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Montreal Coroner's Report - December 6, 1989 Shootings |
| INVESTIGATION REPORTS
(Part II) victims file numbers BERGERON, Geneviève A-41560 COLGAN, Hélène A-41575 CROTEAU, Nathalie A-41573 DAIGNEAULT, Barbara A-41574 EDWARD, Anne-Marie A-41561 HAVIERNICK, Maud A-41567 KLUEZNICK, Barbara Marie A-41558 LAGANIERE, Maryse A-41559 LECLAIRE, Maryse A-41564 LEMAY, Anne-Marie A-41576 LEPINE, Marc A-41563 PELLETIER, Sonia A-41566 RICHARD, Michèle A-41565 ST-ARNEAULT, Annie A-41577 TURCOTTE, Annie A-41568
2.1.1 Description of work done by the comité pour la prévention 2.1.1.1 First floor p. 2 2.1.1.2 Second floor p. 3 2.1.2 Comments p. 3
2.2.1 Description of the scene p. 5 2.2.1.1 First floor p. 5 2.2.1.2 Second floor p. 5 2.2.1.2.1 Room C-230.4 p. 5 2.2.1.2.2 Room B-218 p. 6 2.2.1.2.3 Corridor p. 6 2.2.1.3 Third floor p. 6 2.2.1.3.1 Room B-311 p. 6 2.2.1.3.2 Corridor p. 6 2.2.2 The shooting p. 6 2.2.3 Other relevant facts p. 11 2.2.4 Prior knowledge of the scene p. 12 2.2.6 Weapons used p. 13 2.2.7 Profile of Marc Lépine p. 13
2.3.1 9-1-1 emergency centre p. 15 2.3.2 Urgences-Santé p. 17 2.3.2.1 Period preceding transmission of 2.3.2.2 Period following transmission of 2.3.2.3 Period following arrival of first vehicle 2.3.2.4 Period following access to interior p. 21 2.3.3 SPCUM p. 29 2.3.3.1 Period preceding transmission of 2.3.3.2 Period following transmission of 2.3.3.3 Period following arrival of first vehicle 2.3.3.4 Period following access to interior p. 36 2.3.4 Université de Montréal or École Polytechnique
2.4.1 9-1-1 Centre p. 43 2.4.2 Urgences-Santé p. 43 2.4.1 SPCUM p. 44
2.5.1 9-1-1 Centre p. 46 2.5.1.1 Observations p. 46 2.5.1.2 Questions p. 47 2.5.2 Urgences-Santé p. 47 2.5.2.1 Observations p. 48 2.5.2.2 Questions p. 49 2.5.3 SPCUM p. 51 2.5.3.1 Observations p. 51 2.5.3.2 Questions p. 53 2.5.4 Université de Montréal or 2.5.4.1 Observations p. 57 2.5.4.2 Questions p. 57 2.5.5 General p. 57
victims file numbers BERGERON, Geneviève A-41560
In order to establish whether any one of the victims could have been
saved, in medical terms, having regard to the exact nature of each victim's
injuries, it is useful and even essential, in the circumstances, to consult
medical experts; here, these are the members of the post-trauma mortality
prevention committee of the Montreal General Hospital. 2.1.1 Description of work done by the comité pour la prevention de la mortalité post-traumatique de l'Hôpital Général de Montréal [post-trauma mortality committee of the Montreal General Hospital] This committee includes a cardiovascular surgeon, an emergency medicine specialist, an anaesthetist-resuscitator, an internist and an epidemiologist. In order to perform the specific mandate of objectively assessing the chances of survival of each of the victims who died as a result of the events in the shooting at the Polytechnique, having regard to the circumstances and the injuries received by each of the victims, a two-stage assessment method was used for this purpose. First, all of the autopsy reports were analysed by each of the members of the committee, individually and then as a group. Based on this review of the files, a probability of death index was assigned to each of the cases assessed. Second, the survivors were compared to the victims who died, in terms of the severity and the circumstances surrounding the injuries suffered.
The autopsy reports were studied by each member of the committee individually. The identity of the victims and the details concerning the time when the injuries were inflicted, as well as the exact place where each of the victims was found, were not provided to the assessors. Each case was then assessed by the full committee, with the same restrictions regarding the details referred to above. In addition, each of the committee members was not aware of the individual conclusions of the other members until the final assessment was done. This process included an assessment of the injuries as described in the autopsy reports and the development of an index to measure the severity of the injuries in each case. That index measures the severity of the injuries based on the anatomical region of the injuries, and is a precise predictor of the rates of mortality and disability that result. The points on the index that result in a 100% probability of mortality mean certain death, regardless of the other circumstances. More precisely, that means that the victim cannot survive despite receiving the best first-line care, despite the best time being taken to administer first-line care, despite the best time being taken before definitive care is provided, and despite the best definitive care, that is, in a hospital specializing in the treatment of persons with traumatic injuries. All the cases that were given points on this index resulting in a 100% possibility of death were considered to be closed. For the cases that were given points resulting in a less than 100% probability of death, data such as emergency services response time were disclosed so that they could be taken into consideration in the final assessment. Accordingly, the possible consequences of delay in providing care were assessed having regard to the scene of the tragedy and the distance to hospitals that could treat these kinds of injuries, assuming optimum response by first-line emergency services.
The survivors of this tragedy comprised a control group: injuries inflicted in the same way, at nearly the same time, same age category. By comparing the severity of the injuries of the non-survivors with those of the survivors, it is possible to validate the conclusions reached regarding probability of death. The study showed that all the deaths occurred by reason of the severity of the injuries suffered and that none of the victims could have survived, the injuries suffered by the survivors being significantly less serious than those of the non-survivors.
Use of the concept of avoidable death is becoming increasingly common in assessing the quality of care given to injured persons. In 1974, West was one of the first researchers to use this concept to assess the impact that emergency medicine might have on the mortality rate among injured persons. Since then, this method of assessment has been used by a number of researchers. In any study of mortality prevention, the first step is to define the concept of an injured person who can survive. The criteria that define a death as avoidable must be established before doing any objective assessment of the relevant data, and must not be open to subjective interpretation. Once these criteria have been established, the assessment of the cases based on the available data must make it possible to classify them as avoidable, potentially avoidable or unavoidable deaths. In this study of the cases of deaths resulting from the shooting at the Polytechnique, the probability of death for each case was established based on the point scale referred to earlier, "index of severity of the injuries suffered". Since this method had already been put to the test, it is considered to be a valid predictor of mortality rates and the incidence of disability. While this method is not perfect, it is the best available for assessing the severity of injuries, having regard to the anatomical site of the injuries and the damage caused, including where more than one anatomical region is involved. In addition, given that the points assigned by different assessors are very similar, the results of this study are verifiable.
In order to ensure access to all useful and relevant information for determining the complete circumstances of this case, a large number of documents were assembled and several people were interviewed. That information was then examined and meticulously compared, and then analysed. In order to establish an accurate chronological sequence of the event, it was then necessary to juxtapose the information received from various sources, and so, in some cases, in order to make them comparable, the precise times of certain elements were adjusted to Ottawa's official time. The following is a list of the documents consulted: - police report, together with numerous attachments; 2.2.1 Description of the scene 2.2.1.1 First floor This is the cafeteria inside the school, to the left of the S-17 students' entrance. It is also accessible through the main entrance to the school, using door B-107. This place has a capacity of about 400 persons, and at the time of the incident there were about 100 there. The cafeteria includes a kitchen, and at the end of the room there is an unlocked storage area (polyparty) where a variety of items is stored.
2.2.1.2.1 Room C-230.4
This is the room occupied by the Polytechnique's financial services.
This is the central corridor on the second floor, connecting room C-230.4 to the escalators.
2.2.1.3.1 Room B-311 This is the room where, at the time of the incident, a materials engineering class was being held. According to the school's computer record, there may have been 26 students and 2 instructors.
This is a third-floor corridor located near the escalators and beside room B-311.
During the day of December 6, 1989, Marc Lépine, born October 26, 1964, in Montreal, was seen for the first time in the office of the registrar, room A-201. He was seen there between approximately 16:00 and 16:40. He was sitting on the bench in the entrance to the room, near the door. From that position, he was impeding access to the department, where student traffic is heavy. He was sitting in such a way as to make it difficult to enter the room. At 16:45, Lépine was seen in a corridor on the third floor. He was leaning on the wall, holding a black plastic bag with a long object inside it, and a small white plastic bag. He was dressed in a pair of blue jeans and was wearing Kodiak boots. He was then seen in a corridor on the second floor at about 17:10., at which time he was heading toward room C-230.4. At 17:10, Lépine entered room C-230.4 and moved toward a student who was giving a presentation. Lépine was holding a rifle in both hands. He approached the student and said: "Everybody stop everything." He suddenly fired a shot at the ceiling and said: "Separate - the girls on the left and the guys on the right." No one reacted to his order. He repeated the same words in a much more authoritarian tone. The students then separated, but in their nervousness, the girls and boys mixed together in a group. He pointed with his right hand to the right side of the classroom, the side near the door, and told the boys to go over there. He then indicated with his left hand the back left corner of the classroom, and asked the girls to go over there. After the groups had separated, he told them: "OK, the guys leave, the girls stay there." They thought it was an end of session joke, and that the attacker was firing blanks. During this time, Lépine moved a little closer to the group of
9 girls who were standing together at the back of the classroom, with
no possible exit. He said to them: "Do you know why you are there."
