONTARIO 1111 GRIEVANCE COMMISSION DE SETTLEMENT REGLEMENT BOARD DES GRIEFS 180 DUNDAS STREET WEST SUITE800, TORONTOONM6G 1ZB TELEPHONEITELEPHONE (41tJ) 32tJ-1388 180, RUE DUNDAS OUEST BUREAU 800, TORONTO (ON) M6G 1ZB FACS/MILEITELECOPIE (41tJ) 32tJ-13QtJ GSB # 2624/94, 2625/94 OPSEU # 95C376, 95C418 IN THE HATTER OP AN ARBITRATION Under THE CROWN EMPLOYEES COLLECTIVE BARGAINING ACT Before THE GRIEVANCE SETTLEMENT BOARD BETWEEN OPSEU (Montgomery/Rankin) Grievor - and - The Crown in Right of Ontario (Ministry of Health) ottawa Carleton Regional Ambulance Employer BEPORE H S. Finley Vice-Chair JC Laniel Member D M Clark Member POR THE T. McEwan, Counsel GRIEVOR M Green, R stacey, Students-at-law Gowling, Strathy & Henderson Barristers & Solicitors POR THE D Chondon EMPLOYER Counsel Mathew, Dinsdale & Clark Barristers & Solicitors HEARING August 11, 30, 1995 September 18, 1995 November 27, 1995 January 10, 11, 12, 17, 18, 19, 1996 June 17, 18, 19, 20, 24, 1996 July 16, 17, 18, 19, 22, 23, 24, 29, 1996 GSB 2624/94 2625/94 DECISION INDEX Introduction 2 Relevant Legislation and Policies 5 Individuals Involved in the Call to 61 Finch (# 000475386) on the Evening of December 9,1994, and its Aftermath 8 Administrative Structure of Emergency Health Services 10 Physical, Staffing, and Procedural Details of the Communications Room at the Central Area Communications Centre, Ottawa 11 Vehicle # 4162, the Vehicle Used for the Call to 61 Finch on December 9, 1994 16 The Language of Communication Used in the Provision of Front-line Emergency Health Services 18 Friday, December 9, 1994 25 Post December 9, 1994 82 Argument - the Employer 94 Argument - the Union 99 Decision 109 Appendices 135 1 INTRODUCTION John Montgomery and Blake Rankm are Ambulance Attendants WIth the Ministry of Health, Ottawa-Carleton RegIOnal Ambulance ServIce (OCRAS) They were suspended (wIth pay) by the RegIOnal Manager of the Emergency Health Services Branch, on December 15, 1994, followmg an "mcident" whIch occurred on December 9, 1994, pendmg completIOn of an mvestIgatIOn, and were subsequently dIsmIssed. Mr Montgomery and Mr Rankm are seekmg reinstatement and full redress. They are also seekmg aggravated and punitIve damages based on dIscnmmatory actIons of the Employer against Mr Montgomery which encompassed Mr Rankm, who was hIS partner on December 9, 1994 John Montgomery is m hIS forties, marrIed with two teen-aged children. At the time of the hearmg, he had twenty-six years of servIce WIth OCRAS and its predecessor, and pnor to that, two years as a nursing orderly With the Ottawa CIvic Hospital. Over the years he has taken tramIng In the field of emergency care. For some time he has also worked as a part-time Ambulance Officer at the Almonte Hospital and continued to work there after hIS suspensIOn and subsequent dismIssal. As well, he has' a particular interest In emergency work related to fires and serves as a volunteer firefighter In Almonte. Prior to his suspenSIOn and subsequent dIsmIssal, Mr Montgomery was In the process of qualIfyIng for the paramedIC status. At OCRAS, he IS SIxth from the top of the semonty lIst, WIth a startIng date of 12/73, wluch IS the startIng date of the 7 most semor employees. Dunng his employment there he has partIcipated as an elected offiCial In Local 413 of the Umon. He has been partIcularly Interested and actIve in health and safety Issues. Mr Montgomery belIeves that he has been effective in gaimng Improvements In that partIcular area. A speCIfic area of concern for him that was unresolved at the tIme of hIS dIsmIssal was what he perceived to be an unnecessarIly frequent and sometimes Inappropnate deSIgnatIOn of inCIdents as Code 4 by the Dispatchers at CACC. He felt strongly that the use of the Code 4 deSIgnatIOn In cases where It was determIned not to be not warranted, exposed the Ambulance Officers and the general publIc to unnecessary fIsk. Mr Montgomery's dISCIplIne record conSIsted of a warmng letter m 1980, whIch had remaIned In hIS file 2 Blake Rankin IS also In his fortIes, married, and wIth two young chIldren. He began workIng as an Ambulance Officer In 1982 and WIth OCRAS In 1984 He IS 33rd on the OCRAS semorIty hst of 68, and has a starting date of 07/84 Prior to hIS employment WIth OCRAS, he had a varIety of work experiences, among them three years In the mihtary He left the mihtary as a Corporal. In 1992 he studied Ambulance and Emergency Care at AlgonqUIn College and has, SInce 1982, taken numerous courses to Improve hIS profeSSIOnal skIlls. He had mIhtary and cIvIhan traimng for radIO communicatIOn and maintains hIS quahfication for a restrIcted radIO operator's certIficate. He IS a qualified CPR and first-md instructor, a volunteer fire fighter, and a volunteer member of the Critical InCIdent Stress Debriefing Team. Prior to his suspension and subsequent dIsmissal, Mr Rankm was m the process of meetmg the quahficatIOns for paramedIC status. Mr Rankin has a record free of dIsciplme An ImtIal report on the call to 61 Finch (# 000475386), the subject of the complaint from CACC to OCRAS, was prepared by Mr Alam Groleau, the Actmg SupervIsor on the evemng in questIOn, and the DIspatcher of the call which is at issue. The mternal investigation of thIS complamt at OCRAS, was carried out by Mr Angelo Milo, Operations Manager at OCRAS, and followmg the submiSSIon of hIS report, a discIphnary hearmg was held pursuant to the Public Service Act under the chaIrmanship of David Hunter, the Admmistrator of the BrockvIlle PsychIatrIC Hospital. Both partIes attended and a further report was issued. Their suspenSIon contmued durmg this perIod. Mr Montgomery and Mr Rankin were dIsmIssed on March 7, 1995, by Graham Brand, DIrector of the Emergency Health ServIces. In hIS letter of dIsmIssal, Mr Brand stated. I have now considered all the information resulting from the formal investigation and hearings into ambulance call number 475386 It has been alleged that you refused or neglected to serve citizens requiring services which are part of the normal performance of your duties by delaying, and by failing to complete, an emergency call assigned to you. Mr Brand testIfied that based on [his] understanding of what happened and reviewing the investigation report by the Service or by people representing the Service, the circumstances seemed to be a complete violation of everything we stand for Accordmg to hIm, there IS an underlymg theme that "we always respond and the dispute IS 3 handled afterwards we always go" In thIS mcident, he stated, the "thmg we are there to do was not done" He testified that he concluded, following a reVIew of the investIgatIOn report which was based on a reVIew of the tapes, that "dIrectIOn was gIven" He dId not, as part of hIS decIsion-makmg, reVIew the Personnel FlIes of Mr Montgomery and Mr Rankm, deemmg the mCIdent of such sIgmficance that It rendered the informatIon therem irrelevant even though theIr lIvelIhoods were at stake He made hIS declSlon WIthout speaking WIth Mr Montgomery or Mr Rankm. NeIther did he speak with Mr MIlo, Mr Massender, or Mr Payette, but he dId speak with Mr Forsyth by telephone on 3 or 4 occaSIOns and did dISCUSS the matter With Malcolm Bates, the Semor Manager of OperatIOns and several Human Resources staff members m Toronto He dId not know whether Mr Forsyth or Mr Payette had spoken With Mr Montgomery or Mr Rankm, and assumed that Mr Milo had done so, based on his report. He was not aware of whether or not Mr Montgomery and/or Mr Rankm had been gIven an opportunity to review the tape, but acknowledged that it would be falr for them to have been given such an opportunity (They were not gIven the opportunity to hear the cassette of excerpts pnor to January, 1995, or to hear the master tape prior to the arbItratIOn hearing) In cross- exammation Mr Brand was asked about his expenence as an Ambulance Officer or an observer m an actIve ambulance. He replIed that he had never worked as an Ambulance Officer or a Dispatcher, and had only been in an ambulance once or twice and not recently The reports of Mr Milo and Mr Hunter have not, at the request of the partIes, been admItted m evidence for this hearing on the ments, arid thIS Board, respondmg to a jomt request of the partIes, IS consIdenng the eVIdence WIthout reference to the substance or outcome of the reports m ultImately dIsposmg of the gnevance, mcludmg the Issue of whether or not the penalty of dIscharge should be mItigated. Mr Montgomery and Mr Rankm were remstated effective September 1, 1995, by an mtenm declSlon of thIS Panel, pendmg the outcome of theIr gnevances. (The sectIOn of the Labour Relations Act which permItted such relIef has smce been repealed.) They contmued to be scheduled for work throughout duratIOn of the heanng and, the Panel assumes, to the present. 4 The matter of whether or not their dismIssals were for Just cause, IS bemg consIdered for the first time m thIS decIsIon. RELEV ANT LEGISLATION AND POLICIES Ambulances operators (e.g. OCRAS) are hcensed, m OntarIo and are governed by the AmbulanceAct, R.S.O Ch. A. 19 and the RegulatIOn 19 The Act and Its RegulatIOns set out the qualificatIOns for an mdivIdual to work as an Ambulance Officer (Emergency MedIcal Attendant) The Act also describes the duties and the powers of the Minister to ensure the prOVIsion of adequate ambulance servIces of a certam standard throughout the Province. The relevant sections are set out below' 1. In this Act, "ambulance" means a conveyance used or intended to be used in an ambulance service for the transportation of persons requiring medical attention or under medical care; "ambulance service" means a service held out to the public as available for the conveyance of persons requiring medical attention or under medical care, and includes the service of dispatching ambulances: "operator" means a person or corporation that owns or provides an ambulance service and "operate" has corresponding meaning; Regulation 19 GENERAL 1-(1) In this Regulation, unless the context otherwise requires, "dispatch centre" means a radio station, within the meaning of the Radio Act (Canada), that is equipped to receive calls for ambulance service and to dispatch ambulances by radio or telephone and that is used for such purpose; "dispatcher" means a person who operates radio or telephone equipment at a dispatch centre for the purpose of receiving calls for ambulance service and dispatching ambulances, "emergency" means a situation where delay in responding to a call for ambulance service could endanger the life, limb or a vital organ of a patient: 5 "Emergency medical attendant" means a person who, in the course of providing ambulance service to a patient in Ontario, (a) operates, drives or otherwise has the actual care or control of an ambulance, or (b) attends, assists or renders first aid or emergency medical care, but does not include a physician, intern, nurse, nursing assistant, respiratory technologist or other skilled and duly qualified medical technician who attends on a call for ambulance service with at least two emergency medical attendants for the purpose of rendering specialized health care services to a specific patient; "emergency medical care assistant" means an emergency medical attendant who (a) has successfully completed an ambulance and emergency care program provided by a College of Applied Arts and Technology or has experience and qualifications that are equivalent thereto, and (b) has obtained a pass standing in an emergency medical care examination set by the Director under this Regulation. PART VIII MANAGEMENT, OPERATION AND USE 41 An operator shall not refuse and shall not permit any employee to refuse to provide ambulance service unless directed or permitted to do so by a dispatcher 45.-(1) Subject to section 47, the driver of an ambulance in which a patient is transported shall transport the patient (a) to a facility directed by a dispatcher ordering the movements of the ambulance; or (b) if a direction is not made under clause (a), to the nearest facility where the medical attention apparently required for the care of the patient is available, In the Mimstry of Health's Emergency Health Services, CACC Manual of OperatIOnal PolIcy and Procedure, SectIOns 7 0 and 9 0 address "Emergency Response" and "Ambulance ASSIgnment" 6 SectIOn 7 0 says m part, (1) In emergency response, the dispatcher will assign that available land/air ambulance or EHS additional resource closest in time (rather than distance) to the patient and which is best equipped to meet the immediate needs of the patient. [Emphasis added] SectIon 9 0 says m part, (1) In assigning an ambulance crew to respond, the dispatcher will provide sufficient patient and geographic information so as to insure prompt response. [EmphasIs added] The definitIOn sectIOn sets out several defimtions relating to ambulances whIch are relevant to the matter at hand. a) Ambulance Status: ambulance priority code and location, This information is summarized on the Unit Status Screen in A.R.I.S.. b) A vailable Ambulance: normally an ambulance which has not been assigned a CODE 4 priority response or transport and therefore subject to assignment or reassignment at the direction of the dispatcher; c) Most Appropriate Ambulance Additional Resource: that available land/air ambulance or additional resource closest in time (rather than distance) to the patient which is equipped to best meet the immediate needs of the patient. The Manual of OperatIOnal Pohcy and Procedure ofCACC prohibIts "relaymg", that IS, the changmg of Crews from one ambulance to another, on a Code 4 (No documentary confirmatIOn of thIS was presented m eVIdence) There IS nothmg whIch addresses the changmg of Crews on a Code 4 Employees of OCRAS are not subject to CACC pohcies and procedures. 7 INDIVIDUALS INVOLVED IN THE CALL TO 61 FINCH (#000475386) ON THE EVENING OF DECEMBER 9,1994, AND ITS AFTERMATH The followmg mdIvIduals were mvolved m thIS matter Those whose names have astensk(s) besIde them testified m the hearmg on the ments. Those wIth a double astensk (**) were subpoenaed by the Employer The Employer, The Ministry of Health Emergency Services Branch Graham Brand Director of Emergency Health Services, Ministry of Health, Toronto for 13/14 years at the tIme of the hearing; now retired Malcolm Bates Senior Manager OperatIons, Emergency Health Services, Mimstry of Health Blake Forsyth* Since 1981, RegIOnal Manager, Eastern OntarIO RegIOn (# 4), Emergency Health Services, Mimstry of Health, located m Almonte. PreVIously, an Inspector, Training Officer, and Ambulance Officer He reports to Malcolm Bates, Semor Manager Operations, Emergency Health Services. Frank Payette ASSIstant RegIOnal Manager, Eastern Region (#4), Emergency Health ServIces, Mimstry of Health, located m Almonte Ireyna Kushelnyk Human Resources, Mimstry of Health Management, Ottawa Carleton Regional Ambulance Service Lyle Massender* Manager, Ottawa Carleton Regional Ambulance ServIce (OCRAS), Emergency Health Services, Mimstry of Health, prevIOusly an Ambulance Officer Angelo Milo* Operations Manager, OCRAS from 1990; prevIOusly an Ambulance Officer He works out of the St. Laurent Street headquarters office. Among other dutIes, he supervIses Ambulance Officers and responds to complamts from the DIspatch Centre Bnan Thompson Office Admimstrator, OCRAS, one of the Managers fillmg m for Mr Massender durmg his absence at the tIme of the mCIdent Jim SmIth Actmg OperatIOns Manager, OCRAS, on December 9, 1994 8 Thelinion.-1lttawa Carleton Regional Ambulance SerYke John Montgomery* Full-time Ambulance Officer, OCRAS, part-time Ambulance Officer, Almonte, qualified as an Aero-medical Attendant; volunteer fire-fighter; member of Union Executive and Jomt Health and Safety Committee pnor to 1990; Mr Montgomery IS bllmgual, Gnevor Blake Rankm* Full-time Ambulance Officer, OCRAS since 1984, volunteer fire- fighter, Russell, Ambulance Officer since 1982, Grievor StephanIe Mills** Smce 1991, Ambulance Officer, OCRAS, Paramedic since October 1995, part-tIme Ambulance Officer Ampnor and Kanata, County Medical Attendant WIth "Sky" (aIr ambulance service) ChrIS Anderson** Part-time, floatmg Ambulance Officer, OCRAS smce 1991 Kevm CorrIgan ** Part-tune, floatmg Ambulance Officer at OCRAS smce 1990; assigned to Vehicle # 4158 on the 1600 to 2400 hours shift on December 9, 1994, Partnered With George Handzel on December 9, 1994 George Handzel Part-time Ambulance Officer at OCRAS, AssIgned to VehIcle # 4158 on the 1600 to 2400 hours shift on December 9, 1994, partnered wIth Kevm Corrigan on December 9, 1994 Bnan Molougney Steward, Local 413, attended heanng regularly Mana Wysocki OPSEU Staff RepresentatIve Central Ambulance Communications Centre, Ottawa (CACC, Ottawa) RIchard LavIctolfe* AssIstant Manager, CACC, Ottawa, m December 1994, Actmg Manager CACC temporarIly replacmg Heather Massender, Manager; employed by ElIzabeth Bruyere Health Centre, a dIspatcher for 15 years before becommg Assistant Manager; among hIS admInIstrative dutIes at the tIme was the mvestlgatlOn of complaints and mCIdents, and trammg 9 l\laIn C1roleau* Full-time l\ctmg SupervIsor/DIspatcher (at the time of the mcident), l\ctmg SupervIsor/DIspatcher wIth authority to carry out qualIty control (at the time of the heanng), Cl\CC, Ottawa, employed by ElIzabeth Bruyere Centre since 1989, full-time dIspatcher smce 1990; part-time .Ambulance Officer elsewhere smce 1989; trammg as l\mbulance Officer continumg educatIOn at Base Hospital. Traming for dIspatch. on the job and in-house at Ehzabeth Bruyere Centre; traming included traming for restrIcted radio, Mr C1roleau is bilingual, member of OPSEU Chns Bourque Call Taker/Dispatcher at Cl\CC on the evening of December 9, 1994 The Employer was represented by DaVId Chondon and the Union by Terry McEwan. Mr McEwan was asSIsted by Martha C1reen, and later RIchard Stacey, students-at-law ADMINISTRATIVE STRUCTURE OF EMERGENCY HEALTH SERVICES J\mbulance ServIces m the Provmce of Ontario come under the Emergency Health ServIces Branch of the Mlmstry of Health located m Toronto (This may have changed smce the time of the mCldent.) The servIces provided include both land and aIr ambulance servIces. The ProvInce was dIVIded mto six regIOns, one of whIch was the Eastern Region (# 4). Located Wltlun that regIon was the area serviced by the Ottawa Carleton Regional .Ambulance Service, a servIce operated dnectly by the Mimstry of Health, headquartered m Ottawa south and operated out of three bases in the Ottawa-Carleton area - Hunt Club (02 Base) m the south, LeBreton m the centre, and ParISIen, m the east. OCRA.S had a number of ambulances assIgned to It and each was Identified permanently by a four-digIt number designatIQn and was normally assIgned to one of the three bases The vehIcles whIch were operatIOnal would eIther be on an aSSIgnment, on stand-by at an assIgned locatIon or at rest but ready at one of the bases. These vehIcles were staffed by a dnver and an attendant who worked as a team and who could change roles dunng their ShIftS. The l\mbulance Officer WIth the greater semonty could exerCise hiS semonty m certam SItuatIOns, such as, whIch member of the team was to act as dnver Then ShIftS could 10 have been eight, ten or twelve hours m length. The point was made, by Mr Montgomery, that unlike firefighters who WaIt at the fire statIOn for theIr calls, ambulance attendants are actIve from the time they leave theIr base whether or not they are on partIcular patIent assIgnment. PHYSICAL, STAFFING AND PROCEDURAL DETAILS OF THE COMMUNICATIONS ROOM AT THE CENTRAL AREA COMMUNICATIONS CENTRE Continuous dispatchmg services for OCRAS are provided by the Central Area CommUnICatIons Centre (CACC) In December 1994, the servIce was provided through a provinCIal transfer payment arrangement WIth the Elizabeth Bruyere Centre which is located m the old Ottawa General Hospital In downtown Ottawa. This was the Dispatch Centre that a member of the publIc reqUIring emergency medIcal services would be referred to on placing a "911 call" TIle Centre, although It must follow certain provIncIal regulatIOns, was not the dIrect responsibIlIty of the Emergency Health ServIces DiviSIOn of the MinIstry of Health. The Ministry of Health, however, has a dIrect Interest in how the Dispatch Centre functions and is responsible for Its InSpectIOn. The communicatIOns system IS part of a near province-wIde communication system, the "Ambulance Response InformatIOn System (ARIS), and links with the Ontario MuniCIpal and ProvIncIal PolIce AutomatIOn Co-operative (OMPP AC) ARIS provides the framework for the system of recordIng all calls in a programmed format, aSSIgnIng IdentIfyIng numbers, and recording the times of events. Numbers are for identIficatIOn and retrIeval purposes and the time at WhICh they are Issued should have no effect on ambulance response tIme, In spIte of the OCRAS directIve WhICh states that numbers WIll be aSSIgned by the DIspatcher at the outset of each call. From thIS program, It is possible to retrieve at least the followmg. Other detaIls may be retrievable, but only the above arose m eVIdence. . Call Summary . UnIt History . DIspatch Details . Emergency DetaIls 11 Contact wIth the DIspatch Centre is by radIo between the crews In the vehicles, by portable radios outside the vehICle and by dIrect landhne telephone between the DIspatch Centre and the vanous bases. There IS one portable per crew, usually WIth the dnver It IS normally left In the vehIcle when the parties are at base. Crews also call In to Dispatch on normal telephone lines from various sites. GIVIng the name of the patient over the landline telephone allows the transmission to remam confidential whIch transmISSIon over the radIO does not. There IS no radIO scanner In the 02 Base, so that crew members in the crew quarters or elsewhere in the base bUIldIng do not have access to radio transmIssions. In the DIspatch Centre CommunIcations Room, there were three boards - the Provmcial Board, the RegIOnal Board, and the busiest, the Ottawa Board WIth a call-takmg and a dIspatching desk for each. There was also a work station for the Supervisor The OCRAS-based vehIcles were dIspatched from the Ottawa Board. The Centre was also responsible for vehicles from other centres which happened to be WIthin its purview and it monitors any other transmissions comIng from the provinCial communicatIon channel, such as the air ambulance. At CACC DIspatchers may be assigned throughout their shift, on a two-hour rotation, to one of two functIOns. . as Call Taker to answer, assess, aSSIgn prionty and refer IncomIng calls, or . as DIspatcher of VehIcles to receive the processed mformatIOn WIth the aSSIgned prionty, pinpoint the location of calls, decide on the appropriate vehIcles, communicate the prionty, the nature of the call, the address and locatIOn of the call, the call numbers and further detaIls, to the Crews and vehicles. To dIrect and aSSIst Crews m arrIving at scene and to enter certaIn call-related times into the computer system. The trammg of DIspatchers, accordIng to Mr LaVIctOIre, mvolves, at the outset, 3 two-week phases. Phase I consIsts of call-takIng skills, polIcies and procedures, Phases II and III focus on the skills and mechamcs of dIspatchmg Phase II traming takes place on the less busy out-of - town boards, whIle Phase III IS on the more IntenSIve Ottawa Board. FamIlIarIzatIOn WIth streets 12 and key locations such as fire statIOns, IS not part of the trammg, although dIspatcher tramees are assIsted m how to read a map and use the tools they have for deternllnIng locatIOn. Mr Groleau was asked If he knew the locatIOn of the fire stations m the Ottawa-Carleton area, and he stated that he was not famihar with all the locations, although he might know a few "off the top of [his] head" He explamed that as a DIspatcher he had access to a book wIth the addresses of the fire stations. The fire department dIspatches theIr own, Mr LaVIctoire explamed, but stated that "DIspatchers know there are more fire statIOns than ambulance bases" Traming in the upgrading of SkIlls IS also offered from time to tIme. Usually, although not always, there IS a Call Taker at each desk and a DIspatcher at each board. Accordmg to Mr Groleau, "all boards are responsible to provide coverage for all boards", which means that all DIspatchers are m commUnICatIOn wIth each other There would also be a SupervIsor, who IS not aSSIgned to a partIcular post but who floats and who may fill in for DIspatchers and Call Takers who are on theIr breaks. The SupervIsor has hIslher own statIon for reference. DIspatchers are normally scheduled on rotatmg twelve-hour ShIftS from 0800 to 2000 hours and from 2000 to 0800 hours, whIle some are on eight-hour ShIftS. The Call Taker is eqUIpped WIth a smgle ear-piece headset with a mouthpiece mICrophone and sits at one of three call-take positIons with a computer monitor and keyboard. As well, s/he would have visual access to two panels one showmg the phone hnes, the other, the radio lines. The Call Taker uses both, and the switching between the two occurs automatIcally, with the radIO supersedmg the telephone Accordmg to Mr LaVIctoire, it is expected that a Call Taker would carry out a complete call within one to two minutes, and would elicit sufficient information for a pre-alert to be given within 30 seconds, if the caller is co-operative. S/he must lIsten to and talk to callers m CrISIS and obtam from them mformatIOn as to their locatIOn and the nature of the problem facmg them. S/he also proVIdes, m many cases, first-atd mstructIOns and firm calmmg. ThIS commUnICatIOn can be made more dIfficult when the mdIVIdualIS not speakmg m hIS or her mother tongue, or when the mother tongue of the Caller IS dIfferent from that of the Call Taker, or when that person IS upset or confused. The call which 13 tnggered the incIdent whIch IS the focus of the case, presented all three of these problems to the Call Taker A DIspatcher IS eqUlpped WIth a combined, smgle-ear headset, activated by a foot pedal, as well as a goose-neck microphone. S/he also has a hand or headset to communicate by telephone. Each work statlOn would have two computer screens, and on one SIde a telephone panel, on the other a radIO panel. One of the computer screens, the one to the left, dIsplays the status of the ambulances, that IS, those whIch are m or aVailable, as well as mcoming calls. The Dispatcher would know from thIS computer, whIch ambulance crews were nearmg the end ofthelf ShIftS. The other, the one to the nght, dIsplays the files m use and the details behmd the entrIes. The panels are approxImately two feet square. DIrect telephone lines are also avaIlable to various ambulance bases and wIth the Ottawa Hospitals, that is, the DIspatcher can pIck up the hne and without dlalhng, be m touch wIth certain locations, among them the 02 /Hunt Club Base of OCRAS All mcoming and outgomg communIcations, telephone and radio, at CACC were, in December 1994, contmuously recorded on a computerized, timed, master dIctaphone tape which was part of a multI-track recordmg deVIce Wlth 20 channels. It simultaneously recorded all communIcatlOns on all channels. In December 1994, there were 16 operatmg channels - 8 telephone and 8 radIO Should the system go down for any reason, there was a manual back-up system. The recordmg of these commumcations was a requirement and the recorded mformatlOn had uses m cnmmal tnals, litigation, inquests, and other unusual occurrences whIch reqUIred that "facts" be estabhshed. The recording of commumcatlOns was known to both Mr Montgomery and Mr Rankin. The time momtor of the recording system was checked tWIce daily to see that It was m concert WIth NatlOnal Research CouncIl time. At midnight of each day, a new tape was mstalled and the one removed was securely stored m a locked cabinet. This changeover was the only mvolvement that the staff of the DIspatch Centre had WIth the recordmg process. The custodIans of these tapes were the SupervIsors, ASSIstant Managers and Managers at CACC The tape was IdentIfied on ItS cardboard cover When a tape was borrowed from the 14 secured area, a form was completed. ThIs form provIded a record of the call number, the requester and hlslher telephone number, whether or not the request was m response to a subpoena, and a summary of the reason. When a call arrIved at CACC, It was responded to by the Call Taker, who receIved the mformatIOn, typed It mto a template on the computer as a new case, confirmed and assessed It, and assigned It a pnonty code whIch was also typed mto the computer The call was committed to the computer system by the Call Taker pressmg "Enter" on hislher keyboard. It was then routed to the DIspatcher responsible for the geographical zone m which the emergency was located. The computer then assIgned a number to the call and Immediately generated the next call number ThIS complete, the Call Taker would usually get back on the lme and attempt to elICIt further mformatIOn from the Caller One of the reasons for domg this was for the Call Taker to be able to determine qUIckly whether the call met the criteria for a tIered response by the fire or polIce department, for eIther a multiple emergency service response, or a first response to render first aId, pnor to the arnval of the ambulance. Accordmg to Mr Groleau, It IS the responsibIlIty of both the Call Taker and the Dispatcher to decide whether or not to call on the fire departments for tiered or first response The DIspatcher, who was normally seated at a console, then receIved the mformation on hislher screen, determmed the location and then selected and dIspatched the most appropriate vehlcle(s) to the scene Gettmg the closest vehIcle mobIle and on the way is cruCIal to a prompt response It IS the vehIcle that IS closest m time, not dIstance, whIch the DIspatcher is dIrected to aSSIgn. To aSSIst m locating the scene of the emergency, the Dispatchers had at the time, a wall-mounted map of the area and a Pathfinder Map Book. The Pathfinder Map Book conSIsts of an alphabetlcally-arranged mdex of streets WIth page number and co-ordmates, a map without detaIls, of the total area covered showing the dIVISIOn of the area mto detailed maps, and, the detaIled maps of each sectIOn. After the DIspatcher had dIspatched the vehIcle, slhe would return to the computer to see If further mformatIOn WhICh may be helpful has been subsequently entered. 15 Mr LavIctoire mdIcated that DIspatchers had not been instructed when assIgnmg calls to consIder whether or not one of the Crews IS fresh and the other IS "stale", although that IS not to say that such consideratIOn was never gIven. For mstance, the DIspatcher mIght return a tlred crew to base. He was asked m cross-exammation If it had happened that a call had been assIgned and both crews were at base, that the crew commg on ShIft would take over Mr LaVIctOIre agreed that this could happen but quahfied that by statmg that "if you are mobile it IS a totally dIfferent scenarIo" It has been the practlce, Mr Rankm explamed, when more than one vehIcle IS at base, that the first car m IS the first car out, and at a ShIft change, the Crews would sort It out WIthout duection from DIspatch. VEHICLE # 4162, THE- VEHICLE USED FOR THE CALL TO 61 FINCH ON DECEMBER 9, 1994 The veluc1e WhICh served as Ambulance 4162 was a 1993 Dodge Van which the ServIce has had smce February 11, 1994 The partIes and the Panel viewed this vehIcle and they agree that the mformatIOn below respecting Velucle # 4162 which was viewed on June 19, 1996 at 0930 hours IS accurate. It IS also theu understandmg that no modIficatIOns have been made to thIS partIcular vehICle smce December 9, 1994, although Improvements have been made to the lIghtmg of others, through the mstallation of a SWivel gooseneck halogen lIght and the location of a dome lIght over the attendant. Tlus, accordmg to Mr Montgomery, has resulted m a major Improvement in hghtmg m those vehIcles WhICh have been thus modified. The console and the interior lighting, cab and rear, are part of the original conversion The radio on top of the console is not part of the original conversion but is fitted locally Windshield has the standard 4 to 6 inch glare strip at top In comparison to a standard van, accommodation for the occupants is relatively confined primarily due to equipment. CAB ----.........-----------------------------------------------------------------------------------------...-- In the cab there are the following: Control Console: a 1992/93 model, it has not been changed since 1994 unless repairs it swivels so it is accessible to both seats it activates interior lighting, siren radio 16 there is a radio on top there are 2 microphones. one for the PA system and the other, which is normally located on the driver's side, is the radio microphone Organizer: in centre between seats, below the window on the separating panel between the cab and the rear contains the map book and the zip pack (metal clip board which contains certain forms) .;. Speaker' is centrally located on the rear wall of the cab above the window above the level of the heads of the driver and the attendant Floating flashlights: The vehicle should have two large flashlights with handle: Their location is up to the crew' two may remain in rear, one in front one in back or both in front. Cab Dome and Map Lights: part of the original conversion it has not been altered since it was installed centrally located right above the windshield 3 lights in one - a pair of swivel focus lights, one for each seat, a central fixed light with opaque plastic cover; the centre light functions (1) when the engine is off, only if the door is open (2) if accessory power is activated the swivel lights functIOn (1) only if the engine is running or accessory power is activated all 3 lights function (1) only if the engine is running simultaneously Each can be controlled by an its own on/off switch Degree of illumination. Lap Leve145-42 lux; Mid-level 87-89 lux; High level 225-235 lux* Specifications. 1 - GE 211-2 bulb- 12 candlepower & 2 GE 89 bulbs - 6 candlepower each* Dashboard Clock. There is a digital, illuminated, dashboard.clock REAR -------------------------..-..-----..-----------------..--------------.....--........----...----------------------...