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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
[All dialogue and other quoted material in the document has been translated into English - Tr.]
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TABLE OF CONTENTS
(Part II)
2.1 CAUSES
p. 1
2.1.1
Description of work done by the comité pour la prévention
de la mortalité post-traumatique de l’Hôpital Général
de Montréal
p. 2
2.1.1.1 First floor
p. 2
2.1.1.2 Second floor
p. 3
2.1.2 Comments
p. 3
2.2 CIRCUMSTANCES
p. 4
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
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2.2.5 Absence of alcohol and drugs
p. 12
2.2.6 Weapons used
p. 13
2.2.7 Profile of Marc LĂ©pine
p. 13
2.3 ACTIONS TAKEN
p. 15
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
first call on air
p. 17
2.3.2.2 Period following transmission of
first call on air and preceding arrival
of first vehicle on the scene
p. 18
2.3.2.3
Period following arrival of first vehicle
and preceding access to interior
p. 18
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
first call on air
p. 29
2.3.3.2 Period following transmission of
first call on air and preceding arrival
of first vehicle on the scene
p. 29
2.3.3.3 Period following arrival of first vehicle
on the scene and preceding access to interior
p. 31
2.3.3.4 Period following access to interior
p. 36
2.3.4 Université de Montréal or École Polytechnique
security service
p. 42
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2.3.5 Fire service
p. 42
2.4 TIME
p. 43
2.4.1 9-1-1 Centre
p. 43
2.4.2 Urgences-Santé
p. 43
2.4.1 SPCUM
p. 44
2.5 COMMENTS
p. 45
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
École Polytechnique security service
p. 56
2.5.4.1 Observations
p. 57
2.5.4.2 Questions
p. 57
2.5.5 General
p. 57
2.6 CONCLUSIONS
P. 58
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2.0 PART II
This part is common to all the victims of the shooting that occurred at the
Université de Montréal École Polytechnique in Montreal on December 6, 1989. It is an
integral part of each and every one of the investigatio n reports signed on this date, which
are numbered as follows:
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 CAUSES
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.
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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.
2.1.1.1 First floor
The autopsy reports were studied by each member of the committee individually.
The ident ity 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
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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.
2.1.1.2 Second floor
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.
2.1.2 Comments
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
REPORT OF CORONER’S INVESTIGATION
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A-41563
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that the points assigned by different assessors are very similar, the results of this study are
verifiable.
2.2 CIRCUMSTANCES
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;
-
attachment to the police report comparing the time of the SPCUM dispatch
service recording (S.I.T.I.) and of the 9-1-1 Centre time to the Ottawa official
time;
-
report of the director of the SPCUM to the chair of president of the CUM
executive committee;
-
certain exhibits seized on the scene following the event, and elsewhere,
subsequently;
-
forensic reports;
-
ballistics and other expert reports;
-
video of the scenes of the event;
-
detailed plans of the scene;
-
several tape recordings of Urgences-Santé communications at the time of the
event;
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videos of several televised reports and public affairs programs;
-
tape recordings of several radio reports and public affairs programs;
-
report of the post-trauma mortality prevention committee of the Montreal
General Hospital;
-
transcripts of statements by certain persons involved in the event who were
interviewed;
-
minutes of an Urgences-Santé meeting concerning the event;
-
time-stamped record of 9-1-1 Centre and the SPCUM dispatch service
(S.I.T.I.);
-
list of police vehicles dispatched to the scene;
-
compilation of calls and requests by the SPCUM dispatch service (S.I.T.I.);
-
compilation of telephone calls to the SPCUM concerning the event.
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 Second floor
2.2.1.2.1 Room C-230.4
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This room is located to the east of the escalators and at the end of the corridor. On
that day, there was a mechanical engineering class in the room, and according to the
school’s computer file there could have been 69 students and 2 professors in the room.
2.2.1.2.2 Room B-218
This is the room occupied by the Polytechnique’s financial services.
2.2.1.2.3 Corridor
This is the central corridor on the second floor, connecting room C-230.4 to the
escalators.
2.2.1.3 Third floor
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.
2.2.1.3.2 Corridor
This is a third- floor corridor located near the escalators and beside room B-311.
2.2.2 The shooting
During the day of December 6, 1989, Marc LĂ©pine, 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.
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On several occasions, he was seen rummaging in a green plastic bag that he had
beside him, the contents of which he seemed to be hiding. He did not speak to anyone,
and none of the students spoke to him. At one point, one of the employees working at the
counter asked him whether she could help him. He did not answer and he left the
premises.
