Report to the Minister of Justice
and Attorney General
Public Fatality Inquiry

CANADA

Fatality Inquiries Act

Province of Alberta

WHEREAS a Public Inquiry was held at the
in the

Town

of

Ponoka

(City, Town or Village)

18th

on the

Courthouse
, in the Province of Alberta,

(Name of City, Town, Village)

day of

November

2014

, (and by adjournment

year

19th

on the

day of

November

,

2014

),

year

before

Hon. B.D. Rosborough

into the death of
of

, a Provincial Court Judge,

Elizabeth Ann Bell

72

(Name in Full)

(Age)

#62, 6205 – 54 Street, Ponoka, Alberta

and the following findings were made:

(Residence)

Date and Time of Death:
Place:

February 19, 2013; 10:10 a.m.
#62, 6205 – 54 Street, Ponoka, Alberta

Medical Cause of Death:
(“cause of death” means the medical cause of death according to the International Statistical Classification of
Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose
and published by the World Health Organization – The Fatality Inquiries Act, Section 1(d)).

The cause of Elizabeth Ann Bell’s (‘Bell’s’) death was the subject-matter of competing evidence
at this Fatality Inquiry. Evidence was called on behalf of Philips that Bell may have died due to
natural causes. In the alternative, she may have died of asphyxia when her upper body bed
garment wrapped tightly around her neck and strangled her. It was submitted that the evidence
relating to cause of death was inconclusive. On the other hand, the Medical Examiner, Dr. Jeffery
Gofton, was of the opinion that death was caused by asphyxia when the ‘Lifeline’ Bell was
wearing became entangled in her walker and strangled her. For the reasons to follow, I am
satisfied that Bell’s death was caused in the manner described by Dr. Gofton.
Manner of Death:
(“manner of death” means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable
or undeterminable – The Fatality Inquiries Act, Section 1(h)).