-------.. In the rear there is the following lighting system. A control panel is in the rear Two sets of 4 recessed lights, If everything is off in rear you can activate the left bank of rear lights from the front They have various setting options 2 for degree of illumination (only control from rear) and several for the number of lights on Lighting is straight down and 1157 bulbs Can be controlled from the front or the rear Cabinet lights which appear to have little or no impact in front. * This information was obtained from a July 1996 study undertaken by David Shane of Bovar Environmental. In the study 6 OCRAS vehicles were tested in the parking lot of 02 Base between 2130 and 2210 hours on July 3, 17 1996 On five of the vehicles the lux levels had the following range: Lap Level - low of 24 to a high of 62, Mid- level - low of 37 to a high of 89; high level low of 86 to a high of235 The sixth vehicle which was equipped with a goose-neck, halogen lamp had a -lap level range from 3 I 5 to 324, a mid-level range from 512 to 1450 and the consultant stated that the high level range was not applicable. Vehicle # 4162 ranged between the highest and the lowest level of the 5 vehicles with the following ranges. Lap level- low of 45 to 52, Mid-Ievel- low of 87 to 89; High level, low of225 to high of235 lux. While the study did test at night, it did not test during snowstorm, moving vehicle, or with windshield wipers on. Further, it did not test for Mr Montgomery's particular visual ability In noting this, the Board is not suggesting that Mr Montgomery's visual ability should be the standard. It recognizes that the definition of adequate lighting must be based on standards which are arrived at in a more objective and scientific way One of the forms m the ZIp pack mentioned above IS the Dally VehIcle Call Responses Form, known as the "tnp sheet" It IS filled m by the Attendant, normally at the end of each call. It can also be filled m when the callIS glVen. Each Ambulance Officer also carnes a personal kIt. One of the Items m that kIt IS a notebook m which he or she notes briefly the day's activities at work and other Items conSIdered worthy of note. It is a personal, work-related notebook. Mr Montgomery recorded most of his calls in his, while Mr Rankin only recorded unusual calls, or those requinng overtIme. It was Mr Montgomery's practice to record hIS at home prior to the next day's work and Mr Rankm's to record his at work on the next working day THE LANGUAGE OF COMMUNICATION USED IN THE PROVISION OF FRONT-LINE EMERGENCY HEALTH SERVICES The language used m communication between the Dispatchers and the Ambulance Officers IS a combmatlOn of normal conversatlOnallanguage, medical termmology and radIO commun1catlOn termmology ClarIty IS important and it IS understood that communicatlOns are to be concise m order to maxImIze radio availabIlIty STAND BY AND STANDBY The term "stand by" (The emphasIs is on the second syllable) IS one that was used several 18 times by Mr Groleau when commumcatmg with the crew of Vehicle # 4162 (It IS a verb and as used by Mr Groleau, It was m the imperative, m other words, he was tellIng them to Walt) He testified that to hIm It meant, a break in communication and further information is coming when possible. Mr Montgomery mterpreted it as meanmg wait, something further is coming; don't get back to me, I'll be back to you. Mr Rankm testified that to him It meant continue what you are doing, yet anticipating more information. when mobile we proceed in the general direction or until given more information... A hesitation code, don't complete what you are doing. Mr Rankin explamed that Ifhe had been told to "stand by", he would attempt to get authonzation before completmg a call but that If he could not do that, for some reason, he would make sure that he told the DIspatcher that he was going, so that the DIspatcher would be able to cancel him, if that were the sItuation. He also identified "stand by" commands as suggesting that perhaps he should not be proceeding on a call. Kevm Corngan saId that DIspatch usually says tlus to confinn that they have heard your request and will be back with the information as soon as possible. He explained that the proper response of the Driver is to wait for the DIspatcher to come back WIth the mformatIOn so that the auways do not get clogged, and to proceed as normal to the call. Mr LavIctoue defined it as hold on, I'm getting the information you want, or, I'm getting an update, just don't talk on the air and proceed on what you have He stated that he would expect the person who has been told to stand by not to communicate with [him] because [he] is looking up what [that person required but keep proceeding on the call 19 The four elements of the "stand by" communIcation from the DIspatcher are . The Crew IS to wait . The DIspatcher wIll contact the Crew . The Crew is not to contact the Dispatcher . The Crew IS to proceed based on the informatlOn It has received thus far The Dispatcher mIght also duect a vehicle to "stand by" at a certain locatlOn. The term IS also a noun and an adjective, "standby" (The emphasIs is on the first syllable.), meanmg that a vehicle may be duected to remam "on standby" at a certam locatlOn, and that the location would be referred to as the "standby 10catlOn" CREW CHANGE Crew change means the change of one or more members of the Crew of a partIcular vehIcle. The staffing of vehIcles IS the responsibIhty of OCRAS, not of CACC A crew change takes place If a member of the Crew becomes unable to carry out hIs/her duties, or at the end of one Crew's ShIft and the begmmng of the mcommg Crew's ShIft. The first sItuation would mvolve the DIspatcher, the second would normally not. Crew changes nearly always take place at the home base of the Crews involved. The OCRAS Crews have, subject to their schedules, developed a flexible pattern of crew change around the time of ShIft change whIch fits the emergency nature of theu work and which ensures that vehicles are staffed and available for responding to calls whIch Dispatch assIgns. It had not been the practice for outgomg Crews to "log off', that IS, to mform DIspatch of theIr leavmg the vehIcle at the end of the shift. The practice IS that the mcommg Crew Identifies Itself, by mdIvIdualIdentificatlOn numbers to the DIspatch soon after the crew members are m the vehIcle. Mr Groleau testIfied that m hIS opmlOn a crew change on a Code 4 would result in a response delay 20 RELAY Mr Groleau testIfied that hIS understandmg of the term "relay" was "when crews are changed m order to mImmIze travel distance so the crews can return to theIr respectIve areas wIthm a reasonable amount of time" This practice IS prohibited, he Said, to prevent delay m transport and response Further, Mr Groleau stated, a "relay" IS only dIspatcher imtIated. Mr Groleau drew an anaiogy between "relay" and a "crew change" PRE-ALERT Pre-alert IS a procedure which enhances the efficiency of the response time and is the normal procedure for Code 3 and 4 calls. If the Crew IS at the statIOn and the DIspatcher calls and says "go mobIle for a Code 4" and gives the address that IS a pre-alert. If the crew IS mobIle, the DIspatcher would call and say he had a call, and gIve the nature of the call, Its pnority and the address. It is dIfficult, Mr Montgomery explamed to go mobIle if you do not know where you are gomg. The essential elements of a pre-alert call are the Code (3/4), and the address or at least the general dIrection. TIERED RESPONSE In order to ensure prompt response to medIcal emergencies, the Emergency Health ServIces has developed a co-operative strategy m whIch a number of identified "allied agencies", usually fire departments, WIll be called upon by the local CACC "where apphcable or when the ambulance will be delayed" to render first aid "until an ambulance arrIves on scene to transport" It may also occur that a multI-level agency response to an emergency scene is appropriate, and, once agam fire departments and often polIce are called upon to provide, m this case, a "tIered response", that is "a multI-level agency response to an emergency scene" An addendum to fire department notificatIOn (7 41), sets out the followmg local gUIdeline' 2, Kanata/Ottawa Fire Department(s) will be requested to complete Tiered Response, should Ottawa C.A.C C be advised of the following: - cardiac or respiratory arrest - possible life threatening injuries from being trapped or involved in a. 21 - fire disaster - industrial accident - motor vehicle accident At the time, pnor to the mstItutmg of ParamedIcs, accordmg to Mr Groleau, the FIre Department was to be notIfied when an ambulance could not be actIvated m five minutes, in cases of cardiac or respIratory dIstress, or when a person was trapped. PRIORITY CODES Numencal pnonty codes are used as part of the communication between DIspatchers and Ambulance Officers. Those that describe the prIOrIty gIven to a call are from 1 to 4 mclusive and are generally understood by both CACC and OCRAS personnel to mean the following' Code 1 Deferrable - routine, a call which may be delayed without being physically detrimental to the patient, such as transfers to and from hospital of those patients who are not acutely ill, Code 2 Scheduled - is a call which must be done at a specific time because special treatment or diagnostic facilities are available to the patient only at this time. This does not include scheduling for a patient's convenience or time frames at hospital departments when delays would cause cancellation of the test/treatment (such as X-ray). Code 3 Prompt - is a call that should be done with minimum delays as the patient is suffering from a serious injury or illness but is in a stable condition or is in the care of personnel who are in the process of stabilizing the patient. Code 4 Urgent - is a call where life is threatened, time is of the essence, or the level of care is not sufficient to provide stabilization. Accordmg to the testImony of Mr Groleau, Code 4 also mcludes a threat of loss of 11mb Code 1 and 2 calls are normally dIspatched VIa the telephone, whIle Code 3 and 4 calls are normally sent VIa the radIO There was, at the tIme, no standard for response tIme to the scene for the Code 3 and Code 4 calls, and this was, accordmg to Mr Groleau, due to the fact that there could be CIrcumstances beyond the control of those responsible The pnonty codes assIgned by the Call Taker may be changed by the DIspatcher durmg hIslher mvolvement WIth the call only WIth the agreement of the Call Taker, and by the Ambulance Officers on the return 22 tnp, that IS, from the scene to the destmatIon. Mr Montgomery agreed that "ambIgUIty on the assIgnment of Code 4s to those sItuatIons is because the DIspatcher WIshes to err on the sIde of the patIent and care for the patIent as opposed to other concerns." Other codes are also used. In the eVIdence the following arose' Code 5 ObvIOusly dead Code 7 Out of service (a vehicle) Code 8 Balanced Emergency Coverage (desIrable dIstribution of vehicles) Code 9 Mechanical problems m the vehicle, including radIO problems. Crew member ill Crew member needs to have clean up time NUMERICAL COMMlJNICA TION CODES There is a number of communication codes used regularly to facilitate communication, and an explanatIOn of them IS necessary to understanding the conversatIon between the dispatch and ambulance staffs 10 - 4 Your transmIssion received and understood 10 - 7 Crew has arrived at destmatIon 10 - 8 Crew is returning to the an, that is, they are available by radIo and m then vehIcle 10 - 19 Crew IS returning to base 10 - 20 LocatIon of vehIcle or location of call 10 - 21 Gomg to call by landlme at other end 10 - 34 Status of hospital emergency room for receivmg patients 10 - 42 Gomg for coffee 10 - 200 PolIce required Smce there is no reqUIrement that Crews sIgn off when leaving then ShIft, other than to report theIr return to base, where the crew change IS normally made, there does not appear to be a code for thIS actIVIty Ambulance Dnvers commumcate WIth the publIc by VIsual and aural SIgnals. Mr Montgomery testIfied that It was not mandated that any partIcular warmng systems be used on a Code 4, but 23 that It was at the Dnver's dIscretIOn taking mto account varIOUS factors. He explamed that even on a Code 4, hghts and SIrens were not necessarIly used from the tlme one leaves the garage. As a Dnver, he would take mto account the emergency, the locatIOn, whether or not he knew the locatIOn m order to decIde whether or not to actIvate the warnmg systems. Mr Rankm testified to the nsks mvolved m actlvatmg the warning systems m heavy traffic and under bad weather dnvmg condItions, and Ms. Mills spoke of activating the warnmg systems dependmg on the traffi c ARIS "T" CODES The recordmg of the times at whIch certain procedures respectmg calls take place m response to an emergency callIS an important part of documenting service to clIents and the effiCIency of the mdIvIdual employee and the overall operatIOn. The ARIS computer program takes note of 7 "T" times and these are entered by the Call Taker and the DIspatcher and provided by the DIspatcher to Ambulance Officers followmg a call. They are the following. Tl Call received T2 Crew notified T3 Ambulance mobile T4 Ambulance arrives at scene (patient) T5 Ambulance departs scene T6 Ambulance arnves at hOSpItal T7 Ambulance departs from hospItal It is possible for the computer operator to call up these times by entering the "T" number A dIrectIve to staff of OCRAS respecting ARIS sets out the communIcatIOn reqmrements WIth respect to the Dispatch Centre, CACC The followmg are relevant. 1 At the start of your assigned shift, you will be required to report to the Ottawa C.A.C C by telephone to provide your assigned vehicle number, Ministry I.D., and your assigned shift, i.e. Vehicle' 4151 - 01 I.D #. 12345 & 56789 Shift: 07'00-19'00 Hours. Non-compliance to the above will result in a Code 7 being assigned against the vehicle. 24 4 All call numbers will be assigned at the onset of each call, regardless of the call priority All ambulance officers are to ensure that they document the assigned call, as this number is required when requesting information or making an inquiry N.B. Non-compliance will result in a delay in requesting information or receiving calls, as necessary 6 All crews are to ensure that their radio communications are clear and concise at all times to minimize radio time. FRIDA Y, DECEMBER 9, 1994 Pnor to the Gnevors' testimony, the Board informed them that a lesser weIght could be assIgned to the testImony of the second Grievor to testify, m ItS conSIderatIOn of the eVIdence, Ifhe were present dunng the testImony of the first. The Employer had argued for the exclusion of the other Grievor dunng the testimony of the first; the Umon had argued for the presence of the other Gnevor Mr Rankm, who was to testify second, made the deCIsion to voluntarily absent himself durmg the testimony of Mr Montgomery, who testIfied first. WhIle the actual allegatIOn which resulted in the dIsmIssals of Mr Montgomery and Mr Rankm took place over a bnef penod of tIme, an understandmg of It is not possible without an apprecIatIOn of the partIcular context m which the incident occurred and a detailed reconstructIOn and analYSIS of that penod of time and the time precedmg and following it. This results, unfortunately, in a lengthy settmg out of the facts because we are dealmg wIth two agenCIes and two Gnevors, and, because there was a number of mdlvlduals mvolved and most of them testIfied gIVmg theIr mdIvIdual verSIOns and perspectives, The followmg IS a schematic depIctIOn of the relevant geographIcal locatIOns m order for the reader to understand the evidence and the communICatIOn transcnptIOns set out below It IS based on the Path Fmder map submitted m eVIdence The mdex from the Path Fmder, IS attached as AppendIx A. The relevant maps from the Pathfinder are attached as AppendIX B 25 Dl ~ 1> Z ;Ti (II i ... @ , , I _teLEY RD ~ 1l '" j I ~ 0- , I f i . 02 BI.. t't1oll";,CllJb "''' H t~W' 110 -lIiF!I QTTAWA) I 2000 FT 1 , I (South) SlInK 26 Pn-llllil Hours._on Uecember 9,-1994 On December 9,1994, Mr Montgomery (#12497) and Mr Rankm (#51458) were workmg the 0700 to 1900 hours ShIft, as partners out of their normal locatIOn, "02 Base", often referred to as the "Hunt Club Base" due to ItS locatIOn on Hunt Club Road. It IS Just to the east of BowesvIlle Road. They had worked as partners from thIS base smce early February 1994 Dunng theIr prevIOUS expenence they had worked at all the bases. Mr Groleau was workmg the 0800 to 2000 hours ShIft as the Actmg SupervIsor m the CommunIcatIOns Room at CACC In that capacIty he was responSIble for provIdmg gUIdance to other communicators, answenng questIOns about pohcy and procedure, ensuring that service to the public was not mterrupted, and that the DIspatch Centre was fully staffed and runnmg well. He testIfied that he remamed, for the full ShIft, mcluding breaks (except for smoke breaks), m the Communications Room of the DIspatch Centre, in charge ofmomtonng the operatIOns in that location. However, he later testIfied that he "could have been out on supper" and in other testimony that he dId not have a supper break before gomg home that evening. He saId his lunch break took place around 1400 to 1430 hours. He was also carrymg out front-line dutIes when Call-Takers or Dispatchers required relief and he reheved the DIspatcher on the Ottawa Board, Chris Bourque, who was working the 1600 to 2400 hours shift, from 1752 hours to 1921 hours. Mr Montgomery and Mr Rankm had three vehIcles throughout theIr twelve-hour ShIft - #4150, #4148 and #4162. At 1032 hours whIle they were en route to the aIrport on a Code 4 call, they reported a Code 9 (radIO problems) to CACC, theIr call to the aIrport was cancelled and they were dIrected to "go to fleet" to pIck up a replacement vehIcle They did so, and receIved Vehicle # 4148 Shortly after leavmg the fleet locatIOn, they were assIgned a Code 3 call to "Clementme", but all through the transmIssion they expenenced, once agam, radIO problems. They reported thIS second problem (Code 9, radIO problems) to the DIspatch Centre and were agam dIrected to go to fleet to get another vehIcle. They dId not record these on the DaIly VehIcle Call Responses Form. Mr Montgomery explamed that Code 9s do not reqUIre the fillmg out of an ambulance call report, and It was hIS practIce not to record them. Mr Montgomery testIfied that m the case of the aIrport call, there IS no questIOn that he would 27 have proceeded on this call without his call number, because they were told that there was an airport call to meet a helicopter and they knew where to go and what they were going for Mr Montgomery and Mr Rankm signed off at 1107 hours and received their thud vehicle of the day, Vehicle # 4162 Between this hme and 1900 hours, accordmg to the CACC Call Summary for December 9, 1994 and the Daily Vehicle Call Responses Form filled m by Mr Rankm and Mr Montgomery, Vehicle # 4162 received and carried out the following assignments from CACC 000473776 at 1222 hours Code 1 Dnver' Montgomery; Attendant: Rankin 671 Waddell to Queensway Carleton Hospital Cleanng at 1347 hours Snowstorm began prior to 1500 hours This resulted in traffic congestion, periodic white outs, slippery roads and reduced visibility because of the heavy falling snow 000474218 at 1455 hours Code 1 To scene Dnver Montgomery; Attendant. Rankin From scene Dnver Montgomery, Attendant. Rankm 340-2660 (?) Norberry to Ottawa Civic Hospital Clearmg at 1601 hours 000474744 at 1643 hours Code 8 Dnver' Montgomery or Rankin, Attendant: Montgomery or Rankm (downtown, parallel to the Queensway) (Standby) Isabella and Metcalfe Cancelled at 1705 hours 000474799 at 1703 hours Code 3 Dnver Montgomery; Attendant: Rankm (bumper to bumper down town) 53/875 Montreal Road - Olive Gardens Restaurant Cancelled at 1708 hours, Dispatch found a closer vehicle 28 000474890 at 1732 hours Code 8 Dnver RankIn or Montgomery, Attendant. RankIn or Montgomery Slack and Menvale (Standby) Cancelled at 1743 hours, when they were on Prince of Wales Dnve, south of Baseline, follOWIng theIr reaSSIgnment on a Code 4 to 117 V IlIa whIch was close by 000474946 at 1740 hours Code 4/3 Dnver Montgomery; Attendant. RankIn 117 Villa Found prevIously known elderly patient in distress and transported her to RIversIde HospItal, and aSSIgned Code 3 to the call on return. Clearing at 1900 hours by landhne telephone In hospItal, returned to Vehicle # 4162 and got on the radIO, calling Dispatch, WIth a 10 - 8, the Code indIcatIng they were back on the air, and mobile. They dId not gIve a Code 10 - 19 (returnIng to base) to Dispatch. In the late afternoon, Mr LaVIctoire was travellIng on Highway 16 when he encountered a motor vehIcle aCCIdent whIch was beIng attended by OCRAS and he stopped to observe and aSSISt. The accident resulted In injurIes and one fatalIty He testified that the road surface was slIppery and vehicles in the ditch were a common SIght. Mr Corrigan agreed that the roads were slushy and that it was dark at the tIme he was returning to 02 Base from the motor vehIcle aCCIdent on Highway 16 Ms. Mills also reported that It was snowing and that at 19 13 57 condItIons were slippery and that it was necessary to drive more slowly that she would have liked. Post-1900 hours on December 9,1994 AccordIng to Mr Groleau, around 1900 hours, two of the three call-takIng desks were staffed, the three dIspatch desks were staffed, and Mr Groleau's had the supervIsor's statIOn to WhIch he could refer Between approxImately 1900 and 1930, Mr Bourque was workIng as the Call Taker and Mr Groleau was workmg as the DIspatcher on the Ottawa Board. Mr Groleau also recalled that Mr LaVICtOIre arrived about 1900 hours, although Mr LavictOIre recalls bemg told of the "SItuatIOn" upon hIS arrIval, whIch must have been Just around 1920 hours. Mr LaVIctOIre recalls Mr Groleau stIll bemg on the Ottawa Board at the time of hIS arrIval. 29 It was Mr Groleau's eVIdence that the Ottawa Board was busy and volume exceSSIve dunng the time that he was dIspatchmg whIch was from 1752 to 1921 hours, and that during the time of the call to 61 Fmch, he had a number of Code 4s waItmg. He wrote in hIS report that there were eIghteen calls during the one hour block of time between 1815 and the begmning of the call whIch was dIspatched at 1914 hours. A reVIew of the complete Call Summary for December 9, 1994, mdIcates that 300 umts were dIspatched from the CACC on that date, and that 131 of those were cancellatIOns or pre-emptIOns. The Call Summary sheet shows the total umts for all boards as 24 m the hour selected by Mr Groleau, consisting of 9 cancellatIOns, 1 standby, 4 Code 3s, and 9 Code 4s. The figures suggest that while the calls may have been constant, the volume does not appear exceSSIve The number of calls wItlnn a gIven period of time, IS not the only factor whIch contributes to the level of activIty reqUIred of the Call Takers and the DIspatchers. For example, one call mIght be straightforward, brief, and sImple to process, whIle another mIght be more complex and more dIfficult to process, and a small cluster of those which are complex could demand a greater level of activIty for a given period of time. Mr Groleau testified that there had been a "recent snowstorm" and that "there were a lot of accidents commg in" He explained that on a busy mght, all the DIspatchers and Call Takers could be talking at the same time. Mr Groleau acknowledged that between 19 11'00 and 19 13 00 the only two calls which he had active on his Board, were the Code 4 he had given to Vehicle # 4162 and the Code 3 call he was getting ready to give to Vehicle # 4175, but stated that he was also responsible with the other Dispatchers for maintaining balanced coverage. There was a Code 4 m Kanata, he saId, and they were communIcating amongst each other about VehIcle # 4175, and whether they would gIve that vehIcle a Code 3, as they also had a Code 4 in Kanata. He repeated, they "have to worry about other Boards too" Calli1Uilll41518Uo_61 .Einch Call # 000475386 began at 19'04 53 hours when Call Taker # 56073 (ChrIS Bourque) receIved an emergency call from a dIstressed female person speakmg m EnglIsh, although English was not 30 her first language. She dId not take up hIS mvitatiOn, "quelle VI lIe ?", to speak in French. The geographical scope of thIS call from thIS pomt in time, was in the CIty of Ottawa, south of the Queensway and east of the Rideau RIver, m an area bounded by RIverSIde Dnve on the West, AlbiOn Road on the East, Walkley Road on the North, and Hunt Club Road on the South. The Emergency DetaIls - Part 1 form, records that the call came from a citizen at 61 Finch Avenue, .- and gives the intersection as SheanvaterlUplands, WIthin the CIty of Ottawa. A telephone number, was also recorded. The condItion of the patient was noted as follows. . not noted as unconscious . noted as havmg dIfficult breathmg . not noted as having uncontrolled bleeding. The complaint was noted as - "97" First AId was asSIgned the code "05" and the prionty code was noted as Code 4 The child's first name was available (a gIrl's name), the last was noted as not bemg available. The following comments were recorded 5 Y /0 [year old] FEMALE WAS SENT TO HER ROOM AND LATER WAS FOUND WITH A ROPE AROUND HER NECK No hazards were noted. Mr Groleau stated m his testimony that this was not the ongmal computer informatiOn that was entered into the computer by Mr Bourque, who dId not testify It was the evidence of Mr Groleau that when the informatiOn was conveyed to him, the Dispatcher, the intersect sectiOn read CleanvaterlUplands not SheanvaterlUplands. A review of the mformation available to the Call Taker at the time the call was commItted shows that the only mformatiOn the Call Taker had been gIven by the Caller at the time he commItted the call was "Cleanvater", "Cleanvater project" There are several possibilitIes. Mr Bourque could have had a general Idea of the locatiOn and added "Uplands" from his own expenence, Mr Groleau could have been mIstaken or, a change could have been made to the "Emergency Details - Part I" (Ex. 18) at some tIme followmg the ongmal entry There was no eVIdence as to who mIght have made such an alteratiOn, nor was there eVIdence of a rule statmg that mformatiOn once entered must not be changed. There IS, however, the followmg note m the headmg of the form "DIspatch DetaIls" 31 (Ex. 12/18) 120002 Cannot Alter Information On a Closed Call It was not stated m eVIdence that thIS was a "closed call", but one would not expect to find that restriction noted on a computer record of a call that was not intended as a closed call. The Call Summary shows the destmatIon (ChIldren's HospItal), the DIspatch Pnority Code (4) and the Return Pnonty Code (3). This reduction m code pnonty was made by the NIght Crew en route to the ChIldren's Hospital. The DIspatch Details record the time pomts with respect to InCIdent # 000475386 1907.20 Call commItted by Call Taker; [call receIved at 19 04 53] Time elapsed 00'02 08 19'09.28 VehIcle # 4162 (Montgomery and Rankin) notified Time elapsed 00 00 00 19'09:28 En route (They happened to be mobIle at the tIme) 19'0730 Pohce Department notIfied The Night Crew of VehIcle # 4162 logged on at 19.21 '09 but thIS IS not recorded m the Call Summary, the Emergency Details, or the DIspatch DetaIls. 19.2253 VehIcle # 4162 amved at scene (61 Fmch Avenue) Time elapsed 00 13.25 19 39 19 VehIcle # 4162 departed scene (61 Finch) Time elapsed 00 16.26 19 57 58 VehIcle # 4162 arrIved at destmatIOn Time elapsed 00 1839 20 1203 VehIcle # 4162 cleared destmatIon Time elapsed 00 14 00 It was acknowledged by the WItnesses who were asked about the delay dunng theIr testImony, that the delay m respondmg to thIS call was unacceptable The reasons whIch caused the delay were not, however, agreed upon. 32 Relevant Reco.rdedCommunications and their Transcription The transcnpt records mcoming and outgomg commumcatIOns at CACC on the evenmg of December 9, 1994, between the followmg. Call Taker (ChrIS Bourque) and the Caller (woman seekmg emergency medical servIces) Call Taker and Police Call Taker and Dispatcher (Alam Groleau) DIspatcher (Alain Groleau) and 4158 Day/Evemng Crew, - Kevm Corrigan (at 02 Base) VIa direct landline telephone DIspatcher and 4175 Day Crew DIspatcher and 4162 Day Crew (Montgomery and Rankm) DIspatcher and 4153 Crew DIspatcher and 4163 Crew DIspatcher and 4149 Crew DIspatcher and 4162 Night Crew (Mills and Anderson). All those partIcipatmg in the heanng spent consIderable time and effort wlu.le lIstemng to the tapes of the conversations to try to venfy the transcnptIOns whIch had been provIded by CACC to ensure the accuracy of the transcnptIOns of these communicatIOns. There were occaSIOns, where It was agreed that certam detaIls of the transcnptIOn were not accurate and a corrected verSIOn was agreed upon. Also there was not full agreement in the meanmg of what was actually being said on some small portIOns of the tape. The areas of dIsagreement were left to the Board to detemllne followmg a final, post-hearing lIstenmg to the tape. Further, there were a very few bnef areas in the transcriptIOns which were sImply not deCIpherable. In the opImon of the Board, they were not sIgmficant as they were, for the most part, background commentary The transcnptIon below has been compiled using the viva voce eVIdence, and exhibIts 4, 4A, 6, 7 and 11, the refinements gleaned during the lIstening at the heanng and a further hearmg of selected portIOns by the Board whIch took place at CACC on June 11, 1997 The tape has a tIme recorder The tImes whIch are mdIcated on the left were obtaIned from the transcnpts and from the tape when It was bemg heard durIng the hearmg. The figures on the nght IndIcate the number of mmutes mto the call from the tIme the Call Taker answered the call, and those have been calculated. The commUnICatIOn between Mr Groleau, the Dlspatcher, and 33 the Crew of VehIcle # 4162 IS set out m bold Itahcs. 19 00 00 This IS the approxImate tIme at WhIch the Crew of VehIcle # 4518, Kevm Comgan and George Handzel, returned to 02 Base followmg theIr attendance at a motor vehIcle accIdent on HIghway 16 whIch had resulted m both mJunes and a fatahty They were the second ambulance to be assIgned to thIS accIdent. The other departed to the hospItal With the mjured patIent, and the Crew of VehIcle # 4158 remamed at the scene until the Coroner arrIved. The call was cancelled at 1851 hours. Followmg theIr return, accordmg to Mr Corrigan, they cleaned up and warmed up and he went to the crew quarters to call the Dispatcher for times. Mr Corrigan's call was made at 19'08.48, 1 minute and 28 seconds after the call to 61 Finch was committed at 19'07.20. 19'00'00 hours IS also the tIme at which Mr Montgomery and Mr Rankm were scheduled to end theIr shIft. Mr Groleau testIfied that he had given the Crew theIr tIme of arrival at RIVersIde HospItal (1824 hours) and he understood that they were headmg back to 02 Base, after that. 19'00:28 Mr Montgomery and Mr Rankm left Riverside HospItal, WIth Mr Rankm, the Dnver, and Mr Montgomery, the Attendant. ThIS dId not change untIl 19 15 30 Once in the vehicle, Mr Montgomery and Mr Rankm began to hsten to the radIO commUnICatIOns. As Mr Montgomery and Mr Rankm were workmg the 0700 to 1900 hours ShIft, they were returnmg to 02 Base to turn theIr vehicle over to the Night Crew They left the hospital parkmg lot and turned onto RIversIde Dnve headmg south-west and then mformed DIspatch that they were mobile It was dark and had been snowmg for more than four hours leavmg the road surface slushy The traffic on RIverSIde Dnve was bumper to bumper, and they were therefore movmg slowly At the mtersectIOn of RIVersIde and Bronson A venue, Mr Montgomery recalled cars havmg to back up and "take a run at the mclme" They amved at the mtersectIOn of RIversIde Dnve and Walkley 34 and there, had a chOIce of remammg on RIverside Dnve m the slow traffic condItIOns, or turnmg on to Walkley and gomg to Bank Street whIch was a consIderably longer route to 02 Base, on Hunt Club Road. Mr Rankm chose to contmue on RIverside Drive. Mr Groleau testIfied that he was aware when he gave them theIr assIgnment that at the tIme, theIr ShIft was to have ended at 1900 hours. (The Board recognizes that m emergency servIces employees may be required to remam past the normal end of ShIft, m order to handle emergencIes and meet the reqUIrements of servIce.) Mr Groleau also acknowledged that the normal procedure would be for another crew to be waItmg at 02 Base to staff Vehicle # 4162 on ItS arrIval, from 1900 hours. He testIfied that he would not, however, make the assumptIOn that they were there. 19'04 53 00'00'00 Beginning of communication between Call Taker (Chris Bourque) and Caller of Call # 000475386 Call Taker Ambulance for what CIty, quelle ville ? Caller Hello I'd like an ambulance at 61 Finch, please. Call Taker Hold the lme. You're, where, what's the address Caller 61 Finch Call Taker You're not calling from there are you? Caller Yes I am. Call Taker Well, you're calling from 951 Clyde nght now are you not? Caller No .No, I was just calling the emergency taxI and they sent * ** They transfer me to 911 Call Taker OK, OK, hold on, hold on, You're calling from 61 Finch? Caller Yes, 61 Finch. Call Taker OK, that's near Finch and what? Caller Pardon me ? Call Taker Finch near what street? Caller I, I have no idea. Call Taker What area of town is it, ma'am? Caller It's aah... Call Taker You have to Caller [Someone's name] What's the road here, what's the road here. No not (background at the Caller's. Clearwater). The project is Clearwater but there is 35 Call Taker It, it is near Clearwater? [Clearwater IS east of Bank Street] Caller Yes Call Taker OK, now what's your phone number ma'am? Caller Aah... Ok, just a minute, there, aah [Phone number given) Call Taker That's in Ottawa right? Caller Yes Call Taker OK now, the ambulance for yourself? Caller No, it's for a little girl here, aah Call Taker Is she conscious or unconscious? Caller Aah, she, she, she's up and walking, *** Call Taker Listen to me! Listen to me! Listen to me! Is she having trouble breathing? Caller She says it hurts, Yes. Call Taker No, no that's not what I asked you. Is she having trouble breathing? Caller Background at Caller's. Gaston, viens ici, Gaston viens ici. Crew (DIspatch Centre background) 4/1/6/3 radIO check Caller Background at Caller's As-tu des problemes a respirer ? Call Taker Is she having any bleeding? Caller Not that Call Taker Where's her pain? Caller Her pain is in her neck. The rope was tied all around her neck. Call Taker What do you mean the rope was tied ? What happened to her? Caller She was punished, she was upstairs, her little brother was also punished, he took the blind and wrapped it all around her neck. Call Taker How old is she? Caller She's five Call Taker And she had a rope wrapped around her neck? Caller Right Call Taker Hold the line, I'm goin' to get the ambulance going, stay on the line. 19 06 56 00 02 03 Call Taker (background at Dispatch Centre: 61 Finch. It's a lady .on...) Pnor to commIttmg the call, Mr Bourque had receIved the followmg locatIOn mformatIOn from the Caller 36 . 61 Finch . The road - Clearwater . The project is Clearwater . Near Clearwater . In Ottawa He had not receIved any mformatIOn which specIfied "Uplands" 19'07.20 00'02.27 The call was commItted at this time. In order for the call to appear on the DIspatcher's computer screen, the Call Taker would need to have pressed the "enter" key on hIS computer The call was sent on to the DIspatcher for him to estabhsh the locatIOn and assign an appropnate vehIcle on a pre-alert basis. Mr Groleau testified that the mformation that came to hIm was "ClearwaterlUplands" It IS difficult to see how Mr Bourque could have entered "Uplands" If "Clearwater" was the only intersection street he had had presented to hIm. He might have had personal knowledge of Finch bemg located in the Uplands area but as he dId not testify, we have no eVIdence on this point. Nor can we conclude that he knew where Finch was, because Ifhe had known, there would have been no reason for hIm to ask for further dIrectIOns from the Caller The only eVIdence we have, on that point, IS Mr Groleau's whIch was that when he received the comnlltted call on hIS Dispatcher's screen at 19'07.20, the intersection noted was "ClearwaterfU plands" Further, there was not evidence of any dIScussIon whIch might have taken place between Mr Bourque and Mr Groleau durmg the penod between 19'06 56 and 19 07 20, WIth the exceptIOn of"61 Fmch, It'S a lady on. " Mr Bourque then notified the Pohce and returned to the Caller for more detailed mformatIOn. 19 07 24 00'02.31 Police Hi Call Taker Hi, 61 Finch Pohce 61 Finch 37 Call Taker Yep. We're going on a high priority, for a 5 year old girl, she was punished by somebody, sent to her room, the person went to check on her and they found a rope wrapped around her neck, and aah and I guess she's trying to hang herself or something aah... PolIce But she's not hung? Call Taker No, she's complaining of shortness of breath and aah, hm neck pain, so she could've had a spinal injury PolIce She hanged herself? Call Taker He, aah... either that or I don't know if there was an adult at scene who knows what happened but that's what they're saying that happened. PolIce OK. Call Taker All right, bye, bye. The mformation whIch the Call Taker gave to the PolIce, that the Caller was saying that the chIld "hanged herself' IS not accurate. The Caller saId that the brother "took the blInd and wrappeq It all around her neck" Mr Groleau agreed that If a tIered response were to be actIvated that thIS would be the approXImate pomt in the sequence at which the Call Taker would have imtIated It. Mr LaVIctoire testIfied that the criteria for a first response, is "cardIac or respIratory arrest", that IS, the heart is not beating and/or the patient is not breathing. In this case, the VItal SIgns were not mIssmg, and the patient was breathing and both Mr Groleau and Mr LaVIctoire testIfied that the condItIon of the patIent on thIS call, dId not meet the crIteria for a tIered response. The Call Taker had been told that the child was "up and walking" The Board accepts that in thIS call, the patIent dId not meet the cntena for a tiered response. Further, It recogmzes that the Call Taker sensed there was an incident mvolvmg a chIld that needed lookmg mto and qUite properly notIfied the polIce 19 07 54 00 03 01 Call Taker Hello. Caller Hello. Call Taker [An aSIde] OK, I changed It, AI, I changed It. 38 So you're at 61 Finch? Caller Yes Call Taker OK, the only reason I'm asking is that my 911 screen says that you're at 951 Clyde. Caller No. Call Taker That's wrong? Caller Yes. Call Taker OK, so, she Caller I have like five kids to get dressed right now Call Taker OK. I... Caller I'm alone Call Taker OK, are you babysitting there? Caller Pardon me ? Call Taker You're babysitting them? Caller Yes. Call Taker OK, now listen. It's very important that I get, that I get these aah, this information. OK. Cause it's, gonna, I'm gonna give you some first aid as well. OK? For the next couple of minutes following this part of the conversation, Mr Bourque attempts to gam more specIfic patient informatIOn from the Caller and to gIve her mstructIOns respectmg lInmedmte care for the child. It IS not necessary to set these out. At 19.08.30, the DIspatcher, Mr Groleau, answers a dIrect landlme telephone call imtiated by Kevm Corrigan who is calling from 02 Base part-way through hIS ShIft, followmg hIS return from the motor vehIcle accIdent on Highway 16, which he and hIS partner attended from the tIme of theIr notIfication at 1718 hours to their cancellation at 1851 hours. Mr Montgomery and Mr Rankm were not aware of thIS conversatIOn takmg place. Mr Corrigan was assigned to the evenmg crew of vehIcle 4158 and was callmg for some times whIch he needed to complete hIS paperwork. He would normally obtam these from the DIspatcher one of the persons who enters the tImes mto the computer 19 08.30 00 03.37 Beginning of the direct landline telephone communication between Kevin Corrigan (4158) and Alain Groleau. At this point, assuming that "Uplands" was on the computer screen as Mr Groleau stated, he has had the "Uplands" information for 1 minute and 10 seconds. 