At 16:45, LĂ©pine 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, LĂ©pine entered room C-230.4 and moved toward a student who was giving
a presentation. LĂ©pine was holding a rifle in both ha nds. 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, LĂ©pine 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.
REPORT OF CORONER’S INVESTIGATION
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After having fired perhaps thirty shots, he left the premises, leaving behind 9 victims,
6 of whom were among the victims who died.
LĂ©pine 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.
LĂ©pine 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, LĂ©pine 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 LĂ©pine 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.
LĂ©pine 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 LĂ©pine
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.
LĂ©pine 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, LĂ©pine 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.
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LĂ©pine walked around a bit in the second- floor foyer and on the cafeteria terrace; he
then went over near the financial services office (room B-218), and ultimately moved
opposite room B-211, about 20 feet from the entrance to room B-218.
At that moment, a young woman locked the door to room B-218, and as she was
doing that, LĂ©pine 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.
LĂ©pine 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, LĂ©pine 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.
REPORT OF CORONER’S INVESTIGATION
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A-41567
A-41563
(cont’d)
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LĂ©pine then left the cafeteria by door B-124 and went along the corridor leading to
the supplies room. He was then seen near the foyer on the second floor, just before he
got onto the escalator (not in operation) to go to the third floor.
LĂ©pine 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.
LĂ©pine 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.
LĂ©pine 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 LĂ©pine when he entered the
classroom, asked for help. LĂ©pine 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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
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It was now about 17:28 or 17:29.
Summing up, all of the individuals (including LĂ©pine) 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
2.2.3 Other relevant facts
The following points should also be noted from the facts that are also relevant to this
case.
Marc LĂ©pine had had a stable job for several years, until September 1988. In the fa ll
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, LĂ©pine 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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
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In addition, Marc LĂ©pine 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 LĂ©pine wore during the shootings, and two letters addressed to
friends were subsequently recovered. They were all written by Marc LĂ©pine and dated
December 6, 1989.
2.2.4 Prior knowledge of the scene
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.
2.2.5 Absence of alcohol or drugs
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It is important to note that based on the analyses done after the autopsy performed on
Marc Lépine’s body, the following results were obtained:
- blood alcohol: negative;
- usual and abused drugs: not detected.
2.2.6 Weapons used
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
LĂ©pine 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.
2.2.7 Profile of Marc LĂ©pine
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
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very communicative person, except when he was talking about computers. It was very
difficult to get to know him. He was described as closed, showing no emotion even about
important things.
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 LĂ©pine 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 LĂ©pine, 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 LĂ©pine.
The following are excerpts from that psychological and psychiatric assessment:
-
Marc LĂ©pine 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 LĂ©pine 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.
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From the psychiatric point of view, the expert notes that his study cannot be used to
identify factors that suggest that Marc LĂ©pine had a functional psychiatric illness, nor is
there any indication of any toxic condition.
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 LĂ©pine.
2.3 ACTIONS TAKEN
The event took place over a period of time, and the operations of the various agencies
involved began before the shootings ended, or in any event before all the victims were
known to be dead. It is therefore relevant, and even crucial, to consider the role of the
various agencies involved in order to establish the complete circumstances of this case, as
it is the function of a Coroner’s investigation to do.
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.
2.3.1 9-1-1 emergency centre
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.
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-
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.
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2.3.2 Urgences-Santé
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.
2.3.2.1 Period preceding transmission of first call on air
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.
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At 17:15:42:
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The 9-1-1 centre transferred a call to Urgences-Santé concerning the event, for the
first time.
2.3.2.2 Period following transmission of first call on air and preceding arrival of first
vehicle on the scene
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.
2.3.2.3 Period following arrival of first vehicle and preceding access to interior
At 17:22:
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The first ambulance (#262) arrived on the scene. It took up a position behind the
security perimeter established by the police, several hundred metres from the
institution.
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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.
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The first doctor transport (#502) arrived on the scene.
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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:
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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:
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-
Doctor transport #508, with no doctor on board, arrived on the scene. The driver
of that vehicle had heard a call on air concerning the shootings, and asked
dispatch for permission to go there; despite the fact that dispatch refused, he
decided to go there anyway.
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:
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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 aut horization 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.
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At about 17:43:
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Coordination vehicle #567 was with police vehicle 31-99 (director of station 31).
At 17:44:
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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.
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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.
2.3.2.4 Period following access to interior
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.
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The first emergency medical workers, the doctor from vehicle #502 and five (5)
ambulance workers, entered the interior of the institution and were taken by the
police officers to the elevator from the ground floor.
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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 ambula nce 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.