In support of the proposition that Bell died in a manner other than asphyxia by strangulation,
Philips called Dr. Ben Carruthers (‘Carruthers’). Carruthers was trained as a family physician and
practiced as such in Ontario. In 1982, he was appointed a Coroner for the Province of Ontario
and undertook over 1800 death investigations from then until 2009 when he discontinued his
work as a Coroner.
It is important to note the distinction between the work and qualifications of Coroners in the
Province of Ontario and the work and qualifications of Medical Examiners in the Province of
Alberta. Coroners preside over an investigation into an individual’s death leading to
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recommendations by a 5-member civilian jury. Coroners do not testify at an inquest as an expert
witness or otherwise provide evidence themselves relating to the cause or manner of death.
Medical Examiners, on the other hand, do not preside over Fatality Inquiries. They are forensic
pathologists who investigate the death of an individual and provide the presiding judge with
expert opinion evidence about the manner and cause of the decedent’s death. There are also
differences in the terms used to classify causes of death.
Carruthers’ area of expertise was as a family practitioner who worked part-time as a Coroner. He
was not trained in pathology nor did he have any advanced qualification in forensic pathology.
Carruthers has never performed an autopsy nor has he ever been qualified as an expert witness
in Ontario or elsewhere. In this case, he was retained by Davis & Co. on behalf of Philips to
provide an opinion and evidence at this Fatality Inquiry in relation to the manner and cause of
Bell’s death.
Dr. Jeffery Jason Gofton (‘Gofton’) received his M.D. in 1996. Thereafter he received postgraduate training and specialty qualification in pathology. Before working as a Medical Examiner,
Gofton completed a fellowship in forensic pathology and became ‘Board-certified’ in anatomic
and forensic pathology. ‘Forensic pathology’ is a sub-specialty of pathology that focuses on
determining the cause of death by examining a corpse.
Gofton has been employed as a full-time Medical Examiner in Alberta, Oklahoma and Virginia.
He has worked as a Medical Examiner in Alberta since 2013. During the course of his work as a
Medical Examiner he has performed approximately 3000 autopsies and undertaken 3000 to 4000
external examinations. Those examinations have included strangulation deaths. In addition, he
has been judicially qualified as an expert witness in Texas, Virginia, Oklahoma and Alberta. He
testified at this Fatality Inquiry at the behest of Inquiry Counsel acting for the Minister of Justice
and Solicitor General of Alberta.
Carruthers was provided with all materials relating to the investigation of Bell’s death. This
included witness statements, police reports, photographs and reports from the Medical Examiner.
He did not examine Bell’s body post mortem nor did he examine Bell’s Lifeline.
It was Carruthers’ opinion that death due to asphyxia by strangulation was not the most likely
cause of Bell’s death. Both in his written report and in his viva voce evidence, Carruthers voiced
the opinion that, “ … Elizabeth Ann Bell died from natural causes which may have included a
sudden cardiac arrhythmia, an acute coronary thrombosis, a hypotensive crisis or acute
bronchospasm, with alcohol and drugs being a major contributing factor”.
In cross-examination, Carruthers testified that he based his opinion on 7 factors:
1. Bell’s prior medical history (including her alcoholism and history of falling)
2. The fact that the ligature around her neck was not deep enough to strangle her
3. Lack of petechial (pinpoint) hemorrhaging
4. Asymmetrical lividity around the ligature
5. No evidence that Bell struggled to disentangle herself from the walker
6. Reports by those who found her that death was by natural causes
7. Dr. Du Toit initially reported the cause of death as hypertensive heart disease
In direct examination Carruthers also mentioned the absence of bulging to the eyes, color to
Bell’s face, the fact that the ligature was dislodged easily from Bell’s walker and, in particular, that
the Lifeline cord was not fully extended at the time of death.
Carruthers was also of the view that an autopsy would be essential in order to conclude that
death was caused by strangulation. It was his opinion that an autopsy would have shown any
petechia present or damage to the carotid artery (which would be present and obvious in a case
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like this). It was his view as well that an autopsy and analysis of brain tissue (the ‘anoxic brain’)
would have assisted in concluding that death was (or was not) caused by strangulation. And,
finally, toxicology work (examination and/or analysis of bodily substances taken from the body)
would have revealed the presence of alcohol or drugs and time of death.
Gofton was of the opinion that Bell’s death was caused by asphyxia when the ‘Lifeline’ she was
wearing became entangled in her walker and strangled her. Unlike Carruthers, he undertook a
physical examination of Bell’s body post mortem and made observations that were not apparent
in the photographs made an exhibit at this Fatality Inquiry. Gofton went further, testifying that it
was not possible that Bell died of natural causes.
Gofton testified that he did observe petechia on Bell’s body post mortem and noted that petechia
can be 1 mm in size or less. It was for this reason that photographs taken at his examination of