39 Durmg thIS communicatiOn, Mr Groleau is standing up from his dIspatch desk, consultmg the Pathfinder map book and then the large wall map There was no eVIdence when he consulted the index. He testified that at thIS pomt m time he was not sure of the locatiOn of 61 Finch, although he had two pIeces oflocation informatiOn "Uplands" and "Clearwater" At thIS point, Mr Groleau has had the Uplands and Clearwater mformatiOn for 1 mmute and 10 seconds. Groleau 6/2 10- 20 ? When the Crew of Vehicle # 4162 receIved thIS transmIssion, accordmg to Mr Rankin, they were travellmg south on R.1verside Drive just approachmg Walkley Road. All four lanes of traffic were stop and go and a maxImum of 40 kmph was possible. Mr Rankm explamed that, although it was normally the Driver's responsibility to respond, he dId not do so lInmediately as he was approachmg the intersection, expecting the green light to turn amber at any moment and he felt he should clear the mtersectiOn before talking on the radio Groleau DIspatch CorrIgan Hi. Groleau Yeah, hold on a sec. Corrigan All nght. 19 08.34 00.03 41 Groleau 4/1/6/2 10-20 Groleau Is 6/2 at base ? Comgan No. Groleau No... ? Comgan No. Are they shafting? Groleau Yeah. Mr Groleau acknowledged that in ambulance Jargon, "shaftmg" means aVOIdmg work and Mr 40 Milo agreed that It had a "derogatory" connotation. He vIewed it as "lIght kidding" Mr Groleau explamed his affirmative response to Mr Corrigan by stating that he was "not paymg much attention" and agreed with Counsel's statement that he was "not agreeing wIth Kevm Comgan that they were shafting", adding that he was "just makmg a noise" and was "concerned wIth findmg the street." Mr Comgan testIfied that he made the comment because he didn't know what they were doing, [and] Dispatch was trying to get hold of them, there was some delays; [that he] thought they weren't answering their radio and that's why [he] said they were shafting. He acknowledged that the comment imphed they were trying to avoid a call, and testIfied that thIS was what he mtended, that IS was based solely on the fact he had heard a single request for a 10 - 20 , and the fact that the Dispatcher asked If they were at base He stated his comment was meant to be uncomplimentary of Mr Montgomery and Mr Rankin. Mr Rankin described shafting as "getting out of work, or being lazy" and remarked that he dId not consider hImself a shafter, and noted that he was still working after the end of hIS shift. 19'08 44 00'03'51 Groleau 4/1/6/2 your 10 - 20 ? At thIS pomt, Mr Rankm testified, he had cleared the mtersectIOn of Riverside and Walkley, and was about to speak mto the microphone to respond to Dispatch. 19'08 48 00 03 55 Corrigan Figures. 4162 4/1/6/2 Revelstoke and Riverside Crew Rankin 41 Accordmg to Mr Montgomery, VehIcle # 4162 was just approaching RIversIde and Revelstoke, but had not crossed. Mr Rankm explamed that it is customary to give the mtersectIon you are approachmg rather than the one you have passed through, because If you have passed the mtersection you mention, you cannot turn into It. Groleau Revelstoke and Riverside... hm, that's a tough one to call. Corngan Where's the call ? Groleau The call['s] on Finch Corngan Where's Finch? Groleau Finch, is off of Hunt Club area, east Bank area. [ThIS is mcorrect] Corrigan Then they're the closest. [It IS hard to see how VehIcle # 4162 would be closer on the east of Bank basIs, even WIth the tIme to go mobIle.] [For reasons of efficIency and prompt response, the polIcy IS that the ambulance whIch IS the closest m time is to be sent to the call.] Groleau Hey Corrigan East of Bank? [Mr Corngan then questIOns Mr Groleau's locatIOn. ] Groleau Yeah. Hold on a second, let me find it. [Mr Groleau does not find It] Corngan I know where it is. Yeah, yeah, yeah. [Mr Corrigan doesn't tell Mr Groleau where Finch IS located, and Mr Groleau doesn't ask Mr Corngan where Fmch is located. ] Groleau Yeah. You guys closer? Corngan No. They are. Groleau Aah'n ? [Mr Groleau sounds doubtful.] Corngan They are. [Mr Corngan responds to Mr Groleau's doubt by confirmmg that Vehicle # 4162 IS closer His statement left no room for doubt.] Mr Corngan testIfied that he dId "not know if he SaId mobIle was closer or [he] was closer" and "[he] heard them get a call on Code 4 on 61 Finch" and " [he] heard the vehIcle ask for a 10 - 20 of the call" In hIS testImony, Mr Corngan gave the opmIOn that Vehicle # 4162 was closer 42 because they were m the Hunt Club area, and they were mobIle, so they would be closer than VehIcle # 4158 as they were dnvmg then vehIcle m the area. Mr Corngan agreed that durmg hIS dIscussiOn wIth Mr Groleau, he had a "pretty good Idea where Fmch was", that hIS car was ready to go, that he and hIS partner had been on for 3 hours, and had 5 hours remaming m then ShIft and that he knew that Mr Montgomery and Mr Rankin were past the end of then shift. He was asked m cross-exanllnatIon why he did not say that he would go and do the call and he replIed that because, m his judgement, VehIcle # 4162, being mobIle, was closer at the time, that IS, already towards the call area. At that pomt, he testified, he dId not have a map in front of hIm. He was asked Ifhe thought that being mobIle was partIcularly helpful if you didn't know where the call was located, and he replIed that, it IS the Job of the partner of the driver to look It up and that they should have looked It up on the map Groleau OK. No problems. Corngan Call us back with times later when you have a chance. Groleau What was that? Corrigan I'll need some times. Groleau OK. Bye. End of commumcation between Mr Corrigan and Mr Groleau 19.09:22 00 04.29 Mr CorrIgan told Ms. Mills and Mr Anderson (VehIcle # 4162 Night Crew) who were m the crew quarters and present during his telephone call, that the Day Crew would be delayed because they got a call on the way back to base. He was not told by Mr Groleau that the call had been gIven to the Crew ofVehlCle # 4162, and he must have assumed that ifhe and Mr Handzel (Crew of VehIcle # 4158) were not bemg gIven the call that since he had told Mr Groleau that # 4162 was the closer vehIcle, and since he had not offered to do the call, the Crew of VehIcle # 4162 Crew would receIve the aSSIgnment. At thIS pomt, Mr Groleau has had the locatiOn mformatiOn on hIS computer screen smce 19 06 56, that IS for 2 mmutes and 56 seconds. He testIfied that accordmg to polICIes, he had "a 43 mmute to locate", but that m this case It took hIm a lIttle longer because of the "cross streets not Jibmg" and he also told ChrIS Bourque "to get (him] a better cross street" He testIfied that he pulled out the map book, and looked at the legend (the mdex), and based on the code, It (Fmch) was not where Clearwater was. (Mr Groleau appears to have compared the codes, rather than looking at the map) He explamed that most of the dIspatchmg IS on Page 53 ofthe Pathfinder Map Book, and Clearwater was on page 73 (It IS on page 74) and that IS where It dId not make sense. Clearview was on page 53, and he had that m hIS mmd as well. It is located north of the Queensway Just south ofthe Ottawa River, east ofIsland Park Drive and west of Tunney's Pasture. Clearview and Clearwater are sequential m the index, and appear as CLEARVIEW AV OT 53 J27 CLEARWATER CR OT 74 R29 Mr Groleau also stated that he had the general Idea that Finch was m the Uplands area (He testIfied that It was on his screen.), and that he had someone else trymg to help him locate It off Clearwater Mr Groleau acknowledged that "that's where [he] made [his] mIstake (he] even mIstakened It as "Clearview"" It appears that Mr Groleau compared co-ordinates m the mdex but there was no eVIdence that he took the co-ordmates for Finch and used them to locate the street on the map Mr Groleau also testIfied that he was not aware of the fire station that was located at McCarthy and Twyford, Just west and slightly north of Finch, on the eastern edge of the adjacent subdIvIsIOn. He SaId, however, that m hIS opimon, the case of the chIld with the rope dId not meet the cntena for dIspatchmg assIstance from the fire statIOn, smce, even though hangmg creates a reSpIratory problem, he had no mformatIOn that the chIld's vItal SIgns were absent. The mformatIOn that he had on the computer screen was "possible hangmg", that she was conscious, havmg dIfficulty breathmg, and was not suffenng from uncontrolled bleedmg. He acknowledged that one consequence of that could be respIratory arrest. Mr Groleau testIfied that he "always assume[s] the worst", but reasoned that "the patIent's vItal SIgns could have been absent, or not absent" He also pomted out that he was not on the telephone wIth the Caller, and noted that he had made the call a Code 4 However, he later stated that It was the Call Taker's 44 responsibIhty to assign the code and that he dId not have authonty to change it once It was assIgned, but testified later, that the DIspatcher dId have the authority to change the pnonty code en route to the scene. Mr Groleau testIfied that "once [he) pinpointed it [the location of the call), THEN, [he) determined which was the most appropriate vehicle" He saId he "was able to locate the call location" and "based on locating, decided to dispatch 4162" The fact they were mobIle was Important in hIS choice of vehicles, he testified. It is difficult to tell the consideration which Mr Groleau gave "Uplands" He said he thought Finch was in the Uplands area. However, this time he was still trying to locate Finch with "Clearwater" as his reference point. Yet, he had not established where Finch Avenue was and so, he was in the process of selecting the vehicle for the call without knowing its location. He had only Kevin Corrigan's word that Vehicle # 4162 was closer than Vehicle # 4158 and he had not been informed of the location of Finch by Mr Corrigan, nor at this point, had he confirmed that Mr Corrigan knew where Finch was. It was now 2 minutes and 3 seconds since he received the committed call. 19 09:23 00.4.30 Groleau 41-62, Ottawa At this time the Call Taker has not yet clarified with the Caller that the location is near "the Army base" nor that the reference point is Shearwater NOT Clearwater That does not occur for approximately another minute. While he is clarifying this, the Crew of Vehicle # 4162 and Mr Groleau are communicating with each other 19 09.28 00.04.35 It appears that thIS IS the pomt m the process Mr Groleau determmes he WIll send VehIcle # 4162 This is the time of notification given on the Dispatch Details. It IS not a time WhIch IS 45 noted m the transcnpt. It is now 4 minutes and 35 seconds after the Caller made initial contact with the Dispatch Centre. It is 2 minutes and 7 seconds after Mr Groleau received the call from the Call Taker 19'09:31 00'04.38 Groleau 4/1/6/2 Ottawa 19'09.33 00'04 40 4162 4/1/6/2 Crew 19'09:34 00'04 41 Groleau Code 4 at 61 Finch 6/1 Finch... stand by a sec... DIspatchers normally, but not always, gIve the Crew a call number at the outset of asslgmng a call. As It was, the number was not assIgned until 19'15 16, 5 minutes and 42 seconds after the Crew received the mltIal notIficatIOn of the call. Mr Montgomery mterpreted this transmIssion to mean that the DIspatcher was makmg them aware of a Code 4 at 61 Finch, and then was tellmg them to "hold on", that he may have somethmg else to assIgn to them, that he may have somethmg else m mmd and IS not assIgning them 61 Fmch" Had the words "stand by a see" not been there, Mr Montgomery testified that he would have mterpreted the "Code 4 - 61 Fmch" as a pre-alert and he would have understood that the call had been assIgned to the Crew of VehIcle # 4162. However, Mr Montgomery also agreed dunng hIS testimony that this was the pre-alert on the 61 Fmch call and that thIS was the point at whIch he pulled out the map book and turned on the sWIvel lIght to look for Fmch smce he was not famIliar wIth ItS locatIOn and had not previously responded to a call on that street. Mr Montgomery testified that he turned to page 10 of the map book and looked at the mdex. He was wearmg glasses at the time he dId so Mr Montgomery explamed that whIle he was able 46 to read tmy pnnt wIth hIS glasses, he found the addItional problems of poor hghtmg, the actIOn of the wmdshield WIpers, the glare of the brake hghts m front, and the stop and go movement of the vehIcle in bumper to bumper traffic, made It Impossible for hIm to find "Fmch" m the mdex. Mr Montgomery explamed that he earned a personal flash-light wIth hIm in a holster, but that he dId not take it out as he knew the rechargeable battenes were m need of rechargmg. He also acknowledged that he did not ask to borrow Mr Rankm' s flashhght, nor dId he recalllookmg for the cab flashlight. Mr Montgomery also became unclear about the pre-alert later, accordmg to hIS testimony, because of the absence of an up-date of the 10 - 20, and a second request for the vehIcle's 10 -20 It became hIS impressIOn that DIspatch had not deCIded what he was gomg to do WIth them. Mr Rankm testified that he interpreted DIspatch's communIcation as hIm "startmg to give us a Code 4, a pnority call, and then askmg us to "stand by a sec" whIch is a heSItatIOn or a walt command. He testIfied that there was nothmg in partIcular for them to do at that stage, the stage at whIch they had been alerted that somethmg was commg, or would probably be commg. He testIfied that if they had been at the base when they receIved that mformation, they would have proceeded to the ambulance, would have booked, and been ready to wnte down the information. They would not, however, have driven off, as at that time they would not have known where to go As the Dnver, he did not consider that he had received a pre-alert at thIS time because he had no Idea where 61 Fmch was, smce the informatIOn from the Dispatcher was inadequate and hIS partner, Mr Montgomery, was unable to locate the street on the map 19 09 49 00.04 56 Groleau 4/1/6/2 Ottawa Crew [4149] 49,10-7,01 [Background] 19 09.51 00 04 58 Groleau 4/1/6/2, Ottawa 47 19'09'54 00'05 01 4162 4/1/6/2 Crew 19'09 55 00'05'02 Groleau It's at uh..61 Finch...6/1 Finch...It'sfor afive-year old possible hanging...there is... was a rope around her neck, unknown condition of patient at this time, I'll get back to you with an update [ Tlns could be considered a "stand by" ] Mr Rankin gave the opInion that he considered thIS to be a sufficient statement of patIent mformatlOn for a prompt response to the call. He also explamed that as well as the address and the nature of the call, they needed to have a geographlcallocatlOn or a cross-street, although he testIfied that he dId not know whether or not a geographlcallocatlOn or cross-street was a reqUirement of a pre-alert dispatch. It made sense since the purpose IS to lessen the response time of the ambulance. It was Mr Rankm's opmlOn that the communication from DIspatch at 19'10' 55 would normally be sufficient for a pre-alert. Mr Rankm testIfied that the fact a call number had not been given at that stage, and so had no effect on whether or not they would respond to the call. If they dId not get It then, or later, they would probably call for the number 19'10 14 00'05.21 Groleau 10 - 200 notified. Mr Montgomery Said to Mr Rankm, "I can't see it; I can't find It" (He testified whIle vlewmg the book at the hearmg that he found It "totally dIfficult to read") At thIS pomt accordmg to Mr Montgomery's testimony, Mr Rankm called DIspatch and asked for a 10-20 on 61 Fmch. 19'10 15 00 05.22 4162 Give me a 20 on Finch Crew Montgomery or Rankin 48 Mr Rankm was lookmg to receive the name of a cross street, or a set of cross streets that would be well-known secondary arteries at the very least. Havmg those would, he testified, have enabled him to proceed in a more accurate direction and probably would have gIven Mr Montgomery a better chance of finding the location by using the map It was at thIS pomt that Mr Montgomery ceased looking for Fmch m the map book and began waitmg for a response from DIspatch. Assummg that he was trying to locate Fmch m the map book from the time he opened the book, Mr Montgomery would have spent, at thIS point, 40 seconds, trymg to find Fmch m the map book. Mr Montgomery explained that he anticipated that DIspatch would come back and gIven them a locatIOn as they had done on many occaSIOns in the past. Mr Montgomery testified that he did not recall specIfically asking Mr Rankm if he knew where Fmch was but It seemed clear to him, that neither of them knew, smce Mr Rankin offered no gUIdance. Mr Rankm testIfied that he had no Idea where Finch was, and that, combined with the fact Mr Montgomery saId that he could not find It, was the reason he asked for the location. 19 10'18 00 05.25 Groleau Near Clearwater . apparently... near the Base or something like that... VehIcle # 4162 was at thIS time still travelling south on RIversIde, and was south of Revelstoke and north of Bowesvllle. Mr Rankin gave the opimon that he dId not consIder thIS was suffiCIent geographIcal mformatIOn to ensure a prompt response to the call. He also acknowledged, m cross~examination, that from thIS pomt m time, he was on a Code 4 pre-alert and that at no time dunng the transmIssion, does Mr Groleau tell him to disregard the Code 4 call. Mr Montgomery testIfied that he dId not know the location of Clearwater, or of a street of that name near the Base, and dId not look it up on the map Mr Montgomery testIfied he thought it might be near Claymore, a street With which he was famihar, but which was located on the other SIde of the RIdeau River and north of theIr locatIOn which would have meant crossmg the River 49 and returning north. He explamed that this came to mmd as they were m the area and he knew someone who lived there. Further, it IS not unknown for the DIspatchers to make a mistake, he testIfied. The mentIOn of "the Base" caused Mr Montgomery "total confusion" He mterpreted It as 02 Base but that dId not comcIde WIth hIS mIstaken view of where Clearwater was. Mr Montgomery explamed that he saw the role of the Driver, to drive to the assIgned locatIon, of the Attendant to assist the Dnver from pomt A to point B using a gUIdebook or hIs/her expenence, and if one does not know, then one asks DIspatch. Mr Rankin testIfied that he found the transmissIOns from Dispatch confusing and contradictory and hIS "mmd was not made up as to the relevancy of the different and confusmg mformation [he] had been gIVen" He was further confused because he could not understand why Mr Groleau was gIving the "stand-by" command so often and why there was such a delay in hIS gettmg back to them. He testIfied that he found the expenence frustratmg. As It was, he ended up following the dIrection of the "base" and went in the dIrectIOn of both, which because of theIr proximIty, he could do. lt was suggested to Mr Rankm m cross-exammation that the source of his confusion was hIS partner, Mr Montgomery, and that he, Mr Rankin, had done "absolutely nothing to sort out the confusIOn" Mr Rankin dIsagreed wIth thIS proposItIon and replIed that he conversed with Dispatch back and forth until [he) was told they would get back to [him], then, while [he) was driving in close to blizzard conditions, bad traffic and bad road conditions [he was deciding on [his) options while waiting for Dispatch to get back to [him) as they said they would. Mr Rankm admItted that hIS thought processes were not optImal at the end of his twelve-hour ShIft. Mr Groleau testIfied that he was stIll waztmg for mformatIOn confirmmg the location of Fmch. However, he could not have been waitmg to "confirm" the locatIOn of Fmch smce he dId not have It. He testIfied at that pomt that Clearwater was the nearest he had found. (He dId not 50 explaIn what it was nearest to) He acknowledged that he gave the Crew of Vehicle # 4162 Clearwater as a reference when he knew it was not Clearwater He also clarified that when he said "the Base" he meant the Canadian Forces Base Ottawa at Uplands, not 02 Base on Hunt Club Road. ThIs Information from DIspatch was unclear to the Crew of VehIcle # 4162, and was Incorrect. "Clearwater" IS not near either 02 Base or the "Army Base" Mr Rankin dId not know the location of "Clearwater" or "ClearvIew" WhICh he thought of, but he dId know the locatIOn of "Claymore" WhICh, accordIng to hIm IS a secondary road, on WhICh they have frequent calls. Further, it was not clear which base Mr Groleau was referring to The "Army Base", CanadIan Forces Base Ottawa (South) and the 02 Ambulance Base are both In the same area. 19'10:21 00'05.28 4162 [Undecipherable] Base? Crew Rankin 19 10.23 00 05.30 Groleau .It's near Clearwater .standby... I'll give you a 20 in a second... I've got other 4s ThIs was 49 seconds after the assIgnment of the pre-alert. Mr Groleau acknowledged that he repeated Clearwater and told the Crew of Vehicle # 4162 that he would gIve them a locatIOn "In a second" He added In hIS testImony, that he had "other 4s" and was "a busy guy" From Mr Groleau's "stand by, I'll gIve you a 20 in a second", Mr Montgomery expected that Mr Groleau would be back to them "momentarily" wIth a "20 on FInch" This was offset when Mr Groleau saId "I've got other 4s" Mr Montgomery thought that Mr Groleau mIght be sendIng VehIcle # 4162 on one of the other 4s, that he mIght be consIdenng theIr locatIOn, the time of day and the weather condItions, or that he mIght be sendIng them to the motor vehIcle aCCIdent on Highway 16 (It had been completed at that time.) AccordIng to Mr Montgomery, they expected further InstructIOns. ThIs was not an IndIcatIOn that the Crew of VehIcle # 4162 should 51 get back to DIspatch. Mr Rankm mterpreted thIS "stand by" to mean that the stand-by tIme was to be extended, but that the mformation on the locatIon of Fmch would still be forthcoming m 35/40 seconds, a normal response tIme. He belIeved that the DIspatcher had other calls whIch were Just as Important or more so Mr Rankin testIfied that If the DIspatcher had come back and saId "off Shearwater" , It would not have helped a great deal smce he dId not know where Shearwater was. What would have helped was a locatIon of "Uplands and Hunt Club", even "Cahill and Uplands", and best of all would have been "Off Uplands between Paul Anka and Cahill" Uplands, he explamed, IS a major secondary road. The Uplands mformatIOn had been wIth the DIspatcher since 19 07.20, the time the call was committed. 19.10.28 00.05.35 4162 10 - 4. Crew Rankin WillIe the above exchange has been takmg place between the Crew of VehIcle # 4162 and Mr Groleau, the Call Taker, ChrIS Bourque, has had the followmg conversatIOn m which he clarifies the location beginning at 19 10:28, the same tIme as the 4/1/6/2 "10 - 4" above. He then completes the conversatIOn at 19 10:36 At the start of the conversation the Call Taker still thinks the reference street is Clearwater, although he is having doubts; Mr Groleau still thinks it is Clearwater and he believes that it is "east of Bank" and has also confused it with Clearview which is just south of the Ottawa River; Mr Montgomery wonders if it could be Claymore which is west of the Rideau River, and Mr Rankin, the driver of Vehicle # 4162 does not know where it is, but is being provided with these various directions. Call Taker OK. ma'am, what area of town is that Is that down by Hunt Club or ? 52 Caller Yes. Yeah, down in that area. Call Taker Do, do you know a big street around there that's... Caller You know the street... ***** Call Taker You're near the Army base? Caller Yeah, but it's not like on the Army base. (background at the Caller's. non, bouge pas Gaston, tu peux pas, ok, c'est bien important que tu ne bouge pas, OK?) Call Taker (background at Dispatch Centre: to Dispatcher' by the Army base) Ok, ma/am are you off Uplands Drive? [ThIs IS the first time Uplands Drive IS mentioned m the conversatlOns between the Caller and the Call Taker] Caller Yes. 19'10:28 00'05.35 Call Taker You are, heh, so that's not Clearwater that's Shearwater right? Caller OK. Call Taker OK. We're on our way, you use the first aid, call us back ifthere is any change. OK? Caller OK. Call-taker Bye, bye. End of commumcatlOn between Call-taker and Caller 19'10:36 00'05 43 The other half of the mtersection reference for Finch is finally estabhshed by the Call Taker, 5 mmutes and 43 seconds after the call was recelVed, and 3 mmutes and 16 seconds after the DIspatcher had the call from the Call Taker, and 1 mmute and 2 seconds after the Crew of VehIcle # 4162 was mltially notified of the 61 Fmch call. It was "Shearwater" However, Shearwater IS a very short, pnvate road off Uplands Drive whIch allows access to Fmch and Pmson. It IS not a street WhIch fits the descnption of a reference road smce It must quahfy as one of the most mSlgnificant roads m the CIty of Ottawa. The Crew of Vehicle # 4162 asked for location information 21 seconds ago, at 19'10'15. The Dispatch Centre has had the Uplands Drive information since at least since the call was committed at 19 07.20, that is 3 minutes and 16 seconds, and the Shearwater 53 information has just been received. The Dispatcher has not provided this information to the Crew of Vehicle # 4162. 19.10 49 00.05.56 Groleau 4/1/6/2 your 10 - 20 now? The Crew of Vehicle # 4162 asked for location information 34 seconds ago. The Dispatch Centre has had the Uplands information for 3 minutes and 29 seconds. The Dispatch Centre has had the revised location information for 13 seconds. The location information has not been given to the Crew of Vehicle # 4162. Mr Groleau came back Within the usual time-frame but not WIth the location information. Instead, he asked the Crew ofVelucle # 4162 for their up-to-date location. This second request by Mr Groleau for VehIcle # 4162's location dId not, Mr Montgomery acknowledged, negate the pre-alert; It dId however, from hIS perspective, add to the confusion. He testIfied that some of the reasons DIspatch mIght do this would be that there were people on the scene askIng for an arrIval time, to Judge whether another vehicle IS closer, to deCIde whether the vehIcle should be re-routed to another call, to decide whether he was gOing to cancel the pre-alert, allOWing the vehIcle to return to base for a crew change, and others. When DIspatch asked the Crew of VehIcle # 4162 for its location agam, Mr Montgomery read this as Mr Groleau deciding WhICh of the Code 4s to apply to them, as "he had not yet gIven them a call and we were there for hIm to use" He testIfied that he was wondenng why, If they still had the pre-alert, Dispatch was asking for theIr locatIon rather than gIving them the location of Finch. ThIS caused hIm confuSIOn whIch was compounded by the fact that DIspatch saId he had other Code 4s WhICh Mr Montgomery Interpreted as a suggestIOn that he mIght want to send them on a different Code 4 Mr Montgomery testified that It IS not uncommon to be pre-alerted to a speCIfic locatIOn and then be re-routed to another, on another call, in fact, he stated, it happens every day when, for example, DIspatch finds a closer car Mr Montgomery acknowledged that DIspatch had not cancelled the pre-alert; DIspatch at no time cancelled the call, nor had he at any time told them to dIsregard the Code 4 at 61 Fmch. Two other factors mentioned by Mr Montgomery whIch led 54 hIm to belIeve that they might not have the Fmch call was that Dispatch had yet to gIve them a call number or a "T3" (ambulance mobIle) time. He acknowledged that these were not necessary for the Crew's to carry out a call but explamed that theIr absence added to theIr lack of certamty about whether or not they had the Fmch call. The announcement of cancellations over the radio IS not unusual. There were 131 cancellatIOns or pre-emptions out of 300 unItS announced over the radIo on December 9, 1994 Mr Rankin testified that he was cunous, and slightly frustrated, he did not know what to do next, as he dId not know whether or not DIspatch was giving them the call. This confusion was added to by Mr Montgomery's suggestion that Finch mIght be located near "Claymore" which was the other SIde of the Rideau River, not at all near 02 Base, and by the fact they would soon be commg up to the Hunt Club Bndge, If they were to contmue south on RiversIde. He was also wondenng about whether or not they were to be sent to the motor vehicle accIdent on Highway 16 He expected Dispatch to then come back to hIm fairly qUIckly, but that dId not happen. There are lIghts and a left-turn lane at the RiversidelUplands mtersectIOn and the vehicle had turned mto the left turn lane when DIspatch asked for their 10 - 20 The lIght was red when they approached the mtersectIOn, and Mr Rankm stIll did "not have a clue where 61 Fmch was" Mr Rankm explamed that he waIted for twenty seconds or so expecting further communicatIOn from DIspatch but it was not forthcommg. Mr Rankm explained that he chose to turn left on Uplands rather than follow Mr Montgomery's suggestIOn, because the only clear dIrectIOn gIven to hIm by Dispatch was that Fmch was close to "base" and by turning onto Uplands and then almost immediately right onto Bowesville, he would be headmg m the directIOn of both the ambulance base and the mIlItary base He explamed that there IS a housing development near Uplands and Downpatnck whIch would be near the mIlItary base, and one at Uplands and Bowesvtlle which would be near the ambulance base. The entrance to CFB Ottawa (South) IS at the mtersectIOn of Hunt Club and Bowesvtlle Mr Rankin stated that he "headed to the geographical location which they gave me which was at or near the Base" Mr Rankm was asked If there was an OppOrtunIty to 55 stop and have a better look at the map or get on to DIspatch. Mr Rankin replied that the only locatIOn he bebeved he could have done that was at small mall at the RIversIde Uplands (BowesvIlle) intersection at the pomt when DIspatch asked for their locatIOn. He also recalled that there was an old service road off Hunt Club Road that was barricaded. It did not occur to hIm to pull over, he testIfied, and explamed m cross-exammatIOn that they were travellmg on a four-lane road, WIth bad VIsibility and congested traffic and It would, m hIS opimon, have been dangerous to pull over on the SIde of the road. Mr Rankin testified that If eIther of them had known the location of Finch at that pomt m tIme, he, as the Driver, would have had two chOIces the first, to go along Uplands, which IS a two-lane reSIdentIal road WIth a 50 km speed limIt; the second, to go to Hunt Club which IS a four-lane artenal route and turn left onto Uplands. This second option is sometImes faster Mr Rankin testIfied that he had "a knee-jerk reactIon to go straight on Riverside Dnve, southbound, because it left more options open to go south or west If DIspatch so dIrected" He nevertheless turned left onto Uplands and very shortly nght onto Bowesville, and continued south to Hunt Club Road. At the time he made the turns onto Uplands and Bowesville, the Uplands reference for Fmch had not been conveyed to him. Indeed, it never was. The traffic along Bowesville was mmImal, and they were able to proceed at a faster speed. Mr Montgomery assumed they were contmumg in the dIrectIOn that DIspatch wished them to go, that IS, south toward Hunt Club Road. 19 10.52 00.05.59 4162 Uhh...Riverside and Bowesville (ThIS IS actually RIverSIde and Uplands] Crew Montgomery Mr Groleau testified that he knew the intersection of Riverside and Bowesville (Uplands) and explained that once the Driver of Vehicle # 4162 was "there" they were "heading in the right direction, "and he wanted" to give him directions how to get there" The Driver, who had asked for location information had to decide at that intersection whether to 56 continue southwest on Riverside, whether to turn onto Uplands and continue along Uplands, or whether to turn onto Uplands and then south on Bowesville. He did not receive that information and was then criticized by Mr Groleau for having bypassed Uplands. 19 11 00 00 06 07 Groleau 10-4 This is the last communication between Dispatch and the Crew of Vehicle # 4162 until 19 12.54 - a period of 1 minute and 54 seconds during which Mr Groleau did not contact the Crew of Vehicle # 4162 and they did not contact him. The penod of no contact was broken by a transmIssion mItIated by the Crew of VehIcle # 4162 at 19.12 54. 19 11.00 (Start) Radio communication (ALS) 00.06.07 Mr Groleau testIfied that he was involved in "catch-up" during thIS perIod. 19 11.55 00.07.02 Groleau 4/1/7/5 Ottawa Crew 7/5 Groleau Are you at base yet? Crew We just pulled in, Sir Groleau 10 - 4, advise the night crew I've got a Code 3 I'll call them in a minute to confirm that they ve got it. Crew 10 - 4 Time at base? 19.12 12 00.07 19 Groleau 19'12 Crew Roger 57 19.12 15 00.07 22 WhIle there was no telephone commumcation between 19 12 15 and 19 15 54, there was, however, radIo communICatIOn. 19.12 54 00 08 01 4162 4/1/6/2, 10 - 7, 0/2 Crew Montgomery Mr Rankm testIfied that he had not used hIS hghts or sirens from the time he made contact wIth DIspatch at 19 08 48 and the time he went off duty He explained hIS not havmg done so as follows It is extremely dangerous to proceed lights and sirens through heavy traffic, bad road conditions, twilight visibility It is extremely dangerous to drive Code 4 lights and sirens in those conditions, but especially when you do not know where you are going. There is some leeway given to us regarding the use of lights and sirens on Code 4 calls, and [his] decision was that it was too dangerous without knowing exactly where [he] was going, to use those systems. Mr Rankm was asked what he decIded to do when he came up to the entrance to 02 Base, on Hunt Club Road. He explamed that "it was the terminal point where [he] could go without more information" He therefore decided to pull in and get more information as to their status. He thought that when DIspatch reahzed that they had arrived at 02 Base, he would provIde further informatIOn on the locatIOn of61 Finch. He observed that one of the garage doors was open and at the same time he notIced another vehIcle at the garage, and he explamed that he had thought VehIcle # 4162 was the only vehicle in the area. Accordmg to Mr Montgomery, at thIS pomt m tIme, there was no traffic behmd VehIcle # 4162, and Mr RankIn pulled off Hunt Club Road and backed mto the 4162 lane way nearer to Hunt Club than to the garage doors, and remamed m reverse WIth hIS foot on the brake WIth Mr Montgomery m the vehIcle, for a bnef penod. The Crew of Vehicle # 4162 asked for location information 2 minutes and 39 seconds ago. The Dispatch Centre has had the Uplands information for at least 5 minutes and 45 seconds. 58 The Dispatch Centre has had the Shearwater information for 26 seconds. Neither has been given to the Crew of Vehicle # 4162. Mr Montgomery testIfied that he would have expected to hear "10 - 4" but heard mstead. 19'12.57 00'08:04 Groleau 4/1/6/2, 10 - 7, 0/2 ? 19-12'59 00'08 06 4162 Affirmative Rankin 19'13-03 00'08 10 Groleau 10 - 4, I gave you a Code 4, 4/1/6/2 at 61 Finch, over Mr Rankm recalled thIS communIcatIOn as an angry VOIce, but acknowledged on heanng the tape that hIS recollectIOn was inaccurate; Mr Montgomery recalled no anger m Mr Groleau's VOIce Mr Rankm explamed that he was startled by thIs communIcatIon as he concluded from It that DIspatch had thought they were proceedmg to 61 Fmch and he had thought that DIspatch understood that he could not proceed without the requested mformatIOn. 19 13'08 00'08 15 4162 Uh? you said stand by..uh.. I mean we'll go if you want... We didn't Crew know we had the call... Montgomery Mr Montgomery agreed m cross-examinatIOn that, at thIS point, he was not saymg they dId not have the call, but that he was not certam whether they had the call or not. He told DIspatch he was wIllmg to go on the call, but was perplexed whether or not DIspatch stIll had them on the call He also testIfied that If he had known where they were gomg, he would have gone on the call to 61 Fmch, lIke he always does, m spIte of the confuSIOn. 59 Mr Rankm testIfied that he felt he was "m lImbo" He dId not know whether they had the call nor dId he know Its locatIOn. He thought It was somewhere m the area, but was stIll uncertain whether or not he was on the nght SIde of the bridge. Mr Rankin was emphatIc that he was WIllIng to go on the call at this pomt. He stated in cross.exammatIon that If he had known where thIS call was, he would have gone on It regardless of the use of the term "stand by" If Mr Montgomery had saId that he found the location and he could not get authonty from DIspatch, he would have told DIspatch and completed the call. If he had known where Fmch was, there would have been no need for the "stand by" at 19'10.23 He explamed that It IS Important for DIspatch to know where ambulance crews are, as It IS polIcy that DIspatch IS constantly aware of theIr whereabouts, and thIS IS also for theIr own safety Mr Rankin stated that if he should stop transmIttmg, he would want Dispatch to know hIs whereabouts for his own protection. 