One of the girls answered "No". He replied: "I am fighting
feminism." The student who had spoken added: "We are not feminists,
I have never fought against men." He immediately started firing on
the group, from left to right. Lépine then headed into the corridor opposite room C-229. He fired on some people who were in the photocopier room, about 30 feet away from him. A boy and a girl were hit first and wounded. As he approached the two people who had been shot, he wounded another student whose path he crossed. Lépine then backtracked and headed toward room C-228. He went into that room and stood at the entrance. He looked at the people there and aimed at a female student at the back of the room, trying twice to shoot her, but his weapon was not functioning. He then left that room and went toward an emergency staircase near the door of room C-229. There, Lépine seemed to reload his weapon. At the same time, a student coming down the emergency staircase from the second floor came face to face with him. He heard Lépine say; "Oh shit, I'm out of bullets." The student accidentally bumped into him and continued along the corridor toward the photocopiers. Noticing three people lying on the ground, he turned back around and looked at Lépine who was reloading his weapon. When he saw him lift his weapon again, he left at a run and got onto the escalators, heading for the cafeteria. He then heard a shot. Lépine then went back to the door of room C-228 and tried to go into the room. He fired 3 shots into the locked door, trying unsuccessfully to open it. He then went along the second-floor corridor, passing by 3 wounded people, and when he reached the foyer he crossed paths with a female student who was coming from the escalator. Marc Lépine fired on her and wounded her. After that victim fell, she got back up and went down the corridor, heading for the emergency staircase, and ultimately sought refuge on the fifth floor. Lépine then headed toward a semi-circle located in the foyer,
where one person was hiding behind a counter. After changing the magazine
of his weapon, while leaning on the counter, Lépine moved toward
the person who was hiding. When he had got within 8 feet of that person,
he aimed his weapon at the person and fired. Not having hit the person,
he fired a second time, but again without success. At that moment, a young woman locked the door to room B-218, and as she was doing that, Lépine came back at a run to stop her from closing the door, but without success. Through a window in the door, he saw the young woman moving away, and he fired on her directly through the window. She died from the shot. It was now between 17:15 and 17:20. Lépine headed toward the foyer. He then took the escalator, and went to the cafeteria on the first floor, which he entered by door B-107. It was now 17:20. When he arrived at the cafeteria entrance, he aimed and fired at a female student who was near the wall by the kitchens. She also died. There were then about 100 people in the cafeteria, when the first shots were fired, and they almost all left the room. He moved slowly toward the other end of the cafeteria and fired several shots in various directions, wounding another person. When he reached the other end of the cafeteria, a room called the "polyparty" - an unlocked storage area - he fired again on the 2 students who were there. They are both among the victims who died. Near that spot, Lépine told a male student and a female student
who were hiding under a table to get out from there, which they did without
being shot. Lépine arrived on the third floor. Several people were in the corridor, several shots were fired, and two male students and one female student were wounded. Lépine went down a small hallway, and after turning to the left he came out about 15 feet farther away, in room B-311. It was now about 17:25. In that room, he took several steps toward the dais, and said to the 3 students who were giving a presentation: "Get out, get out." He immediately fired on a student who was on the platform. He turned around and fired again, on the students sitting in the first rows of the class. Two female students who then tried to get away through the front door of the room were wounded. Those students are also among the victims who died. However, a number of students did succeed in getting away through the back door of the room. He then went down the aisle of the classroom, located near the corridor, and fired on several people hiding between the rows of desks. Four people were hit. These four people included one of the deceased victims. Lépine then moved back and forth in the classroom several times. He again replaced the magazine of his weapon, and got up on one of the desks at the back of the classroom. He then went back to the front, and again fired shots more or less in every direction. The student on the platform, the first one who was hit by Lépine
when he entered the classroom, asked for help. Lépine joined her
on the dais and, using a knife (a dagger), struck her three times. She
is also one of the deceased victims. He put down his knife (dagger) on
the instructor's desk, along with two boxes of 20 bullets each, and his
cap. He then said down on the dais. He took his coat off and put it around
the barrel of his weapon, and after speaking the words "Oh shit",
he killed himself by firing the last bullet in the magazine at his head.
Another full box of 20 bullets was found on a chair at the front of the
classroom near the entrance door. It was now about 17:28 or 17:29. Summing up, all of the individuals (including Lépine) were shot when they were in the following precise locations: - cafeteria (ground floor): four (4) individuals - second floor corridor: four (4) individuals - room B-218 on the second floor: one (1) individual - room C-230.4 on the second floor: nine (9) individuals - third floor corridor: three (3) individuals - room B-311 on the third floor: eight (8) individuals
The following points should also be noted from the facts that are also relevant to this case. Marc Lépine had had a stable job for several years, until September 1988. In the fall of 1986, while he was employed in that job, he applied to the Faculté Polytechnique at the Université de Montréal. He was admitted on the condition that he complete two essential courses, including the course in solution chemistry. He subsequently drew unemployment insurance benefits for a period of time ending on November 10, 1988. During that time, from March 1, 1988, to September 22, 1988, he took courses at the Control Data Institute, and then abandoned them. Ultimately, in the winter of 1989, Lépine registered in and completed the solution chemistry course at the CEGEP du Vieux Montréal. In addition, Marc Lépine applied to the Sûreté du Québec, on September 1989, for a firearms acquisition permit, which he was granted. He purchased the firearm used in the shootings on November 21, 1985, at a store in Montréal. In addition, Marc Lépine rented a car on the afternoon of December 5, 1989. The car was found the day after the incident, parked in the area close by the Université de Montréal. The final point of note is that a handwritten three-page letter was found in the inside pocket of the jacket Lépine wore during the shootings, and two letters addressed to friends were subsequently recovered. They were all written by Marc Lépine and dated December 6, 1989.
Marc Lépine was very familiar with the area around the École Polytechnique and possibly with the entire Université de Montréal campus. It has been established that he was there on the following dates: - September 11, 1985, when he made a purchase at the Polytechnique's student cooperative; - at least three (3) occasions between October 1, 1989, and October 31, 1989, when he was seen in the second-floor cafeteria, Room C-210; - about November 22, 1989, when he was seen in the corridor of the Pavillon Administratif building, which is located on campus, downhill from the École Polytechnique; - December 1, 1989, when he was seen in the École, the first time in corridor B on the fourth floor and the second time on the second floor near the bookstore; - December 4, 1989, when he was seen in the École in the AEP office located on the second floor, in room C-217; - December 5, 1989, when he was seen first in the AEP office in room C-217 of the École and then in the cafeteria in the Pavillon Administratif.
- blood alcohol: negative; - usual and abused drugs: not detected.
Based on the expert report prepared by the person in charge of the ballistics section of the Laboratoire de police scientifique [forensic science laboratory], the weapon used by Lépine in the shootings was a Sturm Ruger brand rifle, mini-14 model, .223 calibre Rem., serial no. 185-34626, 5-, 20- or 30- cartridge capacity, with a barrel length of 470 mm and overall length of 943 mm. After the incident, the following items were found at the scene, in Room B-311, near the rifle: a 5-bullet capacity magazine, empty, and, on the first chair in the third row, a 30-bullet capacity magazine, also empty. As well, a second 30-bullet capacity magazine, also empty, was found in the second floor corridor. The rifle was in firing condition and had a trigger pressure of about 2.6 kg for single fire action. The rifle is not connected with any pending case in the ballistics files at the Laboratoire de police scientifique. The weapon is designed and manufactured to fire projectiles at a speed greater than 152.4 m/s (500 ft/sec). The knife was a hunting knife (dagger) with a handle about four (4) inches long and a blade six (6) inches long.