Bell’s body did not depict that petechia. The presence of petechia was an important observation.
It signaled that Bell was alive at the time the ligature was placed across her neck and that blood
was being received notwithstanding strangulation. This is important in relation to coloration and
other concerns expressed by Carruthers. I believe Gofton’s evidence in this regard and accept
that petechia were present.
Gofton was asked how there could be no evidence of a struggle. He noted that strangulation can
lead to unconsciousness in as little as 5 seconds. Death would ensue several minutes thereafter.
Inquiry Counsel noted that Bell’s head was seen to be only 1’ above the floor when observed by
Hieb. Gofton was of the opinion that this was unremarkable. Indeed, he had both investigated
and read of instances where the deceased was strangled in all manner of positions: sitting up,
face down, lying recumbent, etc.
It was important to Gofton that there was a furrowed abrasion precisely conforming to the Lifeline
cord around Bell’s neck. It was his view that the furrows were, indeed, deep enough to cause
strangulation. Gofton testified with the benefit of having observed ligature strangulation in other
cases.
I have viewed the furrowed abrasion around Bell’s neck as depicted in the booklet of photographs
marked as Exhibit 3 at this Fatality Inquiry. I refer, in particular, to photographs 15 to 18, 20, 22
and 23. Two observations are clear from these photographs: (1) the furrowed abrasion depicted
in those photographs was caused by the Lifeline cord worn by Bell; and (2) the abrasion is
remarkable. There is a deep and significant indentation into Bell’s neck area notwithstanding that
Bell’s death occurred quite some time before the photographs were taken. On this point, I
expressly accept Gofton’s opinion and reject Carruther’s opinion that the ligature mark was not
very deep.
I note that Gofton had reviewed Carruthers’ report prior to testifying and disagreed with its
conclusions. He was also aware of Bell’s medical history and treatment, including potential
alcohol abuse and polypharmacy. The fact that he did not review information relating to Lifelines,
EMS records or Cpl. Taylor’s (‘Taylor’s’) statement that he observed no friction caused by the
Lifeline cord did not, in my view, compromise Gofton’s opinion as to cause of death.
While an autopsy would have shown damage to blood vessels if that had occurred, asphyxia due
to strangulation does not always involve damage to blood vessels; an autopsy may reveal
nothing in that regard. Similarly, toxicological analysis of body substances will disclose the
presence of alcohol or drugs but this does not necessarily correlate with a cause of death.
Finally, Gofton testified quite simply that one need not view the ‘anoxic brain’ in order to come to
a conclusion of death by asphyxia. Gofton also noted, as a forensic pathologist, that autopsies
are not typical in cases of strangulation.
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I have considered the evidence of both Carruthers and Gofton in this matter and have concluded
that the manner of death was asphyxia brought about when the Lifeline Bell was wearing became
entangled in her walker and strangled her. Before leaving this part of my report, however, I
should comment upon two additional factual matters addressed by Carruthers in his evidence.
These are: (1) the fact that no one observed the Lifeline around Bell’s death before she was
examined at the Funeral Home and; (2) Dr. Du Toit’s initial report that Bell’s death had been
brought about by hypertensive heart disease.
Although there is no direct evidence that Bell wore her Lifeline under garments worn on the upper
part of her body, I am satisfied that at the time of her death she was wearing the Lifeline
underneath the T-shirt worn by her as an upper body night garment. There is simply no other way
that the ligature furrows observed around her neck could have been caused. Given that fact and
Hieb’s observation that this T-shirt had itself become entangled in the walker, it is highly likely
that the Lifeline would have been invisible to any observer at the time her body was discovered,
dislodged from the walker or transported to the Funeral Home. It was under the neckline of Bell’s
T-shirt.
I also reject the suggestion that the T-shirt itself could have caused Bell’s asphyxiation. If that
were the case, one would expect ligature furrows that would conform more to the seam of Bell’s
T-shirt than is visible in any of the photographs. And if the seam of her T-shirt were tangled tightly
around her neck, this would not have caused the Lifeline to become embedded significantly
deeper into Bell’s neck than could be explained by pressure from the seam. I am aware that the
Lifeline was not fully extended. Nevertheless, I have no evidence that the sliders on that Lifeline
could not have failed to operate or did not bind in some fashion. Moreover, the compelling reality
of the photographs in Exhibit 3 is that the Lifeline was pressed deeply into Bell’s neck, regardless
of its extension. There is also little significance to the fact that the upper bed garment worn by
Bell slipped easily from the walker. Hieb would no doubt have pulled on Bell’s body to dislodge
her.
Finally, Dr. Du Toit testified that her comment on the cause of death was based entirely upon
information received from someone at the Medical Examiner’s office. This was not her opinion. It
was merely noted by her as some type of formality.

