Skip to main content

The horror story behind the death of Andrew Szabo



The inquest report into the 2006 death of Blue Bombers fan Andrew Szabo was released on Tuesday -- but news reports only hint at the actual horror story behind the tragedy.

Szabo slowly bled to death in Grace Hospital after falling off a landing onto the concrete below and suffering a broken pelvis that went undiagnosed.

Inquest Judge Mary Kate Harvie tries to make ER doctor Terrance Bergmann the scapegoat but news reports failed to point out that she cited Winnipeg paramedics as sharing the blame.

Here's the full story...

Imagine this scenario: a man trips and free-falls, say, 15 feet before crashing into the cement. He' s unconscious and bleeding from the back of his head.

What do you think happens next?

Most people would say somebody calls 911, an ambulance shows up, and the unfortunate man is taken to a hospital as quickly as possible for x-rays to his skull.

You dreamer.

Here's how it worked in real life in Winnipeg.

* Szabo stumbled on the stairs and tumbled off a landing at the stadium about 7:25 p.m. He was immediately attended to by paramedics working for Criti Care, a private paramedic company hired to work the Bombers game.

They found he was semi-conscious and had obviously broken his collar bone. And he was drunk. The inquest was told Szabo's blood-alcohol reading at the time he fell would have been in the range of .221 to .276. But Szabo was a hardcore drinker who might have masked his impairment well.

* Szabo slowly regained his senses, but the paramedics still called 911. At 7:37, 12 minutes after the fall, a Winnipeg city ambulance arrived. The city paramedics didn't trust the private paramedics, even though one of them was one of their own who was a moonlighting, so they repeated the examination of the injured man, then called in a supervisor, then decided to take Szabo to Grace Hospital rather than the city's only trauma hospital, Health Sciences Centre.

* All in all, the city paramedics spent 21 minutes at the scene, and another 14 minutes getting Szabo to the hospital and admitted. In other words, Andrew Szabo didn't get to a hospital until 47 minutes after he fell.

And Judge Harvie declared they took Szabo to the wrong hospital
--- which wouldn't have happened if they used their judgement instead of following the rules to the letter.

[170] The addition of either the “EMS Provider Judgement” or the “When in Doubt” criteria would have given the WFPS paramedics the flexibility to consider transport to the HSC as opposed to the Grace General Hospital. For example, such flexibility may have allowed Medical Supervisor Charles Thomas to consider the GCS scores obtained from Mr. Nienhuis, who happened to be working in the capacity of a Criti Care employee as opposed to a WFPS employee. It is clear that Mr. Thomas was working under the understanding that he had “zero” discretion to do anything but apply the triage protocols. This strict approach needs to change.

And that was just the beginning of the disaster.

* When paramedics briefed the triage nurse at Grace Hospital on Szabo's accident and his responses to their on-the-scene examination, she immediately felt he should have been taken to HSC. But without the authority to order the ambulance to take him there, she admitted him but red-flagged him for the doctor's attention within 15 minutes. (This is Winnipeg. There is only one ER doctor on shift.)

Not long afterward, Dr. Bergmann checked on Szabo. His understanding after talking with a nurse was that Szabo had fallen down 20 stairs and banged his head. There was no chart for him to read, he said. The patient was conscious, and not complaining of any pain. The doctor ordered urinalysis, a CT scan, and X-rays of his spine. Later in the evening he returned and stitched up the cut on Szabo's head.

* That night the nurses (and doctor, we imagine) were run off their feet.

Some staff described the evening as “the worst night in five years.” wrote Judge Harvie.

Szabo's bedside nurse Holly Johnson described the hour after leaving him to the care of nurse Lora di Bernardo as “a blur.”