19 13 14 00'08.21 Groleau 10- 4...1 regave it to you afterwards...I said...I just wanted to confirm the address That was at 61 Finch. IfMr Groleau's comment was mtended to mean that "he saId he Just wanted to confirm the address" he dId not say that. "I saId" may, however, mean that Mr Groleau was startmg to say what he had Said and then changed to say "I just wanted to confirm the address" Mr Rankm testIfied that whIle he dId not thmk of the possible mIscommunIcatIOn m Dispatch's use of the phrase "confirm the address", on thinkmg about It later, he realized that Dispatch meant "confirmmg the locatlon" whIch, Mr Rankin stated, was what he asked hIm to do, and that DIspatch was saymg when he gave the pre-alert, that 61 Fmch was the nght address. It was now 2 minutes and 59 seconds since the Crew ofVehicIe # 4162 requested location information. The Dispatch Centre has had the Uplands information for 5 minutes and 54 seconds. The Dispatch Centre has had the Shearwater information for 2 minutes and 38 seconds. The location information has not been given to the Crew of Vehicle # 4162. 60 19'13.21 00'08.28 4162 Right , give the information again... please go ahead. Crew Montgomery The first request for information by the Crew of Vehicle # 4162 was for a "20 on Finch", that is, for location information. It is the only information the Crew of Vehicle # 4162 had requested. This was their second request for information, The information they were seeking was the location of Finch, although Mr. Montgomery's use of "again" may have confused Mr Groleau, since he had not given location information previously There was no questIOn m Mr Rankm' s mmd that at this time Mr Montgomery was ready and WIllIng to do the call. 19'13.24 00'08.31 Groleau 10 - 4, 61 Finch, 5 year old was found with ro..rope around the neck...stand by I'll get you the details... [This is the second time they have been told to stand by, the first was at 19'09:34. If one interprets "I'll get back to you with an update" at 19'09 55 as a "stand by", it is the third time. ] ThIs IS the pomt at whIch, according to Mr Montgomery, he accepted they had been assIgned the call to 61 Fmch, but still did not know where they were gomg. He testIfied that he was "absolutely" prepared to do the call. He dId not take out the map book although It mIght have been eaSIer to read the book smce the vehIcle was not in motion. Mr Montgomery, havmg been told to stand by, expected some delay He testified that as a result he deCIded to see ifthe NIght Crew was wIllmg to take the call and Said to Mr Rankin. "I'll go and see If the Night Crew IS m" Mr Rankin stated that at 19 13.24, Mr Montgomery slIpped the mIcrophone on the hook and left the ambulance, leavmg the door open. He dId not recall Mr Montgomery gIvmg a reason for hIS departure At that pomt, Mr Rankm explamed the vehIcle was stIll In reverse, from hIS havmg backed m, and hIS foot was on the brake. 61 In cross-exammation, Mr Montgomery explained that as they were at the 02 Base, he assumed the Night Crew was m at 1900 hours, and he was going to see If they wanted to do thIS call. He pomted out that as he and Mr Rankm still dId not have the location of 61 FInch there was gOIng to be a delay Mr Montgomery was asked at the hearing if he wanted to try and make a crew change, and he replied "absolutely" He was gone from the vehIcle for approximately 1 mmute Mr Montgomery explamed that he believed that gIven the circumstances, thIS actIOn dId not contravene the policy whIch contemplates "dnving back to Base and doing a crew change", and that, he saId "IS a major dIfference" His asking the Night Crew If they were prepared to do the call, always left the possibilIty that Mr Montgomery and Mr Rankm would do it. Mr Montgomery explamed that though he wanted to go off duty, if the Night Crew was not wdlmg to undertake the assigned call, then he "IS married to that call" Mr Montgomery, did not, accordmg to him, have the complete mformation. He got out of the vehIcle and left the attendant's door open, and walked quickly to the maIn door of 02 Base bUlldmg. He entered the vestibule through the main door, and proceeded to the crew quarters through the vestibule door He observed Mr Comgan, Mr Handzel, Ms. Mills and Mr Anderson. He was not aware who was assigned to the Night Crew of VehIcle # 4162, although smce he had already heard Mr Comgan on the air and had not heard Ms. Mills, he assumed that It was Ms. Mills. Accordmg to hIS testImony he recalled lookmg at Ms. Mills, and saying, "DIspatch is gIvmg us a call and Blake IS in the vehIcle, do you want to go and do It or do you want us to go?" Mr Montgomery stated that Ms. Mills, who was seated, got up right away and said they would go At that pomt, Mr Comgan saId, accordmg to Mr Montgomery, "I heard DIspatch gIve you that call" and Mr Montgomery stated that he replIed "No, DIspatch made us aware of the call, but told us to stand by tWIce" At that point, Mr Montgomery testified that as Ms. Mills started to walk towards hIm and Mr Anderson, and he turned and proceeded to the garage through the dIrect access door Ms Mills recalled Mr Montgomery entermg the crew quarters at 02 Base, and statIng that there was a Code 4, a possible hangIng, call not yet confirmed. (Ms. MIlls understood thIS to mean the 62 "call was pendmg") Ms. Mills dId not recall Mr Montgomery askmg her or her partner, Mr Anderson if they would undertake the call She explamed in her testImony that there was a discussion amongst Chris Anderson, Kevm Corngan, George Handzel and herself and it was determmed that the other vehicle (Vehicle # 4158) would do the call Ms. Mills was not able to recall whether or not the name of the street had been mentIOned. She testIfied that she went to the garage wIth Mr Montgomery, Mr Corngan and Mr Handzel to open the door for Vehicle # 4158 and when Mr Montgomery Said that the Crew of VehIcle # 4162 should do the call, she returned to the crew quarters to retrIeve her kIt WhICh was not yet m the vehIcle. She recalled gettmg mto VehICle # 4162 at approximately the same time as Mr Anderson. Mr Anderson recalled that Mr Montgomery came into the crew quarters shortly after 1900 hours. He was m the crew quarters, along with his partner Ms. Mills and Kevm Corngan and George Handzel, the day-evenmg crew After Mr Montgomery announced the call, he testified, he prepared his eqmpment, and went out through the garage to proceed to the car to do the call. He recalled Ms. Mills partIcipatmg m a dIScussIon following Mr Montgomery's announcement, although he was not aware of the subject. He was also aware of a dISCUSSIOn in the garage. He was not a partiCIpant m dIScussion. Mr Corrigan testified that Mr Montgomery came into the crew area and said there was a "Code 4 waIting, a five-year old, possible hangmg on Finch" (Mr Montgomery does not beheve that he used the words "Code 4") Accordmg to Mr Corrigan, he asked why he was not acceptmg the call and stated that Mr Montgomery said he was not gIven the call. As a result of thIs Mr Comgan and hIS partner (George Handzel) deCIded that they would undertake It. They came to thIS deCISIOn because they were "fresh and ready to go, and the Night Crew [VehIcle # 4162] had not checked theIr vehicle and theIrs, (Vehicle # 4158] was fully stocked and ready" When Mr Montgomery had not returned WIthin 5 to 10 seconds, Mr Rankm put the vehIcle mto park got out, and walked around and closed the door and looked around to see Ifhe could spot Mr Montgomery He dId not see hIm and thought that "he mIght have slIpped m to go to the 63 washroom qUickly" or "to talk to DIspatch by landhne" Mr Rankm acknowledged that Mr Montgomery's unusual absence and hIS havmg not Said where or why he was gomg, created a feeling of frustratIOn for hIm. He did not recall Mr Montgomery having explamed that he was gomg to see If the Night Crew wanted to take the call. He could not do the call on hIS own were he to receIve the mformatIOn he was awaiting. Mr Rankm then got back into the drIver's seat leavmg the door open and the engme running. He testIfied that he was functIOnmg rather slowly and heSItantly at the end of the ShIft whIch had been made more fatIgumg by bad weather and the resultmg dnvmg condItIOns. At thIS pomt, he deCIded to try to look up Fmch m the Pathfinder Map Book. He described the lightmg m the cab as "kmd of a twihght" He went to the index. To the F's on page 10 and found the referral to page 73 co-ordinates R-27 He dId not get to the map, before Ms. Mills arrIved. There was no radIO transmission during thIS time. Mr Montgomery testified that when he was leavmg the crew quarters, m the 02 Base buildmg, Ms. Mills was dIrectly behind him, and was carrying her personal kit. There was a vehicle, he recalled, m the space on the far side from the entry mto the crew quarters. He remembered being approxImately 4 feet from it at one point, and near the front, close to the electrIcal SWItch on the centre post between the bar doors. There are two SWItches, one for each door Mr Montgomery recalled that he actIvated the empty bay door and Vehicle # 4162 was about five feet from the open door Mr Montgomery testified that Ms. Mills came out directly behmd him, walking at a fast pace, and that she passed hIm and went nght to the door He stated that to the best of hIS recollectIOn, he turned around and George Handzel came mto the garage, Kevin Corngan follOWIng hIm, and saId that they were gomg to do the call According to Mr Montgomery, thIS was the first tIme that he was aware that Mr Corrigan and Mr Handzel were going to go on the call. Ms. Mills, then saId, "you guys are ?" and Mr Corngan saId "yes" Mr Rankm, was stIll m VehIcle # 4162 waItIng for the mformatIOn to come from DIspatch. Mr Montgomery recalled that at that pOInt, Ms. Mills was on his left and Mr Corngan on hIS rIght and Just as Mr Corngan was about to get into the attendant door of VehIcle # 4158, Mr Montgomery saId "DIspatch IS gIving us the call and Blake IS m the vehIcle" and he pointed to Vehicle # 4162 WhICh was outside. 64 At that pomt m tlme, Mr Rankin was consulting the map book. He heard somethmg behmd hIm and when he looked back and around the door he saw StephanIe Mills, and ChrIS Anderson and John Montgomery on the other SIde. Accordmg to Mr Rankm they were about ten feet behind the ambulance and Ms. Mills was walkmg bnskly and carrying her gear He recalled at least one of the garage doors bemg open. Mr Montgomery recounted that he and Ms. Mills went outside to VehIcle # 4162, she to the driver's door, and he to the attendant's. Mr Anderson was already m the attendant's seat and he testified that he observed Ms. Mills and Mr Rankm standmg by the dnver's door When Ms. Mills approached the driver's door, Mr Rankm saId he thought that she was there to relIeve him but, not wantmg to take anythmg for granted, he asked her if she was there to relIeve hIm and she replIed that she was. At the tIme, he assumed that her relieving hIm was "offiCial" and had no reason to beheve that It was not. He also stated that if he had been relieved by the mcommg crew, he would not consider it necessary to mform the DIspatch of that, as the mcoming crew would log on. Mr Rankm testified that he got out of the seat, stIll in posseSSIOn of the map book, "grabbed some of his gear" and slIpped out of the vehIcle. Ms. Mills, then got m and placed her gear between the seats. Mr Rankm testIfied that he handed her the map book and told her the co-ordmates from the mdex; Ms. Mills rephed she thought she knew the location, but that she would confirm It and turned bnefly to the map Mr Montgomery recalled that when he returned to the vehIcle, Ms. Mills went to the left to the dnver's door and he went to the attendant's door; Mr Anderson was already in the Attendant's seat. Mr Rankm testIfied he was able to observe Mr Anderson gettmg mto the attendant's seat and Mr Montgomery pickmg up the radIO at the same tlme that Ms. Mills was consultmg the map book. Mr Montgomery asked Mr Rankin If Dispatch had got back to them yet. He replIed that he had not. It has been 1 minute and 11 seconds since Mr Groleau most recently told Mr Montgomery and Mr Rankin to "stand by" and he has not yet got back to them. Mr Montgomery then took the mItlative and called the DIspatch Centre and Said. "Ottawa, we're waiting for the information update..." (see transmISSIon at 19 14 35) ThIS could have caused 65 some confusIOn for Mr Groleau, as It could be the latest mformatlOn on the status of the call or the patIent, as distmct from location mformation. At this point m time, he stated, he stIll dId not know where Fmch was. Ms. Mills, according to Mr Rankm, found Fmch qUIckly because it was only a very short tIme untll she dropped the map book between the seats and placed her hands on the steenng wheel. 19'14.35 00'09 42 4162 **** Ottawa, we're waiting for the information update. Crew Montgomery This is the third time that Vehicle # 4162 is asking for the information. They have not yet had an answer to their original request for location information, that is a "20 on Finch", made at 19'10:15. It is 4 minutes and 20 seconds since they made their original location request. 19 14.37 00'09'44 Groleau 10 - 4, just ahead to 61 Finch. Mr Groleau has, within 2 seconds, provided the address once again, but has not provided any location information. 19'15 16 00'10:23 Groleau and, uh, 4/1/6/2... it's a patient... was found with a rope around her neck...possible back injury... 10 - 200 have been notified call # 4/7/5/3/8/6 4/7/5/3/8/6. 39 seconds later, Mr Groleau has provided once again the rope information, adding the "possible back injury" information, the police information and the call number He has still not provided the location information. Mr Montgomery testIfied that Mr Anderson dId not have a pen and so, he, Mr Montgomery, grabbed the kleenex box and wrote out the call mformatIOn for hIm on it and gave It to hIm. At the tIme he was standmg on the ground, WIth the attendant's door open. He did not recall Mr 66 Rankm wntmg It down. (Those notes were not available m eVIdence) He testIfied that he dId not have any conversatIOn at that pomt in time wIth Ms. Mills. Ms. Mills recalled that they (she and ChrIS Anderson) were handed some mformatIOn on a scrap of paper when she was gettmg mto the vehIcle; she testIfied that she dId not hear any transmISSIOns from DIspatch. Mr Montgomery testlfied that he backed away from the vehicle, closed the attendant door and walked a dIstance of about twenty feet to hIS own vehIcle and left. He stated that he dId not return to the bUlldmg, and explamed that he goes to work and home m his uniform. Mr RankIn testlfied that they parted almost immediately and he went mSIde Mr Montgomery began to get hIS kIt and hIS books out of the vehicle, and accordmg to him, Ms. Mills had gotten mto the drIver's seat. It was Mr Montgomery's testimony that if the Night Crew had mdIcated an unwillIngness to take the call that he would have returned to the attendant's seat and done the call with Mr Rankm who was then still in the driver's seat. At this point Vehicle # 4162 has made 3 requests for location information, the "20 on Finch" The first was made 5 minutes and 1 second ago. The Dispatch Centre has had the Uplands location information for 7 minutes and 56 seconds. The Dispatch Centre had had the Shearwater information for 4 minutes and 40 seconds. The Dispatch Centre has given neither to the Crew of Vehicle # 4162. Mr Groleau rejected the suggestIOn that when 1 minutes and 54 seconds passes without his contactmg them, that he had forgotten to get back to the Crew of VehIcle # 4162 with a 10-20 on Fmch. He testIfied he was dealIng with a Code 3, while theIr Code 4 IS waitmg. He agreed that he dId not gIve the informatIOn, but explamed that at the same time he "did not fail to gIve It and (he] was preoccupIed WIth other emergenCIes and catch-up dutIes" "Failing" to hIm meant that he dId not do a proper job and he testIfied that he dIsagreed with that. He was asked If it was hIS eVIdence that he conSIdered balanced coverage more Important that a locatIOn on a Code 4 , and he WIth some reluctance, replIed m the affirmatIve Mr Groleau testIfied that he was not aware of any complamt concernmg the patIent or from the patIent's famIly respectmg thIS call. 67 19'15.30 00 10:37 This was the approximate departure time of Ms. Mills and Mr Anderson in Vehicle # 4162 Ms. Mills wrote m her second InCIdent Report dated December 22, 1994, that When Chris and I climbed into the cab of the ambulance, John Montgomery told us that finch was accessed of[sic] of McCarthy across from the fire station. [She] had been on finch before and was familiar with the area, but these directions did not seem right. Before departing the base, [she] checked the Pathfinder map book to confIrm finch was off Uplands Drive. En route [she] had Chris recheck the Pathfinder mapbook to see how far finch was from Cahill and what was the name of the Street (Stearwater) [sic] from Uplands to access finch. In her thIrd InCIdent Report dated January 13, 1995, she wrote m response to the questIOn "Who gave the mformatIOn about the call ?" Primary information, ie 5 yr old possible hanging, was given when Mr J Montgomery came into the crew quarters. The update information was given to Chris and I as we climbed into the cab of the ambulance. This update was given to us by the day crew In response to the questIOn "Was any information given to us by dispatch before leaving statIOn?", she responded No information was given to us by dispatch. She testIfied that at the tIme she wrote her InCIdent Report that it was John Montgomery who gave those dIrectIOns and that she belIeved that the informatIOn was correct. She stated that she dId remember that the directIOns she was gIven did not seem right and for that reason she had her partner check It on the way to the call. She also testified that she recalled receIvmg a "verbal update" from Blake Rankm when she was starting to get mto the seat of the car Accordmg to Mr Montgomery he dId not offer any suggestions as to the locatIOn of "Fmch" as he dId not know where It was Ms. Mills also testIfied that she had worked m the area for qUIte a time and "the area dId not seem rIght: and so "she took a mmute to look It up m the map book" Ms. MIlls stated that five seconds after she got into Vehicle # 4162, she drove off With Mr Anderson III the attendant's seat, lights and SIren activated m accordance WIth the traffic at the tIme 68 19'15'55 00'11'02 Groleau 4/1/5/3 10 - 20 19'17 10 00 12 17 Crew 4/1/7/5, 10 - 8 Groleau 4/1/7/5, 10 - 4 I'll need one crew number before I can assign you the call. Crew 58655 and 89898 Mr Rankm testlfied that he felt the call "was screwed up but he was finally glad that the call was In progress one way or another" He explamed that it had taken longer than It should have nght from the start; it had been confusmg, and he had had the feeling that DIspatch had some sort of animosity agamst them dunng thIS call. He did not consIder the change of the crews unusual, as It was a sItuation whIch had occurred to him a number of tImes In the past, both as the person relIeVIng and as the person relIeved. He was confident that If Ms. Mills had consIdered there was anythIng untoward, that she would not have had any problem conveymg this to hIm as they had worked together as partners in the past. When Mr Rankm went inSIde he dId not recall telephoning Dispatch explaming that there is no reqUIrement for hIm to do so NotIfication comes at the beginning when the crew IS to let DIspatch know the number of the vehIcle and their mdividual numbers. On occasion, Dispatch sometImes asks for the times of the ShIft. Mr Rankm did not know whether the Night Crew had mformed DIspatch of theIr commg on but assumed that they had, smce it was past the start of theIr ShIft. One also carrIes out the mechanIcal check of the vehIcle at that tIme, provIdmg one IS not assIgned to a pnonty call nght at the start of the ShIft. It is normal for this check to be carned out m the garage When Mr Rankm entered the crew quarters, Mr Corngan and Mr Handzel were there Mr RankIn testIfied that there was some dIScussion around the call to Fmch. He dId not recall Mr Handzel bemg m the ImmedIate area when he and Mr Corngan dIscussed this subject. He recalled mentIOnIng that DIspatch had told them to stand by, and Mr CorrIgan asked why he 69 hadn't pulled over to the sIde of the road as that IS what he would have done. Mr Rankm, who had been Mr CorrIgan's preceptor, testIfied that he found that strange, smce to hIS knowledge, no Attendant had ever been told to do that, nor had he heard of anyone domg so, he knew that he had never instructed him to do that. Mr Rankin also recalled telling Mr Handzel and Mr Corngan that he dId not know where Fmch was, and asked if they did. He testified that Mr Corngan replIed that he thought it was off Twyford behmd the fire hall, whIch accordmg to Mr Rankm he thought was correct at the tIme, as he had no access to a map, but later dIscovered It to be mcorrect. During this conversation, Mr Rankin testified, he was not aware that Mr Corrigan, a few minutes before, had had a conversation with Dispatch, and Mr Corrigan did not divulge this to him. Accordmg to Mr Rankin, during this five-mmute conversatIOn, Mr CorrIgan also mentIOned that he and Mr Handzel were going to do the call, but that "John had told them not to" Followmg thIS conversatIon, Mr Rankm gathered hIS personal gear except what he had left in VehIcle # 4162, and went home. 19 17.27 00 12.34 Groleau 10 - 4 Start proceeding to Croydon Code 3 I'll get back to you in a sec. 19 17.34 00 12 41 Crew Ottawa 4/1/5/3 Groleau Last car, say again Crew Ottawa 4/1/5/3 Groleau Go ahead 4/1/5/3 Crew 10 - 7 base. 19 1744 00'12 51 Groleau 4/1/5/3, 10 - 4 I've been trying to reach you. I have a Code 4 but disregard now Crew How many times did you call ? Groleau 2 to 3, over Crew Oh. Didn't hear you, We called several times too 19'18.03 00 13 10 Groleau 10 - 4 No problem Crew 5 is 10 - 7 70 Groleau It's 5/5, 10 - 7 Crew 10 - 4 Groleau 10 - 4 Crew 6/3, 10 - 8 19 18 50 00 13 57 Groleau 4/1/6/3, 10 - 4 You're proceeding priority 4, Rideau Street at Wurtenburg and Charlotte. Rideau, Wurtenburg and Charlotte. It's for an MV A [motor vehicle accident] there's possible injuries, possibly one child, call number 475410, 475410 and your time out is 19'19 Crew The only car rolling it ? Groleau 10 - 4 That's the only car right now Groleau 4/1/7/5, Ottawa. Crew Aah. 4/1/7/5 go ahead 19'19:57 00'15:04 Groleau 4/1/7/5 You're goin' to be heading to 360 Croydon, 360 Croydon, apartment 904,904, access the same, Carling, Richmond - female just got back from the hospital a few hours ago, now her hands are all swollen, she was at the hospital for a stroke, call number 475342,475342,192... 19'18 your time out. Crew 10 - 4 Crew 4/1/4/9 main radio check Groleau 4/1/4/9 strength 5 How do you copy? Crew Copy you strength 5 on the main. Standby for the portable. Groleau 10 - 4 Crew 4/1/4/9 portable check 19:20 00 ThIS IS approximately when Mr LaVIctoIre dropped by the Dispatch Centre. He was mformed by Mr Groleau "ofthe SItuation" and m response, told him to prepare an mCIdent report, arrange for a cassette, and secure the master tape and have everythmg on hIS desk by Monday Mr Groleau mterpreted hIS aSSIgnment as "a full mvestIgatIOn whIch reqUIred the tape recordmg of the mCIdent Itself, a fact findmg mISSIon" 71 19:21 07 00'16 14 Groleau Strength 5 19.21 09 00 16 16 4162 Ottawa, 4162,10 - 7 Be advised this is the Night Crew. 10 - 34 ? (This IS spoken by a female VOIce, the VOIce of StephanIe Mills, the first person to really know where Finch A venue was.] VehIc1e # 4162 was en route to 61 Fmch from 02 Base, arrIving approXImately 1 minute after thIS transmIssion. At this point the Crew of Vehicle # 4162 has made 3 requests for location information - a "20 on Finch" The first was made at 19 10 15 - 10 minutes and 54 seconds ago. The last was made at 19 13.21 - 7 minutes and 48 seconds ago. The last standby was given to the Crew of Vehicle # 4162, 7 minutes and 45 seconds ago. At this point, Mr Groleau is not aware that Vehicle # 4162 has a driver who knows the location of Finch. 19.21 13 00'16.20 Groleau 4/1/6/2 so this is not the original crew, I need one number on the Crew so I can log it on properly and 10 - 34, Civic and General 37 19.21.27 00 16.34 4162 4/7/4/3/5/4, my number and we're going to 10 - 21 over this. (10-21 means "I am going to call by landlme telephone at the other end.) Ms. Mills testIfied that she needed to give her partner's number as well, "to confirm that the crew change was done" , and to let DIspatch know she and her partner were mIssmg eqUIpment (galoshes) and needed to return to 02 Base for these Mr Anderson testIfied that he dId have boots on. 72 19.21.33 00'16 40 Groleau 10-4 Exhibit 11 notes this as the end ofthe transcript at 19:21 14. Exhibit 4 continues 19:22.50 00'17 57 1 mmute and 37 seconds later, after he realIzes that there has been a change of crew, Mr Groleau called m the following report to OCRAS and spoke to the Night ShIft SupervIsor, Jim Smith. He testlfied that his concern was that "they bypassed Uplands and went to base to do a crew change" and "the Crew went to base to do a crew change on a Code 4" "It [was] deeper than that but that [was] one of the concerns" He dId not explam what the other concerns were, or what was "deeper" and thIS was not explored In testImony ThIs statement, however, imphed that there was something else that the Day Crew of VehIcle # 4162 had done but that he was only mentIOning "one of the concerns", leaving the listener to thmk that there must be others. The Board cannot gIve any weIght whatsoever to innuendo Mr Groleau found fault with theIr havmg bypassed Uplands when he had not mentioned Uplands to them m hIS communIcatIOns, and when they had indicated to him that they needed a locatIOn for 61 Fmch, and the evidence demonstrates that Mr Groleau understood that they needed a locatIOn. Further Mr Groleau assumed that the Day Crew had gone to base for the purpose of makmg a crew change ThIS was a conclUSIOn that he was not in a pOSItion to draw, haVIng no knowledge of theIr reason for gomg to base. Groleau Callmg OCRAS Headquarters SupervIsor Hello! Groleau Hi, who am I talkmg to ? SupervIsor It's Jimmy Groleau Jimmy, got a problem SmIth What's the problem? Groleau 4162 crew change on a 4 SmIth Say what? Groleau They did a crew change on a 4 73 SmIth Aah, I don't believe it Groleau You better, they went from 2 males to 1 female on board and the Crew advises it's now the Night Crew that's arrived at scene. SmIth OK, well when was the call dIspatched and all that Groleau OK, gimme a sec, there. What happened, OK, IS the Crew was dIspatched, gImme a sec, aah, 8 F-8, they were dIspatched at 19'09 SmIth OK Groleau They were, hm, Revelstoke and Riverside for a call on Uplands [The Crew of VehIcle # 4162 did not have that informatIOn when they were at the mtersection of Uplands, nor were they gIven it at any other tIme.] for a fe 5 year-old female, possible hangmg, hm, rope marks on the neck and neck pams, possible assaulted, I don't know; I told him to stand by so I can verify the address, verify the address [That IS not true. He was trymg to find the location, he had had the address since the call was committed. ] and I gave them the full call [He dId not give them the reference intersectIOn for locatmg Fmch A venue] They asked for the 20 of the call, whereabouts it was and I said it was about Uplands near Airport area. [ Later in hIS testImony Mr Groleau acknowledged that he dId not refer the crew to Uplands, and explained that he "dId not have the luxury of the tape at the tIme" He dId not tell the Crew the call was near the "AIrport area", he saId It was "near Base", of whIch there are two] [Mr Groleau told them "Clearwater, apparently near the Base", and those two locations are mcompatible. ] SmIth Euh, euh. Groleau Then they say 4/1/6/2 10 - 7 Base, I said you're?? 10-7 Base?, 10-4 I says, I gave you a 4. Oh, you told us to stand by and the next thing I know it's the Night Crew that's booking 10-7 at scene. Smith So they made a SWItch after that. [Mr SmIth does not explain after what.] Groleau Euh, euh. SmIth OK, who, who's m the Day Crew, aah? Groleau Aah, Montgomery and Rankm, that's what I've got logged on. SmIth OK, well what I'll do IS, I'll forward the mformatIOn to theIr SupervIsor Groleau OK SmIth Euh, so that they can euh, so he can euh, mvestIgate It and deal WIth It Groleau Yeah, I'm Just lettmg you know as per protocol and It'S gonna be documented and you'll have a package ready SmIth OK Groleau All nght 74 Smith If you can fax all the mformatlOn, I'll, aah, gIve It to aah, Angelo to, ah-ah, to mvestlgate this. Groleau OK SmIth All nght Groleau Thanks, bye now 19:22 53 00'18.00 Arrival of Vehicle # 4162 (Ms. Mills and Mr Anderson) at 61 Finch PolIce who had had prevIous contact WIth the family, arrIved shortly before Vehicle # 4162, accordmg to Ms. Mills. Mr Anderson assessed the patient, and found there was no cord around her neck at that time , that she was conscious and ambulatory He dId not render any treatment at the scene but applIed a paediatric oxygen mask en route to the hospital. 19.24 47 00 19'54 Nothmg IS recorded from 19:2447 untll19 39'06 when another DIspatcher (ChrIS Bourque) comes on and is called by the crew of VehIcle # 4162. 19.39'06 00.34 13 4162 Ottawa 4/1/6/2 DIspatcher 4/1/6/2 - Go 4162 Will be 10 - 8 to CHEO on a PrIonty 3, over DIspatcher 4/1/6/2 10 - 4, you are mobile 19.39 4162 Be adVIsed, we wIll have to return to Base, aah, neIther my partner or I have our galoshes and an msurance wIll be ??? 10 - 4 19.39.30 00 34.37 19 57 45 00 52 52 4162 Ottawa 4/1/6/2 Bourque Sorry, aah, 6/2, you're 10 - 7 at CHEO? 4162 That's affirmatIve 75 Bourque 10 - 4 [It IS not clear If there was no communIcation between 19'39 30 and 19 5745 or Ifthese were excerpts. ] Mr LavIctOIre and Mr Groleau left together at approXImately 2000 hours. Mr Groleau testified that he had found the location, that he was able to locate the call location, that he decided to dispatch Vehicle # 4162 based on locating the call, that he believed Finch was in the "square of Uplands area" However, at 19'10:23, he was instructing the Crew of Vehicle # 4162 that Finch was near Clearwater, and that is the last location instruction he provided for them. There is no evidence that at the time of his departure from CACC Mr Groleau had discovered the precise location of Finch Avenue. The evidence shows that he never did provide the reference intersection to the Crew of Vehicle # 4162. 20 06.20 01'01.27 (ThIS IS on a different channel from the previous communIcatIOns] Bourque Hello, Dispatch 4162 Hello Bourque Hello 4162 Yes, 6/2 here Bourque 6/2 4162 We're gomg to 10 - 19 for you and aah, get some proper footwear and mItts so we can, aah, respond to some calls for you. Bourque Oh, yeah, you're the galosh less crew 4162 Yeah, and aah, we have aah, basically, this IS an mformatIOn lIst call The member of the Crew who was speaking then went on to provIde case-related mformatIOn and mformed the DIspatcher that 4162 Aah, so we'll go back a..and aah get aah set up to aah do the, to do the evemng Bourque OK 20'07.30 01 02.37 ThIS conversatIOn ended. 76 It was still snowing at this time. Mr Montgomery was asked, during his exammatIOn-m-chIef, to reVIew the first two pages ofthe transcnpt of the communICatIOn between Mr Groleau and the Crew of VehIcle # 4162 (ExhibIt 4) to find the words whIch would lead hIm to conclude that they had been gIven the call. He dId so and responded that "nowhere m there, where we were gIven, confirmatIOn, or us acknowledgmg we had the call, nowhere." He was then dIrected by Counsel to the followmg commumcation. 191435 (C) 6/2 Ottawa, we're waItmg for the informatIOn update 19'1437 (D) 10-4, just head to 61 Finch 19'15 16 (D) and uhh. 4/1/6/2. It's a patIent. was found WIth a rope around her neck. possible back Injury neck mjury 10-200 have been notlfied. Call number 4/7/5/3/8/6 4/7 Mr Montgomery concluded that the call had been given when Mr Groleau said "head to sixty',;, one Fmch" and the complete mformation, WIth the exceptIOn of the location, had been provided once the call number was Issued. During thIS commUnIcation, Mr Montgomery was standing outsIde m the 02 Base lane, at the open attendant door of Vehicle # 4162. Mr Montgomery testified that he was tIred at the end of the shIft, that IS at 1900 hours. He explaIned that he gets up at 0500 hours when he works a shift begmnmg at 0700 hours, and on that partIcular day, he awoke rather tired and the snowstorm added to hIS fatigue. That dId not, however, have any beanng on hIS actions that evening. The sItuatlon has occurred m the past that he has been aSSIgned an emergency call at the end of a tIring day, and he has taken the call. He also acknowledged that he, or any Crew he was part of, would respond to a call WIthout a call number havmg been aSSIgned at the outset. Mr Montgomery testlfied that had he not wanted to do the aSSIgnment, It would have been quite easy for hIm tell Mr Groleau that they were not recelVmg hIm clearly and that would have put Mr Groleau in the positIOn of having to declare a Code 9 They could also have simply ignored the radIO He also testIfied that he did not believe that there should be a delay m responding to an emergency call, nor should there be a crew change on a pre-alert If the change would result m a delay He stated that a deCISIOn as to 77 whether a crew change whIch would result in a delay should take place, would be at the dIscretIOn of the DIspatcher Mr Montgomery acknowledged that he had not requested the permISSIon of the DIspatcher to make a crew change and hIS explanation was that it was not uncommon, to come back to base at the end of the shift, and for Dispatch to say "I'll have a call for you", and for an oncommg shift member to relieve you. Mr Montgomery saId, "If a Crew that is gomg off gets a last-mmute call and one of them asks me to relieve them, I wIll relIeve them fifteen or twenty mmutes before the begmning of the ShIft and go out and do the call for them, and that mcludes Code 4s. We do not, in that case, notify Dispatch." Mr Montgomery was asked If thIS was a permItted practice and he replied that "it goes on every day", partIcularly at base It frequently happens that crews relIeve each other, he saId, and It IS more usual that two people replace two, rather than one person replaces one; this IS partIcularly true when one crew has Just receIved a call that would place It mto overtIme. It IS the practIce to do so expedItIously Mr Montgomery stated that he was not aware of any written or unwritten policy of hIS Employer that dealt With the CIrcumstance of a crew change on a Code 4 call. Mr Montgomery was asked what his understanding was of hIS responsibilIty to notIfy the DIspatcher of absence from the vehIcle. He stated that the Crew IS m constant communicatIOn WIth CACC, the DIspatch Centre, by a portable 2-way radio He explamed that ifhe were to book off SIck, he would mform the DIspatcher that he was "Code 9", and ask that the DIspatcher to notify hIS SupervIsor (OCRAS) that the vehIcle was returning to base. The DIspatcher would ask for the numbers of the mdIvIdual crew members and would report to the OCRAS SupervIsor WhIch number IS bookmg off. Once returned to the base, the crew member who IS bookmg off would call or Walt for a call from his/her Immediate SupervIsor, and mform hun/her of the reason. If a crew member were going on a meal break, m the SItuatIOn m whIch It was past meal tIme and he was at the hospItal, he would pIck up something Just to get hImself through. He would usually notIfy DIspatch of a 10 - 42, that IS, "gomg for coffee", he testIfied, although if It were not gomg to take any length of tIme, he would do It WIthout notIfymg the DIspatcher If you 78 need fuel, It is the practlce to notify the Dispatch Centre of that need. If you are Just cleanng the hospItal, you would get fuel wIthout informing the DIspatch Centre. It also occurs that If the Dispatcher is consIdenng your vehIcle for a Code 3 or Code 4 that s/he would ask If you have suffiCIent fuel. If you are a member of the rehef Crew and you are at base and the shift tlme has started and your vehIcle has not yet returned, Mr Montgomery explamed he would, m that sItuatlon, not call CACC, but would waIt for the vehIcle to come into base. The DIspatcher would know that the vehicle has returned to base when the retIring Crew gives 10 - 7 (returned to base) to the DIspatch Centre. It IS not the practIce for the retiring Crew to call CACC and mform them that they have been relIeved. He stated that the DIspatcher would probably assume that the incommg Crew IS cleanmg up the vehicle. The incommg Crew will call the Dispatch Centre if they need information Mr Montgomery cIted three examples all of whIch could apply to a single crew member or to both partners in a Crew' 1 He reports for 0700 duty at 0640 hours and at 0645 hours there is a Code 4/3 That means that the Night Crew has to go out on the call. One of those indIVIduals might ask him to relieve him and when he does so, that mdIvIdual would get to go home early and he, Mr Montgomery, would assume the pOSItIon of the departmg member of the Crew and would go out and do the call. He would not notify Dispatch. 