Upgrade Winnipeg stadium: inquest report
A Manitoba judge is calling for safety upgrades at Canad Inns Stadium in Winnipeg following a deadly fall from the stands.
Provincial court Judge Mary Kate Harvie is also calling for better treatment of trauma patients at the city's community hospitals.
Andrew Szabo, 52, was drunk when he tumbled through a guardrail during a Blue Bombers Canadian Football League game in August 2006 and fell six metres to the concrete below.
The Winnipeg Regional Health Authority has issued a response to provincial court Judge Mary Kate Harvie's findings. The release, issued by spokeswoman Kathryn McBurney, reads in part:
"We have just received the inquest report and recommendations, and are in the process of reviewing them. Some of the recommendations are complex and will have an impact across the health system. As such, it will take time to review the recommendations to determine how best to move forward with implementation.
"Some recommendations, however, have already been implemented." For example:
- CT (computerized axial tomography) hours at the Grace and other hospitals have been expanded.
- Winnipeg Fire and Paramedic trauma triage protocol expanded to include the mechanism of injury along with the patient’s level of consciousness to best determine the appropriate hospital for care.
Changes at Grace Hospital include:
- Expanded diagnostic services: In 2006, CT scans were only completed during work hours on weekdays. As of February 2009, the CT scanner is staffed for weekdays, evenings and weekends.
- Increased front line staff in the emergency department: 2.6 new nurse positions added to ensure there is a dedicated overnight triage/reassessment nurse (March 2009); 2.8 health-care aides to address volume increases and ensure that patient needs associated with toileting, personal hygiene and feeding are addressed (May 2011).
- Work toward summer opening an emergency short stay unit, a 10-bed unit for the assessment, care planning and discharge of frail elderly patients who do not require acute care admission but are not physically able to return home quickly. This will move the care of these patients away from the emergency department.
Szabo died several hours later after lying in the Grace Hospital for hours, doctors oblivious to his many broken bones and internal bleeding. He eventually went into shock before physicians realized there was something seriously wrong.
"I conclude that Mr. Szabo's death was preventable," Harvie wrote in her report, released Wednesday.
"The recommendations in this report identify for consideration areas of improvement at the Canad Inns Stadium, for changes to the pre-hospital system, as well as recommendations for the enhancement of care of trauma patients at community hospitals."
Harvie says in her inquest report that guardrails, stairs and other aspects of the north-end stands need to be inspected and upgraded.
This is the final season the stadium will be used. The Bombers are moving to a new facility next year and the stadium is slated to be torn down.
She also has several recommendations for hospital improvements, including retraining programs for nursing staff in trauma care.
She pointed to a failure by doctors to notice many of Szabo's injuries — not only the broken pelvis and slow internal bleeding, but also a broken collar bone, broken ribs and a collapsed lung.
"A number of witnesses confirmed that Mr. Szabo had an obvious fracture to his clavicle — a fact not noted by (emergency room physician Terence) Bergmann in his examination," Harvie wrote.
"When asked how he could have missed the fractured clavicle, his only response was that while Mr. Szabo's shirt would have been open, he is not sure if it was open wide enough for him to see the collar bone."
Tripped while meeting friend
Szabo was an alcoholic and had consumed liquor before arriving at the stadium for the game, his widow, Barbara, testified at the inquest in September 2009.
He had just come back from ordering two beers at the start of the game and stood up to go meet a friend when he tripped.
Paramedics took him to the nearby Grace Hospital instead of the city's main trauma unit at the Health Sciences Centre downtown.
Barbara Szabo told the inquest — which wrapped up in October 2010 after a number of breaks in its schedule — that doctors at the Grace Hospital told her that evening her husband had no broken bones. It was only several hours later, near midnight, that his blood pressure plummeted and he was rushed to the Health Sciences Centre where he died.
ER examination 'fell short'
"It would appear from the evidence … that the most significant injury sustained by Mr. Szabo, being the pelvic fracture, could have been detected if the appropriate X-rays had been ordered," Harvie wrote.
"The initial examination conducted by Dr. Bergmann fell short of obtaining the kind of detail expected of an emergency room doctor."
Harvie's report also urges federal and provincial agencies that set national building codes to consider making them retroactive for stadiums, hockey arenas and other public facilities. Currently, older buildings only have to upgrade their safety measures if they undergo a major renovation.
Hospital officials were not immediately available to comment. The lawyer for the Winnipeg Blue Bombers, who own the stadium, said upgrades will be made.
"If the judge says these improvements should be done, they will be done," Bob Sokalski said.
The football club took over Canad Inns from the city in 2004, and the team assumed that everything complied with the safety code, Sokalski added. In recognition of that, Harvie has ordered the city to pay for any upgrades.
Canad Inns Stadium was built in 1953. The north-end stands were added three years later.