"Subsequent to the evening of August 4, nursing staff filled out an “Unsafe Work” form documenting their concerns about the patient to staff ratio. Lora di Bernardo described that for a period of time she was responsible for seven acute patients."
* The doctor still thought he was dealing with a drunk who had fallen down some stairs. The X-rays showed nothing and the urinalysis results hadn't turned up by the time his shift ended at midnight.
Neither he nor the nurses realized that Szabo was broken to pieces inside ---fractured rib, a collapsed lung, a fractured pelvis---because there was no whole-body CT scan available at the Grace.
From the inquest report:
258] Sometime around 00:30 hrs on August 5, 2006 Mr. Szabo’s condition was found to have deteriorated. He had earlier been moved by staff from the hallway in preparation for possible discharge. After concerns were raised by Mrs. Szabo and by nursing staff, he was moved again to the Resuscitation bay.

Yes, you read that right. FROM THE HALLWAY.

It was too late. Szabo was transferred to Health Sciences Cente but died there.

So...

* It took 47 minutes to get Andrew Szabo to a hospital by ambulance.

He could have gotten there faster taking a bus.

Even though the paramedics thought he should go to Winnipeg's only trauma hospital and the triage nurse thought he should go to Winnipeg's only trauma hospital, the rules said he had to go to a community hospital because he fell less than 20 feet.

* The judge hints that one reason the rules require ambulances to take patients everywhere except Health Science Centre, is because HSC is already overwhelmed with the dregs of Winnipeg. As she put it so circumspectly:

131] The HSC, Manitoba’s only trauma center, faces its own specific challenges in respect of over-triaging. While it has an exceptionally small catchment area of approximately one square mile, there is the significant call volume of patients that attend to the HSC from that catchment area, regardless of the nature of their injuries. At the risk of over-simplifying the matter the Court heard that the issues affecting the call volume at HSC, given the population in its catchment area, include issues related to poverty, homelessness, the easy physical access to the HSC, as well as specific challenges related to public education.
* Miscommunication between doctor and nurses at Grace Hospital meant the doctor thought he had taken a less serious fall than was true, so he wasn't looking for serious injuries.

Neither the doctor nor nurses realized Szabo had a broken collar bone, or that he had shit himself when he fell. That's just odd.

* The chronic nursing shortage contributed to the overall dysfunction of the Grace ER.
----------

A severely injured man gets to a hospital only to spend hours dying of undiagnosed injuries. This would be shocking if it was the only time this happened. But it's not the only time.

The Szabo case is a foreshadowing of what we will see when the Brian Sinclair inquest finally gets underway. Sinclair, you remember, died in the HSC emergency room in 2008 under the eyes of medical staff while waiting to see a doctor to change a blocked catheter, a simple procedure. He was there for 30 hours before anyone noticed he was dead.

The NDP has managed to stall that inquest until after the coming provincial election because they know how explosive it will be.

Popular posts from this blog

The unreported bombshell conspiracy evidence in the Trudeau/SNC-Lavelin scandal

Wow. No, double-wow. A game-changing bombshell lies buried in the supplementary evidence provided to the House of Commons Judiciary Committee by former Attorney General Jody Wilson-Raybould. It has gone virtually unreported since she submitted the material almost a week ago. As far as we can find, only one journalist-- Andrew Coyne, columnist for the National Post--- has even mentioned it and even then he badly missed what it meant, burying it in paragraph 10 of a 14 paragraph story. The gist of the greatest political scandal in modern Canadian history is well-known by now. It's bigger than Adscam, the revelation 15 years ago that prominent members of the Liberal Party of Canada and the party itself funneled tens of millions of dollars in kickbacks into their own pockets from federal spending in Quebec sponsoring ads promoting Canadian unity. That was just venal politicians and a crooked political party helping themselves to public money. The Trudeau-Snc-Lavalin scandal is

Manitoba Hydro is on its deathbed. There, we said it.