2. He reports early for duty and the garage doors are opening and a crew IS gomg out on a call at the end of theIr shift, usually a Code 3/4 one of the employees wIll asked to be reheved and that would mvolve SImply removing hIs/her personal kIt from the vehIcle and letting the new crew member come m WIth hIS kIt and go He would not notify Dispatch. 3 There IS an mdIvldual who wants to get off early, the next day ShIft he/she WIll make arrangements WIth the mcommg Crew, be It day or mght. If the indIVIdual IS workmg the day ShIft and wants to get off early by 20 /30 mmutes, he/she would make arrangements for the mcomIng mght shift to come m early to relIeve hIm/her and If that person comes in early, he/she will do the crew change. If the Crew IS not at base, the replacement person would pIck up the phone and tell 79 DIspatch the crew replacement IS in. It has also happened on occaSIOn that the current Crew wIll call DIspatch as they are returnmg to Base or are on standby and ask Dispatch to phone the Base to see if the replacement IS m. Mr Montgomery testIfied that had he and Mr Rankin been, say at Heron and Bank Streets, they would not even have asked about a crew change In that situatIon, you have a call and you are stuck with It. Had they proceeded out the parkmg lot of the 02 Base onto Hunt Club Road, they would not even have known In whIch dIrectIOn to turn. Mr Montgomery was asked If there were any CIrcumstances under whIch a crew change would take place away from the base. He explamed that m the SItuatIOn where a crew member has been at the hospItal for medical care, and needs to be replaced, the SupervIsor wIll mform the relIef crew member, to report to a partIcular station where he, the SupervIsor, will pick hIm up and transport hIm to the hospItal, or court, or on a call, and then that relief person would contmue the ShIft WIth the remammg member of the crew Ms. Mills testIfied that it can happen that when you return to base following your last call you do a qUick crew change WIth the mcoming crew She explamed that "these kmds of thmgs happen, they are not remarkable" Mr Montgomery agreed that a "14-mmute response time" to a Code 4 call was not acceptable, but noted that vanables sometimes dictate delays. He testIfied that he belIeved there was delay In the handlmg of the call and cIted the followmg' . there would, m his opmion, have been a shorter response tIme had VehIcle # 4158 been asSIgned. (He based that on the testImony of Mr Groleau and Mr COrrIgan) . the lack of mformatIOn . the use ofthe mcorrect reference pOInt (Clearwater) 80 He was asked what he belIeved that he and Mr Rankm had done to try and ensure an expedItious response to the 61 Fmch Street, Code 4 call. Mr Montgomery replied . hIS attempt to locate 61 Fmch m the gUidebook . Mr Rankin's attempt to ask DIspatch for a 10 - 20 He also stated that If he had known where he was gomg, there was no questIOn that he would have responded to the call. Mr Montgomery acknowledged that to refuse or neglect to serve citizens requiring services which are part of the normal performance of his /her duties IS a senous breach of the Code of Conduct He stated emphatIcally that he had never durmg all hIS years of service, refused to respond to a call. He explained his attItude as follows. I am hired by the Ministry, they rent my services and productivity; I am there to do ajob, to serve the public in a pre-hospital setting I am the front line response to hospital. Mr Rankm explamed that he had never been made aware of any polIcy or procedure respecting a crew change on a Code 4, and that such changes, whIle not happemng every day, dId occur dunng or after ShIft changes. In hIS experience, if one was mobIle to a Code 4 and the route was not by the Base, one would proceed dIrectly to the call. While it has occurred that crews have asked permISSIOn of Dispatch and been granted the time for the crew change, the rules on that have been tIghtened, Mr Rankm explained. Mr Rankm testIfied that he conSIdered the response time of "a lIttle over 11 mmutes" to be unacceptable. He estImated that 5/6 would have been a more acceptable time, but one would have to take mto account weather and traffic condItIOns. Mr Rankin was asked if the fact hIS shift had ended when he was assIgned the call affected his wIllmgness to proceed, and he responded, "I would never have done that" He was also asked if he had refused or neglected to serve the patIent m questIOn and he responded that he had not, nor would he ever refuse to do so 81 POSTD~CEMBER~.~1994 Mr Montgomery was not scheduled to return to work the followmg day, December 10, 1994 Mr RankIn was, however, and on arrIval he telephoned the on-duty SupervIsor, Jim SmIth, on the landlIne and made arrangements to pick up the items of hIS gear whIch he had left m the VehIcle # 4162 the mght before. He heard during that conversation that the complaint from Dispatch was that the Night Crew took the call. He then entered the prevIOUS day's actIvItIes m hIS notebook. At the tlme he did so, he testIfied, he had not spoken with Mr Montgomery SInce they went theIr separate ways the preVIOUS evemng, and he had no access to the master tape or a transcnpt of It. He spoke again WIth the on-duty SupervIsor, Jim Smith to get some tImes. Dunng thIS second conversatIOn or the earlIer one, Mr Smith asked Mr Rankin for an Incident Report and informed him that the complaint had to do with a shift change without notification. Accordmg to Mr Rankm, Mr SmIth dId not mentIOn anythmg about "a crew change on a Code 4", nor dId he mdlcate that there would be an investIgation, or that there mIght be a possible disciplInary outcome for Mr Rankm. Mr RankIn prepared the Incident Report that same day and It was his recollectIOn that he handed It to Mr Milo at 02 Base. It appears that he dId that on December 14, 1994 He dId not take a copy and dId not see It agam until the "Hunter investIgation" whIch was held m February 1995, although a note in the reVIew section of the report whIch appears to have been written by Mr Milo says, "copy sent to B Rankm 94-12-15" On December 14, 1995, Mr Rankm, along WIth Mr Montgomery, requested of and was gIven by Mr Milo, a memorandum settmg out the substance of the complamt that hIS InCIdent Report already filed was about. As per your request as follows: That you failed to complete an assignment of a priority four Without benefit of the tape or a transcnpt, Mr Rankm wrote the follOWIng - Proceeding to base, location Riverside southbound between Walkley & Revelstoke when Dispatch asked 10 - 20 - I replied Riverside & Revelstoke -Dispatch started to give us a priority call, but never completed it as per "ARIS" P&P standards, However, 82 1 immediately asked for a "10 - 20" as 1 had no idea of location of 61 finch -Dispatch replied with a curt "standby" & then (asked [lined out]) forthwith asked another car their location still mobile on a major artery, 1 complied with their order to await further instruction by continuing southbound Reason Unknown - Once again, Dispatch asked our 10 - 20 - My partner replied (I believe) Uplands @ Bowesville Still with no further inst[r]uction from Dispatch - 10 - 7'd @ base. Therefore @ this time, 4162 was backed up to garage door & my partner was going out door - Dispatch then came screaming on the air that he had sent us on a code "4" I stated his last (instruction [lined out]) direction was "standby" - When he stated to proceed on the call, I by myself, & didn't know ifmy partner had heard (I don't think he did - This occurred after 1900 hours (10 - 7 @ 02 Base) - 1 asked him to repeat information & copied it down John (12497) & the Night Crew came to the unit (4162). - Since call was finally confirmed when asked, Night Crew said they would do call - They left post haste Note* ARtS P & P, Item # 4 all call numbers will be assigned at the onset of each call, regardless of call priority Item # 6 all crews are to ensure that their radio communications are clear & concise at all times to minimize radio time (If this also applied to Dispatch, it would eliminate this confusion) I submit this report under compulsion as a non-voluntary statement to a person in authority as required of me in the discharge of my duties as an Ambulance Officer, and further, request this report be treated as a statement by me to resolve informally the complaint of Ottawa C.A.C C. This is also submitted as a complaint against Ottawa C.A.C.C. SIgned. K.B Rankin, and dated December 10, 1994 ReVIewed by A. Milo December 14, 1994 Mr Rankm explamed that hIS complaint agamst Ottawa CACC was that the number had not been gIVen at the outset and that the commumcatIon from DIspatch was not clear and conCIse, and was confusing m the extreme. He never receIved a response to hIS complamt, he testIfied. Mr MIlo testIfied that he dId nothmg WIth the complaint. Mr Rankm explaIned that "(they] had been told preVIOusly that the RegIOnal Office would no longer entertaIn complaInts agamst DIspatch" 83 CACClnv~stigation Mr Groleau testified that he was asked to complete an investigation by Mr Lavictoire because "there appeared to be an undue delay in responding to this call" In the week immediately followmg his complaint to Mr SmIth and Mr LavIctOIre on December 9, 1994, he carned out the mItIal mvestIgatIOn of the complaint that he hImself had made. Mr Groleau listened to the tape and the call details, and prepared a wntten summary; on December 14, 1994, he prepared a transcnpt of the communications between the Crews of VehIcle # 4162 and himself, between 19'08.30 and 19:21.33 hours. Mr Groleau charactenzed the mcident as a "Delay in response to priority call" He set out the detaIls of the problem at the scene, and then began hIS transcript excerpt at 19.08 30, 3 minutes and 37 seconds mto the call. In the summary, he excluded call-taker/caller portIOns WhICh Illustrate the dIfficulty the Call Taker was having in obtaining accurate geographIcal mformatIOn, the call-taker/polIce portIOn and the tIme at whIch he, as Dispatcher, receIved the call (19'07.20) and was having the most difficulty locating the scene As well, he faIled to include hIS conversatIOn with Kevm Corrigan. He did not report his conversation with Mr Jim Smith of OCRAS, but mstead summarIzed It as "OCRAS SUPERVISOR NOTIFIED" He noted the tImes VehIcle # 4162 was en route to the Children's HospItal, and its arrIval tIme there. At the end of hIS report, he made a number offindmgs. (These are not mcluded here for the truth of the substance and the Board has not drawn any conclusions respectmg the ments based on these findIngs) FINDINGS . VehICle 4162 (167-0210) was the most appropnate car to respond. . VehIcle 4162 (167-02) was aSSIgned to the call, there was never any mentIOn of call cancelatIOn (sic], or vehicle cancelled off call. . VehIcle 4162 (167-02) acknowledged call by requestmg locatIOn of FInch. General area was given tWIce, exact locatIOn not relayed. [ThIS IS only true If Mr Groleau conSIdered that east of Bank Street and Clearwater were m the general area.] . VehIcle was adVIsed to stand-by; 15 seconds later, 4162 (167-02) was gIven the call detaIls. [The call details dId not mclude a locatIOn reference.] 84 . VehIcle 4162 was told to stand by a second tIme, however, VehIcle # 4162 (167- 02) was advIsed" stand by, I'll gIve you a twenty m a second. " . Crew 4162 (167-02) never mquired about status of their call. . Address of call transmitted five tImes to crew [The Crew was requestmg locatIOn mformatIOn, they had the address from the outset.] . One mmute and eleven seconds after 4162 was re-Issued the code four from base, the day crew requested an update. The crew that arrIved at scene was the mght crew IndIcates the crew was stIll at base after the call was reassIgned. . Snow storm m progress. Call volume exceSSIve during the tIme span. (18 prionty calls durmg the 1 hour span of the call) [This refers to the tIme span on the Call Summary beginning at 1815 and endmg followmg the call whIch begms at 1914 The hour shows 24 unItS on the Ottawa, RegIonal and ProvmcIal Boards. Of these 10 were cancellations or pre-emptions, of the remaining 14 1 was a standby 4 were Code 3 s, 1 retamed Code 3 3 were downgraded to Code 1 9 were Code 4s 1 retained Code 4 5 were downgraded to Code 3 1 was downgraded to Code 1] . Vehicle 4162 was on overtime and mobile in close proximIty of the scene when aSSIgned code four [Mr Groleau dId not know the location of the scene when he aSSIgned VehIcle # 4162 to the call. ] . 14 mmutes elapsed from call receipt to arrive at scene. [It IS not clear whether he means receIpt by the Call Taker, the Dispatcher or the Crew] ThIS report With its findmg was made by an indIvidual WIth a conSIderable mterest in the SItuatIOn and its outcome, an mdividual who was a major player in the mCIdent. The report contams some truths, some omIssions, some dIstortIOns and some maccuracies. It is Important to remember that these were the first findmgs made and they were commItted to paper and became avaIlable to a number of people dunng and after the mvestigatIOn, although there IS no eVIdence they were made aVailable to Mr Montgomery and Mr Rankm. ThIS IS the mformatIOn that went to Mr Groleau's supervIsor, over to OCRAS and part-way up the lIne there Although Mr Groleau's report was not mcluded m Mr Milo's, as a report, there was no eVIdence that any part of It had been rejected by Mr Milo and the detaIls thereIn must have been mfluentIal m formIng the baSIS of the perceptIOn of future readers. Smce Mr Milo's report was not submItted m eVIdence, the Board cannot comment on the preCIse nature of that mfluence. 85 Mr Groleau submItted thIS report along WIth a cassette (presumably of the excerpts m hIS report) and the master tape to Mr LavIctoire Mr Lavictoire testified that he received the three Items, read the report and lIstened to the cassette. He did not listen to anything on the master tape. He also testified that the investigation did not show any explanation for the delay Mr Lavictoire explained that he selected Mr Groleau to carry out the investigation because he was the Acting Superintendent on the shift and the incident occurred while he was there. The fact that he was the Dispatcher involved in the incident was to him irrelevant in his selection of Mr Groleau to carry out the investigation. Mr Lavictoire viewed the duties assigned to Mr Groleau respecting the investigation as gathering documents and tapes, and making some findings to assist OCRAS in its investigation. Mr LaVIctOIre explamed that he receIved the report, a cassette with the excerpt prepared m transcript form by Mr Groleau), and the master tape. After revIewing the cassette and the report, without the aid of a map, he submitted them with a covering memorandum to OCRAS directed to Mr Milo, for mvestigation and follow-up In it, he characterized the situation as "Ambulance officers completing a crew change at base, without C.A.C.C. notification or approval, after being issued a code 4" Once he had done thIS, the matter, accordmg to him was out of hIS hands. Mr Lavictoire explained that he submitted It to OCRAS "because the incident related to a Crew not responding to a Code 4, and doing a crew change before responding to a Code 4" Even though the call was completed, Mr LaVIctOIre explamed that he was concerned "Because the call was given to that Crew to handle and they did not do It, the Night Crew dId and that Crew was directed and had enough information and was advised to do the call" He also stated that "they have a map and they have worked this area for quite a few years and should know the area" Mr LaVIctoire later stated that "the problem is the Crew did not go on the Code 4...the Crew did not go on the priority and finally they went to base and the other Crew did the call" His initial concern was "why they went to base and did not proceed on the call" Mr LaVIctOIre testified that he had no concerns with the conduct or the communications of 86 Mr Groleau, explaining that "he did his best, he gave the call to the Crew, he had a snow storm and a lot of priority calls" He also testified that he had no problem with the call taking, although he testified that he had not realized that it took 2 minutes to get to the pre-alert. He acknowledged that at the time he reviewed the report, Mr Groleau did not mention that there had been a mix up between Clearwater and Shearwater Mr Lavictoire stated that he knew that "Finch" was in the Hunt Club area, but that he did not know the location of "Clearwater" When it was put to him whether or not he knew whether "Finch was near Clearwater or Shearwater", he replied that this was not his concern. His concern was "that they did not respond to the call" Mr Lavictoire was also asked if he was not concerned that the Dispatcher was sending them to the wrong address, He replied that "they had the address, the wrong cross street, maybe" What you would not do, if given an incompatible address and reference point, is go back to base. Mr Lavictoire did acknowledge that if one of the Dispatchers were giving inaccurate information, that he would want to know about that and correct it. He was asked in cross- examination if he inquired of Mr Groleau why he did not get back to the Crew of Vehicle # 4162, and he replied that he did so, and was told that he was trying to find the location and was dispatching priority calls at the same time. Mr Groleau testified that he was not the subject of any discipline with respect to Call # 000475386. Mr LaVIctoire testIfied that once he had dispatched the mformatIOn to OCRAS, he receIved requests for nothmg further although he indIcated that OCRAS could have made such a request to the Supervisors. The mveStIgatIOn was not, he explained, hIS, and the consequences were not to hIS staff. OCRAS InYeStigation Mr Milo testified that on Sunday, December 11, 1994 he returned to duty and when mformed of the complaint by Mr SmIth, assumed responsibIlity for investIgatmg it at the mItial stage. He spoke to Mr Massender and then to Mr Forsyth. Mr Massender adVIsed him to proVIde hIm 87 wIth the mformatIOn and begm a prelImmary mvestIgation. Mr Forsyth gave hIm the authonty to request and ensure receIpt of the IncIdent Reports and "to pass on the message to the employees that they were suspended pending an InvestIgation and to give that notIfication m wntIng" ThIs contact with Mr Milo respectmg the incident was the extent of Mr Massender's mvolvement smce he was on leave from December 12, 1994 to March 6, 1995 He was adVIsed of the declSlon to termmate on hIS return and at that tIme revIewed the incIdent file. However Mr Massender indicated that, based on the information provided, there was a violation of the Code of Conduct and a failure to provide service to the public, which is a requirement of OCRAS as a service provider The Code of Conduct had been provIded to all staff of the ServIce Mr Massender also testIfied that the practIce of gIving wntten performance evaluatIOns at the OCRAS ceased a number of years prior to the hearing. He stated that he was not aware of any disciplinary record m the file of either Mr Montgomery or Mr Rankm and, although Mr Massender was not willing to grant that there was anythIng above average about the two Gnevors, he dId acknowledge that "they perform in a satIsfactory and careful way" Mr Montgomery and Mr Rankm were next scheduled to work together on Wednesday, December 14, 1994, on the 0900 to 1900 hour ShIft. They both arrIved at work and while they were m the garage domg the check on theIr vehIcle, Mr Rankin told Mr Montgomery that he had been asked to fill out an InCIdent Report respectmg December 9, 1994 At that pomt, Mr Milo arrIved and asked Mr Montgomery if "he had a minute", that he needed an Incident Report respecting what happened at the end of the shift, the preVIOUS Fnday Mr Montgomery asked If there was a problem, and, accordmg to Mr Montgomery, Mr Milo responded that there was and that he needed an Incident Report about the call they did not do (Call # 000475386) Mr Montgomery testIfied that he asked about the call and Mr Milo explamed that It was about a Code 4 on Fmch, and asked what happened. At that tIme Mr Montgomery gave hIm a verbal account of the InCIdent. From Mr Montgomery's perspectIve, it was detailed, from Mr Milo's It was not suffiCIently detaIled. Dunng hIS recounting It was mentIOned, by Mr MIlo, that the complamt arose from CACC and that the DIspatcher had Said that the call had been assIgned to them. Mr Montgomery asked for the nature of the complamt and Mr Milo asked Mr 88 Montgomery to submIt the IncIdent Report once agam. Mr Montgomery submItted an IncIdent Report askmg for a "wrItten complamt" from Mr MIlo, explammg that he found It "dIfficult to respond m wrItmg wIthout all the times etc. of the complamt" ThIS dId not take Mr Montgomery long and he handed it to Mr Milo whIle they were still in the garage at 02 Base. It read December 14, - 94 To whom it may concern Please be advised, that as per a complaint that I'v [sic] just been advised of and to which I have verbally explained to my supervisor as to what transpired on said call - I am requesting the written complaint from my supervisor so I may address the complaint in a more professionall [sic] and concise manner Until - I am informed - by way of reading the complaint, I find it difficult to respond to in writing without all the times etc. Of the complaint. SIgned. John Montgomery Later in the afternoon, Mr Montgomery and Mr Rankin were Just backmg in to 02 Base when Mr Milo arrIved. Mr Rankin had been mJured and was going home on a WCB Mr Milo handed Mr Montgomery a memorandum whIch stated "that [he] failed to complete an aSSIgnment of a priOrIty four" At that pomt, Mr Rankm had parked the vehicle and was out and Mr Montgomery spoke to him and recounted the contents of the memorandum to hIm. Either Mr Rankm or Mr Montgomery asked Mr Milo If he was going to do the mvestigation, and, accordmg to Mr Montgomery, he replIed that he was not gomg to be domg it but was SImply accumulatmg the paperwork. (The importance of the accumulation of paperwork In an mvestIgatIOn should not be underestimated, smce It forms a large part of the foundatIOn of the later findIngs and conclUSIOns.) FollOWIng this discussion, Mr Milo wrote out the suspenSIOn memoranda, and handed them to Mr Montgomery and Mr Rankin. Mr Montgomery asked If they were to leave immedIately and Mr MIlo replIed that they should do so Mr Rankm described hIS reactIOn to being suspended as "shocked" ThIS had not happened to hIm before Mr Rankm testIfied that at thIS pomt he was aware that there was to be an InvestigatIOn. It was Mr RankIn'S assumptIOn that the mvestlgatIOn would be done by the InvestIgations Umt from Toronto (It IS the Board's opmIOn that thIS was Mr Milo's belIef at the time) 89 Mr Montgomery was asked in a memorandum from Mr Milo, to complete "an Incident report regardmg the above call number (475386) Submltt [sic] the report to headquarters by 94-12-15, your next day ShIft start. Thank you" Mr Montgomery mdIcated that he had spoken to hIS SupervIsor (Jim SmIth). Mr Montgomery testified that he prepared the second Incident Report m part, at home, that afternoon on his return, and the balance the followmg morning. He then submItted It to the office, on December 15, 1994 His InCIdent Report read as follows. Attention. Mr Angelo Milo Shift Supervisor Note; I submit this report under compulsion as a non-voluntary statement to a person in authority, as required of me in the discharge of my duties as an ambulance officer Further, I request that this report be treated as a statement by me to resolve informally the complaint of Ottawa "C.A.C.C." - Central Ambulance Communication Centre. On December 09 - 1994 = Vehicle # 4162 cleared (time ?) from the Riverside Hospital. Crew of # 4162 were 10/19 to base = 02 Hunt Club Rd. Need I say, Ottawa was being subjected to a winter storm "that started about 15'00 hrs. Numerous MV A's = one being a major MV A on Hwy # 16 which caused trafic [sic] congestion right back to Hunt Club bridge and Riverside Dr " TIME ?" C.A.C C = called & asked our location of# 4162 Response = Driver = Blake = Riverside Dr & Revelstoke CACC = Stand by At this time Dispatch = gave out a code 4 to an other ambulance to respond as second car to the MV A on Hwy 16 [with] possible code 5 CACC = then called # 4162, and stated he had a code 4 - then stand-by CACC = then called for the location of2 other ambulances for their 10 - 20 4ln2 was no further south on Riverside Dr when, CA CC = called for # 4162's 10/20 again 4162 = Attendant John = responded Riverside & Uplands 4162 = shortly after booked 10/7 = 02 station. CACC = 4162 = I GAVE YOU A CODE 4 4162 = DRIVER = Blake - No You Did Not, You Told Us To Stand By I - John - had now left the vehicle & went in to the base. Informed Night crew of a code 4 They left, Outside - my partner - Blake still in the vehicle, I heard CACC call 4162 - & responded = go ahead CACC - Now gave crew the code 4 and the call number for 61 finch [with] an information ofa child that had a rope around its neck & complaining of back pain. Night crew left. Note At no time were we given the call or did we refuse to do the call Imtlalled "JM" Reviewed by signed A. Milo 94-12-15 90 Mr Milo then attended a meeting wIth Mr Forsyth and Mr Bnan Thompson at whIch they reviewed the information to date, although not, according to Mr Forsyth's recollection, the audio material. On the basIs of the matenal and theIr dIScussIon, they decIded to suspend Mr Montgomery and Mr Rankm wIth pay, and further, in consultatIon wIth the staff of the LIcensing and InvestigatIOn Branch of the MmIstry of Health (Toronto), they decIded that Mr Milo should carry out the investIgatIOn. In the afternoon, Mr Milo mformed Mr Montgomery and Mr Rankm verbally and m wntIng that they were suspended for their next shift, December 15, 1994 There was a concern on the part ofMr Forsyth, that they not be present the followmg day, and for this reason, they were suspended for the smgle day with formal notIce of longer-term suspenSIOn followmg on December 15, 1994 His reVIew of the Incident Reports of the co-workers, particularly that of StephanIe Mills, he testified, led hIm to beheve that "they were somewhat dIstressed" He also belIeved that Ms. Mills' comment to Dispatch that "We're going to ten twenty one over thIs. " was mdIcatIve of concern. There was no eVIdence, however, that he enqUIred about these assumptIOns. He explained that "usually when they want to call on the phone, they are concerned about somethmg and they want to do It over the telephone." However, m cross- exammatIOn, Mr Forsyth acknowledged that he had no way of knowmg the source of the "concern", whether It was the scene or the base. Mr Forsyth's readIng of the InCIdent Reports could also have been by hIS havmg mterpreted the subject matter box "complaint" whIch was checked off on most of the InCIdent Reports, and the addition on Ms. Mills' of "agamst another staff' as a complamt made by the author of the report when in fact, It was not. At the hearmg It was clanfied that it mdicated that the mcident they were wntmg about mvolved a complamt agamst other staff The notlficatIOn of their single day's suspenSIOn took place at the end of theIr shift. Mr Montgomery perceIved that he was asked to leave the Base by Mr MIlo, Mr Milo has no recollectIOn of tellIng them to leave. Both asked for a wntten explanatIOn and each receIved a memorandum statmg that they "failed to complete an assignment of a priority four" 91 Accordmg to Mr Milo, Mr SmIth had receIved an InCIdent Report from 4 employees workmg at 02 Base at the tIme of the base phase the mCIdent, and he was gIven thIS report (StephanIe MIlls, George Handzel, Kevm COrrIgan, and ChrIS Anderson). The ImplicatIOn was that thIS was a report generated by the employees when in fact, it had been InItIated at the request of Mr SmIth and sIgned by the other three mdlvlduals, also at hIS request. Mr Anderson recalled that on December 9, 1994, "one of our crew members had written an Incident Report and the SupervIsor was at our statIon and [he] was asked, smce h[ e] was not makmg out a report, that (he] confirmed or agreed WIth the statement being made m thIS document" and was asked to SIgn it, whIch he dId. Mr Anderson also submitted, at the Employer's request three further IncIdent Reports. Over and above thIS, Mr Milo requested the same indIVIduals to submIt "theIr own InCIdent Reports" and he revIewed all m preparIng hIS report. He asked for these to gam " a better understandmg of what transpIred at the statIon from when the call arrived" Mr Montgomery and Mr Rankin wrote their Incident Reports Without the benefit of hearing the communIcatIOns, or of seeing a transcnpt of them. They did have access to theIr personal logs. Mr Milo testIfied that dUrIng hIS investigatIon he reviewed the followmg" . A number of Incident Reports from a number of individuals . A 1 hour call summary to understand the volume of calls . The detaIl report of the call from CACC . The transcnpt of the call from CACC which mcluded Mr Groleau's findmgs . The cassette from CACC whIch was rejected as the tape was avaIlable . The policies and procedures from CACC . The radio operators' manual from CACC . The schedulIng roster from OCRAS . The Ambulance Act . The Code of Conduct . Road measurements from OPS Manager . Weather reports from the Ottawa AIrport . Road reports from the SupervIsor of Road ServIces, CIty of Ottawa . The Pathfinder Map Book from Vehicle # 4162 and others as well. Mr MIlo also spoke to the 4 co-workers who were at 02 Base at the tIme of the mCIdent. He spoke to them mdIvldually, by telephone, pnor to December 21, 1994, and receIved verbal 92 accounts of what happened at 02 Base on December 9, 1994 Mr Milo also relIed on the InCIdent Reports of these employees m the preparatIOn of hIS report. Mr Milo then prepared hIS draft report. Its purpose was to Identlfy what had occurred, to establIsh findmgs and reach conclusIOns. When the draft report was complete, Mr MIlo forwarded It, WIth all the documentatIOn he had accumulated and his findings and recommendatIOns, to the Regional Manager, Blake Forsyth. The findmgs ofMr Groleau were not included in the report as It was the practlce not to mclude "findmgs wIthm findmgs" m the body of the report or m the appendices. Mr Milo testified that he took no steps to InstItute a complamt agamst Ottawa CACC respecting thIS inCIdent, and was not aware of any other person having done so The report was reviewed by the Mimstry of Health Licensmg and InvestigatIOn Branch m Toronto, and a final verSIOn of the report was Issued m January 1995 On receIving a further letter of suspension WhICh requIred him to turn m hIS OCRAS IdentIficatIOn card, Mr Rankin testified that he believed that he was bemg treated as if he were "gUIlty untIl proven mnocent" He received a hand-delIvered letter from Management every twenty days advising him of the contmuatIOn of his suspenSIOn. In early January 1995, he receIved a letter WIth a report attached which had been prepared by Mr Milo He found thIs demoralizmg and was surprised that Mr Milo, who had told him he would not be doing the mvestIgation, had, m the end, done so He was accused of refusmg to serve the public, as Mr Rankm put It, gUIlty of not domg his duty, and several readIngs of the report prepared by Mr MIlo convmced hIm that It was biased and on no matter were he and Mr Montgomery, m hIS OpInIOn, gIven the benefit of the doubt. On the baSIS of Mr MIlo's report, the hearIng under the Public Service Act was held under the chairmanshIp ofMr Hunter, (an admmIstrator at the same level as Mr Forsyth) and the report resultmg from that hearmg went to Graham Brand, the Director of Emergency ServIces m Toronto In March, Mr Forsyth (MOH) and Mr Payette (OCRAS) receIved notice that Mr Montgomery and Mr Rankin had been termmated. A conference call Involving Mr Forsyth, Mr Payette, and Mr Jon Hambides, Manager of Resource Development at the MmIstry and aide 93 to Mr Brand, took place. The result was the dismIssal of Mr Montgomery and Mr Rankm. Mr Rankm testIfied that by mid-February 1995, it had been made known to him by Management that "the reason for suspenSIOn was that [they] were consIdered a danger to the publIc" Durmg that time, they were awaitmg the decisIOn of Mr Hunter who, Mr Rankin assumed, was a person in hIgher authority than Mr Forsyth, the RegIOnal Manager Mr Rankm testlfied that he did not receIve a copy of the Hunter report or any mformation about It but on March 7th or 8th, received hIS letter of dismissal by courier and, when he read It "It felt like the floor fell out from beneath [hIs] feet, and a great dIsbelIef IS what [he] felt" ARGUMENT The Employer Mr Chondon outlmed two primary issues to be deCIded. . Was there just cause for dIsciplIne being imposed? . Assummg that there was some cause for diSCIpline, was dIsmIssal the appropnate form of dIscIpline? Accordmg to the Ambulance Act, the Ministry of Health, Mr Chondon stated, IS responsible for transportatIOn and emergency care of those members of the publIc requiring it, and that encompasses the dIspatchmg functions. The Ambulance Act covers both private, lIcensed servIces such as Ottawa CACC operated by ElIzabeth Bruyere and ministry-operated services such as OCRAS The Regional Manager (Blake Forsyth) IS responsible for seemg that the servIces meet theIr oblIgatIOns under the Ambulance Act and administenng the fundmg for those servIces. Mr Brand, at that tIme, held the most semor position m the Emergency Health ServIces Branch of the Ministry of Health. It IS important, Mr Chondon submItted, that mmIstry-operated services mamtain the standard of profeSSIOnalism expected of Ambulance Officers m the performance of theIr dutIes, and that mdeed, the Ministry should be takmg the lead m ensurmg thIS. Mr Chondon addressed the authority of the DIspatchers, both Call Taker and DIspatcher, m the process and noted that the Call Taker aSSIgns the Pnonty to a call. That aSSIgned pnonty remams m place at least untIl the patIent is en route to hospItal, at whIch tIme the members of the ambulance crew have authonty to adjust It based on theIr assessment of the patIent. Ambulances m the system respond to emergenCIes as dIrected by the DIspatcher and It is the responsibIlIty of ambulance crews to keep the DIspatch Centre mformed of theIr whereabouts at all tImes. The authonty of the Dispatcher, IS set out in RegulatIOn 19 (supra), and Mr Chondon 94 submItted thIS authonty encompasses both the ambulance crew and the vehIcle. When consIdenng the questIOn of whether or not the Gnevors refused to serve citizens requiring services which are part of the normal performance of[their] duties by delaying, and by failing to complete, an emergency call assigned to [them] he suggested that there are three questIOns which must be answered arIsing out of that allegatIOn. . Was the emergency call assigned to the Gnevors ? . If so, dId they delay or fail to complete the call m questIon? . If so, dId that delay or failure to complete, constltute refusal or neglect to render servIces in the normal performance of their duties? Was the emergency call assigned to the Grievors ? Mr Chondon argued that the inescapable conclUSIOn, based on the preponderance of eVIdence, includmg that of the Grievors, was that the emergency call was assigned to them and theIr vehIcle (4162) on the night of December 9, 1994 None of the Witnesses testified that the use of the term "stand by" by the DIspatcher meant that the Gnevors were not bemg assigned a call, at the most, it meant they were to wait for an mformation update. Mr Chondon carefully revIewed the eVIdence m thIS regard. As to when they were assIgned the call, Mr Chondon submItted that the crew was on pre-alert "as early as 19'09:34 (Mr Montgomery's eVIdence) or as late 19 10 18 (Mr Rankm's eVIdence) In other words, they were assigned the call long before they arrIved at 02 Base, and the call to 61 Fmch was not cancelled pnor to their arrival at the Base. Did the Grievors delay or fail to complete the call in question? To find that the call was delayed, It IS not necessary to find that the Gnevors themselves delayed the call, Mr Chondon submItted. On a SImple, factual mqUlry, not one whIch IS "blame- onented" the Board must, he maintamed, find that they delayed the response to the emergency call and, m any event, faIled to complete the response to the emergency call These two factors are, Mr Chondon submItted, prima facie eVIdence of refusal or neglect on theIr part, and the onus, he argued, IS on the Gnevors to put forward explanatIons as to why the call was not responded to by them, and why the call was delayed to the pomt that It was. He conSIdered these In light of the eVIdence and rejected eight explanations whIch the Gnevors put forward. The lack of a call number IS not, m Mr Chondon's VIew, an adequate explanatIOn. He rejected the explanation of the term "stand by", and made the pomt that, at no tIme, as a result of the transmItted use of the term "stand by", was the Crew told not to proceed, or that the Code 4 call was bemg cancelled. He also rejected the explanatIOn of the request for the 10-20 at 19 10 49 and 95 the anticIpated reassIgnment. There is no eVIdence of actual reassignment or other directions bemg gIven by the DIspatcher Mr Chondon dId not accept that the DIspatcher faIled to select the most appropnate ambulance to respond to the Code 4 at 61 Fmch and suggested that the route map (ExhibIt 17), supports a finding that Mr Groleau, the Dispatcher, dId select, on a balance of probabihtles the most appropriate ambulance to respond to the call. The suggestIon that by usmg a tIered response a more prompt response was available does not in any way excuse any failure on the part of the Grievors to respond to the call. Furthermore, Mr Chondon stated, the call, accordmg to the evidence, dId not meet the criterIa. The explanatIOn of the crew change on thIS Code 4 call , IS not acceptable, accordmg to Mr Chondon, even though there was no pohcy respectmg that. The eVIdence that Mr Groleau would not have authorized such a change on a Code 4 call, along WIth that of Mr LaVIctOIre who determined that It was an appropnate matter for InvestIgation, support the argument that It IS not a satisfactory explanatIOn for failmg or delaYIng the response to 61 Fmch. The faIlure of Mr Montgomery to locate as an explanatIOn for delay and the "phYSIcal lImitatIOns or lIghtmg m the vehIcle" do not provide a credible explanatIOn of delay as a contmual effort to find the location of the street was not bemg made Fmally, Mr Chondon concedes that not knowing the locatlon of Fmch, of all the explanatIOns, has some sigmficance, and mdeed, it is acknowledged as the significant factor by both Grievors. But even this, on closer examinatIOn, he submitted, has no credibility, in light of the fact that there were a number of reasonable steps the crew could have taken to remedy any confuSIOn or to confirm the locatIOn, and their failure to take any steps over a period of almost two mmutes. Mr Chondon submItted that the evidence of neglect on the part of both the Grievors, is substantIal. If one accepts the evidence ofMr Montgomery's not being able to locate Finch in the map book, one must conclude that this constItutes neglect given that the searching and findmg of destmatIOns is a reqUIrement of the positIOn and is not an uncommon requIrement of the nature and the performance of the dutIes. Combined with Mr Montgomery's faIlure to try to clanfy the confuSIOn, despIte the fact that a Code 4 call was waItmg constltutes neglect on Mr Montgomery's part. The same, can be Said, Mr Chondon submitted, ofMr Rankin. It IS not necessary, accordmg to Mr Chondon, for the Board to make a findmg of refusal, although It IS, he maintamed supported by the facts, in partIcular m the transmIssion (ExhibIt 4), m whIch Mr Montgomery expresses hIS WIllingness to attend at the scene but does not do so, m spIte of the fact that he had some Idea of the locatIon of Finch. On Mr Rankm's part, hIS notes mdIcatmg that he was prepared to respond if no one else was avaIlable, evidence hIS refusal, to respond because It was the end of hIS ShIft. The Gnevors dId have sufficient mformatIOn to attend at the call, and chose not to do so and this constitutes a refusal. The Employer has, Mr Chondon concluded, met ItS onus on the balance of probabIlities on the baSIS of clear and cogent eVIdence as well as a significant amount of cIrcumstantial evidence whIch establIshed that "Mr Rankm and Mr Montgomery "refused or neglected to respond to an emergency call m the normal performance of theIr dutIes, as dIrected by DIspatch. 