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.
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.
 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."
Yes, you read that right. FROM THE HALLWAY.
It was too late. Szabo was transferred to Health Sciences Cente but died there.
* 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.
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.