Marc Lépine was 25 years old and of medium size (5'10",
154 pounds). He was described by people who knew him, including his family,
as a not very social and not He did not accept authority, and this was said to have caused him problems both at work and while he was a student. In addition, again according to people who knew him well, Marc Lépine left nothing to chance. Everything he did was planned down to the smallest detail. A psychiatrist who was consulted during the police investigation formed an opinion regarding the psychological and psychiatric profile of Marc Lépine, which he based on information he gathered in interviews with members of his family and his entourage, and from analyzing various documents (letters) written by Lépine. The following are excerpts from that psychological and psychiatric assessment: - Marc Lépine defined suicide as the primary motivation for what he did. - He then described that suicide very specifically. He characterized the multiple homicide situation as an extended suicide, or as an act of multiple homicide/suicide. - This specific suicidal strategy, killing one's self after killing another/others, is a familiar one in forensic psychiatry. - The multiple homicide/suicide strategy is also known to be a characteristic of individuals who have a serious personality disorder. - Such individuals may identify a person or group of persons negatively and the collected aggressive emotions experienced may be projected onto them. In two documents, Marc Lépine identified feminists, women, as
the enemy, the bad thing to be destroyed. He regarded them as invested
with negative characteristics, based on a projective mode of thinking:
all the evil was on their side. In addition, in the case of individuals who use the multiple homicide/suicide strategy, this expert says, we find extreme narcissistic vulnerability, manifested in the level of expectations and demands placed on themselves, through fantasies of success and powerfulness, or through a desire and need for recognition by others, through extreme sensitivity to rejection and failure, through intolerance to depressing emotions that experience as such only badly or to a slight extent. We also frequently find retreat into a violent and sometimes grandiose imaginary life that is an attempt to compensate for a fundamental feeling of powerlessness and incompetence. In the psychiatrist's opinion, this description of the aggressive and grandiose imaginary life found in such subjects is applicable to Marc Lépine.
In this instance, the actions taken by the École Polytechnique's security service, the 9-1-1 emergency centre, Urgences-Santé, the Montréal Urban Community police service (SPCUM) and the MUC's fire service will be examined in this investigation report.
At 17:12:28: - The first call was received by agent #36, position 616, and the caller was a student at the École Polytechnique. - The call lasted until 17:15:01. The student put the shootings on the second floor; he explained that the individual had fired a shot and told the boys to leave and kept the girls. Then, he said, he fired more or less randomly. During this call, the agent was able to hear the shots and a person moaning. - During this conversation, the agent attempted to transfer the information to the dispatch side of the police service. He experienced some difficulties and was unable to transfer the call. At 17:13:18: - The second and third calls were received simultaneously. - The second call was received by agent #97, position 606. The caller was the security guard at the École Polytechnique. At 17:15:51: - The agent transferred the second call to Urgences-Santé. The Urgences-Santé agent said that he had already been informed and said that ambulances had already been dispatched to the scene. That call lasted until 17:18:16. - The third call, also at 17:13:18, was received by agent 85, position 613, and lasted until 17:25:15. At 17:15:58: - This call was transferred to S.I.T.I. (Système informatisé de telecommunications integrés [automated integrated telecommunications system]), the SPCUM's dispatch centre. From 17:13:18 to 17:17:47: - Several other calls came in simultaneously. Details were provided regarding the event. Again, a person moaning and gunshots could be heard. Having regard to the seriousness of the situation, the person in charge
of the 9-1-1 centre tried to put one of the agents (#85) in direct contact
with SPCUM dispatch (S.I.T.I.). The sergeant in charge of S.I.T.I. refused,
asking instead that the information be taken and then transmitted. Subsequently,
the captain who was the assistant to the director and in charge of S.I.T.I.
allowed the caller to be transferred directly to dispatch. In this operation, Urgences-Santé assigned thirteen (13) ambulances, five (5) doctor transports, one of which was accompanied by a trainee nurse (#513) and three (3) coordination vehicles to the scene, in the sequence described below. A sixth doctor transport, with no doctor, also went to the scene, without being assigned. In total, fourteen (14) persons were hospitalized, including one person who went to hospital independently. Of the thirteen (13) people transported by the ten (10) ambulances, four (4) were treated by Urgences-Santé right outside the building.
At 17:15: - Urgences-Santé received its first call from a person on the scene of the event who said that someone had been shot at the École Polytechnique on the Université de Montréal campus. - A second call came in from another person also on the scene, who said that an armed man at the Université de Montréal was firing shots and that there were people wounded. The Urgences-Santé agent told the person that an ambulance, a doctor and a police officer had been sent and that they were on route. - The third call again came from another person on the scene who said that the event was taking place on the second floor of the École Polytechnique on the Université de Montréal campus. It should be noted that during these first three calls, the statement
that something was happening at the École Polytechnique on the
Université de Montréal campus seems to have been entirely
inadequate for the Urgences-Santé agents to immediately direct
emergency services. During the calls, demands were made for the precise
address, or, if not, the exact intersection. - The 9-1-1 centre transferred a call to Urgences-Santé concerning the event, for the first time.
At 17:17: - First resources assigned by Urgences-Santé. Three (3) vehicles dispatched to the École Polytechnique on the Université de Montréal campus, and were told via which intersection to go. They were told that there were gunshot injuries and that there were two (2) men and ten (10) women down. They were told that the police were en route and asked to wait until the police arrived before going ahead. - Doctor transport vehicle #502 was assigned. It should be noted that simultaneously with this first assignment of resources, a fourth call was received in which the exact street and location of the event was again demanded. Gunshots could be heard in the background. In the minutes that followed, Urgences-Santé again told its people, several times, to proceed with caution because this was a crazy shooter. It must be noted that initially, Urgences-Santé did not regard the event as a disaster. The disaster procedure, which involves modification to the assignment of resources and the use of the mobile command post (vehicle 901) was only belatedly put into effect.
At 17:22: - That ambulance (vehicle # 262) asked that another ambulance (only one more) be sent because it seemed to it that there were several injured people and it could not get more details as long as it could not go and look. - The first doctor transport (#502) arrived on the scene. - Ambulance # 289 was assigned. At 17:24: - The driver of ambulance # 262 informed dispatch that he had received one (1) injured person and that apparently there were three (3) others. He asked for two (2) more ambulances. - Three injured persons made their own way to the emergency vehicles. The doctor in vehicle #502 provided first aid. At 17:27: - Ambulances #211 and #268 were assigned. - The driver of ambulance #262 requested an other doctor. He was told that it wasn't certain that one could be sent, and the ambulance driver requested that one in that part of the city at least be approached. - The driver of ambulance #262 asked that he be given the name of a hospital for transporting the first two victims who had come out on their own and were not seriously injured. There was a little hesitation on the part of the Urgences-Santé dispatch because it was afraid that a more seriously injured person would come out before the other ambulances arrived. Ultimately ambulance #262 was authorized to transport those two (2) inured persons before the other ambulances arrived. At 17:28: At 17:31: - Doctor transport #502 told dispatch that there were more injured people coming out of the building and that more ambulances had to be sent. - Coordination vehicle #907 informed dispatch that it would be on the scene in two to three minutes. Dispatch asked it to report how many ambulances and doctor transports were needed. At 17:36: - Coordination vehicle #967, which had arrived on the scene, reported that there were three ambulances (#221, #268 and #289) and one doctor transport (#502) on the scene. It reported that no additional ambulances were needed for the moment, but asked that one more doctor transport be sent. - Doctor transport #505 was assigned and arrived on the scene shortly afterward. At 17:37: - Coordination vehicle #967 cancelled the request for the second doctor, reporting that there was no need for the moment. Dispatch asked the second doctor transport to take up a waiting position on the scene. At about 17:41: - Emergency medical services received authorization to enter the interior of the institution, accompanied by police officers. - The doctor in vehicle #502 and five (5) ambulance attendants crowded into an ambulance and drove toward the entrance to the building located several hundred metres farther away, escorted by four (4) police officers. - Coordination vehicle #567 was with police vehicle 31-99 (director of station 31). At 17:44: - Coordination vehicle #967 requested two more ambulances to be on stand-by. - Coordination vehicle #967 repeated its request for two more ambulances, stating that they should report to police vehicle 31-30. It said that they were going to enter the institution. - Dispatch informed coordination vehicle #967 that inside, on the second floor, near the escalators, in the area of the photocopiers, in rooms C-229 and C-230, there were two injured persons. In total, five (5) persons were transported by the ambulances in this first phase, which took place before the first emergency workers entered the interior. While they were waiting, the emergency medical services received no information from the police. They were unable to assess the situation until they had gone inside.