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Circumstances under which Death occurred:
Bell was born on April 27th, 1940. She married and had two daughters, one of whom currently
resides in Denver, Colorado and the other in Vancouver, B.C. Bell had two daughters, Lisa and
Stacey Greenwood. Stacey Greenwood attended and participated in this Fatality Inquiry.
Bell was in declining health in the years before her death. She was under the care of a family
physician, Dr. Martha Du Toit, who testified at this inquiry. Dr. Du Toit testified that Bell suffered
from chronic obstructive pulmonary disease (‘COPD’), arthritis, angioedema, insomnia and
intermittent gout. Bell had complained of chest pain in 2008 but investigation revealed no
significant coronary obstruction and her blood pressure was well-controlled. Later examination
(2010) revealed an abnormal ECG and elevated cholesterol levels leading to observation for
cardiovascular disease.
Medical intervention to treat these ailments was ongoing. Bell was prescribed a variety of
medication including a ‘beta blocker’, Lipitor, Hydrathyazine and medication for insomnia, reflux
and gout. The sheer amount of medication (‘polypharmacy’) became a concern. In addition,
dizziness was liable to occur through the use of at least some of these drugs. Finally, Alberta
Health Service records disclose that Bell had an issue with alcohol abuse. The consumption of
alcohol can exacerbate the side effects of the other drugs consumed by Bell. There were
occasions when Bell ‘passed out’ in her home, likely due to a combination of drugs and alcohol.
At the time of her death, Bell resided alone in a mobile home located at #62, 6205 – 54th Street in
Ponoka, Alberta. She had two close neighbors: Lenora Hieb (‘Hieb’) and Carol Hennessy
(‘Hennessy’). Hieb had known Bell for 6 or 7 years and, since Bell was in declining health, Hieb
set up a system whereby Bell would telephone Hieb each morning at 8:00 a.m. and ‘check in’.
There were some occasions when Bell forgot or neglected to call Hieb.
In August of 2008, arrangements had been made for Bell to acquire a device called a ‘Lifeline’.
This device consisted of a relatively small circular ‘button’ worn by the consumer either around
the neck (as a pendant) or on the wrist (like a watch). When depressed, the button activated the
consumer’s telephone which, in turn, contacted Lifeline’s ‘Emergency Response Centre’ (‘ERC’).
Staff at ERC monitor Lifelines continuously and react to the pressing of a Lifeline button by
contacting those who are designated by the consumer as ‘responders’.
Lifeline is manufactured and marketed by Philips. It has been available to consumers in the
United States since 1973. Worldwide there are estimated to be between 4.5 and 5 million users
with approximately 600,000 users in the United States and 100,000 users in Canada. The
consumer demographic for Lifelines indicate that 75% of users are female, the average age is 84
and users have, on average, 2 chronic medical conditions.
The pendant version of Lifeline was introduced in 1992. It consisted of the emergency button (a
plastic rectangular-shaped object) and a lanyard with 2 small plastic tabs (or sliders) which could
be used to lengthen or shorten the length of the lanyard to suit the user. Counsel demonstrated
movement of the sliders in court. Minimal force was used. Nevertheless, there was no evidence
of circumstances (or the absence of circumstances) which might lead those sliders to malfunction
or bind. There was no evidence of the potential (or lack of potential) for binding to occur by
twisting or through interaction with any clothing likely to be worn by users.
Philips became aware of ‘medical events’ involving the Lifeline pendant prior to 2009. The
precise nature of these events is not in evidence but they did include choking and at least one
fatality (strangulation). This prompted the U.S. Food and Drug Administration (‘FDA’) to have
Philips distribute a warning to those using the pendant. The warning stated (in part):
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Caution: The Pendant’s neck cord is designed not to break away. Therefore, it can pose a
choking risk, including the possibility of death and serious injuries. This may apply to
wearers in wheelchairs, using walkers, using beds with guard rails, or who might
encounter other protruding objects upon which the cord can become tangled. Wearers for
whom this is a concern may wish to consider the Wrist Style method.
Philips issued a ‘Safety Notice’ on September 11, 2009. And the warning noted above was
distributed to all subscribers and distributers of Lifelines, also in 2009.
In 2008, Philips began development of Lifelines with a ‘breakaway cord’. This type of cord had a
‘fuse’ built into each of the plastic sliders. Under extreme force, the slider would separate and the
lanyard break. The cost of this modification was minimal.
By 2011, Lifelines without breakaway cords were no longer manufactured. Nevertheless, those
that were still in the distribution chain were still used and distributed to consumers after that date,
at the purchaser’s discretion. In other words, non-breakaway cords continued to be provided after
those with a breakaway cord became available. Existing Lifelines without breakaway cords were
not recalled. Philips Canada’s records indicate that approximately 16,000 Lifelines with nonbreakaway cords were distributed. Of those, only 3000 were replaced.
David Doyle (‘Doyle’), a representative of Philips testified at this inquiry and was asked why the
non-breakaway cord continued to be used after the breakaway cord was available. He testified
that this was done: (1) because the non-breakaway cord had historically been the model used;
(2) once the fuse(s) were broken, the Lifeline button may fall outside the user’s grasp and be of
no use to him or her; and (3) the ‘broken’ Lifeline would need to be repaired or the user may be
disinclined to use an unrepaired Lifeline because it would need to be carried about.
Sometime after 2011, Health Canada investigated a “strangulation event” involving a Lifeline that