Manitoba Hydro is on its deathbed. Oh, you won't find anyone official to say it. Yet . Like relatives trying to appear cheery and optimistic around a loved one that's been diagnosed with terminal cancer, the people in power are in the first stage of grief -- denial. The prognosis for Hydro was delivered three weeks ago at hearings before the Public Utilities Board where the utility was seeking punishingly higher rates for customers in Manitoba. It took us this long to read through the hundred-plus pages of transcript, to decipher the coded language of the witnesses, to interpret what they were getting at, and, finally, to understand the terrible conclusion.  We couldn't believe it, just as, we're sure, you can't--- so we did it all again, to get a second opinion, so to speak.  Hydro conceded to the PUB that it undertook a massive expansion program--- involving three (it was once four) new dams and two new major powerlines (one in the United States)---whi

Crips and Bloodz true cultural anchors of Winnipeg's aboriginal gangs

(Bebo tribute page to Aaron Nabess on the right, his handgun-toting friend on the left) At least six murder victims in Winnipeg in the past year are linked to a network of thuglife, gangster rap-styled, mainly aboriginal street gangs calling themselves Crips and Bloods after the major black gangs of L.A. The Black Rod has been monitoring these gangs for several months ever since discovering memorial tributes to victim Josh Prince on numerous pages on Bebo.com, a social networking website like Myspace and Facebook. Josh Prince , a student of Kildonan East Collegiate, was stabbed to death the night of May 26 allegedly while breaking up a fight. His family said at the time he had once been associated with an unidentified gang, but had since broken away. But the devotion to Prince on sites like Watt Street Bloodz and Kingk Notorious Bloodz (King-K-BLOODZ4Life) shows that at the time of his death he was still accepted as one of their own. Our searches of Bebo have turned up another f

Nahanni Fontaine, the NDP's Christian-bashing, cop-smearing, other star candidate

As the vultures of the press circle over the wounded Liberal Party of Manitoba, one NDP star candidate must be laughing up her sleeve at how her extremist past has escaped the scrutiny of reporters and pundits. Parachuted into a safe NDP seat in Winnipeg's North End, she nonetheless feared a bruising campaign against a well-heeled Liberal opponent.  Ha ha.  Instead, the sleepy newspeeps have turned a blind eye to her years of vitriolic attacks on Christianity, white people, and police. * She's spent years  bashing Christianity  as the root cause of all the problems of native people in Canada. * She's called for  a boycott of white businesses . * And with her  Marxist research partner, she's  smeared city police as intransigent racists . Step up Nahanni Fontaine, running for election in St. John's riding as successor to the retiring Gord Macintosh. While her male counterpart in the NDP's galaxy of stars, Wab Kinew, has responded to the controversy over

Exposing the CBC/WFP double-team smear of a hero cop

Published since 2006 on territory ceded, released, surrendered and yielded up in 1871 to Her Majesty the Queen and successors forever. Exposing the CBC/FP double-team smear of a hero cop Some of the shoddiest journalism in recent times appeared this long August weekend when the CBC and Winnipeg Free Press doubled teamed on a blatant smear of a veteran city police officer. In the latest example of narrative journalism these media outlets spun stories with total disregard for facts that contradicted the central message of the reports which, simplified, is: police are bad and the system is covering up. Let's start with the story on the taxpayer funded CBC by Sarah Petz that can be summed up in the lead. "A February incident where an off-duty Winnipeg officer allegedly knocked a suspect unconscious wasn't reported to the province's police watchdog, and one criminologist says it shows how flawed oversight of law enforcement can be." There you have it. A policeman, not

Winnipeg needs a new police chief - ASAP

When did the magic die? A week ago the Winnipeg police department delivered the bad news---crime in the city is out of control. The picture painted by the numbers (for 2018) was appalling. Robberies up ten percent in  a single year.  (And that was the good news.) Property crimes were up almost 20 percent.  Total crime was 33 percent higher than the five year average. The measure of violent crime in Winnipeg had soared to a rating of 161.  Only four years earlier it stood at 116. That's a 38 percent deterioration in safety. How did it happen? How, when in 2015 the police and Winnipeg's police board announced they had discovered the magic solution to crime? "Smart Policing" they called it.    A team of crime analysts would pore through data to spot crime hot-spots and as soon as they identified a trend (car thefts, muggings, liquor store robberies) they could call in police resources to descend on the problem and nip it. The police