At 17:45: - Dispatch tried to verify with coordination vehicle #967 whether the two additional ambulances requested would be assigned to the two cases on the second floor or whether ambulances #221 or #268 which were already on the scene would be handling them. - Those emergency medical workers did not go to the cafeteria because the police said that there were injured persons only on the second and third floors; - The emergency medical workers got into the elevator alone, and, believing that there were not other medical resources available, the doctor from vehicle #502 divided the group into two. He delegated responsibility for examining the victims on the second floor to the ambulance worker from doctor transport #508. That ambulance worker got out of the elevator on the second floor, accompanied by two (2) other co-workers, and took charge of the victims on that floor. - The rest of the group continued to the third floor. With no one to guide them, they had trouble knowing where to go. They called out, and a police officer in civilian clothing appeared and directed them to room B-311. The doctor from vehicle #502 discovered, on entering, that five (5) people were dead, and provided medical care to one other injured person. According to a comment made to the doctor at that time by the police officer, one of the victims, the victim lying in the middle of the classroom between the rows of desks, was breathing until just before the doctor entered. Before 17:46: - Coordination vehicle #967 left its position to enter the interior of the building. Between 17:45 and 18:00: - When the ambulance worker from doctor transport #508, who had been given instructions by the doctor from vehicle #502 to do triage on the second floor, got out on that floor with two (2) ambulance workers, he first saw, at the end of the corridor, a patient in acceptable condition. The group moved ahead, and halfway down the corridor, it discovered a victim with a very serious head injury. One of the ambulance workers stayed with her and the rest of the group continued. A little farther, they discovered another victim, who, as verified by the ambulance worker from vehicle #508, was apparently dead. - During the assessment of those three (3) injured persons, the ambulance worker from vehicle #508 asked another worker to go and get materials and equipment. - They then saw the six (6) victims at the back of the classroom. The ambulance worker from vehicle #508 examined each victim and concluded that they were dead. - Doctor transport #505 and an ambulance were directed by a police vehicle to the main entrance. The doctor from vehicle #505 and an ambulance worker entered the interior and, with directions from students, went to the cafeteria on the first floor. - When the doctor from vehicle #505 entered the cafeteria, he determined that a victim who had collapsed in a chair was dead. - The doctor from vehicle #505 then learned from someone in civilian clothing who was at the back of the cafeteria, probably a student, that there were two other people who were apparently dead, but he did not go and examine them. At 17:47:16: - Police vehicle 31-99 (director of station 31) requested another Urgences-Santé coordinator at its command post to manage the ambulances. At 17:48: - Ambulances #204, #261 and #282 were assigned. - Dispatch was told that with two doctors on the scene, no more were needed. At about 17:49: In response to that communication from coordination vehicle #967, a number of communications were undertaken for the benefit of ambulance workers en route, specifying which routes to take. At about 17:50: - Ambulance #266 was assigned. Between 17:50 and 17:55: - The doctor from vehicle #502, at someone's request, went down from the third floor to examine a young lady in a corridor on the second floor. He determined that she was dead and went back up to the injured woman on the third floor. After the stretcher arrived, he went into another room on the third floor, where he provide medical care to two other injured persons. At about 18:00: - The doctor from vehicle #502 met another doctor on the third floor, who informed him that more injured persons had been seen on the fifth floor and that they had been attended to. Medical care was then given to a person with a minor injury who had taken refuge in another room on the third floor. - No more patients were found on the third floor, and so the doctor from vehicle #502 then went downstairs with his team into the hall on the first floor to await any developments. It should be noted that at that time, the police wanted the medical teams to stay in the various locations for as little time as possible, primarily for their own safety and also to protect the crime scenes. After 18:00: - The doctor from vehicle #505 treated several injured persons who had gone to the cafeteria. - It was about fifteen minutes after entering room C-230.4 on the second floor, where there were three (3) injured persons and six (6) others who were apparently dead, that the ambulance worker from vehicle #508 saw that doctor appear and briefly question the injured victims and leave again without examining the ones who were apparently dead. It was the ambulance worker from vehicle #508 who provided medical care himself. At 18:02: - The first injured person was evacuated. This person had been seriously injured. Subsequently: - Ambulances #317 and #276 were assigned. At 18:07: - Ambulances #302 and #324 were assigned, along with doctor transport #513. As well, ambulance #289 was reassigned. - Coordination vehicle #967 asked dispatch for more ambulances and was informed that three (3) ambulances were then en route. At about 18:10: - After another person was sent to request resources, the first team
arrived to evaluate a patient from room C-230.4. The other two were evacuated
in the next ten minutes. Before leaving that room, the ambulance worker
from vehicle #508 examined the six (6) other victims a second time, to
be quite sure they were dead. - Ambulance #232 informed dispatch that it was going back to the scene. At 18:18: - The fourth ambulance, #515, reported to dispatch. Dispatch replied that it should remain on stand-by because there had been no request. At 18:24: - The second coordination vehicle, #972, confirmed to dispatch that it was on the scene. At about 18:25: - Doctor transport #513 arrived on the scene. The doctor entered the interior and checked on the various floors (with the exception of the second floor) to see whether his services were required. He then went to the main hall to remain available, following the instructions of the police officers. At 18:34: - The assistant head of ambulance services, vehicle #901 (CNCC), contact dispatch from the scene. That vehicle is a mobile command post, with portable radios on board, and is meant to be used in the case of a disaster. It must be noted that its efficacy was of little significance in this situation because of the late point at which it arrived and the poor operating condition of its radio equipment. At 18:36: - The person in charge of emergency medical services (CNCC) (vehicle #901) on site at that time confirmed to dispatch that all ambulances were en route to hospitals. - There were several communications between the ambulance workers and dispatch concerning the evacuation of the injured persons (the first evacuation, of a victim who had been attended to inside the institution, took place at 18:02, and the last at 18:41), the nature of their injuries and the hospitals to which they were to be taken. At about 18:41: - Last injured person transported. - The person in charge of Urgences-Santé (CNCC) on site at that time informed dispatch that doctor transport #505 would be back on the road in a few minutes. At about 19:00: - The doctor from vehicle #505, after first going past the victim lying in the corridor on the second floor, checked that victim to be sure there was no pulse, using a monitor, to eliminate any doubt. At about 19:15: - The doctor from vehicle #513, who was waiting in the main hall, was informed by the police that two more victims had been discovered in the cafeteria. He went there and determined that they were dead. During this second phase, the phase after the first emergency workers entered the inside of the building, eight (8) persons were evacuated and transported to a hospital. Throughout the event, the following ambulances transported injured persons: - The injured victim in the cafeteria: she went to hospital herself. - The four (4) injured victims in the second floor corridor: by vehicles #266, #268 and #289; and one victim who came out of the building on her own: by vehicle #262. - The three (3) injured victims in room B-311: by vehicle #204; and the victims who came out of the building on their own: by vehicles #317 and #289. - The three (3) injured victims in the third floor corridor: by vehicles #268 and #221; and one victim who came out of the building by herself, by vehicle #262. With respect to the deceased victims who were not transported to a hospital, the deaths were determined by the following persons: - The three (3) victims in the cafeteria: one (1) victim by the doctor from vehicle #505 at about 17:45, and two (2) victims by the doctor from vehicle #513 at about 19:15. - The six (6) victims in room C-230.4: by the ambulance worker from vehicle #508 at about 1:45 (no determination of death by a doctor). - The victim in room B-218: by the doctor from vehicle #502 between 1:50 and 17:55 and the doctor from vehicle #505 at about 19:00. - The five (5) victims in room B-311: by the doctor from vehicle #502 between 17:45 and 17:50. Doctor transport #502 stayed on site to assist witnesses and families of the victims. Doctor transport #510 arrived on the scene at 00:50 to relieve doctor transport #502. Doctor transport #502, which reported at 18:18, remained outside. Its presence was not required inside. Once inside, because of the lack of adequate equipment, emergency medical
workers were unable to communicate among themselves or with the resources
outside the building, and this made it more difficult for them to perform
their functions. We would also note that the presence of several armed police officers and police officers in civilian clothing was briefly a cause of some concerns among the emergency medical workers. In addition, after an initial phase involving the evacuation of injured persons, the unfounded and uncontrolled rumour that there might be a second suspect resulted in medical resources being temporarily recalled. In general, it appears that the absence of precise directives concerning the disaster plan was a subject of severe criticism by some of the medical workers. 2.3.3 SPCUM
At 17:15:58: - The call was transmitted to the 9-1-1 centre. Having regard to the seriousness of the situation, the person in charge of the 9-1-1 emergency centre tried to put one of his agents in direct contact with dispatch (S.I.T.I.) and the supervising sergeant at S.I.T.I. refused, and asked instead that the information be taken and transmitted. Subsequent intervention by the captain in charge of S.I.T.I. and assistant to the director resulted in it being possible to transfer a caller directly to dispatch.