96 The Inycstigation Mr Chondon questIOned the relevance of the mvestIgatIOn and suggested that thIS Board IS responsible for reachmg ItS own findings of fact in support, or otherwIse, of the MmIstry's deCISIon to term mate the Grievors. It's only relevance would be, accordmg to Mr Chondon, If somehow the Gnevors were mIsled about the Issues whIch ultlmately resulted in theIr termInatIOn or were somehow denied the opportunity to put forward theIr SIde of the story Such a demal would not, however, expunge the baSIS for any dIscIplme The investIgation was requested by the Actmg Manager at CACC based on the concern of an Actmg SupervIsor at CACC. Throughout the mvestigatIOn process, the Employer was WIthin ItS nghts to suspend the Gnevors and to select the investIgator, and during the hearing under the Public Service Act the Gnevors were gIven a full opportumty to present their SIde ofthe story and to call and cross- examme WItnesses. The Mimstry cannot, he mamtamed, be faulted for followmg the process m the manner In whIch it dId, and certamly not to an extent that would suggest that the process was so flawed as to find that dISCIpline was unwarranted. Was the dismissal on the part of the Ministry the appropriate discipline? Mr Chondon submItted that if the Board finds that the allegations of refusal or neglect to respond to a Code 4 emergency are valid, then dIsmissal is the appropnate response in light of the pOSItions held by the Gnevors and the sIgmficant publIc duty WIth whIch the ambulance servIce is charged. The performance of the duties of the Grievors, m theIr role as Emergency Medical Care Attendants, also mvolves sigmficant publIc trust. Accordmg to Mr Chondon, there was "nothing abnormal or unreasonable about the dispatchmg of the call to 61 Fmch to the Gnevors on December 9, 1994" If the Board finds that the allegatIOns are correct, that is, that the Gnevors failed, refused or neglected to respond to the call, then It must be concluded that conduct of that nature undermmes publIc trust m the system and IS a complete VIOlatIOn of everythmg the Emergency Health ServIces stands for Further It IS contrary to the Code of Conduct (ExhibIt 42) DIsmIssal IS also appropnate, indeed necessary, he submItted, to deter any Ambulance Officers from partlcipatmg m SImIlar conduct m future The Issue_ of Credibility Mr Chondon submItted that It was one thmg for the Gnevors to try to defend theIr actIOns based upon what was reasonably appropnate in the CIrcumstances. It was quite another for them to contnve explanatIOns for faIlures after the fact and to try to put forward such explanatIOns to the Board. He CIted three explanatIOns whIch he belIeved fell mto this category . the suggestIOn by Mr Montgomery that Ms. Mills had every intention of domg the call and SImply followed him out to the ambulance after he attended m crew quarters. 97 . the suggestIOn by Mr Montgomery and Mr Rankm that Ms. Mills and Mr Anderson heard the transmISSIons pnor to departmg on the call from DIspatch. . Mr Montgomery's claIm of having no knowledge of the locatIOn of Fmch m light of the fact that he dId not mention this in his Incident Report which was submItted wIthm 5/6 days of the mcident. Mr Chondon also submitted that the following explanatIOns were not worthy of credence . the suggestIOn by Mr Montgomery that there IS an outstandmg Health and Safety GrIevance and that thIS is the source of some ongomg anImOSIty when m fact the parties reached an agreement m this matter . the suggestIon by Mr Montgomery that he was not aware of any corporate dISCIpline polIcy when one of the ExhibIts suggests otherwIse, . the suggestIOn by Mr Montgomery that hIS twenty-SIX year employment WIth OCRAS was diSCIplIne-free when ExhibIt 66 confirms otherwIse. . Mr Rankin's explanatIon that he thought the crew change was official, yet throughout, he was not willmg to take action to complete the call. The Grievors have, in Mr Chondon's opmIOn, contrived explanatIOns m an attempt to mIslead the Board. At the end of the day they were, he maintamed, not prepared to assume any responsibIlIty whatsoever for the delay m respondmg to the call at 61 Fmch and that, coupled with the nature of theIr pOSItion, the publIc duty owed, and the neceSSIty for deterrence, and for those reasons, dIsmIssal is the appropnate penalty and he urged the Board to uphold the dIsmIssaL Mr Chondon CIted the followmg cases m support of his argument: Re Midas Canada Inc. and United Steelworkers of America (Honigan) (1993),37 L.AC (4th) 1 (Bnggs) Re City of Lethbridge and International Association of Fire Fighters, Local 237 (1988), 34 L.AC (3rd) 165 (A.V.M. BeattIe) Re Canada Safeway Ltd. and United Food & Commercial Workers, Local 2000 (1987), 29 L.AC (3rd) (Hope) OPSEU (Kulmatycky) and The Crown in Right of Ontario (Ministry of Community and Social Services) (1987) GSB # 418/84 (Venty) CUPE (Hibbitt) and The Crown in Right of Ontario (Ministry of Municipal Affairs and Housing) (1983) GSB # 87/83 (Swan) 98 THE UNION Mr McEwan stated that it IS important to dlstmgUIsh between "refusal" and "neglect" He artIculated the followmg dIstinctIOn. while refusal denotes intent, deliberateness, wIlfulness and conSCIOusness and has an element of mens rea (knowledge of the wrongfulness of the act), neglect does not. Mr McEwan submItted that the case for the Employer IS inherently improbable, smce it assumes that two expenenced Ambulance Officers, both of whom have chIldren of theIr own, would, under the CIrcumstances set out, have refused to go to the aid of a five-year old chIld. That assumptIOn IS, he mamtamed "Inherently Improbable" Further, both the Gnevors knew that all of the transmISSIOns m the communIcatIOn system were recorded and preserved, both have demonstrated a hIgh level of publIc servIce both WIthin and outside theIr employment, and It IS mherently improbable that they would choose to throwaway theIr careers, along WIth theIr personal and profeSSIOnal reputations for the sake of gettmg back to Base to do a crew change at the end of a ShIft. Mr McEwan submitted that the graVIty of the consequences to these two men - loss of lIvelihood, loss of career, loss of standmg m theIr communIties and loss of standmg WIth theIr famIlies - is so dIre that proof of thIS alleged mIsconduct must be reqUIred to the hIghest degree WIthin the standard of the balance of probablhtIes. He asks the Board to conSIder the eVIdence agamst thIS background. Mr McEwan reVIewed the eVIdence relatmg to the evenmg of December 9, 1994, and the call to 61 Fmch m detail, askmg the Board to be mmdful of the details and the conclUSIOns he had drawn from hIS reVIew He noted a number of errors made at the DIspatch Centre, and submItted that there were at least eleven. He assigned one of these to the Call Taker and the remamder to the DIspatcher, Mr Groleau. Mr McEwan commented on the role ofMr Groleau and submItted that he dId not come to the hearing as an objectIve and neutral WItness but as one who has commItted a wrong, and who has investigated that wrongdomg hImself and has reported It to the authoritIes. Once the wrongdoing has been laId at the feet of others, he IS in the happy CIrcumstance of bemg summoned to give evidence to confirm theIr responsibilIty for the wrongdomg, knowmg that he IS the one responsible for it. Mr McEwan charactenzed hIm as a WItness wIshmg to please his Employer for his own advancement. Some of the errors Mr McEwan referred to are included m the points he made . The Call Taker (Mr Bourque) misinterpreted the Caller's "Shearwater" as "Clearwater" (The Board has concluded that the Caller Said "Clearwater" ) . Mr Groleau's behefthat Fmch was east of Bank Street whIch It IS not, when he made hIS declSlon about WhICh ambulance to send. . Mr Groleau selected VehIcle # 4162 rather than VehIcle # 4158 WhICh had amved at 02 Base from a prevIOUS call thIrty seconds pnor to one of the crew 99 members, Mr Corrigan, contactmg DIspatch (Mr Groleau) by landlIne telephone. Dunng the conversation Mr COrrIgan told Mr Groleau that he knew where Fmch was. His vehIcle was ready and kItted and Mr Groleau would have known that. Mr McEwan's estimate was that It would have taken thIS vehIcle thIrty seconds to one mmute to be on its way That time to gettmg mobile was demonstrated following the return of Vehicle # 4162 to 02 Base. Vehicle # 4162, on the other hand on RIverSIde Dnve at Walkley, was m bumper to bumper traffic, in snowy, slushy conditIOns. Followmg a review of the route map (ExhibIt 17), Mr McEwan calculated, taking mto account the traffic condItIons on Riverside, the fact that Uplands is a heavIly residentIal street with a lower speed lImIt and numerous stop SIgns, contrasted WIth the Hunt Club which IS a hIgher speed limIt and mostly open space, that Vehicle # 4158 was the closer car by one to two mmutes. . Mr Groleau erred in accepting Mr COrrIgan's opimon that VehIcle # 4162 was closer than VehIcle # 4158 (Mr Corrigan's assigned vehIcle) before he knew the location of Finch. . Iyfr Groleau erred, accordmg to Mr McEwan, in faIlmg to call for a tIered response gIven that one of the consequences of hanging IS respIratory arrest. ThIS was the oplmon ofMr Montgomery and Mr Rankm, but not Mr Groleau's since he stated, he dId not have the information that the child had ceased breathmg. The fact the police had been notified by the Call Taker should have alerted Mr Groleau to the serIousness of the matter, he mamtamed, and further, he found It astoundmg that Mr Groleau, as a DIspatcher, did not know where the fire statIOns were located. . Mr Groleau, at mImmum, Mr McEwan argued, neglected to follow proper procedure by falling to provide the call number to the Crew of Vehicle # 4162 sooner than he did. He provIded it almost automatically at the outset when he assigned other calls. . Mr McEwan submItted that CACC's policies and procedures make it clear that the DIspatcher IS to provIde sufficient geographIcal information. Mr Groleau gave the wrong mtersectIOn to the Crew of Vehicle # 4162 and compounded the error by domg so when he says that he had found Fmch and knew that It was off Uplands Dnve. Accordmg to Mr McEwan, Mr Groleau gave eVIdence that at 19 10 18 and 19 10.23 his screen would have been showmg "Clearwater" and, accordIng to Mr McEwan, he told the crew of 4162 m response to theIr Inquiry that Fmch was located near "Clearwater" , what was on the screen, even after he had already located Fmch and personally venfied ItS locatIOn as being off Uplands Dnve, and he must have known that Clearwater was the wrong street to gIve as an mtersectmg street. From 19 10.28 Mr Groleau was finally aware of 100 the Clear/Shearwater error, accordmg to Mr McEwan, and realIzed that he had conveyed the wrong informatIOn to the crew of Vehicle # 4162. ThIS must be seen, he said, in the context ofMr Rankm's SItuatIOn. He had no Idea of the location of Finch, whIch IS a smaller pnvate street off a small pnvate street. He did not know where Clearwater was, nor dId he know where Shearwater was. He dId however, know where Uplands Dnve, a secondary road, was. It IS not reasonable to have expected any person involved to be famIlIar WIth the locatIOn of Finch unless there was preVIOUS expenence or personal knowledge of thIS address. . When consIdenng the Employer's critIcism ofMr Montgomery for not contmuing to look for the locatIOn of Fmch after he was unable to find It m the Path Finder Map Book one must take into account his situatIon on that evenmg, to have an awareness of what he was facmg. He was in the vehIcle, WIth the JarrIng movements of stop and go traffic, the brake lIghts were reflectIng on the WIndshIeld, the index pages of the Path Fmder were fairly small black on whIte pnntmg and the IIghtmg in VehIcle # 4162 was not the best lighting for map reading as It was located forward of the attendant against the wmdsmeld at the top, as dIstinct from the newer lightmg which has a gooseneck lamp and a large dome lIght over the attendant's head. The illumination in other vehicles where the lighting has been upgraded is 7 to 8 times better than the lIghtmg m VehIcle # 4162. There was no point m going back to look up "Clearwater" whIle the vehIcle was stIll m motIOn, when he was having problems looking up another street m the mdex. Mr McEwan made the point that had Mr Montgomery found "Clearwater" they would have gone to a wrong locatIOn, nowhere near FInch. . Mr Groleau failed to adVIse the Crew of Vehicle # 4162 of the locatIOn of Fmch even when he had the correct mformatIOn. . Mr McEwan noted that he asked Mr Groleau why he asked the Crew of VehICle # 4162 for its locatIOn and the reply he receIved was that he wanted to gIve them dIrectIOns. However he dId not do so, even though he had it m hIS mmd that he should do so . Mr McEwan submitted that between 19 10'49 when Mr Groleau asked for the locatIOn of VehIcle # 4162 and 19 12 54 when the Crew of VehICle # 4162 commumcates theIr arrIval at 02 Base, the only transmISSIOn of Mr Groleau began at 19 11 '00 and ended at 19'12 15 He was alertmg the Crew of VehICle # 4175 to tell the Night Crew a Code 3 was waItmg. . Between 19 12 15 and 19 12 54, almost 3/4 of a mmute, there IS no transmISSIOn, m spIte of the fact that Mr Groleau stated he was going to gIve them dIrectIOns, and meanwhIle, Mr RankIn IS expectmg hIm to come back WIth 101 the "better InfOrmatIOn" but he did not and a plausible conclUSIOn IS that, accordmg to Mr McEwan, he simply forgot. . When Mr Groleau was about to give dIrections to the Crew of VehIcle # 4162 he prefaced It by askmg for their 10 - 20 and by doing so, raised the possibilIty m the mmd of Mr Rankin that he mIght be sendmg them on another call. . Mr McEwan described the posItion of Mr Rankin who was trymg to process the informatIOn that he had received and the only locatIOn informatIOn that he could recogmze was 02 Base, He was, as he candidly put It, according to Mr McEwan, "muddling through" Mr McEwan made the point that Mr Rankin who had been told to "stand by" agreed that he could have kept proceedmg had he known where to go Mr McEwan also emphasIzed the point that m both the mIlitary and the ambulance services, it was clear that "stand by" meant don't call me I'll call you. There was no evidence whatsoever, that during hIS thought process, he had any intentIOn of returning to the Base for the purposes of effecting a crew change, nor was there evidence of deliberateness on hIS part to disobey the direction of the DIspatcher Mr Rankin, in hIS capacity as the Driver, tned to obey the dIrections of the Dispatcher as best he could, and the only thing that made sense to him was to move to 02 Base. . Between 19'09'55 when It appeared to the Grievors that the Dispatcher wanted them to head towards Finch, and 19'11 '00, the communIcations had created confUSIOn in their mmds and the best that Mr Rankm could do was to head to 02 Base proceeding as if, he said, he were stIll on the call to Finch. Mr Montgomery's transmiSSIOn at 19'13'08 "Uh? you saId stand by uh..I mean we'll go if you want. We didn't know we had the call. " , was, accordmg to Mr McEwan, delIvered in a courteous and professional vOice as was Mr Groleau's communIcation. Mr McEwan submitted that there was no suggestIOn of argument or accusation present in Mr Montgomery's voice and no concern was expressed m the VOIce of Mr Groleau. This response made it clear that, at least from Mr Montgomery's pomt of view, he dIdn't know they had the call. Mr Rankm testIfied that he did not know whether they had the call or not. . The transmISSIOn of Mr Montgomery at 19 12 54 alertmg Dispatch that they had arrIved at 02 Base was quite proper; it alerted DIspatch to their locatIOn and to the fact that they were confused. . In response to the Employer's argument that Mr Montgomery did know the locatIOn of Fmch based on statements m later InCIdent Reports, Mr McEwan suggested that the knowledge was commumcated from the Day Crew to the NIght Crew when Mr Rankm passed to Ms. Mills the map book as they were exchangmg places and told her the page number and the co-ordmates. That, he 102 mamtained, is the best eVIdence on all probabIlItles. Ms. MIlls eVIdence that she receIVed the mformatIon on the location of Finch from Mr Montgomery could very lIkely be a mIstaken recall. Mr McEwan noted that dunng both tlmes he cross-exammed her, she admItted she had lIttle recall of other than what she had wntten in her Incident Reports. Unlike, Mr Montgomery, she had little reason to remember details of thIS call. Further, he submitted, Ms. Mills was present in the crew quarters dunng the telephone conversatIOn that Mr Corrigan had WIth Mr Groleau m WhICh Finch and a location, since It was mentIOned. This was followed by Mr Corrigan's telhng the Night Crew that the Day Crew would be delayed because they had a call on Finch. Later, the Day/Evenmg Crew of VehIcle # 4158 and the Night Crew of Vehicle # 4162 had a diSCUSSIOn about the call and It is reasonable to assume that the location could have come up at that tIme. Mr Montgomery was not present for that dIscussion. Ms. Mill's mSlstence that she heard no transmIssions from Dispatch whIle VehIcle # 4162 was at 02 Base, means that she was in the vehIcle some time after 19 15 30 and they departed seconds later There was simply no tlme for Mr Montgomery to have come around to the driver's SIde to gIve her the locatIOn on Finch. It IS more lIkely that she heard the location information, near the fire hall, from Mr Corrigan. . ThIS was a situatIOn in whIch the Night Crew agreed to do the call. It IS not uncommon for this to happen when both Crews and the vehicle are at base. On occaSIOn even one Ambulance Officer from each Crew might do the call. ThIS IS, Mr McEwan maIntained, far from a situatIon in whIch the Crew of VehIcle # 4162 deliberately drove to the base to do a crew change. Rather, he submItted, they amved at base, and once there, being given another stand by, by the DIspatcher, Mr Montgomery exercised hIS judgement, got out of the car, went mto the crew quarters to see if the Relief Crew would do the call. Mr McEwan concluded, based upon his analYSIS of the eVIdence set out above, that there is absolutely no eVIdence of refusal. To establIsh that, the Board would have to find "wilfulness" or "deliberateness" and, accordmg to hIm, It IS not there He referred the Board to the followmg defimtIOn " " The use of the word "refuse" m the RegulatIOns to the Ambulance Act refers, Mr McEwan, submIts to the "operator", m this case, OCRAS, and there IS a question as to whether thIS refers to the employees as the RegulatIOns dlstmguish employee by use of the terms "employee", "drIver", "attendant", and define employees. The RegulatIOns are sIlent WIth respect to "neglect", Mr McEwan submItted, and the only way that "neglect"comes in is through the Code of Conduct and by using this, the Employer has arguably extended the defimtIOn of "refuse" beyond the statutory term "refusal" The Board, Mr McEwan submitted, WIll have to conSIder whether the Code of Conduct, and a breach of It, IS somethmg that can be taken Into account and also, whether the promulgatIOn of a rule, such as neglect to serve the publIc WIll result m dIscIplme, and whether It IS fair and reasonable that the Employer should be allowed to use that rule to dIsclplme ItS employees. 103 If the Board concludes that it IS faIr and reasonable for the Employer to dIscIplIne for "neglect" , then It follows, submitted Mr McEwan, that It IS necessary to dIstmgUIsh between neglect WhICh IS culpable which falls below some acceptable standard, and a permIsSIble error m Judgement. He submitted that errors in Judgement do not always mean that the mdIvIdual commItting that error, IS guilty of neglect. Mr McEwan argued that If one exerCIses one's Judgement based on all the InfOrmatIOn one has and If one applies one's skIlls and expenence to the facts that one has, one IS not gomg to be guilty of neglect If one has done what a reasonable person should do m the CIrcumstances. There are, he Said, degrees of Judgement and, presented with a gIven set of facts, no two people wIll necessarIly make the same deciSIon m every case. Ambulance Officers who are m the field dealmg WIth cnSIS SItuatIons day after day have to be allowed to exerCIse Judgement. If they are gomg to be second guessed on every deCISIon they make, he mamtamed, the ServIce IS not gomg to be able to functIOn. Accordmg to Mr McEwan, the test is foresight, not hindSIght, and unfortunately, the Employer applied the test of hindsight, from the comfort of the office and now comes and says the Gnevors should have done this and that and that Mr Rankin should have been on the radIO "naggmg" DIspatch for the locatIOn of Finch. However, Mr Rankm had been given the command to "stand by" and was told that the DIspatch had "other 4s" It IS the Dispatcher, accordmg to Mr McEwan, who has the bIg picture, not Mr Rankm who must obey the best mformatIOn that he has. He does not and goes to base. There IS no neglect in that, maintained Mr McEwan. Mr Montgomery IS back at 02 Base and still does not know where Finch is, DIspatch want them to go on the call, but another "stand by" transmiSSIOn comes. It IS surely not, Mr McEwan stated, neglect by hIm to go out of the vehicle to the crew quarters to find another crew wIllmg to do the call, one that happens to know the locatIOn of Finch. Mr McEwan argued that It IS open to the Board to award either or both aggravated and punitIve damages, whether It finds that there was no cause, or some cause, dIsmIssal was, he submItted, an mappropriate penalty, so pumtIve and so completely disproportIOnate that It can only have been actIvated by unIOn anImus agamst Mr Montgomery He gave the followmg arguments to support this . Mr Montgomery's hIStOry of union actiVIsm, partIcularly in the health and safety area . Mr Montgomery's gnevance respectmg the aSSIgnment of Code 4s which was outstanding at the tIme of the mCIdent and mvestIgatIOn. . Mr Montgomery's confrontatIOn WIth Mr Milo respectmg, what Mr Montgomery perceIved as his "overzealousness" and hIS "harassment" of hIm. . Mr Milo's attItude to Mr Montgomery expressed at a major fire, followmg a SIncere expreSSIOn of thanks from Mr Massender Both Mr Montgomery and Mr Rankm found the gesture and comment on the part of Mr Milo sarcastIC and contemptuous and mdlcatIve ofMr Milo's attItude towards Mr Montgomery 104 . The evolutIOn of thIS complamt whIch began as a complamt about, accordmg to Jim SmIth, a crew change on a Code 4, wIthout notificatIOn to DIspatch. It then moved to being consIdered a faIlure to complete a Code 4 call, to bemg, a day later, "refusmg or neglectmg to serve the publIc" What started as a DIspatcher concern, ended up becommg, from the Employer pomt of view, a refusal, or neglect to serve the publIc. Mr McEwan poses the question "What publIc was refused service or was neglected?" Accordmg to Mr Anderson, on hIS arrIval at the scene, the patIent was found to be in no dIstress. There has never been any complamt from the public, the patient's famIly, the pohce, nor from the ChIldren's AId Society In short, Mr McEwan submItted, there has been no complamt of refusal of service or neglect to serve He submIts that the reason for the Employer turning an internal admimstratIve matter of a crew change into refusmg or neglectmg to serve the publIc, whIch IS blowing the complamt all out of proportion, is the anImus towards Mr Montgomery . Mr Milo's asSIgnment to investIgate the inCIdent and his mformmg Mr Rankm that he is not doing the mvestigatIOn. . Mr Forsyth's deCISIon to suspend both the Gnevors before the investigatIOn IS even underway, and does so WIthout havmg confirmed the extent of hIs authonty To humIlIate them further, they were told to turn in theIr IdentIfication cards. Mr Montgomery, however, smce he was workmg for another ambulance servIce retamed a provinCial ambulance officer card. . As of December 14, 1994, Mr Milo was m posseSSIOn ofa tape of the call and a transcript, and yet he asked Mr Montgomery to prepare hIS Incident Report m the dark, without benefit of the transcript, and then used hIS report to pomt out dIscrepancies. . Mr Milo who must have receIved and read the InCIdent Reports, and was m posseSSIOn of the tape and transcript, would have realIzed there were dIscrepancIes, and yet he did not go back to Mr Montgomery or Mr RankIn and ask for an explanatIOn of them. . The fact that Mr Milo wrote hIS report WIthout ever gIving Mr Montgomery or Mr Rankin the opportumty of hearing the tape or the communicatIOn, or of revIewmg the transcnption. . The Employer dId not follow up on Mr Rankm s complaInt agamst CACC . The Employer made no effort to conSIder the numerous dlspatchmg errors of Mr Groleau. If emergency ambulance servIce to the public IS to work, there must be 105 be co-operatIOn between the ambulance and the dIspatch servIces. One has to ask why, he submItted, a responsible management of a servIce would look at the transcnpt, and find out from Its own employees what had gone wrong and , would not make an honest effort to follow up with the management at the DIspatch Centre to dISCUSS the obvious errors from the dIspatch sIde. . The faIlure of Mr Brand to give senous conSIderation to the recommendatIOn of Mr Hunter for a month's suspension. . The failure of Mr Brand to reVIew the personnel files of the Gnevors. . The complete absence of any detaIls m the letters of dIsmissal whIch undercuts any credibIlIty of the investIgatIOn and decisIOn-makmg process. Aggravated damages, Mr McEwan submItted, are mtended to be compensatory for emotIonal upset and humIlIatIOn suffered by a complamant at the hands of a wrong-doer The Ontario Human Rights Code prohIbItS discrImmatIon on a number of grounds and, In the event that the Board finds that there has been dIscnmination contrary to the Code, the Board is, he mamtamed, empowered to order monetary compensation up to $10,000 over and above normal order to make whole DIscnmmatIOn on prohibited grounds results m mental anguish and IS compensable, he submItted. In the case before the Panel, the dIscnmmatIOn, accordmg to Mr McEwan, IS because ofMr Montgomery's union actIVItIes and actIVIsm, and has been transferred to Blake Rankm, SImply by VIrtue of the fact that he was Mr Montgomery's partner, on the evemng in questIOn. The result is that both are victIms of antI-union dISCrImination and both, therefore can be compensated for that breach of the CollectIve Agreement, and Mr McEwan suggests that each be awarded $5,000 Mr McEwan noted that the Gnevors' stnving to become paramedICS has been cut off by theIr dIsmIssal, and that Mr Rankin, because of the emotIOnal turmoil that hIS dIsmIssal has caused has had, WIth hIS famIly, to seek counsellmg. There IS, Mr McEwan submItted, clear eVIdence of the humIlIatmg and emotIonally devastatmg effect that the dIsmIssal and ItS arbItrarmess have had on the GrIevors. 106 The Board should also award the Gnevors punItlve damages so that the declSlon-makers m semor management are deterred from destroymg the lIvelihoods and reputatlons of employees m such a careless and ruthless manner They need to be told that they must have regard to personnel files and pre-discIplInary reports, and that they should not appoint mvestlgators who are In a SItuatIOn where personal bias may skew the investlgatIOn. If they are not so deterred, they WIll dIsmiss people they do not lIke, because they are active m the Umon, and a "thorn m theIr SIde" Mr McEwan submItted that "strictly" m the alternatIve, in the event that we find that there is some cause for dISCIpline, we should find that there is reason to mItIgate the penalty and m dOIng so should take mto account the following . The excellent personal and profeSSIOnal records of both these men . The letters attestmg to their good character and actIOns . The community mvolvement - e.g. both volunteer fire fighters . Their length of service WIth the Mimstry - 26 and 12 years . The discIplme records of each - Mr Montgomery's clean except for a wammg m 1980 for a minor matter; Mr Rankin's absolutely clean . The failure of the Employer to follow any form of progressive discipline . The fact that there was no publIc complamt . The faIlure of the Employer to provIde clear polICIes and procedures respectmg ShIft changes . The fact that thIS was a crew change at base, not a return to base to do a crew change . The lack of a reqUIrement for a retinng Crew to log off . The lack of authority of DIspatchers to determine the Crew of an ambulance . The exceSSIve nature of the disciplme m relation to other OCRAS InCIdents . Total lack of eVIdence of deliberateness or wIlfulness on the part of the Gnevors . The denial of the Mimstry respecting the errors of the DIspatcher . The lack of applIcabilIty of deterrence Should the Board find, Mr McEwan submItted, that there was some error on the part of Mr Rankm or Mr Montgomery whIch crosses the boundary mto the territory of neglect, the error was very mmor, there was no WIlfulness, and at most, there should have been a wntten warnIng 107 Mr McEwan referred the Panel to the followmg cases, m support of hIS submIsSIOns Re School District No. 33 and Chilliwack Teachers' Association (1990), 16 L.A.C (4th) 94 (Hope). Re Toronto (Metropolitan) and CUPE (Local 79) (1992), 28 L.A.C (4th) 160 (Gray) Re George Lanthier et Fils Ltee and Milk & Bread Drivers (19087), 331 L.A.C (3d) 320 (Bendel) Re Ontario Hydro and CUPE Local 1000 (1990), 16 L.A.C (4th) 264 (Kates) Re Hertz Canada and Office & Technical Employees' Union (1994), 46 L.A.C (4th) 416 (Hope) OPSEU (MacMillan) and Crown in Right of Ontario (Ministry of Health, Thames Valley Ambulance Ltd.), GSB No 967/93, January 13, 1995, (DIssanayake) 108 DECISION The Board has consIdered in detail the eVIdence whIch was placed before It and has, as well, exammed the cases to which It was referred. To answer the questIOn of whether or not there was Just cause for dIscIplme to be Imposed on Mr Rankin and Mr Montgomery over theIr conduct durmg Call # 000475386, the Board establIshed the following context before conSIdering theIr actIOns. The onus is on the Employer to prove, on the balance of probabilitIes, that what it has alleged, occurred. If the evidence demonstrates that It dId occur, the onus then shifts to the Gnevors to provide an explanation for their alleged conduct. The consequence to the Gnevors in thIS case IS the most serious in the employment field. Therefore, the proof that IS required IS of a hIgh level, usually termed clear and cogent wIthm the realm of the balance of probabIlItles, m keeping WIth the consequences to the Gnevors. The followmg allegatIOns were made agamst Mr Rankin and Mr Montgomery respectmg theIr conduct on call # 000475386 m documents and testImony . They were shaftmg (Mr COrrIgan and Mr Groleau) . They did a crew change on a Code 4 (Mr Groleau to Mr SmIth) . They "went to base to do a crew change on a Code 4" (Mr Groleau in testImony) . They had done a ShIft change WIthout notIficatIOn (Relayed by Mr SmIth) . They completed a crew change at base without notification or approval after bemg Issued a Code 4 (Mr LavIctoire) . They dId not respond to a Code 4 (Mr LavIctOIre) . They dId a crew change before responding to a Code 4 (Mr LavICtOIre) . They did not go on the pnority and finally went to base and the other Crew dId the call. (Mr LavIctoire) . They went to base and dId not proceed on the call. (Mr LavictoIre) . They faIled to enquire about the status of theIr call (Mr Groleau) . They VIolated the Code of Conduct (Mr Massender) . They failed to provide servIce to the publIc whIch IS a reqUIrement of OCRAS as a servIce proVIder (Mr Massender) . They faIled to complete an assignment of a PnorIty 4 (Mr MIlo) . They refused to serve CItIzens requmng servIces (Mr Brand) OR . They neglected to serve CItIzens requmng servIces (Mr Brand) . They faIled to carry out the dutIes whIch are part oftheIr normal Job performance (Mr Brand) . They delayed an aSSIgned emergency call (Mr Brand) 109 . They faIled to complete an assIgned emergency call (Mr Brand) . They faIled to do the thmg they were there to do (Mr Brand) Ambulance Officers m the Provmce of Ontario have a duty to serve the public, and part of that duty comes from the duty m the Ambulance Act whIch IS imposed on "operators" to not refuse and .not permit any employee to refuse to provide ambulance service unless directed or permitted to do so by a dispatcher They also have a duty of care, and that duty IS hIgher than that of a member of the general public who IS not designated as an Ambulance Officer and IS not performing the dutIes of one. In considenng the declSlons taken by Mr Rankin and Mr Montgomery, the Board has applIed the standard of not what a reasonable person would decide, but what a reasonable Ambulance Officer would deCIde. That standard brmgs into play for these two Ambulance Officers, the accumulated expenence of 12 years and 26 years expenence respectIvely It does not reqUIre perfectIOn, nor does It reqUIre that each deCIsion taken be the same as the one whIch a member of Management belIeves, m reviewing the matter, would have been the best or the correct deCIsion. The Board does not conSIder that the detaIls of the partIcular patIent, for example, her gender and her age, should havmg any bearing on ItS conclUSIOns. In other words, the response of dIspatch and ambulance staff to a Code 4 call should be prompt, efficient and safe, Irrespective of the patient details, and It is not the role of the Ambulance Officer to second guess the Call Taker's code selectIon durmg the trip to the scene It IS only after an assessment has been made by the Attendant, and the Crew IS on ItS way to the destination, that a crew member may change the Code based on hIS or her first-hand assessment and Judgement. Up to that tIme, If the Crew IS told they are dealing WIth a Code 4, they must proceed on that baSIS. The Board is also of the VIew that when a call is aSSigned to a mobile crew, the fact that the aSSIgnment IS gIven after the end of theIr ShIft has no bearmg on theIr takIng on the call. ThIS IS m keepmg WIth the proVISIon of prompt emergency medical service to the publIc There was no evidence that the Employer had mstructed employees to take speCIfic actIOns to aVOId overtIme. 