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SEX: Male MARITAL STATUS: N/A COMMUNITY: Iqaluit, NT RESIDENCE: Iqaluit, NT D.O.D. July 21,1997 D.O.B. February 25, 1997 AGE: 4 months, 27 days WHERE DEATH OCCURRED: Baffin Regional Hospital, Iqaluit, NT AUTOPSY: yes INQUEST: no TOXICOLOGY EXAMINATION: no CAUSE OF DEATH: Part I a) craniocerebral trauma CLASSIFICATION:Accidental BRIEF HISTORY: This 4 month old baby was being carried in a amouti by his mother as they walked along a roadway. Her husband was walking with them and carried the 4 month old's twin brother. A front end loader/forklift towing an empty flatbed trailer approached them from behind and was headed in the same direction. The husband and second infant crossed the road to walk on the other side. The mother and the decedent remained on the same side as before. As the flatbed trailer passed them, one of the dual wheels dislodged from the axle and accelerated toward the mother. She was struck from behind and was pushed upward and outward toward the ditch. She landed on her back with the infant under her. The trailer unit continued on its course and did not stop. The husband went to the aid of his wife and child. The mother sustained several cuts, bruises and broken bones while the infant appeared at first to have suffered minor injuries. The child had a visible bump on his head and some minor bruising. Ambulances were called and arrived at the scene. Shortly after the incident it became apparant that the baby was having trouble breathing. Resuscitation efforts began and were continued enroute and upon arrival at the hospital. All resuscitation efforts failed and the child was pronounced dead at 18:50 hours by the attending physician. The mother was admitted to the hospital with non-life threatening injuries. An autopsy was ordered and performed in Toronto, Ontario. At autopsy severe head injuries were visible with a complex fracture of the left side of the head which extended to the base of the skull. The brain was swollen but not lacerated. There was bleeding present both under the scalp and under the skull. The baby's left forearm was fractured and there was a fracture of the right first rib. The nature of the head injury suggests a crushing injury rather than a high velocity impact injury which is consistent with the mother being thrown up and then down on the baby from the impact. There were no other injuries or natural disease processes to account for death, however there was evidence of granulomatous inflammation in the skin, marrow and liver which could indicate tuberculosis exposure. Given the investigation, evidence and autopsy results, I find that he died from craniocerebral trauma due to a pedestrian motor vehicle accident. I further classify this death as accidental. COMMENTS AND RECOMMENDATIONS: The investigation revealed that neither the loader or trailer used were licenced or registered for road or highway use. Following the incident, a mechanical inspection was performed on the trailer unit by a licenced mechanic who determined that the bearings in the wheel in question were dry and had siezed during use. The continued use of the unit caused the wheel bearings to become fractured and dislodged from the wheel housing. The wheel subsequently became loose and displaced from the axle. Other wheel bearings on the unit were approaching a similar condition. In addition, some of the tires on the trailer were badly worn. There was no functioning air brake system and no functioning lighting or signals. There is no evidence that any manner of inspection other than a passing visual inspection was performed on the trailer prior to it's use on that day, indeed it appears that the trailer unit had been unused and in storage for the past 8 months. The operators of the loader and trailer unit were aware of the problems with the wheels and had observed it failing to turn from time to time during the day but lacked either the training or understanding of the dangers involved in proceeding with the operation of a trailer with this kind of defect. This incident brings into question the ineffectiveness of current legislation designed to provide for the safe operation and maintenance of commercial vehicles on northern roadways. Although other jurisdictions in Canada employ some sort of regular inspection criteria for the licencing and registration of commercial vehicles and trailers, the NWT and Nunavut do not have any mandatory safety inspection criteria for the licencing and registration of such vehicles. It also brings into question the inadequacy of some general regulations for the operation and maintenance of vehicles as it relates to off highway communities. Some rules and regulations regarding vehicle operations and maintenance relate only to communities attached to the highway system and are not in effect in "off road" communities. The National Safety Code and the Commercial Vehicle Safety Alliance do not apply to communities off the highway system in the NWT and do not apply anywhere in Nunavut. Citizens in smaller, "off road" communities deserve the same level of protection and safety required in larger communities and within the rest of Canada. Therefore I make the following recommendations: To the Minister of Transportation in the NWT and the Minister for Community Government, Housing and Transportation in Nunavut. 1) Review all current legislation regarding the operation, maintenance, and registration of commercial vehicles and consider applying them universally in all communities. 2) The territorial government develop or adopt legislation which requires all commercial vehicles and trailer units operating on public roadways to pass a basic annual safety inspection as a condition of licencing and registration. To the Minister of Municipal and Community Affairs in the NWT and the Minister for Community Government, Housing and Transportation in Nunavut. 1) Should mandatory inspection legislation be adopted, the department should encourage all communities, through their by-law officers, to diligently enforce commercial vehicle registration and inspection requirements and allow communities to retain all revenues generated by that enforcement. 2) The department should consider developing and launching an awareness campaign targeted toward commercial vehicle operators promoting the use of Loose Wheel Management Systems. To the Minister of Justice in the NWT and the Minister of Justice in Nunavut. 1) Should an annual inspection criteria be adopted, the minister should communicate to the RCMP that enforcement of the legislation regarding the registration of commercial vehicles is paramount to promoting compliance and that the RCMP should maintain diligence in enforcing registration and inspection requirements. Original signed by: Percy Kinney Chief Coroner |