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When the approached room C-230.4, they saw three (3) persons lying on the
ground, but conscious. The ambulance worker from vehicle #508 then asked his
co-worker to go back and get his team and start the triage operation.
-
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:
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Police vehicle 31-99 (director of station 31) requested another Urgences-Santé
coordinator at its command post to manage the ambulances.
At 17:48:
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Ambulances #204, #261 and #282 were assigned.
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Dispatch was told that with two doctors on the scene, no more were needed.
At about 17:49:
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Coordination vehicle #967 informed dispatch that it was still waiting for the
resources it had requested.
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:
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Ambulance #266 was assigned.
Between 17:50 and 17:55:
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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:
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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.
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The doctor from vehicle #505 then went to a few floors. When he came back
down, he saw the doctor from vehicle #502 in a classroom on the third floor near
some victims and he did not need to assist. He probably stopped on the second
floor to check a few injured persons.
-
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.
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At 18:17:
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Ambulance #232 informed dispatch that it was going back to the scene.
At 18:18:
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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 emergenc y medical services (CNCC) (vehicle #901) on
site at that time confirmed to dispatch that all ambulances were en route to
hospitals.
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From 18:02 to 18:41:
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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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 28 of 58
-
The three (3) injured victims in room C-230.4: by vehicles #261, #307 and #282.
-
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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 29 of 58
In addition, in the course of the process of assessment and triage of the injured
persons, emergency workers did not have the materials they needed for identifying
patients, and this may have resulted in omissions or duplications. The entire triage
process suffered from the absence of a clearly defined protocol.
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
2.3.3.1 Period preceding transmission first call on air
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.
2.3.3.2 Period following transmission first call on air and preceding arrival of first vehicle
on the scene
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 30 of 58
At 17:17:58:
-
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 CĂ´tes-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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 31 of 58
At 17:19:47:
-
Information was given on air stating tha t 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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 32 of 58
-
He was still on air on channel U-4 and asked the vehicles to join him at the main
entrance. They were unable to hear him because they were all on channel U-1.
He therefore went toward them, lower down, opposite the main students’
entrance, the location that then became the command post for the police
operations.
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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 33 of 58
At 17:26:16:
-
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
interve ntion 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):
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 34 of 58
-
vehicle 31-135 (2 police officers) which arrived at about 17:21 and took up a
position near the students’ entrance;
-
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 CĂ´tes-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;
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 35 of 58
-
vehicle 31-132 (2 police officers) which arrived at about 17:24 and took up a
position at the southwest corner of the École.
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 ove r 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:
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 36 of 58
-
31-7 transmitted the information received that there were a number of people in
room B-301 and the cafeteria who were dead.
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.
2.3.3.4 Period following access to interior by the first police officers
At 17:36:16:
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 37 of 58
-
After receiving the information about the suicide, vehicles 31-7 (2 police
officers), 31-2 (2 police officers), 31-143 (1 police officer) and 31-134 (2 police
officers) entered the building.
-
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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 38 of 58
At about 17:40:
-
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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 39 of 58
At 17:45:39:
-
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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 40 of 58
-
31-4 (2 police officers), who had gone in at 17:41 and who were moving from one
scene to another, replied that the suspect was in B-311 and confirmed that it was
safe to enter the interior of the building.
-
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);
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 41 of 58
-
room C-230.4: vehicles 31-85 (the sergeant), 31-7 (1 of the 2 police officers), 31-
2 (1 of the 2 police officers) and 31-90 (a sergeant);
-
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-LĂ©onard 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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 42 of 58
At about 20:00:
-
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.
2.3.4 Université de Montréal or École Polytechnique security service
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
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(cont’d)
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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
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(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;
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(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.
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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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
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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
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
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A-41564 A-41577
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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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
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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 informatio n, 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?
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
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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?
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
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-
Are there clearly defined protocols concerning the assessment and triage of
patients?
-
If so, are Urgences-Santé personnel adequa tely 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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
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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 LĂ©pine 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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
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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 entir e 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?
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
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II Page 54 of 58
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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?
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
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A-41574
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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?
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
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II Page 56 of 58
-
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
REPORT OF CORONER’S INVESTIGATION
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A-41567
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(cont’d)
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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.
REPORT OF CORONER’S INVESTIGATION
A-41560
A-41567
A-41563
(cont’d)
A-41575 A-41558 A-41566
A-41573 A-41559 A-41565
A-41574
A-41564 A-41577
A-41561 A-41576 A-41568
Notification number
II Page 58 of 58
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 LĂ©pine 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 LĂ©pine 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
Teresa Z. Sourour, MD, FRCPC
Investigating Coroner
[signed] Teresa Sourour