Communication failure delayed ambulance for marathoner

It took paramedics nine minutes from officer’s first call for help to reach scene

The city, police and organizers of the Montreal Marathon must better co-ordinate emergency procedures, a Quebec coroner says in a report on the death of 24-year-old runner Patrick Neely.

The young engineer from Beaconsfield, who suffered from congenital heart disease, collapsed less than one kilometre from the finish line during the half-marathon event on Sept. 22.

Paramedics arrived at 10:03 a.m., about nine minutes after the first call from a police officer who tended to Neely after he collapsed, coroner Géhane Kamel says.

In the seven-page report, Kamel faults organizers of the International Oasis Rock ’n’ Roll Montréal Marathon for lack of communication with the City of Montreal. This resulted in “not having on site the necessary personnel for such a large deployment, nor clear instructions as to the deployment of aid to marathon runners,” he writes.

Urgences-santé should have been able to reach its ambulance without delay, and the patient should have been taken to a hospital that specialized in cardiac cases, he adds.

Of the 200 employees who were supposed to be posted along the marathon’s route, only 60 showed up, Kamel notes. As a result, Montreal police had to deploy more than 200 additional officers.

Neely died of multi-organ failure after suffering cardiac arrest, he reported.

To help prevent future tragedies, the coroner recommends:

Marathon organizers must

■

ensure that the location of defibrillators be known by everyone on duty, including police officers;

Urgences-santé personnel must

■

know the position of its vehicles and paramedics and guarantee the provision of emergency services;

Cardiopulmonary resuscitation

■ training must be mandatory for all Montreal police officers;

The provincial health department

■ must instruct ambulance crews to take cardiac patients to a hospital that offers hemodynamic monitoring rather than to the closest hospital;

During sports events, the City of

■

Montreal must ensure that medical and organizational infrastructures comply with proper standards. It must refuse to authorize any event where those standards are not met.

Neely was physically fit, practised several sports and was followed annually at the Montreal Heart Institute, the report says. His medical condition was indicated on his bib, it says.

In his report, Kamel retraces the sequence of events, noting that several aspects of the emergency response “certainly compromised his chances of survival.”

Police requested support at least three times between 9:52 and 9:56 a.m., he notes.

At 9:51 a.m., a Montreal police officer stationed at the intersection of Cherrier and St-hubert Sts. saw Neely stagger and rushed to his side. Neely collapsed, had trouble speaking and then lost consciousness.

At 9:52, the officer called her lieutenant at police Station 7. Two minutes later, she requested assistance from Urgences-santé, saying Neely had an irregular pulse. At 9:55, she spoke with Urgences-santé again, saying the case was a priority.

While waiting for the ambulance, the officer performed cardiopulmonary resuscitation on the patient with a bystander who was a nurse, assisted by another officer and citizen.

At 9:57, Urgences-santé told the officer it had not managed to reach the ambulance, because the paramedics had been assigned to a mobile medical clinic. It took two more minutes to reach them. The ambulance finally got on the road at 10 a.m. Firefighters, alerted by a police officer who ran to the fire station, arrived on the scene at 10:01, followed by the paramedics at 10:03.

The patient was taken by ambulance to Notre-dame Hospital and later transferred to the Centre hospitalier de l’université de Montréal (CHUM), where he was declared dead at 8:11 p.m.

Kamel notes the police officer had CPR training because she had previously worked for another police force where the training was mandatory. He recommended it should be required for all Montreal police officers.

The marathon’s director, Dominique Piché, resigned after the race. In addition to being marred by the tragedy, the race started almost an hour behind schedule because of a shortage of staff and volunteers to secure the course.

At 9:57, Urgences-santé told the officer it had not managed to reach the ambulance, because the paramedics had been assigned to a mobile medical clinic.