- The call was dispatched for the first time to the vehicles at station 31. At that time, the call was transmitted for 2500 Édouard-Montpetit with the code 214 SU, that is, "abduction, hostage-taking and confinement". The suspect was holding twenty (2) girls hostage, at rifle-point, in room C-229, and had fired shots in the air. It was given to vehicle 31-4 (2 police officers), vehicle 31-85 (the sergeant) and all vehicles at station 31. The dispatch agent, using a computer, on channel U-1, repeated the call and said that she had no further information and although she had been informed that the event was taking place at the École Polytechnique, she did not provide details. At 17:18:06: - Vehicle 31-4 (2 police officers), which was at the intersection of Côtes-des-neiges and Édouard-Montpetit, responded to the call. Vehicles 31-2 (2 police officers), 31-7 (2 police officers), 31-70 (1 police officer) and 31-25 (1 police officer) reported that they were cooperating. At 17:18:51: - 31-85 (the sergeant) was informed over the air that 31-95 (the lieutenant) had been informed that there were injured persons. 31-85 then requested that Urgences-Santé attend. At 17:19:06: - vehicle 31-7 (2 police officers) stated that it would be on the scene in thirty (30) seconds, at the Tour des Vierges (women students' residence). It asked what building it should go to. The first vehicles, 31-7 (2 police officers) and 31-4 (2 police officers), went to the student residence, believing that 2500 Édouard-Montpetit was the address of that building. At about 17:19: - the operations director for the northern region was on the scene, by
chance, having gone there to pick up his son, a student at the École
Polytechnique. His son informed him that there may have been gunshots
inside the building. - Information was given on air stating that the scene was on the second floor of the École Polytechnique, that the man was armed, that he was shooting and that there were injured people inside the building. At about 17:20: - 31-99 (the director of station 31), which was then on the road, reported that it was going to the scene and asked 31-95 (the lieutenant) to go there. At 17:20:34: - The operations director for the northern region requested emergency cars for the École Polytechnique on channel U-4. At 17:22:06: - 31-99 (the director of station 31) asked for the Groupe Technique [technical squad], which was responsible for crime scenes. 2.3.3.3 Period following arrival of first vehicle on the scene and preceding access to interior At 17:22:08: - Vehicles 31-7 (2 police officers) and 31-4 (2 police officers) informed S.I.T.I. that they had arrived on the scene. They stated that there were several injured persons and requested ambulances. They were told that ambulances were en route. - At the point when the operations director for the northern region informed the dispatcher that he wanted to enter the École by the main entrance (students' entrance), he heard police vehicles approaching and decided to wait for them and enter as a group. Vehicle 31-4 (2 police officers) assumed the leadership of the operation before its supervisor arrived and positioned some vehicles to establish a security perimeter several hundred metres from the institution, outside the parking area. From 17:23 to 17:25: - vehicle 31-4 (2 police officers) positioned vehicle 31-2 (2 police officers) southwest of the building and 31-7 (2 police officers) northwest of it. 31-4 then exchanged information with the operations director of the northern region. At that point, it was incorrectly believed that there were only three vehicles on the scene and they were waiting for more resources before taking action. At about 17:24: - The Groupe Tactique d'intervention [tactical squad] (1 officer and 13 police officers) was requested. At 17:24:16: - While en route, 31-99 (the director of station 31) requested that the exits be covered. The first ambulances to arrive at the command post attended to the injured persons who had come out of the building on their own. Vehicle 31-4 was at the command post with the ambulance workers. Vehicles 31-2 and 31-7 dispersed the crowd and directed the injured persons to the command post. At 17:24:54: - The call from a student was transmitted directly by dispatch over channel
U-1. He reported several gunshots and injuries. - Another student gave a description of the suspect, his weapon, his weight and his age, directly over channel U-1. At 17:28:51: - The dispatcher retransmitted the description over the air. At 17:26:56: - Vehicle 31-2 transmitted information to the effect that the suspect was on the fourth floor and the suggestion made by a student that the fire alarm be set off. The dispatcher gave permission to set the alarm off. - That permission was countermanded by a decision by 31-99 (the director of station 31) but the alarm was already ringing. At 17:27:16: - Vehicle 31-85 (the sergeant) arrived on the scene and coordinated its actions with the operations director for the northern region, who was formulating several intervention strategies. Additional resources were requested and they asked whether vehicle 31-99 (the direction of station 31) was en route. - It was still incorrectly believed that there were only five (5) vehicles on the scene: vehicles 31-4 (2 police officers), 31-7 (2 police officers), 31-2 (2 police officers), 40-99 (the operations director for the northern region) and 31-85 (the sergeant). In fact, there were several vehicles, but they had not all confirmed their arrival to the dispatcher or had not all informed the command post of their presence. As of 17:22, the following vehicles were in fact on the scene, in addition to vehicles 40-99 (operations director for the northern region), 31-4 (2 police officers), 31-7 (2 police officers) and 31-2 (police officer): - vehicle 31-143 (1 police officer) which arrived at about 17:22 and joined 31-7 at the students' entrance; - vehicle 31-71 (1 police officer) which arrived at about 17:22 and took up a position at the intersection of Côtes-des-neiges and Decelles to control traffic; - vehicle 31-70 (1 police officer) which arrived at about 17:22 and took up a position at the intersection of Édouard-Montpetit and Louis-Collin to control traffic. That vehicle informed dispatch of its arrival on the scene but the command post was not informed; - vehicle 31-15 (1 police officer) which arrived at about 17:22 and went to the command post, and at its request went to station 31 to get four bullet-proof vests; - vehicle 31-133 (2 police officers) which arrived at about 17:22 and took up a position opposite the main door on the north side; - vehicle 31-66 (1 police officer) which arrived at about 17:22 and took up a position at the intersection of Chemin de la Rampe and Chemin de la Polytechnique to control traffic. Summarizing, by 17:22 there were eleven (11) police vehicles with a total of sixteen (16) police officers, including a superior officer, on the scene. In addition, within the next two (2) minutes, three (3) more vehicles arrived, bringing six (6) more police officers, so that when vehicle 31-85 (the sergeant) arrived at 17:27:16, there were a total of fourteen 914) vehicles with twenty-two (22) police officers already on the scene. The last three (3) vehicles to arrive were: - vehicle 31-1 (2 police officers) which arrived at about 17:23 and took up a position near the main door on the north side; - vehicle 31-141 (2 police officers) which arrived at about 17:24 and took up a position facing the students' door at the southwest corner; The police action at that time consisted of securing the perimeter, evacuating the crowd, particularly from around the entrances, and assisting the injured persons who came out of the building. From 17:27:16 to 17:26:16: - The dispatcher received information from a student that she retransmitted over the air, to the effect that the suspect was on the fourth floor, that he had an repeat-firing weapon, that he was shooting at everybody, and that there were several very seriously injured people. At 17:29:28: - 31-85 (the sergeant) said that his command post had been set up uphill on the campus across from the d-p and that downhill there was a police vehicle that was directing the ambulances. He requested more vehicles to do crowd control. At 17:31:16: - 31-95 (the lieutenant) reported that he was on his way. - 31-2 (2 police officers) reported that they could get in through the garage and 31-85 (the sergeant) replied: negative; no one goes in for the moment. At 17:31:36: - Vehicle 31-134 (2 police officers) informed 31-85 (the sergeant) that there were several police officers in civilian clothing available for the command post. - The dispatch centre asked 31-85 (the sergeant) to report the location of his command post. At 17:32:45: At 17:33:01: - The dispatch centre again asked 31-85 (the sergeant) to report the location of his command post to let 31-95 (the lieutenant) know. At 17:34:13: - 31-85 (the sergeant) requested more vehicles. The dispatch centre replied that the technical squad was en route. 31-85 (the sergeant) reiterated its request for four additional vehicles. At 17:34:16: - 31-17 confirmed that it was on the scene. At 17:34:16: - 31-99 (the director of station 31) arrived on the scene. He exchanged information with 31-85 (the sergeant) and the operations director for the northern region. At 17:35:52: - 31-99 (the director of station 31) gave information to 31-95 (the lieutenant); - 31-7 reported the information received, that the suspect had killed himself on the third floor.