110 It IS mstructIve to note that the street on WhICh the call was located, Fmch Street, and the street bemg used as a reference street, Shearwater, are both streets of the most minor category m the hIerarchy of CIty streets. Shearwater is a private entry street whIch provides access from Uplands DrIve to a pmr of prIvate streets which branch off it, Fmch to the left and Pinson to the nght whIch curve and meet as a cul-de-sac. There are no reSIdences facmg on Shearwater These streets are, in other words, both insIgmficant m the scheme of city streets and Shearwater, therefore, does not quahfy as a SUItable reference street. It was not unreasonable that almost no one knew where Fmch Street was located. Nor was it unreasonable to find It difficult to locate VIsually on a map The Pathfinder book is dIfficult to read m less than favourable conditions It IS printed on a paper whIch does not provide the optImal contrast for printing and, the maps are shaded m gray, WhICh dimmishes the contrast even further Although the map qualIty did not affect Mr Montgomery's situation, since he did not look at the map Itself, it may have contributed to Mr Groleau's dIfficulty Further the index typeface IS crowded. The sequentIal procedure of processing a call at the Dispatch Centre, once the call has been commItted, IS as follows 1 The Dispatcher locates the call geographIcally 2. The DIspatcher reVIews the location of the ambulances 3 The DIspatcher determmes WhICh ambulance IS closest in time 4 The Dispatcher contacts the Crew of that ambulance 5 The Dispatcher aSSIgns the call. Mr Groleau made hIS determmation to send Vehicle # 4162, 2 mmutes and 27 seconds after the call was commItted and WIthout knowmg where Fmch was. In fact, there was no eVIdence that Mr Groleau ever dId find out the precise locatIOn of Fmch on December 9, 1994, m spIte of the fact that he testified on more than one occaSIOn that he pinpomted the locatIOn, that he had located the call He dId not locate the call geographically pnor to determmmg that he would aSSIgn the call to VehIcle # 4162, he SImply took Mr COrrIgan's word that he knew where It was and that VehIcle # 4162 was closer It is the Board's opinion, that this is an unsuitable basis III on which to determine the assignment of vehicles to emergency calls. The Board has consIdered carefully the transmissIOns of DIspatch, namely Mr Groleau, to the Crew of VehIcle # 4162, and theIr tIming, and has concluded that they were frequently inadequate, mcorrect and imprecise, and therefore mIsleadmg and confusmg for the Gnevors. The reasons for thIS, the Board belIeves, are several . the misleadmg and erroneous location mformation provided by the Caller to the Call Taker . the search for the incorrect reference street rather than a search for Fmch m the mdex and on the map by Mr Groleau . the failure of Mr Groleau to pass on the "Uplands" mformatIOn to the Gnevors . the faIlure of Mr Groleau to pass on the Shearwater locatIOn mformatIOn . the faIlure of Mr Groleau to get back to the Crew after hIS transmIsSIon at 19 11 '00 "10 - 4" for a crucial period of 1 minute and 54 seconds . Mr Groleau's use of the term "base" Without specIfying WhICh one . the mcorrect response to Mr Rankin's query about "base ?" , namely "near Clearwater" . Mr Groleau's use of the phrase "m a sec" which suggests WIthin 5 seconds, and not the "later"or "soon", which IS clearly what he means when he uses the phrase, "In a sec " . Mr Groleau's directmg the Crew to "Clearwater" when he knew that It was an mcorrect reference . the failure of the Crew of VehIcle # 4162 to tell Mr Groleau that they could not locate Fmch m the map book . The faIlure of Mr Groleau to be up front WIth the Crew and let them know that he was havmg dIfficulty locatmg Fmch . Mr Groleau's Issumg of, m effect, 3 stand-by orders wlthm 3 mmutes and 50 seconds 112 The Board finds It dIfficult to understand how, IfMr LavIctOIre were to undertake a careful review, he could, as he testIfied, find that there was no problem with the dIspatch handlmg of thIS call The Board questIOns why, when Mr Corrigan told Mr Groleau that he knew where Finch was, that he dId not tell hIm, or that Mr Groleau, m hIS turn, dId not ask Mr Comgan. The Board finds unfortunate Mr Comgan's prompt certItude that Vehicle # 4162 was closer He dId not say that he thought it was probably closer, or that, m hIS opimon, It was closer, but was very defimte that VehICle # 4162 was closer when In actual fact that was not so clear The selectIOn of the closest vehIcle m tIme mvolves the taking mto account of more factors than simply dIstance and mobIlIty Further, the fact that Vehicle # 4162 might have been closer m Mr Comgan's mmd, need not have precluded him from offering to take the call. The Board notes as well Mr CorrIgan's accusatIOn of shaftmg which he acknowledged he meant to be uncomphmentary towards the Gnevors, and his faIlure to be up front with Mr RankIn about his conversatIOn WIth Mr Groleau during their dIscussion of the call on December 9, 1994 Many of the deCISIons taken during the 5 mmutes and 56 seconds dunng which Mr Montgomery and Mr Rankm had the call were not deciSIOns for which there was a clear "right and wrong" or "correct and mcorrect" Furthermore, the deCIsions taken were not taken In a static atmosphere but rather one of constant actIvity, contmually changing location, difficult dnVIng and VIsibIlIty and ongoIng, sporadIC input from the DIspatcher who was in a different location, that is, In the CommunIcations Room of the DIspatch Centre. Mr Rankin was the driver of VehIcle # 4162 on the way from RIverSIde HospItal. In that capaCIty he had a number of deCISIOns to make and the Board has reVIewed them and made the followmg determmatIOns. At the time of the departure of VehICle # 4162 from the RiverSIde HospItal, It was Just at the end ofthe ShIft for him, and hIS partner, and they were therefore makmg theIr way back to 02/Hunt Club Base to turn Vehicle # 4162 over to the Night Crew They mformed DIspatch that they were mobIle (19'00.28). 8 minutes and 2 seconds later 113 (19'08.30) they were asked for theIr locatlon by Mr Groleau. Mr Rankm was approachmg the traffic lIghts at the mtersectIOn of RIversIde Dnve and Walkley Road, m poor dnvmg condItIons, and antIcipated that the green hght would change to amber He made the deCISIon to clear the intersection before he replied to the request for his location (10 - 20) Before he got back to DIspatch, there was a second request for his locatIOn 4 seconds later (1908 34) to whIch he dId not respond immediately, and then 10 seconds later (19 08 44) the thIrd request came and he responded m 4 seconds, (19 08 48), gIving the intersectIOn he was approachmg, that IS, Revelstoke and RIversIde. The Board has taken into account the driving circumstances and the fact that the first two requests from Dispatch were fewer than 4 seconds apart, and finds that there was no undue delay in Mr Rankin's response, and that his decision to wait until he had managed the intersection was reasonable. Mr Rankin contmued to dnve southwest on RIverside Drive As he was covering the dIstance between Revelstoke (19 08 48) and Uplands/Bowesville, he had several contacts with Mr Groleau. 38 seconds after giving their location at Revelstoke and Riverside (19'09 31), Mr Groleau called them "4/1/6/2/ Ottawa" and they responded "4/1/6/2" 3 seconds later (19'09 34) he contacted them and gave them the following mformatIOn "Code 4 at 61 Fmch. 6/1 " He had at that point, then, provided them with the address and priority code (4) of a call. In the same transmIssion, he told them to "stand by a see ", which means 'walt, I'll get back to you, don't call me' They had the address, the priority code and are in a holdmg pattern since they are not certam If they have the call. Meanwhile, Mr Rankm was contInuing south-west on RIverSIde Dnve as Ifhe had the call. 15 seconds after the beginning of the last transmission (19 0949) Mr Groleau called them again, "4/1/6/2 Ottawa", and repeated his call "4/1/6/2 Ottawa", 2 seconds later (190951). They responded "4/1/6/2" 3 seconds after the beginning of the second call (19'09 54). In the next second, Mr Groleau, m followmg up on hIS stand-by order, gave them the followmg mformation. "It's at. uh. 61 Finch. 6/1 FInch" , that IS he has repeated the address, but has not provided any geographical reference point whIch mIght gUIde Mr Rankin to the small, pnvate street. Mr Groleau contmued, "It's for a five-year old. possible hangmg. there IS. was a rope around her neck, unknown condItlon of 114 patIent at this tIme" He provided the patIent's age, the possible cause of the SItuatIOn, and nothmg about her condItion. Mr Rankin consIdered he had a pre-alert and was not concerned about whether or not there was a number assigned. At that pomt, he was no longer returnIng to 02 Base to turn over VehIcle # 4162 to the Night Crew The Board finds that there was no evidence that Mr Rankin determined that he was going to then return to Base to do a crew change. 19 seconds (19 10 14) after repeating the address with no geographical reference and provIdmg age of patient and situation but no information about the patIent's conditIOn, Mr Groleau came back on and announced "10-200 notIfied", that IS, the polIce have been notIfied and at approXImately the same time Mr Montgomery announced to Mr Rankm that he could not see or find the street in the map book. The polIce mformatIOn was not helpful to the Crew in locatIng the street, and one of them replied in 1 second with "Give me a 20 on Finch" Mr RankIn was stIll travellIng south on RIverSIde Drive and had not yet come to BowesvillelUplands. Mr Groleau replIed in 3 seconds (19 10'18) that FInch was "near Clearwater" which was incorrect and misleadIng, "apparently" (which expressed some doubt on hIS part), "near the Base or " whIch could have been either the ambulance or the milItary base, "Or somethmg like that. " which agaIn expressed some lack of certamty on hIS part. Mr Rankm testified he kept both bases in mmd. 3 seconds later, Mr Rankm attempted to clarIfy which Base by askmg "(Undecipherable] Base?" and receIved a prompt reply, 2 seconds later, "It's near Clearwater" WhICh does not clarify the Base and WhICh confirms the earlIer mcorrect mformatIOn, "stand by", meaning wait, he wIll get back to them, and don't call hIm. Mr Groleau then Said, "I'll gIve you a 20 m a second", so it IS ObVIOUS that he was aware that they needed the geographICal mformatlOn. and he confinned that they needed to waIt by tellmg them he was busy "I've got other 4s" Mr Rankm replIed promptly, 4 seconds after the start of the previous transmission, that he had receIved and understood the message Mr Rankm was stIll travellmg southwest on RIverSIde Drive. When he was contacted 21 seconds later (19 10 49) by Mr Groleau, he was approachmg RIverSIde and Uplands/Bowesvllle He was asked for theIr "10 - 20 now", he was not prOVIded WIth a geographIcal reference pomt for Fmch. Mr Montgomery replIed, promptly, 3 seconds after the start of the previous transmission, "Uhh", whIch could be a questIOning of the transmiSSIOn, or It could be a pause In whIch he IS 115 thmkmg, "RIverside and BowesvIlle", and 8 seconds after the start of that transmission (19 11 00) Mr Groleau replIed that he had receIved and understood the transmiSSIOn of theIr locatIOn, "10 - 4" Mr RankIn had a number of route optIons. They were m the context of beIng mobile on a pre- alert, not knowmg the locatIOn of Fmch, and waiting for geographIcal informatIOn. He could have . continued on Riverside Drive to Hunt Club and turned right over the Hunt Club Bridge into Nepean and Carleton Heights where Claymore was located thereby following the suggestion Mr Montgomery had made. He rejected thIS option . turned around He did not consider thIS optIOn . stopped along the roadway He did not conSIder thIS optIOn . stopped at the strip mall at the intersection of Riverside and Uplands He dId not conSIder this optIOn . stopped at the barricaded road along the way He did not conSIder thIS optIOn . continued on Riverside Drive to Hunt Club Road away from the Bases He rejected thIS optIOn . continued on Riverside Drive and turned onto Uplands, and continued on Uplands, a residential, secondary road with stop streets along the route. This would have brought him past Shearwater and Finch and eventually out on Hunt Club Road to the west. He took the turn onto Uplands but rejected the contmuatIOn on Uplands In favour of turnIng onto BowesvIlle, a non-reSIdential road without IntersectIOns. He did not have at thIS point the Uplands or the Shearwater InfOrmatIOn. . continued on Riverside Drive and turned onto Bowesville and south to Hunt Club which would have brought him out in the immediate vicinity of both CFB Ottawa (South), just south of Hunt Club Road, and 02/Hunt Club 116 Base, at the intersection of Bowesville and Hunt Club Road. He took thIS route WhICh brought hIm to the intersectIOn where the two Bases are located. He dId have informatIOn suggestmg "bases" The Board finds that his decision to take the Bowesville Route was a reasonable one. WhIchever route he took, he was expectmg to receIve more precise mstructlOns as he proceeded on the pre-alert. From the time that Mr Groleau confirmed receIpt of the transmIssion of the locatIOn of VehICle # 4162, Just prior to theIr entering the mtersection of RIversIde and BowesvIllelUplands, It took 1 minute and 54 seconds to travel the dIstance to Hunt Club Road and to turn mto the 02 Base, where Mr Montgomery announced theIr arrIval to DIspatch as part of the normal procedure on arrIving at base. The Board finds that Mr Rankin's decision to turn into the Base rather than to proceed easterly along Hunt Club Drive, a route which would have taken him away from both the Bases, without having a geographical reference point, was a reasonable one. There is no evidence that Mr Montgomery had any part in that decision. Mr Rankm elected not to use lights and sirens dUrIng this tnp and the Board accepts his explanation as a reasonable exercise of his discretion. Mr Groleau dId not contact the Crew of VehIcle # 4162 durmg the tIme It took them to travel from the mtersectlOn of RIverside and BowesvIlle to 02 Base on Hunt Club Road, nor dId they contact hIm. Mr RankIn was stIll on pre-alert waIting for a geographIcal reference pomt from DIspatch, when he backed mto the 02 Base. He remamed in the vehicle, had hIS foot on the brake, dId not get hIS kIt together There was no eVIdence of any action on his part whIch was mdIcatlve of hIS readmess to hand over VehIcle # 4162 at the time he arrIved at 02 Base The Board finds that there is no evidence which suggests that Mr Rankin returned to 02 Base for the purpose of effecting a crew change. Should Mr Rankm, a member of the Day Crew on a pre-alert, aWaItmg mformatIOn to enable hIm to proceed, and trying at that time to find It hImself, have told Ms. MIlls that he was takmg 117 the call when she approached the vehIcle and mdIcated her wilhngness to do the call 7 In the opinion of the Board, his action in leaving the vehicle following Ms. Mills' confirmation that she was there as the incoming crew to undertake the call, and his providing her with his own recent map search while doing so, was not improper Mr Montgomery's role dunng the drIve from RiversIde HospItal was that of Attendant. Durmg the tnp, most of the communIcatIOn with Dispatch was handled by Mr Rankm, ThIS IS reasonable because of the dnvmg deCISIOns whIch have to be made m relatIOn to DIspatch. Mr Montgomery was aware of the poor weather, and the dnvmg and vlSlbIhty condItions. He had lIttle to do during the first 8 mmutes, that IS, from the tIme the left the RIverside HospItal Just before 19'00.28 untIl 19'08 30 when Mr Groleau called the Crew "6/2, 10-20 7" ThIS would have alerted Mr Montgomery that somethmg further might be commg. His alert would have been mamtamed by Mr Groleau's second transmISSIon "4/1/6/2, 10-20" 4 seconds later (19'08.34) and agam 10 seconds later (19'0844), Mr Groleau's thIrd transmIssion, "4/1/6/2 your 10-207" (19'0844) Once Mr Rankm had gIven theIr location, "Revelstoke and RIversIde", 4 seconds later, (190848) Mr Montgomery was stIll In the pOSItIOn ofthmkmg that something might be coming. 35 seconds later (19'09.23), DIspatch contacted them agam, "41-62, Ottawa", and agam in 5 seconds (19'09 31), "4/1/6/2, Ottawa" Mr Rankin or Mr Montgomery responded 2 seconds later (19'0933) "4/1/6/2" Mr Groleau came on immediately (190934) and prOVIded speCific call mformatlon, that IS, pnorIty and address, "Code 4 at 61 Fmch. 6/1 Fmch. ", and gave the crew the mstructIOn to "stand by a sec", In other words, 'I'll be back to you promptly", keep movmg but walt, and don't call me, I'll call you" At this point, Mr Montgomery, quite properly, in the opinion of the Board, picked up the Pathfinder Map Book to look for Finch. He was wearmg hIS glasses, and turned to the mdex. The print on these pages IS small and Mr Montgomery who under good condItlons and WIth hIS glasses IS able to read pnnt of that SIze, was, under the condItlons prevaIlmg at that tIme not able to do so He attributed his dIfficulty to a varIety of condItIOns - the hghtmg In the cab, the actIOn of the wmdshIeld WIpers, the glare of car lIghts, the stop-and-go actIOn of the vehIcle The Board accepts that these conditions caused a valid problem for Mr Montgomery and 118 that for a person of his age, with normal sight deterioration due to aging, such a difficulty would not be unusual. The Board notes, however, that an ability to read the map book in both good and poor visual conditions in order to locate calls, must be part of the responsibility of an Ambulance Officer If he or she has a condition which hampers that ability, he or she must compensate in some way so that his or her ability to read the map book in both minimal and optimal light conditions, is maintained. For instance, IfMr Montgomery has dIfficulty readmg the mdex, he could carry a blown-up version or a magmfier WIth hIm. One of the ways in which Mr Montgomery had compensated was to carry a personal flashlIght, even though his carrymg of It may have not been for that speCIfic purpose. The flashlIght, however, was in need ofre-chargmg and by not having it in working order, in the opinion of the Board, Mr Montgomery failed to maintain his ability to read, one of the tools necessary for an Ambulance Officer to carry out his/her responsibilities. That Improved hghting was deSIrable is recognized by the Board and the major improvement m lightmg of the vehIcles m whIch improved IIghtmg had been mstalled IS mdIcative of the Employer's recogmtIOn of thIS. However, it IS usual for electIve upgradmg programs to take place over a penod of time and m the mtenm, it IS necessary for those usmg the faCIlIty to functIon withm the existmg conditions. Mr Groleau called the Crew of Vehicle # 416215 seconds later (19'0949)" 4/1/6/2, Ottawa" and repeated the call 2 seconds later (19'0951) "4/1/6/2, Ottawa" The Crew m turn replIed 3 seconds later (19 09 54) "4/1/6/2" and were given immediately, (19'09 55) by Mr Groleau the followmg mformatIOn. the address "61 Finch", the age of the child "a five-year old", a speculatIOn on the cause of the emergency "possible hanging", the fact that a rope had been around her neck, the mformation that the conditIOn of the patient was unknown at thIS tIme. They were told, "I'll get back to you with an update", that IS, don't call me I'll call you and gIve you more Information about this speCIfic call. Mr Montgomery, who had been lookIng for the address smce approxImately 1909 35, mformed Mr Rankm of hIS mabIlIty to find the address. Mr Groleau dId get back WIth hIS update 19 seconds later (19'10 14) and told the Crew that the polIce had been notIfied about thIS call, "10-200 notIfied" Immediately, (19 10 15), one of 119 the Crew asked Mr Groleau to "gIve (him] a 20 on Fmch" Mr Montgomery was sure that he dId not know the locatIOn of Finch and believed that Mr Rankin was also ignorant of Its locatIOn. Mr Montgomery did not ask Mr Rankin for his flashlight, nor did he make any attempt to locate either of the vehicle flashlights. At this point, Mr Montgomery shifted the problem of physically locating Finch to the Dispatcher, and ceased trying to locate it with the tools he had. He and Mr Rankin did, however, continue to discuss the location, trying to draw on their experience. 3 seconds later, (19 10 18), Mr Groleau dId come back and prOVIded them WIth locatIOn informatIOn but it was unclear, incorrect and contradIctory - "near Clearwater .apparently .near the Base or something like that" From thIS point, Mr Montgomery was actIvely trymg to sort out Mr Groleau's informatIOn. He was not famIliar WIth Clearwater, nor dId he look It up on the map He would have had to use the index agam. He gave the matter some thought and wondered If It could be near Claymore a street WIth whIch he was famIlIar, but then that did not comcide with the "Base" which he mterpreted as 02 Base. He was, m other words, actIvely trying to sort out the location from the mformation provided. 3 seconds later (19 10:21) Mr Rankin tried to clanfy the "Base" With Dispatch. The Crew IS told 2 seconds later (19 10.23) that It is "near Clearwater" and are told to "stand by", that is, waIt, and that Mr Groleau Will "gIVe [them] a 20 m a second" This statement on the part ofMr Groleau indIcates that he knew that the Crew of VehIcle # 4162 needed a location for the Fmch call. He also told them he was busy by stating "I've got other 4s" Mr Montgomery's thought IS reInforced by the mcorrect informatIOn "near Clearwater" and then he IS told to expect a location but that they wIll need to waIt for it. A further confuSIOn was caused Mr Montgomery because "I've got other 4s" could mean, I may want to use you on another 4 Mr Rankm informed Mr Groleau that he had receIved and understood the mstructions "10-4" ,5 seconds after the beginning of the last transmission (19 10.28) At thIS pomt, Mr Groleau stIll dId not have a correct locatIOn for Fmch. 8 seconds later, the Call-Taker completed the call durIng whIch he found out that the reference street gIven earlIer should have been "Shearwater" not "Clearwater" 13 seconds later (19 10 49), Mr Groleau asked the Crew of VehIcle # 4162 for theIr locatIOn "4/1/6/2 your 10-20 now", Just as they were approachmg RIversIde and BowesvIlle/Uplands, and m 3 seconds (19 10 52) Mr Montgomery came back to DIspatch WIth 120 the mformatIOn that they were at "RiversIde and Bowesville", mformatIOn whIch he mdlcated Mr Groleau receIved 8 seconds later (19 11 '00). The fact that Mr Groleau had Shearwater information must not have helped him, since it appears that he did not know that street either Mr Rankin made the decision to turn onto Uplands and immediately onto Bowesville, and there is no evidence that Mr Montgomery had any input into that decision. Mr Rankin drove south on Bowesville until he reached Hunt Club Road and then turned left onto Hunt Club and left again into the 02 Base parking area. There was no evidence of Mr Montgomery having input into that decision. There was no communIcatIOn from DIspatch dUrIng the 1 minute and 54 seconds that it took them to arrive at the Base, and then, It was Mr Montgomery who, accordIng to normal protocol, announced theIr arrIval at base to Dispatch "4/1/6/2, 10 - 7, 0/2" at 19 1254 He did not make any secret of the If amval. 3 seconds later, Mr Groleau communIcated to them hIS surpnse, that they were at 02 Base, "4//1/6/2, 10 - 7, 0/2 ?", and Mr Rankm confirmed It 2 seconds later (19'1259). Both Mr Rankm and Mr Montgomery sat in theIr vehIcle waitmg to hear from DIspatch. 4 seconds later, (19 13 03), Mr Groleau mdicated to them that he had received theIr communication "10-4", and then told them that he "gave (them] a Code 4 at 61 Fmch" 5 seconds after the beginning of Mr Groleau's transmission, (19 13 08), Mr Montgomery came back on m a questIOnmg voice, saymg they had been told to "stand by", which they had, and statmg that they would go and do the call If Mr Groleau wanted them to, addmg that they dIdn't know they had the call. 6 seconds after Mr Montgomery's transmission (19 13 14), Mr Groleau contacted them again and let them know that he had receIved theIr communicatIOn "10-4", that "(he] regave It to [them] afterwards" whIch suggests that he gave it InItIally, then took It back, and then gave It agam, although there is no eVIdence to suggest that in the tapes. It may mean, however, If that statement IS mdIcatlve of hIS thought process, that he was consIdenng gIvmg the call to another vehIcle at one pomt dunng the transmISSIOn. He then told them, as they are sIttmg there m the vehIcle, that he "Just wanted to confirm the address" and repeated It, "that was at 61 FInch" Mr Groleau dId not confirm the address, he was seekmg the locatIOn. He had the address from the tIme the call was commItted and once the matter of the telephone number on the Call Taker's screen was cleared up, there was never any doubt about It. Further, he proVIded It to the Crew of 121 VehIcle # 4162 several tlmes. Then, whIle Mr Montgomery and Mr Rankm were stIll sIttmg In the vehIcle, Mr Montgomery replied, 7 seconds after the beginning of the previous transmission (19 13.21), "RIght, give the mformatlOn agam. please go ahead" Mr Montgomery dId not try to locate the address agam, nor dId he ask Mr Rankm. He asked Mr Groleau. The Board finds that it was not unreasonable for Mr Montgomery to make the assumption that since Mr Groleau had selected them as the vehicle which was closest in time, that he would have some idea of the location, given that the sequence for dispatching must be to locate the call first and select the vehicle second. Mr Groleau came back immediately (19 13.24), tellIng the crew that he had received their communIcation" 1 0-4", gIving them the address which he had gIven them 3 times before, the age of the chIld, whIch he had preVIOusly gIven them, the fact that the child had been found with a rope around its neck, whIch they had been preVIOusly told, but he did not give them the location information. Instead, he told them to "stand by" that IS, wait, I'll be back to you, don't call me I'll call you, and mdIcated to them that he would "get [them] the detaIls" All along they have been askmg for locatIOn mformatIOn and they were stIll waitmg for It. He then Said he would "get back WIth an update", whIch, it IS reasonable to assume, means that he WIll prOVIde them WIth more current informatIOn. Mr Montgomery beheved that there would be a slight delay and at that pomt followmg Mr Groleau's transmISSIon at 19 13.24, he slIpped the mIcrophone on the hook, got out of the car and went mto the crew quarters. He belIeves that he told Mr Rankm he was gomg to ask the Night Crew If they were WIlling to do the call, although Mr RankIn dId not recall that. It could have happened that he mentioned It as he left, and it was not heard by Mr RankIn, or It could be that Mr Montgomery's recollectIOn was maccurate. Nonetheless it is clear that the reason Mr Montgomery left the vehicle was to ask the Night Crew if they were willing to take on the Finch call. Mr Montgomery IS not denymg thIS. The Board finds, however, that Mr Montgomery had no influence on Mr Rankin's decision to return to 02 Base, and that at the time they entered the base parking area, he did not take any action that was indicative of an intention to do a crew change. His decision to do so was triggered, the Board believes, 122 by the delay which was, in effect, announced by Mr Groleau by telling them to "stand by" Mr Rankin had no input into Mr Montgomery's on-the-spot decision to leave Vehicle # 4162 and to enter the crew quarters to see if the Night Crew was willing to undertake the call. There IS no eVIdence that Mr Montgomery and Mr Rankin colluded to return to 02 Base There IS no eVIdence that Mr Montgomery and Mr Rankm colluded to aVOId undertakmg Call # 000475386 Nor IS there evidence that Mr Montgomery, on hIS own, tned to effect a return to 02 Base for the purpose of aVOIdmg undertaking Call # 000475386, nor that Mr Rankm dId so Counsel for the Employer, in argument, submItted that Mr Montgomery and Mr Rankm "contnved explanatIOns in an attempt to mIslead the Board" ThIS of course, bnngs mto questIOn theIr credibilIty (See pages 97 and 98) The Board notes that the level of detall that was part of the eVIdence in this case made it dIfficult for most of the witnesses to recall all the varIOUS details of preCIse tIming and location of persons during the change over from the Day Crew to the Night Crew and as a result, there was some vanatIOn m the details of theIr recollectIOn. It is the conclusion of the majority of the Board that Mr Montgomery and Mr Rankin gave their evidence to the best of their recollection and did not attempt to mislead the Board. The one pomt whIch IS of partIcular note during the change-over penod IS whether or not Ms. Mills heard from Mr Montgomery that Fmch was located off McCarthy across from the fire hall If he dId tell her that, It IS mdIcative of hIS very probably having known the general area of the call locatIOn before he arrIved at 02 Base Mr Montgomery mamtamed steadfastly that he dId not know the locatIOn of FInch. Mr Comgan Said that he, Mr Comgan, knew but then he dId not tell Mr Groleau. Mr Rankm says that Mr Comgan IdentIfied Fmch as bemg located "off Twyford behmd the fire hall" after the Night Crew had left. Ms. Mills Said she had preVIously been to Fmch and recalled It partIcularly havmg on one occaSIOn reqUired polIce escort. Ms MIlls could have heard the "McCarthy/Twyford/fire hall" locatIOn between the tIme Mr Comgan spoke to DIspatch (19'09 22) m the crew quarters and the tIme the Night Crew amved 123 at scene (19 22 53) She could have heard It durmg the dIscussion about WhICh vehIcle would do the call, or as she was walkmg out to open the garage doors, or dunng her return to retneve her kIt or her walk to VehIcle # 4162 NeIther Mr Corngan nor Mr Anderson testIfied to hearmg thIS from Mr Montgomery in the crew quarters or In the garage. She could have heard It when she was at VehIcle # 4162 but she was on the OpposIte SIde to Mr Montgomery speakmg to Mr Rankm and the engme was runmng. It IS possible that Mr Rankm told her He had found the co-ordmates and had just turned to the map when she arrIved. Mr Anderson dId not testIfy that he heard these dIrections from Mr Montgomery who was on the same SIde of the vehIcle as he was and smce he was usmg the mIcrophone, must have been quite close No one testIfied that the note which was not available to be entered mto eVIdence mcluded any mformatIOn whIch mcluded "McCarthy, Twyford or fire hall" Ms. Mills testIfied that she dId not hear the transmISSIons from DIspatch, so It appears that she arrIved at VehIcle # 4162 following Mr Montgomery's contact with DIspatch which finished at approximately 19'15.20 She left at 19 15 30, so that she was there for approXImately 10 seconds, part of the tIme outsIde the vehICle speakmg with Mr Rankm and waIting for hIm to leave the vehIcle, part whIle gettmg mto the vehIcle WIth her kIt, part whIle he turned over the map book and hIS findmgs thus far, and part of the tIme mside consultmg the map. The Board has concluded, based on the above reVIew, that there IS not clear and cogent evidence which would prove that Ms. Mills heard the McCarthylTwyford/FIre hall locatIOn from Mr Montgomery The majority of the Board has concluded that neither Mr Montgomery nor Mr Rankin knew the location of Finch prior to 19:20'00 hours on December 9, 1994. Mr Rankm and Mr Montgomery handed theIr Code 4 call over to the Night Crew during the tIme the DIspatcher told them to stand by between 19 13.24 and the tIme the Night Crew left 02 Base at 19 15 30 Dunng that time they dId not Wait for the DIspatcher to come back to them, but contacted hIm for the locatIOn InfOrmatIOn whIch agam, he dId not gIve them. Mr Groleau's ongInal complamt was that they had gone back to base to do a crew change on a Code 4 whIch, accordmg to hIm, IS not allowed and causes delay The Board has found that at the time the Crew of Vehicle # 4162 entered 02 Base, they did not intend to change crews. Mr Groleau 124 testIfied that there was no polIcy m the CACC OperatIOnal PolIcy and Procedure Manual respectmg crew changes on prionty calls but that an Internal memorandum eXIsted to the effect that a Code 4 IS not to be delayed under any circumstances. The Employer did not produce that memorandum. It would however, apply to CACC employees, that is to DIspatchers, and If It forbIds crew changes on a Code 4, It would be dIrected at Dispatchers, tellIng them not to authonze Ambulance Officers to undertake a crew change which would delay a Code 4 call. There was no rule at OCRAS that Ambulance Officers were not to effect a crew change on a Code 4 The Board recogmzes that It IS common sense that if one IS on a pnority call that one does not, for the purpose of effectmg a crew change, stop en route or return to base to do that, but It has found that Mr Montgomery and Mr Rankm did not do that. Once they were told to stand by for the third time, thIS tIme for the detaIls, Mr Montgomery made a qUIck declSlon to ask If the mcommg crew whIch was 13 mmutes into ItS shift, was willmg and ready to take over the call to 61 Fmch. The Board accepts the assertion ofMr Montgomery that If for some reason the mcoming Crew was unable or unwilling, that he would have returned to waiting VehIcle # 4162 whIch was waiting, engine running, and, once they had found out the locatIOn, contmued on to the scene He mIght have deCIded to have another look at the map book, to go Into the crew quarters to ask If there was anyone who knew where FInch was, he might have perSIsted WIth the DIspatcher in contraventIOn of the accepted communIcatIOns rule following the "stand by" command. Instead, he chose to go m to see If the incommg crew was Willing to take over Was thIS an unreasonable deCISIon for hIm to have made? If there had been a rule prohibItmg a crew change at base on a pnority call, then hIS declSlon would have been contrary to the rules. He followed a practIce of handIng over to the incommg crew, m thIS case, dunng a Code 4 call for whIch he was awaItmg DIspatch's dIrection. He did not contravene any rule respectmg crew change. In the opinion of the majority of the Board his decision was not an unreasonable one to take under the particular circumstances. This opinion, however, is situation specific and should not be read as condoning crew changes on priority calls. The Board IS also of the VIew, as were the partIes, that there was a delay on the call to 61 FInch and that that delay was unacceptable whether one conSIders the delay to be from the InItIal call 125 (19'04 53) to the arrIval at scene tIme (18 minutes), from call commIttal tIme (19'07.20) to arnval at scene tlme (15 minutes and 33 seconds) , from Imtial notlficatIOn tIme to the Crew of VehIcle # 4162 (19'09 34) to arrIval at scene tIme (13 minutes, 19 seconds) , or from pre-alert tIme (19'09 55) to arrival at scene time (12 minutes and 58 seconds) The responsibIlity for that delay cannot be laId at the feet of anyone indIvidual. From the tIme the call was receIved at 19'0453 to the arrival at scene at 19.22 53 . the call was solely in the hands of the Call Taker for the first 2 minutes and 3 seconds. . the call was solely m the hands of the Dispatcher for the next 2 minutes and 39 seconds, except for hIS sharIng of the informatIOn with Kevm Corngan. . the call was jointly m the hands of the Dispatcher and the Day Crew of VehIcle # 4162 for approXImately 5 minutes and 56 seconds (19'0934 to 19 15.30) . The call was jointly in the hands of the Dispatcher