Manitoba judge blames stadium, doctor in fatal football fall

WINNIPEG – Andrew Szabo died slowly after a drunken fall from the stands at a Canadian Football League game.
    
Lying in a Winnipeg hospital for hours, staff oblivious to his many broken bones and internal bleeding, Szabo eventually went into shock before anyone realized there was something seriously wrong.
    
On Wednesday, a provincial court judge ruled that outdated stadium stands and a failure to run X-rays and other basic tests contributed to the 52-year-old man’s death.
    
“I conclude that Mr. Szabo’s death was preventable,” Judge Mary Kate Harvie wrote in an inquest report. “The recommendations in this report identify for consideration areas of improvement at the Canad Inns Stadium, for changes to the pre-hospital system, as well as recommendations for the enhancement of care of trauma patients at community hospitals.”
    
Szabo was an alcoholic and had consumed liquor before arriving at the stadium in August 2006, his widow, Barbara, testified at the inquest.
    
He had just come back from ordering two beers at the start of the game and stood up to go meet a friend when he tripped, tumbled down the stairs and through a guardrail. He fell roughly six metres to the concrete below. Paramedics took him to the nearby Grace Hospital instead of the city’s main trauma unit at the Health Sciences Centre downtown.
    
The guardrails in the stadium’s north-end stands should be upgraded immediately, Harvie recommended. She also said building inspectors should assess handrails, steps and other parts of the aging stands to see whether more improvements are needed.
    
The judge urged federal and provincial agencies that set national building codes to consider making them retroactive for stadiums, hockey arenas and other public facilities. Currently, older buildings only have to upgrade their safety measures if they undergo a major renovation.
    
Harvie also called for better trauma training at the Grace Hospital. She pointed to a failure by a doctor to notice many of Szabo’s injuries _ not only the broken pelvis and slow internal bleeding, but also a broken collar bone, broken ribs and a collapsed lung.
    
“A number of witnesses confirmed that Mr. Szabo had an obvious fracture to his clavicle _ a fact not noted by (emergency room physician Terence) Bergmann in his examination,” Harvie wrote. “When asked how he could have missed the fractured clavicle, his only response was that while Mr. Szabo’s shirt would have been open, he is not sure if it was open wide enough for him to see the collar bone.”
    
Szabo’s widow told the inquest that she’d been told that evening that her husband had no broken bones. It was only several hours later, near midnight, that his blood pressure plummeted and he was rushed to the Health Sciences Centre where he died.
    
“It would appear from the evidence … that the most significant injury sustained by Mr. Szabo, being the pelvic fracture, could have been detected if the appropriate X-rays had been ordered,” Harvie wrote.

“The initial examination conducted by Dr. Bergmann fell short of obtaining the kind of detail expected of an emergency room doctor.”

The Winnipeg Regional Healthy Authority said Wednesday it has added personnel to the emergency room at the Grace and has expanded its CT scans to nights and weekends. The triage system is also being revamped.

“Grace Hospital emergency department will undergo an expansion and modernization, expected to open in 2013,”  authority spokesperson Kathryn McBurney wrote in an email.
    
“The new design will improve patient flow by adding a new triage area and a rapid-assessment zone while also expanding the minor-treatment area.”

As for stadium upgrades, the lawyer for the Winnipeg Blue Bombers said they will be made.
    
“If the judge says these improvements should be done, they will be done,” Bob Sokalski said.
    
The football club took over Canad Inns from the city in 2004 and the team assumed that everything complied with the safety code, Sokalski added. In recognition of that, Harvie has ordered the city to pay for any upgrades.

Canad Inns Stadium was built in 1953. The north-end stands were added three years later. The Blue Bombers are moving to a new stadium next year. The city hopes to eventually tear down Canad Inns to make room for a shopping centre.