At 17:36:16: - 31-95 (the lieutenant) arrived on the scene in vehicle 31-150 (2 police officers). At 17:36:46: - 31-99 (the director of station 31) took command of the operation. He requested the mobile unit and he was informed that thirteen officers and a superior officer from the tactical squad were en route. At 17:38:16: - 31-99 (the director of station 31) asked 31-150 (2 police officers) and 31-4 (2 police officers) to go in with the ambulance workers to attend to the injured persons. They went into the building at about 17:45. At 17:38:32: - The dispatch centre informed 31-99 (the director of station 31) that the suspect was reported to be in room B-218. 31-99 asked dispatch to send him two investigators. At 17:39:59: - 31-2 (2 police officers) urgently asked to have ambulance workers go in to the second floor, stating that there were some ten injured persons and confirming that that floor had been secured, and went to room B-311. - When they arrived with the first group of police officers, at 17:36:16, those two police officers went directly to the second floor. One of the two requested medical assistance and the other, on information received from a professor, went directly to room B-311. He was the first police officer to enter that room and that was where he located the suspect, who had committed suicide. - 31-143 (1 police officer), also in the first group to enter the building,
also went, with other police officers, to room B-311. He requested ambulance
workers for a number of injured persons in that room. He confirmed that
the suspect had committed suicide. - In response to information that there was an injured woman in the cafeteria, vehicles 31-133 (2 police officers) and 31-135 (1 of the 2 police officers) entered by the main door on the north side and went to the cafeteria to look for that victim. At 17:41:16: - 31-143 (1 police officer) repeated his request for ambulance workers for the victims in room B-311. - 31=7 (2 police officers) also requested ambulance workers urgently for a victim with a bullet in her skull in room B-311 and reported that there were six (6) seriously injured persons on the second floor. At about 17:43: - 31-85 (the sergeant) entered the interior and went to room 230-4. Because communication via walkie-talkies was non-functional, he went back to get ambulance workers. At 17:43:31: - 31-95 (the lieutenant) requested several ambulances at the entrance. At 17:45: - 31-1 (2 police officers) entered and reported one (1) seriously injured person in room A-583-3. - 31-143 (1 police officer) reported two (2) seriously injured persons in room B 303. - An Urgences-Santé coordinator (vehicle #967) was with 31-99 (the director of station 31). - The technical squad, composed of ten (10) police officers, including
two (2) sergeants, arrived on the scene. - More requests for ambulance workers were made by 31-7 (2 police officers), to evacuate four (4) injured persons, two (2) of whom were seriously injured. One of those two (2) police officers had gone to the second floor (corridor and room C 230 4) and the other had gone immediately to rooms B-311 and B303. Before 17:45:39: - The Urgences-Santé coordinator (vehicle #967) left the command post to enter the interior. It then became necessary to go through the dispatch centre to request more ambulances. At 17:47:16: - 31-99 (the director of station 31) requested another coordinator for the command post, to manage the ambulances. The coordinator from vehicle #972, and then the assistant head of ambulance services (vehicle #901), subsequently got involved. - 31-134 (1 of the 2 police officers) also requested ambulance workers for the person in room B-311 who had been injured by a bullet to the head. At 17:49:26: - 31-95 (the lieutenant) asked all police officers to remain outside and to monitor the perimeter. At about 17:50:00: - The tactical squad, composed of fourteen (14) police officers, arrived on the scene. At 17:52:16: - 31-99 (the director of station 31) asked the police officers inside the building for information on the suspect's position. - 31-95 (the lieutenant) repeated his request that the other police officers remain outside the building and prevent people from entering. At 17:54:16: - 31-99 (the director of station 31) asked the police officers to prohibit access and to protect the crime scenes. - 31-95 (the lieutenant) entered the interior with the members of the technical squad. - He was followed by 31-99 (the director of station 31). A number of requests for ambulance workers were again made from inside the building for victims located in rooms B-311, A-583, A-281, B-303 and B-210. Vehicle 31-99 (the director of station 31) installed his command post at the security guards' station and toured the premises. He was accompanied by the operations director for the northern region. Vehicle 31-85 (the sergeant) coordinated personnel from the interior with the sergeant in charge of the tactical squad. Summarizing, the following police officers went to the various locations and rooms to locate all the victims, in the first few minutes after they entered the building, with the exception of the two persons at the far end of the cafeteria (polyparty room) who were dead and who were not discovered until 19:15: - the cafeteria: vehicles 31-133 (2 police officers), 31-135 (1 of the 2 police officers) and 31-131 (1 of the 2 police officers). It was the police officers from vehicle 31-133 who were in charge of securing the scene in the cafeteria who discovered the last two victims at 19:15; - the second floor corridor: vehicles 31-2 (1 of the 2 police officers), 31-7 (1 of the 2 police officers), 31-131 (1 of the 2 police officers) and 31-134 (1 of the 2 police officers); - room B-218: vehicles 31-135 (1 of the 2 police officers) and 31-132 (2 police officers); - the third floor corridor and room B-311: vehicles 31-2 (1 of the 2 police officers), 31-134 (1 of the 2 police officers), 31-143 (1 police officer), 31-1 (2 police officers) and 31-7 (1 of the 2 police officers); - room B-303, where some victims had taken refuge: vehicles 31-143 (1 police officer) and 31-7 (1 of the 2 police officers); - room A-583.3, where one victim had taken refuge: vehicles 31-2 (2 police officers) and 31-150 (2 police officers); - moving from one scene to another on the various floors: 31-4 (2 police officers), 31-85 (the sergeant), 31-95 (the lieutenant) and 31-99 (the director of station 31). At about 18:20: - A detective lieutenant arrived on the scene. He informed himself about the situation, met with 31-99 (the director of station 31) and requisitioned the resources needed for the investigation portion. - While there was an operation underway in the St-Léonard area involving the entire Crimes contre la personne [crimes against the person] division, the officers in charge had been informed that there was a shooting at the École Polytechnique, at about 18:00. A majority of the investigators were dispatched to the scene and the first ones arrived at about 18:20. At about 18:45: - The director of the crimes against the person division arrived on the scene, and took charge of the operations at about 19:00. At about 19:15: - Two victims were discovered in the cafeteria. - At the request of the police officers, the person in charge of security unlocked all the rooms that had not yet been inspected, to allow for a systematic search in order to ensure that there were no other victims.
At 17:15: - A professor went to the security service's guards' station and told the guard that an armed individual was accosting the students in C-230-4. From 17:15 to 17:40: - While gunshots could be heard, a number of calls were made by the guard to the 9-1-1 centre. At 19:10: - The person in charge of the security service arrived on the scene with his assistant. At about 20:00: - All of the available guards were called so that they could provide assistance. - At the request of the police, the security service unlocked the doors of all the rooms to allow for a search by the police in order to ensure that there were no more victims. At the request of the SPCUM, the Polytechnique's security service took charge of the personal effects abandoned by the students in the classrooms. 2.3.5 Fire service At about 17:27: - The fire alarm was set off at the suggestion of a student and with the authorization of the SPCUM dispatcher. Eight (8) vehicles were dispatched to the scene. No operations were undertaken by this service. 2.4 TIME It is impossible to overemphasize the importance of pre-hospital care in the initial treatment of victims of traumatic injury. The primary objective is to reduce the time taken to reach the patient to a minimum, in order to determine the care, through appropriate triage adapted to the patient's needs, the situation and the available resources. Specially equipped ambulances, medical personnel qualified in emergency situations and the capacity to reach the patients as quickly as possible represent the basic requirements for ensuring that this objective as achieved. Accordingly, the effectiveness of emergency services in emergency situations is measured, first and foremost, by response time. This is true in all cases and for all emergency personnel and services. This is why it is important to examine all of the actions taken from the standpoint of the response time for each one. The times may be summarized as follows: 2.4.1 9-1-1 Centre (a) from the time when the first call to the 9-1-1 centre began (17:12:28) to the time when the relaying of the request to Urgences-Santé began (17:15:51), 3 minutes and 28 seconds elapsed; (b) from the time when the first call to the 9-1-1 centre began (17:12:28) to the time when the relaying of the request to S.I.T.I. (SPCUM) began (17:15:58), 3 minutes and 30 seconds elapsed. 2.4.2 Urgences-Santé (a) from the time when the first call to Urgences-Santé began (17:15:00) to the first transmission over the air (17:17), 2 minutes elapsed; (b) from the time of the first transmission over the air (17:17) to the arrival of the first ambulances on the scene (17:24:16), about 7 minutes elapsed; (c) from the time of the arrival of the first ambulances (17:24) to the arrival of the mobile command post (vehicle #901) (18:11), 47 minutes elapsed; (d) from the time of the arrival of the first ambulances (17:24) to the entry of the first emergency medical workers into the interior (17:45), 21 minutes elapsed; (e) at the time of the entry of the first emergency medical workers (17:45) about 9 minutes had elapsed from the receipt by the police of information regarding the suicide of the suspect (17:35:52); (f) from the time of the entry of the first emergency medical workers (17:45) to when the last injured person was transported (18:41), 56 minutes elapsed. 2.4.1 SPCUM (a) from the time when the request was relayed to S.I.T.I. (SPCUM) (17:15:58) to the time when the first transmission of the request over the air began (17:17:58), 2 minutes elapsed; (b) from the time when the request was relayed to S.I.T.I. (SPCUM) (17:15:58) to the time when the request for tactical squad involvement was made (17:24), about 8 minutes elapsed; (c) from the time when the transmission of the request over the air began (17:17:58) to the time when confirmation of receipt of the request by a police vehicle began (17:18:06), 8 seconds elapsed; (d) from the time when a police vehicle (31-4) confirmed receipt of the request (17:18:06) to the time when the first police vehicle (31-135) arrived on the scene (17:21), 2 minutes and 54 seconds elapsed; (e) from the time when the first police vehicle arrived on the scene (17:21) to when the information that the suspect had committed suicide was transmitted for the first time (17:35:52), 14 minutes and 52 seconds elapsed; (f) from the time when the information that the suspect had committed suicide was transmitted for the first time (17:35:52) to when the first police officers entered the interior (17:36:16), 24 seconds elapsed; (g) from the time when the information that the suspect had committed suicide was transmitted for the first time (17:35:52) to when the police authorized the ambulance workers to enter the interior (17;41), about 5 minutes elapsed, and it was 9 minutes until the first emergency medical workers actually entered the building. From the time when the first call to the 9-1-1 centre began (17:12:28) to the time when the first police vehicle arrived on the scene (17:21), a total of 8 minutes and 32 seconds elapsed, and from the time when the first police vehicle arrived (17:21) to the time when the first police officers entered the interior (17:36:16), 15 minutes and 12 seconds elapsed, for a grand total of 23 minutes and 44 seconds. With the exception of the two victims who were dead and who were discovered in the cafeteria (in the polyparty room), the victims were located within the first few minutes after the police entered the interior. 