and the Night Crew of VehIcle # 4162 for approXImately 7 minutes and 23 seconds (19 15 30 to 19.2253) . the call was solely In the hands of CACC for 5 minutes and 9 seconds. . The call was jointly in the hands of CACC and OCRAS for 13 minutes and 19 seconds Did Mr Rankm or Mr Montgomery contribute to that delay? The Board has concluded that the major reason for the delay was the faIlure to find the locatIOn of Fmch. There are, In the Board's VIew, 5 persons mvolved m the locatIOn of a call . the Caller . the Call Taker . the DIspatcher . the Ambulance Officer acting as Attendant . the Ambulance Officer acting as Dnver The Caller prOVIdes mformatIOn from hIS or her personal knowledge, the Call Taker enters that informatIOn and any mformatIOn he or she may have whIch helps to locate the call Into the 126 computer; the DIspatcher must at least narrow the locatIOn area of the call before assIgnmg a vehIcle and he or she uses maps to locate the call, the Attendant, when the Crew has not receIved precIse or m adequate informatIOn, uses his/her map book and/or experience to locate the call preCIsely; and the Dnver, gIven that he or she IS dnvmg, can only contribute expenence The key person m the locatIOn of the callIs the DIspatcher It IS he or she who IS control of the call mformation and the vehICle locatIOn and who provides the lmk between the DIspatch Centre and the ambulance crews. Mr Groleau when asked "How could they find a locatIOn If they had to" replIed "They have a map book and If they cannot find It there they should be able to ask me and I should be able to help them" and later, "They can look It up in the map book and then, If they are stIll havmg problems, they can contact me for better dIrections" Mr Groleau VIewed hImself in hIS role as DIspatcher, qUite correctly m the Board's opimon, as the person who would ultImately prOVIde the locatIOn information to the Ambulance Crews. However, the prOVlSlon of emergency and cnsis services demands the cooperation of all involved m the prOVlSlon of that service and part of that mcludes Ambulance Officers, partIcularly Attendants smce they are not dnvmg, lookmg to find the location of calls as well. Smce the DIspatcher must locate the call before he can determme the most appropnate vehIcle to send, It IS reasonable to assume that he or she has at least an area knowledge of the locatIOn once a pre-alert IS gIven and therefore, It was not unreasonable for Mr Montgomery and Mr Rankm to assume the DIspatcher had the location mformatIOn when Mr Montgomery was unable to locate It. It IS clear from the eVIdence that the DIspatcher dId not fulfill hIS responsibIlitIes In thIS regard. It is the opinion of the Board, that Mr Montgomery's failure to pursue looking for the location by seeking better lighting, such as Mr Rankin's flashlight or one ofthe flashlights in the vehicle, when he had allowed his own to run down, meant that he did not put forth his best effort in this regard and might have contributed to the delay It does not necessarily follow that even Ifhe had used a flashlIght that he could have located FInch. Mr Groleau had the same mdex and map and he was m the DIspatch Centre CommunIcatIOns Room and he dId not locate It. In the view of the majority of the Board, Mr Rankin did not contribute to the delay Was It refusmg servIce to a CItizen requmng It, for Mr Montgomery to go mto the crew quarters 127 to mqUlre If the NIght Crew was WIllIng to take on the call? In the opinion of the Board it was not. The purpose of hIS gomg m was to hand over the call to the mcommg Crew, and m the event that thIS did not prove possIble, he was prepared to return to the waItmg vehICle and attend to the call hImself WIth Mr Rankm once the locatIOn had been establIshed. There was no actIOn on hIS part to suggest that he was deliberately actmg in such a way as to prevent the cItIzen from .. receIvmg servIce Was It a refusal of servIce to a cItIzen requmng It, for Mr Montgomery and Mr Rankm to hand over the call to the incoming Night Crew? Handmg the call over to the relIef Crew whIch was made up of two competent Ambulance Officers prepared to take over the call was not a refusal of servIce. The service, albeit delayed, was provided to that citizen. OCRAS fulfilled its duty under the Ambulance Act as an operator of an ambulance service on Call # 000475386. The Board finds that neither Mr Montgomery nor Mr Rankin refused to provide service to the citizen requesting it on Call # 000475386. It is the opinion of the majority of the Board that there was nothing in Mr Rankin's decision-making or actions respecting Call # 000475386 which constitutes neglect. In the case of Mr Montgomery, it has been noted that, in the opinion of the Board, he should have made more effort to locate the call, however, it cannot be said that he made no effort, and in the opinion of the majority of the Board, his shortfall does not constitute neglect. During the Board's conSIderatIOn of ItS draft deciSIOn, It was made aware, by Counsel for the Employer, of a Gnevance Settlement Board DeclSlon which had been recently rendered. OPSEU (Bowes/Bell) and The Crown in Right of Ontario (Superior Ambulance Ltd.), (June 1997) GSB 787/96, 788/96 (Mikus) Counsel for the partIes agreed that the Panel should reVIew the deCISIOn, and they made submiSSIOns thereon. The declSlon concerned the dIsmIssal of two "long-servIce" Ambulance Officers, followmg a wntten complamt submItted by the Transport Resource Nurse, at the Neo-natal IntenSIve Care Umt at Chedoke-McMaster HospItals. She related m her letter of complamt that the Transport Team had been called by staff at Guelph General HospItal at 0845 hours to transfer to the Neo-natal Umt at Chedoke-McMaster HospItals, a premature infant, born WIthout VItal SIgns who was undergomg reSUSCItatIOn. The 128 Transport Team was to travel by dIspatched ambulance, from Chedoke-McMaster HospItals to Guelph General HospItal, (normally a tnp of 40 minutes), take the child mto ItS care, and return WIth the patient In an incubator to the Neo-natal IntenSIve Care Umt at Chedoke-McMaster HospItals. The Hamilton Dispatch Centre was contacted and following receipt of the patIent mformatIOn a Code 3 was aSSIgned to the call by the Centre. The Neo-natal Transport Team arrIved at the Emergency Room ofChedoke-McMaster HOSpItalS at 0855 hours but the ambulance was not there. Concerned about the delay, the Transport Resource Nurse called DIspatch. At 0920 an assIst-only Ambulance Crew arrIved and offered to take the Transport Team but when Dispatch was called, he/she, behevmg the aSSIgned Crew was to arrIve momentarIly, dId not reassIgn the call. At 0927 hours the Ambulance Crew whIch had been dIspatched to proVIde the transportatIOn, arrived, 42 minutes after the call to the DIspatch Centre. The complamant mentIOned the following concerns . The Crew would not speak ,. The Crew faIled to ask about the patIent etc. . The Crew hfted the mcubator into the ambulance, whIle the assIst-only Crew stood by watchmg . The ambulance travelled slowly during the first leg of the Journey WIth no SIrens m spite of the complainant mdicating that the case was a Code 4 . The complainant four tImes reminded the Dnver they were gomg to Guelph and gave dIrections to the hospItal, the Ambulance Driver Ignored her remmders and contmued along Highway 40 I to KItchener and then called Cambridge DIspatch for dIrections. . The Ambulance Attendant occupied herself domg cross-stItch and, in the VIew of the complamant, expressed no concern . The ambulance arrIved at Guelph HospItal at 1035 hours, 1 hour and 55 mmutes after the call had been placed by Guelph HospItal to Chedoke-McMaster HospItals and at least 1 hour and 50 mmutes after Chedoke-McMaster staff placed the call to HamIlton DIspatch. . Once at Guelph HospItal, the Crew followed With the transporter to the nursery, sat down, offered no aSSIstance, and made no mqumes about the patient. The Ambulance Attendant contInued to "do crafts" . The Crew mformed the complamant that there would be a problem connectIng the mcubator smce all ambulances had had theIr 12-volt power supply dIsconnected due to a fire hazard. The sortmg out of thIS problem with varIOUS agenCIes was left to the complamant. In the end, the mformatIOn proved to be erroneous. The tIme spent on the telephone took her "away from the patIent, causmg anxIety to the transport team and the patIent's famIly" The Ambulance Crew sat 129 throughout m the Guelph Hospital Nursery, the Attendant contmumg "her crafts" . In the end, It was arranged that the patient and the Transport Team would travel m a Guelph Ambulance and the complaInant was told to tell the HamIlton Ambulance Crew to return to HamIlton WIth the Guelph stretcher; the HamIlton Ambulance Crew dId not partiCIpate in the sorting out of this problem . The patIent, m the company of the Transport Team and the Guelph Ambulance Crew arrIved at Chedoke-McMaster HospItals after travelling Code 4, at 1245 hours, that is, 4 hours after the imtIal call was made. The mvestIgatIOn was conducted on the baSIS that the delay was unacceptable and dunng It, those mvestIgatmg dIscovered that there had been a ten-minute stop to pIck up coffee en route. The Dnver acknowledged the stop, although not ImtIally the length, and also that he had taken the wrong eXIt and gotten lost on the way to the Guelph HospItal. There was company policy whIch dIctated that Ambulance Officers "do not do personal errands whilst on duty unless authorised by the company or dIspatch" TheIr ten-minute stop WIthout the DIspatcher's knowledge affected a deCISIon whIch he/she made to not have the assist-only Ambulance Crew undertake the call, thereby contributmg to the delay The Ambulance Driver testIfied that the deCIsion to stop was hIs and his alone, that he was aware of the polIcy of not stopping for personal reasons Without notIfymg Dispatch and that he was wrong to have done so, although he did not thmk so at the time since he and others had done so and he had done so With a supervIsor previously He further testIfied that he drove "Code 4" as soon as he was adVIsed by the Transport Resource Nurse, and did not realIze he had missed the Guelph eXIt untIl mformed by her and that It was polIcy not to rely on the Transport Team for directIons. His mformatIOn respecting the electrIcal connectIOns, he testIfied, came from a mechanic dunng a maintenance check on hIs ambulance, and he belIeved that there was no power in the outlet. The Attendant-Gnevor, acknowledged that m the past she had stopped, also WIth a supervIsor, whIle on call, but never on a Code 3 She regretted havmg stopped and the problems that were caused. She testIfied that she belIeved the Dnver knew the route and therefore did not watch the SIgns, but dId her cross-stItch, untIl the pOInt where he mIssed the exit. She then tned to reach Cambndge DIspatch and consulted the maps, to confirm that Highway 7 went to Guelph. She also dId not consult the Transport Team for dIrectIOns, belIevmg dIrectIOns were to come from DIspatch. She had no dutIes at the 130 hospItal nursery untIl the patient and the Transport Team were ready to depart, although at one pomt durIng the dISCUSSIons of the electncal equipment, she spoke by telephone to Mr MacDonnell when the complamant was called away from the phone. When the members of the Ambulance Crew were mformed that they were to return to Hamilton with the Guelph stretcher, they dId so They were terminated two days later The Umon agreed, gIven the acknowledgement of the Grievors, that they made a ten-minute, unauthonzed stop for coffee whIle on a call, contrary to company pohcies and Ministry of Health dIrectIves, that some penalty was warranted but that dismIssal was exceSSIve gIven the Gnevors' prompt admIssions of gUIlt and expreSSIOns of remorse. Vice-chaIr Mikus found that [t]heir decision to stop and pick up a coffee on the way to MUMC was a serious breach of the rules that could have had significant consequences to the patient and the Company They were both aware of the rules and yet appear to have made a practice of ignoring them. .It was, in the case of [the Driver], a rational decision based on a past practice of ignoring Company rules. and that Mr Bell continued to excuse their behaviour, in part, on the fact that the rules were observed more in the breach. [and that the Driver's] insistence that they were not lost on their way to GGH[ was] frankly inconsistent with the transcript of his conversation with Cambridge Dispatch. In the result, Vice-chaIr Mikus took mto account the fact that the Grievors were "long servIce employees" of 11 and 8 years, one WIth a clean discIplme record, the other with a wammg mvolving delay m reportmg a maintenance/safety problem. She concluded that they made a serious error in judgement which, to some extent, was based on their mistaken belief that the Company was aware of and accepted the breach of the rules prohibiting unauthorised stops on a call, that they had learned a lesson and that "theIr future prospects for acceptable behavIOur (were] favourable" AcknowledgIng "a deliberate floutmg of the rules and polICIes" she ordered that they be remstated, and substItuted a penalty of a one-year suspenSIOn. 131 Mr Chondon for the Employer charactensed "the essence of the offence In the Supenor Ambulance [as a] declSlon mvolv(ing] Improper conduct on the part of an ambulance crew whIch resulted m a delay on a Code 3 call" He submItted that the seriousness of the case at hand IS greater gIven that it was a Code 4 and that "there was no eVIdence to support a findmg that crew changes at the end of a ShIft was a practice to WhICh any supervISOry or management members had partICIpated m or had knowledge of' He further argued that there was "no prompt admIssIon of gUilt nor any genume expreSSIOn of remorse on the part of eIther grievors (sic] In theIr eVIdence", and at the same time, he submItted there was a "lack of sufficent mItIgatmg factors to support a finding that the grievors' future prospects for employment were favourable" It was hIs opmIOn that the deCISIon m the Supenor Ambulance case, would lead one to conclude that It was appropnate to uphold the dIsmIssals In the matter at hand, or m the alternatIve, to substItute a lengthy suspenSIOn. Mr McEwan, for the Union, submItted that The Bowes/Bell case stands for the proposition that an unauthorized stop for coffee is serious misconduct which warrants some discipline. Stopping for coffee is a wilful and deliberate act. It bears no resemblance to the facts of this case which related to dispatch errors which led to a genuine uncertainty on the part of Rankin and Montgomery as to what dispatch was requiring them to do. The delay which occurred in responding to the call was not the result of any willful [sic] or deliberate misconduct; and that In the Bowes/Bell the fact of stopping for coffee was indisputable. By way of contrast in the present case the misconduct alleged by the employer is not undisputable [sic] In fact, if the evidence of the grievors is accepted it will be open to this panel to find that there was no misconduct and the issue of an admission of guilt will not arise. He dIstInguished the case WIth respect to remedy as follows Rankin and Montgomery are admitted to be competent and diligent ambulance attendants and their dedication goes beyond their employment and is reflected in their volunteer community activities in fire fighting and rslated work, There is no evidence in this case to suggest that the complained of behaviour is part of a persIstent pattern of behaviour ThIS is an isolated incident. These factors distinguish this case from 132 Bowes/Bell and provide overwhelming support for a finding by this panel that the employment relationship should be maintained and not destroyed. ThIs majority ofthe Board is of the opimon that the case at hand IS dIstmguishable from the BoweslBell case. It has not found any deliberate floutmg of the rules, or any senous error in Judgement on the part of eIther of the Gnevors. Nor has It found a pattern of Ignonng rules and dIrectIves. It has found against one of the Gnevors m one aspect only' that Mr Montgomery faIled to make hIS best effort to find the locatIOn of Finch, and once he found he was unable to read the map mdex, relIed solely on the DIspatcher to find the call locatIOn. To rely solely on the DIspatcher was not an error m judgement or a contraventIOn of any rule, rather It was a faIlure to be prepared to carry out, and to carry out a partIcular aspect of hIS work, that IS the Attendant's map-readmg to locate a call, to the best of hIS /her abilIty The Board does not conSIder It appropnate to follow the BoweslBell case, m its conSIderatIOn of eIther the merits or the remedy In the Montgomery/Rankin case. The Board WIshes to comment only bnefly on the mvestigatIOn. The Board belIeves that It was mappropnate for Mr Groleau to have been assIgned the role of mvestigator of hIS own complaInt, one In whIch he had a major interest. Mr Milo, on the other hand, had no mvolvement m the SItuatIOn and the Employer's appomtment of hIm was, m the Board's opImon, qUIte proper Employers cannot be expected to ensure that each tIme an mvestIgatIOn IS reqUIred that the mvestIgator and the employees mvolved in the inCIdent being investigated have a pOSItIve workIng relatIOnshIp If there IS a conflIct between Mr Milo and Mr Montgomery, the Board suggests that the partIes be offered some unbIased and mdependent aSSIstance to medIate theIr dIfferences. Other concerns whIch the Board had respectmg the procedure have been mentIOned throughout the declSlon. WhIle the Board IS cogmzant ofMr Montgomery's role m Health and Safety and Umon matters and recogmzes that hIS approach may be VIewed on occaSIOn by the Employer as troublesome, 133 the Board has concluded that the Umon has not made out a case for aggravated damages. It IS also declmmg to award punitIve damages. ThIS should not, however, be interpreted as the Board belIevmg that the Employer s actIOns In dlsmlssmg the two Gnevors dId not create hardshIp and humIlIatIOn far them. Each tIme an indIvidual's livelihood IS removed that person and the famIlIes who are dependent on them suffer DIsmIssal of long servIce employees, partIcularly, should not, m the VIew of the Board be undertaken lIghtly and should only be undertaken WIth respect bemg gIven to a thoughtful and thorough process pnor to the deCIsion bemg taken. In the result, Mr Rankin and Mr Montgomery are to be reinstated to full duties Immediately WIth no loss of semonty or benefits, and they are to receive compensation from the tIme of theIr suspension to theIr remstatement with mterest at 7 49 % (which IS the average pnme rate for the penod begmnmg January 1, 1995 and ending May 31,1997 - 6 49 + 1%) 11r Montgomery IS to have a letter ofwammg placed m his file for a period of 1 year, m whIch hIs duties as an Ambulance Officer respectmg his role m call locatIOn are set out. The letter IS to be removed after one year One of the major impacts that the dIsmIssals have had on 11r Montgomery and Mr Rankm IS the delay m theIr undertakmg traming as ParamedIcs. The Board orders therefore, that they be permItted to resume their progress through that program from the pomt at which they were forced to abandoned It and that they contmue the program, provIdmg they meet the qualIficatIOns as they progress, at the earlIest possible time follOWIng theIr reinstatement. The Board wIll remaIn seIsed to aSSIst the partIes in the event that they expenence difficulty WIth the implementatIOn of thIS deciSIOn. 134 Dated at Kmgston, OntarIo ~ c1~1 ler;! t/ DIssents D M. Clark, Member (Wntten dissent to follow) ~ueF J -C Laniel, Member 135 APPENDICES Appendix A Index, Page 10, Pathfinder Map Book Appendix B Map, Pages 73 & 74, Pathfinder Map Book 136 /ffrlN/J/) )- - C) . 1~~il~I~~II!~~~!! 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':H" . . ~ . ~, ' 'eI I! ..:l~Nnc ),-, ,._ n: 0 ~ ....... ::> <:e 1~ I ~'.;.",' ~ J - " DISSENT GSB #2624/94, 2625/94 REC EIVED OPSEU (Montgomery/Rankin) OCT 3 0 1997 PUBliC SERViCE and The Crown in Right of Ontario APPEl.\L GOARDS (Ministry of Health) Ottawa Carleton Regional Ambulance --------------------------------------------------- I have read the majority decision and, with respect, I dissent This member would like to make it very clear at the outset that the grievors appeared to be very dedicated Ambulance Attendants However, their actions on the evening of December 9 , 1994 were unconscionable In the opinion of this Board member, the grievors espoused every excuse in the book for not attending the Code 4 priority call, short of an Elvis sighting The majority of the Board felt that Mr Montgomery should only receive a written warning and for Nr Rankin, no discipline whatsoever With respect this flies in the face of the GSB decision, OPSEU (Bowes/Bell) and The Crown in Right of OntarlO (Superior Ambulance Ltd ) , (June 1997) GSB 787/96, 788/96 (Mikus) In that case, the grievors received a one year suspenslon for stopping for a coffee on a Code 3 call In the case at hand, the grievors did not complete a - 2 - call on a Code 4, but rather, did a crew change and went home In OPSEU (MacMillan) and Crown in Right of Ontario (Ministry of Health), Thames Valley Ambulance Ltd ) , GSB 967/93,(January 1995) ,(Dissanayake) , the grievor was given a 10 day suspension for delaying a Code 1 (the lowest priority) call In the case at hand, the grievors not only delayed a Code 4 call, they did not complete the call The majority of the Board went to great lengths to detail what they felt were the "errors" made by the Dispatcher They focused on what information the Dispatcher did not give the grievors and questioned whether or not the correct ambulance had been assigned the call However, notwithstanding this fact (and this member is not necessarily in agreement with all of their conclusions ) , at the end of the day, when all is said and done, two facts remain The Dispatcher did assign the grievors the Code 4 priority call and it was the responsibilitv of the grievors to go to the location given to them by the Dispatcher This did not happen In the opinion of this member, the discharge for Nr Montgomery and Mr Ranking should have been upheld For reasons detailed below, this would be in line with the one year suspension imposed in the Bowes/Bell case where they stopped for a cup of coffee during a Code 3 call - 3 - This member will deal with Mr Montgomery first MR. MONTGOMERY At 19 13 08, Mr Montgomery told the Dispatcher " I mean we'll go if you want We didn't know we had the call /I In his Incident Report of December 14, 1994, the last statement he wrote was "at no time were we given the call or did we refuse to do the call", During the course of this hearing, he indicated that he did not complete the call because of a number of factors These included a lack of a call number, confusion with the reference to "standby", an anticipated reassignment, the suggestion that the Dispatcher did not select the most appropriate vehicle, there should have been a tiered response, the lighting in the vehicle was insufficient to read the map and they did not know the location of Finch If Mr Montgomery did not know the location of Finch, but told the Dispatcher he would go "if you want" ! then one would expect the next question the grievor would ask the Dispatcher is "where is Finch, we cannot find it" The next statement the grievor made over tne radio was a request for the Dispatcher to give him "the information again" This was a Code 4 priority call According to the grievor he could not complete the call because he did not know the location of Finch Did he say "hey, wait a minute we'll go but please tell us how to get there because I can't read - 4 - this map due to the poor lighting conditions in the vehicle and the 5 year old child who is possibly hanging will not receive medical attention until we get there"? No He asked for the information again From 19 09 34 until 19 14 37, the Dispatcher gave the Crew the address as being 61 Finch a total of 8 times during the course of 6 transmissions. The 19 09 34 transmission started with the words "Code 4" Mr. Montgomery agreed that at 19 09 34 he was on a pre-alert on the 61 Finch call and that the pre-alert was never cancelled by the Dispatcher. It was at this time he pulled out the map book and turned on the swivel light to look for the location of Finch According to Mr Montgomery, he was unable to find Finch in the book because of the tiny print, the poor lighting in the vehicle, the action of the ,~ windshield wipers, the glare of the brake lights in front and the stop and go movement of the vehicle in bumper to bumper traffic According to him, he did not bother to take his personal flashlight out of its holster because he knew the batteries were in need of recharging He acknowledged that he did not ask to borrow Mr Rankin's flashlight and he did not recall looking for the cab flashlight With respect to the issue of Mr Montgomery not being able to read the small print in the map book, Mr Chondon, - 5 - counsel for the Ministry, introduced into evidence Exhibit #62 This exhibit was a photocopy of Mr Montgomery's diary note concerning the call in question The photocopy was the same size as the note Mr Montgomery had made It was approximately 3/4" in height by 7/8" wide. Mr Montgomery wrote 9 lines describing what had occurred during the call in question Having seen the small print which Mr Montgomery wrote and was subsequently able to read, this member has a great deal of difficulty accepting his statement that he could not read the small print in the map book, even if one accepts his assertion that the lighting in the vehicle was poor This member also has difficulty accepting this assertion given the evidence introduced by the Employer concerning the lighting specifications in the vehicle. During the course of one of the hearing days, the Chair of this panel asked Mr Montgomery a clarification question She asked him, in spite of the confusion about whether or not he had the call, if he would have proceeded to 61 Finch if he knew where it-.was His response was "yes Madam Chair" Two days later, Mr Chondon asked Mr Montgomery an almost identical question Mr Chondon's question " . was 1n spite of the confusion, if you knew where you were going, you would have responded to the call, wouldn't you?" Mr Montgomery's response was "absolutely" - 6 - During cross-examination, Mr Montgomery admitted that he did not look up the location of Clearwater when the Dispatcher told them Finch was near Clearwater for the second time at 19 10 23 Mr Montgomery also stated that he had stopped looking for Finch in the map book when Mr Rankin requested "a twenty" on Finch at 19 10 15. Mr Montgomery testified that he thought Clearwater might be near Claymore, a street with which he was familiar Did he ask the Dispatcher if Clearwater was near Claymore? He did not. The confusion with respect to Claymore and Clearwater did not originate from the Dispatcher It originated from Mr. Montgomery At 19 12 54, the crew arrived at the ambulance base Mr Montgomery did not pull out the map book and once again try to look up the location of Finch despite the fact that the vehicle was stationary, they were no longer in bumper to bumper traffic and there was no glare from the tail lights reflecting off the windshield Mr Montgomery was of the op1.n1.on t rra t they had been assigned the call at 19 13 24 while they were at the ambulance station He still, however, did not take out the map book Instead he went into the station to see if another crew was willing to take the call, i e , to do a crew change on a Code 4 priority call - 7 - This member would like to emphasize the fact that during cross-examination, Mr Chondon asked Mr Montgomery if he would agree that he (Mr Montgomery) , in part, contributed to the delay in responding to the call Mr Montgomery's response was "no sir", In the opinion of this member, Mr Montgomery's actions were the main reason for the call being delayed Clearly, Mr Montgomery's refusal to accept, even in part, some of the responsibility for the delay in responding to the call, has to be considered in light of the issue of mitigating circumstances and this Board's authority to substitute the discharge penalty for a lesser penalty, This member would also like to emphasize that, at page 121 of the award, the Chair wrote " there was no , communication from Dispatch during the 1 minute and 54 seconds that it took them to arrive at the Base, and then, it was Mr Montgomery who, according to normal protocol, announced their arrival at base " (The Chair's emphasis) With respect, during the 1 minute and 54 seconds that it took them to arrive at the Base neither Mr Montgomery or Mr Rankin got on the radio and said "hey look. we can~"t find Finch in the map book" What were they doing for these nearly two minutes? What they were not doing was everything in their power to come to the ald of a child, which was why they were assigned the call ln the first place - 8 - This member preferred the evidence of Ms Mills over Mr Montgomery when it came to the issue of knowing where Finch was According to Mr. Montgomery, he did not tell Ms. Mills where Finch was According to Ms Mills, he did Ms Mills' second Incident Report of December 22, 1994 indicated that Mr Montgomery told her that Finch was near McCarthy across from the fire station In addition, in her third Incident Report of January 13, 1995, she indicated that Mr Montgomery gave her the information about the call and that she did not receive any information from Dispatch. One must remember that Mr Montgomery was a volunteer fire fighter and it is not beyond the realm of possibility that he would be familiar with where the fire stations were Ms Mills' testimony concerning Mr Montgomery's knowledge of the location of Finch was corroborated by Mr Anderson's Incident Report of January 12, 1995 (Exhibit #87) Mr Anderson wrote " when I proceeded to the vehicle Mr Montgomery had provided my partner IMs Mills) with some further details and was nOH explaining the 10-20 (the location of the call)" MR RANKIN Hr Rankin Has of the opinion that the communications from the Dispatcher at 19 09 55 would normally be sufficient for a pre-alert The pre-alert Has never cancelled - 9 - In cross-examination, Mr Rankin admitted that during the 1 minute and 54 seconds between 19 11 00 and 19 12 54, he did not think to ask his partner to find the location of Finch in the map book He also indicated that at 19 13 03, he was given the call Once he was given the call did he try to complete it'? No Instead he allowed Mr Montgomery to leave the ambulance and go into the station during which time Mr Montgomery asked another crew if they would be willing to do the call. Mr Rankin's personal notes described his version of the call in question Nowhere in his notes does he indicate that they could not find Finch Instead, his notes indicate that he was confused with the Dispatcher's use of the term "standby" He wrote that he was given the call after he arrived at base and also wrote that this was after his "assigned shift" In the last line of his document, he wrote "this driver was prepared to respond if no-one (sic) else available" Mr Rankin's note clearly demonstrates hlS preoccupation with the fact he felt he l-'as given the call after his shift was over There is nothing in his notes about being unable to find Finch If the lighting conditions in the ambulance were so poor as to prevent Mr Montgomery from reading the map book, Nr Rankin could have stopped at the strip mall at the - 10 - '" intersection of Riverside and Uplands As the award points out, he did not consider this. He could have also stopped at the barricaded road along the way. As the award points out, he did not consider this either. During the 1 minute and 54 seconds when there was no transmission between the Dispatcher and the ambulance crew, he could have told the Dispatcher they had no idea where Finch was. He did not do this. In cross-examination, Mr. Chondon asked Mr Rankin if it was not incumbent on Mr Rankin and his partner to do something to alleviate the confusion about the location of Finch Mr Rankin replied "looking back, everyone should have done more" (emphasis added) Mr. Rankin then went on to say that, in hindsight, he could have stayed on the radio and "nagged" the Dispatcher after the 19 10 23 transmission concerning Clearwater. Mr Rankin then quickly said this would not have done any good because of what he interpreted the Dispatcher's transmission at 19 13 14 to mean, i e , the Dispatcher said he wanted to confirm the address It should be note d that the Dispatcher twice gave the address as 61 Finch during the transmission at 19 09 34 and two more times during the transmission at 19 09 55 This member has difficulty understanding how Mr Rankin felt the Dispatcher, at 19 13 14, still wanted to confirm the address Mr Rankin did not want to accept any responsibility for the delay in the call - 11 - In conclusiont the entire defence of the grievors was premised on what the Dispatcher did wrong It is not the role of the Dispatcher to go out on a call. That is the role of the Ambulance Attendants Their job is to attend at the scene, render treatment and transport the patient The grievors did not do this. In Mr Montgomery's Incident Report, he did not mention that he was unable to find Finch The evidence of Ms Mills and Mr. Anderson suggests Mr Montgomery did know the location of Finch The communications at 19 13 08 between Mr Montgomery and the Dispatcher was based on the alleged confusion about the term standby and not knowing whether or not he (Mr Montgomery) had the call Mr Montgomery advised the Dispatcher they would go if the Dispatcher wanted them to. Nowhere in the transcript does it show Mr Montgomery asking the Dispatcher where Finch was What did Mr. Montgomery do next? He left the ambulance to see if another crew would do the call Mr Rankin's Incident Report also did not mention they were unable to find the location of Finch His report indicated that he was confused with the term standby and that they were assigned the call after the end of their shift In Mr Rankin's opinion, he was given the call at 19 13 03 He then allowed Mr Montgomerv to enter the ambulance station to see if another crew would complete the call - 12 - Both Mr Montgomery and Mr Rankin agreed that at some point during the call in question they were proceeding as if they were on a pre-alert Both agreed the pre-alert was never cancelled by the Dispatcher Both gave written reasons in their Incident Reports as to why they could not complete the Code 4 call In the opinion of this member, for Mr Montgomery and Mr Rankin to come before this Board and now say they could not complete the call because they did not know the location of Finch stretches their credibility to the breaking point. During the call in question, it is most fortunate that the patient survived despite the unacceptable time it took to eventually respond to the call The grievors can receive no credit whatsoever for the fortuitous outcome in this matter This member would like to make one last point In the award the majority concluded, at page 125, that it was not unreasonable for Mr Montgomery to hand over the Code 4 call to a different crew The Chair wrote that Mr Montgomery "followed a practice" of handing over calls to incoming crews and Mr Montgomery did "not contravene any rule respecting crew change" The Chair added that this related to this specific situation and "should not be read as condoning crew changes on priority calls" With respect, this member could not disagree more - 13 - Even if there was no "rule" which prohibited a crew change on a Code 4 priority call, common sense should prevail Even Mr Rankin admitted during the hearing that a crew change on a Code 4 would be appropriate only in exceptional circumstances There were no exceptional circumstances in this situation In addition, there was no request from the grievors to do a crew change The Dispatcher was not aware of the crew change and he certainly did not authorize the change. A crew change, in most circumstances, will result in a delay In this member's opinion, it should not have been necessary for the Employer to have a policy prohibiting a crew change on a Code 4 call. The grievors, as Ambulance Attendants, knew they were required to respond to the call They were clearly aware of this responsibility This member fully agrees with Mr Chondon's assertion that there was no evidence to support a finding that crew changes at the end of a shift was a practice to which any supervisory or management members had participated in or had knowledge of Accordingly, this member would have upheld the discharge for Mr Montgomery and Mr Rankin It is the opinion of this member that the actions of both grievors constituted "neglect" This neglect directly resulted in a totally - 14 - unacceptable response time to a Code 4 priority call, a call which they did not even bother to complete, but rather ,just handed it over to another crew f)t, d/ Don M. Clark October 22, 1997