2.5 COMMENTS In addition to establishing the probable causes and circumstances of a death, and whether the Coroner is acting in the course of an investigation or in the course of a public inquest, the Coroner may make recommendations for the purpose of ensuring that human life is better protected. It goes without saying that to that end, it is important to examine this case as a whole and to report any failings or deficiencies identified. This examination prompts a number of comments and raises several questions. For the purposes of making those comments and stating the relevant questions fairly, we need to review some of the facts and observations set out above. 2.5.1 9-1-1 Centre As has been pointed out, the primary objective in all emergency situations is to reduce the time needed for reaching the person or persons who need assistance to a minimum. This is referred to as the response time. The response time period does not start merely at the point when the request for assistance is received; rather, it starts at the very moment when the need for assistance arises, that is, at the very moment when the incident that results in that need for assistance occurs. Accordingly, for the purpose of reducing emergency services' response time as far as possible, it is essential, first, to have access as soon as possible to a means of communication, to be able to identify, without delay, the location to be communicated with to request the necessary assistance, for immediate and effective assistance to be given there, and for the request for assistance to be transmitted efficiently without delay to the appropriate emergency services. This, therefore, is the chain of the various initial stages that are desirable in order to achieve the result of minimum response time. The 9-1-1 centre's objective is, among other things, to respond to this need. The effect of the existence of an emergency centre that can be contacted by a single, simple telephone number (9-1-1) that is known to the public, and that centralizes all emergency requests and transfers them to the appropriate emergency services, must be to keep the initial stages of response time to a minimum. 2.5.1.1 Observations Access to a telephone was not a source of problems in this case. A number of people in fact contacted Urgences-Santé directly, rather than calling the 9-1-1 centre. During the first call, some problems arose when the centre tried to transfer the information to the SPCUM. The need to have the caller provide the exact address of the place where the event was taking place, despite the fact that it was a major public place and was clearly identified, resulted in delays. The disagreement that arose at the beginning of the operations, between the 9-1-1 centre and S.I.T.I. (SPCUM), regarding whether the caller could be transferred directly, slowed down the transmission of certain important information to the appropriate emergency services. The times of 3 minutes and 23 seconds and 3 minutes and 30 seconds, respectively, which elapsed between the time when the first call received by the centre began and when the first transmission of the request for assistance to Urgences-Santé and S.I.T.I. (SPCUM) began are simply too long. 2.5.1.2 Questions - Is the public in the Montreal Urban Community sufficiently well-informed about the importance of calling 9-1-1 in the event of an emergency: - Do the technical difficulties encountered in transferring the first call to S.I.T.I. (SPCUM) call for a review of equipment and facilities, or the processes for using them? - Is there a strict procedure that, in some cases, allows for a caller to be transferred directly to S.I.T.I. (SPCUM)? - If so, are agents at the 9-1-1 centre and S.I.T.I. (SPCUM) properly informed about it? - Should the 9-1-1 centre not be able, armed with only the name of a public building, to ensure that the building can be located immediately, at least in the case of buildings that have large numbers of users? - Are there clearly defined protocols for ensuring that, in a minimum of time, the essential information is taken and immediately transferred to the appropriate emergency services: - If so, are the agents at the 9-1-1 centre adequately trained to follow those protocols? 2.5.2 Urgences-Santé The importance of pre-hospital care in the initial treatment of victims of traumatic injury was stressed earlier. In addition to reducing the time for reaching patients to the extent possible, the time taken for determining care, through appropriate triage adapted to needs, the situation and the resources available, must also be reduced. As noted earlier, specially equipped ambulances, medical personnel who are qualified in emergency situations and the capacity for enough personnel to reach patients as quickly as possible represent the basic requirements for ensuring that this objective as achieved. 2.4.2.1 Observations: The first three calls received by Urgences-Santé came directly from people at the Polytechnique. During those calls, the statement that the event was taking place at the École Polytechnique located on the campus of the Université de Montréal also seemed to be insufficient for the Urgences-Santé agents to be able to immediately direct emergency services properly. The first calls received by Urgences-Santé were not transmitted to either the SPCUM or the 9-1-1 centre. It was when the first communication was received from the 9-1-1 centre that Urgences-Santé informed that centre that it was already aware of the event. The two (2) minutes that elapsed between the time when the first call received by Urgences-Santé began and the time when the request for action was first transmitted over the air was too long. However, that time is of no consequence in this instance. Some ambulance drivers had trouble finding the right route. During the seventeen (17) minutes' waiting time that preceded authorization to enter the building, medical emergency services received little or no information from the police. Urgences-Santé did not consider the event to be a disaster at the time when it should have. The late arrival of the vehicle that was the mobile command post made it of little or no use. The inadequacy of the emergency medical services available at the time authorization to enter the building was given, and the absence of functioning communications equipment inside the building, increased the length of time that elapsed until the last injured person was transported. The emergency services teams did not have the materials needed for identifying patients during the triage process. The triage and patient assessment process was carried out without following a clearly established and defined protocol. The disaster plan was poorly defined and the medical services workers were not familiar with it. The operation as a whole suffered as a result. 2.5.2.2 Questions - Because it seemed, from the first calls received by Urgences-Santé, that this was an event calling for immediate action by the police, and given that the calls came directly from users rather than from the 9-1-1 centre, why did Urgences-Santé not make arrangements without delay to inform S.I.T.I. (SPCUM)? - Should Urgences-Santé not be able to locate a public building immediately, from its name alone, at least for buildings with large numbers of users? - Is there a strict directive for an ambulance worker assigned to the scene of an event to report to his or her dispatch without delay if the worker is unable, or foresees being unable, to determine the appropriate route for getting there? - Are there clearly defined protocols for taking the essential information, assigning the appropriate emergency services and transmitting the relevant information, in a minimum of time? - If so, did the Urgences-Santé agents have adequate training for following those protocols? - Should there not be a strict procedures established so that when a criminal and medical event occurs, there is a systematic exchange of information between the police and emergency medical services, so that the medical emergency services are able to plan their actions appropriately? - Should the disaster plan not be better defined? - Who has responsibility for setting the disaster plan process in motion, and at what point and based on what criteria? - On what basis and in what circumstances should agents report to their supervisor any information that might set the implementation of the disaster plan in motion? Are they trained for this purpose? - At what point should the vehicle that is to be the mobile command post be assigned? - What equipment should be specially used when the disaster plan is implemented? - What are the communications devices? - Are they functional inside buildings? - What materials are needed for identifying patients and categorizing them based on the seriousness of their injuries? - Who has responsibility for maintaining that equipment and those triage materials and for ensuring that they are available without delay when needed? - How is direction of operations in the event of a disaster assumed, and by whom? - How are emergency medical services coordinated with police operations, and by whom? - Are Urgences-Santé personnel trained for the specific operations that result from the setting in motion of the disaster plan? - Are there clearly defined protocols concerning the assessment and triage of patients? - If so, are Urgences-Santé personnel adequately trained in those protocols? - Why were the deaths of the victims in room C-230.4 on the second floor not determined by a doctor, when there was an additional doctor waiting on the outside and no one had requested his services? - Was this a lack of coordination? 2.5.1 SPCUM It should be noted, again, that the quality of the services provided in an emergency situation is measured, first and foremost, by the services' response time, and then by their efficiency in performing their functions. 2.5.3.1 Observations The first request for emergency services was transmitted over the air after some time had already elapsed: two minutes after receipt of the request by the 9-1-1 centre began. That request was made to all vehicles from police station 31, and related to 2500 Édouard-Montpetit although it was not specified that this was the École Polytechnique, even though the dispatch agent had been informed of this. The code used in that transmission referred to an abduction, hostage-taking and confinement case. It was said that a group of twenty (20) girls had been taken hostage and that the suspect had fired shots in the air. Dispatch, however, had already been informed that there were injured persons. Nonetheless, the information about the presence of injured persons was transmitted to the vehicles before they arrived on the scene. A disagreement arose briefly in the first few moments, between the 9-1-1 centre and S.I.T.I. (SPCUM), regarding whether to permit a caller to be transferred directly. The nearly three (3) minutes that the first vehicles took to arrive on the scene was caused in part by the fact that it was not stated at the outset that the location was the École Polytechnique. Although the serious of the situation was apparent from the first information received, the tactical squad was not called in until eight (8) minutes after the dispatch centre was informed of the nature of the event, and even about two (2) minutes later than the information transmitted to the technical squad. From the time when the first police vehicle arrived on the scene to the time when the police learned that the suspect had killed himself, about fifteen (15) minutes elapsed. In other words, the police learned the suicide information about twenty (20) minutes after the first call they received concerning this event, and twenty-three and a half (23½) minutes after the first [call] made to the 9-1-1 centre began. Throughout all that time, the police actions consisted of securing a security perimeter and evacuating the crowd. At the point when it was announced that the suspect had killed himself, there was a very large number of police officers on the scene, who had been there for approximately fourteen (14) minutes - about six (6) or seven (7) minutes before Marc Lépine actually killed himself. However, the police did not know the exact number of resources available. Some of them had not confirmed their arrival to the dispatch centre or to the command post established on the scene. When it was announced that the suspect had killed himself, therefore, the police were waiting for reinforcements. At that point, no intervention operation was underway and none was in the process of being executed, or even being formulated. During the period preceding the announcement of the suicide, a number of police officers, in turn, took charge of the operation, and even, for a moment, some of them even at the same time. Little or no information was provided to the emergency medical services on site regarding the situation inside the building. No effective connection was established with the École's security service, in order to obtain details about the status of the situation, a description of the scene and an estimate of the number of users inside, although the guard communicated with dispatch, through the 9-1-1 centre, several times. There was some confusion among the police regarding whether the fire alarm should be used to force the evacuation of the building. Bullet-proof vests were not available in the vehicles. On the initiative of the first senior police officer on site, a vehicle already on the scene was sent to the station to get them. About five (5) minutes elapsed between when the suicide was announced and when the ambulance workers were given authorization to enter the interior. That operation was not prepared in advance, and so it took about four (4) minutes itself. Although the first concern of the police who entered the interior was plainly to locate the injured persons and obtain emergency medical services, the people in charge of the police evidently had a major concern relating to protecting the crime scenes for the purpose of preserving evidence. Because the emergency medical services personnel could not communicate easily among themselves inside the building, they did not have the benefit of proper coordination between their operation and the police operation. The effect of the presence of police officers in civilian clothing, with handguns, among the emergency medical services personnel inside the building, and the uncontrolled rumour that there might be another suspect, was that some personnel felt unsafe, and this did not enhance their ability to provide the best possible services. Ultimately, a systematic and organized search of the entire institution, to ensure that there were no other victims, was undertaken very late. 2.5.3.2 Questions - Is there a clearly defined procedure for transmitting requests for action in a minimum of time? - If so, do personnel at the dispatch centre have the training needed for implementing it? - Is it advisable, in the case of a well-known public building, to transmit a request without specifying the municipal address? - Are there policies in this respect? - Are they followed? - What are the precise criteria that govern the selection of a code when a request is transmitted? - Are the agents at the dispatch centre properly informed regarding the importance of using the appropriate code? - Are there clearly defined policies concerning the situations in which the 9-1-1 centre may transfer a caller directly? - Is there a directive dealing with a request for involvement by the tactical squad? - Who may make the decision? - At what point may that person make that decision, and based on what criteria? - Are there cases in which the dispatch centre should notify the authorities without delay? - When the police respond to a call, should they have to inform dispatch when they arrive on the scene? - When dispatch is informed by the police that they have arrived on the scene, should it not immediately inform the command post that has been established on site, if one has been established? - When a command post is established on the scene, should dispatch not systematically inform all vehicles of this? - Do the authorities regularly monitor how these directions are followed? - What directives govern the duties of a police officer on the scene of an ongoing armed attack where persons are potentially in danger? - Are there pre-established intervention plans? - What are the intervention protocols in ongoing armed attack cases where persons are potentially in danger? - How should leadership of the operation on site be ensured? - How are the lines of authority established? - What equipment is required and how is it ensured that it is immediately available? - Should a strategy designed both to neutralize the suspect and protect that actual and potential victims not have been formulated quickly, without waiting for the tactical squad to become involved? - Did the people in charge of the police have the training, and have adequate preparation, for quickly formulating and implementing that kind of strategy? - Are there permanent links in place between the security services in public buildings and police forces, to plan intervention protocols, and a degree of coordination, in advance? - Could the École's security service not have been an important source of information for a description of the scene and the situation inside the building, and an estimate of the number of people who were potentially in danger during the event? - Is it an established practice to use the fire alarm to effect speedy evacuation in the case of an armed assault or attack, or is it known to be dangerous to do this, and if so, should the police and the security services in public buildings not be informed of the procedure to follow in order to avoid any ad hoc decisions? - Is there a clearly defined procedure, as between Urgences-Santé and the SPCUM, regarding situations that are both criminal and medical in nature? - If so, does that procedure provide for a process of exchanging information in order to plan their respective actions? - Are there joint protocols for prioritizing emergency medical services to injured persons while also preserving crime scenes to the extent possible? - On what basis is the decision made, and by whom, to authorize ambulance workers to enter premises which have not already been secured? - In addition to locating victims, should the police participate in the process by which emergency medical services workers provide services? - Should they participate in coordinating the operation when the victims are in several different locations? - Should they, when necessary, provide support for emergency medical services workers to communicate among themselves? - Should they ensure that emergency medical services workers are at all times, and feel, safe? 2.5.4 Université de Montréal or École Polytechnique security service 2.5.4.1 Observations The École Polytechnique security service had little or no contact with the police involved in the operation before they entered the building. There is no strict procedure for whether or not to set off the fire alarm in the event of an armed assault or attack. 2.5.4.1 Questions - Did the Université de Montréal security service have permanent connections with the SPCUM for the purpose of establishing protocols for intervention and coordination? - Does the Université de Montréal security service have plans for its buildings that can be very speedily accessed by the police? - Is the use of the fire alarm to effect speedy evacuation in the case of an armed assault or attack, or the danger of using the fire alarm, established practice for the Université de Montréal security service, and should all security service employees not be informed of whichever practice has been established? 2.5.5 General Based on the study by the medical committee, it was established, to a certainty, that none of the victims who died could have been saved by medical treatment, having regard to the nature of their injuries, even had emergency medical services responded more rapidly. Obviously, the only question to be answered is this: having regard to the brief time frame in which the entire event took place, would each and every one of the victims who died have been shot, in any event, even if the police had implemented a strategy that was formulated speedily to neutralize the attacker? It was not possible to answer that last question in the affirmative, to a certainty, nor could the question regarding the strictly medical component, having regard to the delays that occurred: the delay caused when the request was transmitted by the 9-1-1 centre, the time taken by the SPCUM to transmit the request over the air, the delay caused by the provision of incomplete information to the vehicles regarding the exact location of the event, and the time spent waiting for reinforcements because of an inaccurate assessment of the resources already available. 2.6 CONCLUSIONS As unfortunate as this event was, it was not an exceptional one from the perspective of the emergency services. An armed attack by a single person is, in itself, an event that the SPCUM must deal with on a regular basis. Nonetheless, we must consider the sixty (60) unused bullets that Marc Lépine left at the scene when he decided to put an end to this terrible episode, although he was in no danger: no police assault was in progress or in any obvious state of preparation. Thank heaven, he decided on his own that enough was enough. The issue of firearms control has intentionally not been addressed. With the unlimited ammunition and time that Marc Lépine had available to him, he would probably have been able to achieve similar results even with a conventional hunting weapon, which itself is readily accessible. On the other hand, the importance of the questions raised in respect of pre-hospital care and police emergency response are matters that are worthy of our full attention. The deficiencies identified in relation to the emergency response call for us, in all good conscience, to give them serious thought, not so that we can assign responsibility to anyone in particular, but so that we can take corrective action to ensure that better protection is provided for human life. Some of the questions stated in the preceding section do not require answers, since the answers are self-evident from the questions. Nonetheless, this does not mean that it is not worth acting on them, even though no formal recommendations are made. There are numerous other questions, on the other hand, that it would be neither wise nor fair to try to answer without first hearing all of the people involved, particularly since the complexity of some elements means that various experts would have to be heard, and this was not the function of a Coroner's investigation. Montréal, May 10, 1991 |