had occurred in the United States and entered into discussions with Philips. Doyle testified that
Health Canada did not mandate a recall of non-breakaway Lifeline cords but did promote
issuance of an “Important Safety Reminder Regarding Your Lifeline Personal Help Button”. That
reminder stated (in part):
If you were a Lifeline subscriber prior to 2011, you may recall receiving a caution card or
letter describing the risk associated with the Philips Lifeline pendant style neck cord.
That notice explained that the neck cord provided at the time was not designed to break
away. Any cord worn around the neck can pose a strangulation risk, including the
possibility of death and serious injuries. This may be more of a concern to wearers in
wheelchairs, using walkers, using beds with guard rails, or who might encounter other
protruding objects upon which the cord can become tangled.
(emphasis in original)
Doyle confirmed that the concern expressed in this reminder was elevated for those using
wheelchairs, using walkers, etc. And Philips records relating to Lifeline subscribers would
occasionally reflect that the subscriber now had such an elevated risk. He was asked by Inquiry
Counsel why Philips did not proactively contact subscribers in those situations to encourage them
not to use the pendant Lifeline. He responded that the customer’s decision governed and that it
was better to have a consumer wearing the necklace even with the added risk than for the
consumer not to have a Lifeline at all.
By letter to all Lifeline Program Managers dated June 1, 2011, Philips announced the availability
of, “ … new neck cords designed to break off to avoid the remote risk of accidental strangulation.”
Appended to that letter was a document entitled: “Frequently Asked Question sheet”. One such
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frequently asked question and Philips’ response to it was as follows:
Q. Are programs or Philips Lifeline customer sales to proactively sell the new neck
cord to subscribers?
A. Programs and Philips Lifeline sales should not proactively communicate our improved
neck cord design with consumers or referral sources. Lifeline messaging to consumers
should continue to focus on the core features and benefits of our medical alert service
offering, not on how we are addressing a remote risk of strangulation. Should a consumer
or referral source specifically inquire about our neck cord design or the risks of either
strangulation or breakage, we would respond by explaining the advantages of our design:
…
(emphasis in original)
Doyle was questioned about why Philips chose not to proactively promote the breakaway cord or
advise consumers about the health risks associated with the non-breakaway cord. His evidence
was that there was a possibility consumers would become concerned about a risk that wouldn’t
apply to them or was rare; that they would be unnecessarily alarmed. He testified that warnings
had also been sent out to all subscribers and program partners.
Philips Canada is a subsidiary of Philips. It engaged representatives throughout Canada
(‘program partners’) and assigned them responsibility for assisting subscribers with the
acquisition, set up and use of Lifelines. Family & Community Support Services (‘FCSS’), a nonprofit organization, acted as that representative in the Ponoka area. Kimberly Saunders
(‘Saunders’) and Ethel McLellan (‘McLellan’) were employed by FCSS and were involved in
administering the Lifeline program there.
FCSS had, as its overall goal, assistance to seniors designed to permit them to remain living in
their own homes. Approximately 30 programs were provided by FCSS. Supplying seniors with
access to Lifelines was one of those programs. By 2013, there were 80 to 90 Lifeline subscribers
in the Ponoka area. Bell was one of them.
Philips Canada representatives (or representative organizations such as FCSS) required
subscribers to enter into a ‘Monitoring Service Agreement’. The agreement for Bell’s Lifeline
required a one-time activation and set up fee of $20.00 together with a monthly payment of
$22.00. Both the one-time fee and $13 of each monthly payment were remitted to Philips Canada
by FCSS. The agreement also provided that all equipment required for the use of a Lifeline
remained the property of Philips Canada and Philips Canada assumed responsibility for its
maintenance.
Escorting the Monitoring Service Agreement was a document called a ‘Care Plan’. It contained
information about the program, subscriber, contacts, site, physician, medical conditions,
emergency phone numbers and additional services. In Bell’s case, Hieb, Hennessy and at least 2
others were included in the Care Plan’s contact information as responders. And it was noted in
Care Plans completed in both 2008 and 2011 that Bell used a cane, had problems walking and
was taking “blood pressure medication”.
Saunders testified that in 2008 the wrist version of Lifeline was the only product available to
subscribers and Bell was provided with one (as noted on Saunders’ ‘Lifeline Installation Checklist’
and Bell’s Care Plans). In 2013, however, Bell switched from the wrist model to the nonbreakaway pendant model. FCSS has no record of that change. Saunders could not recall why or
how that change came about.
Saunders was made aware of the availability of the breakaway cord by Philips’ letter (and
appended documents) of June 1, 2011. Saunders described this development as fairly significant
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or, in her words, “It was pretty large.”
Of course, FCSS had a supply of non-breakaway cords in stock and elected to use them up
rather than switching exclusively to the new breakaway cords. Saunders testified that there was
no sense of urgency in the switch and she did not proactively encourage clients to opt for the
breakaway cords. Rather, in accordance with Philips’ instructions, she simply provided the client
with the available options.
Bell actually activated her Lifeline from time to time in the years before her death. There were
occasions when she was either unable to walk or had fallen and couldn’t stand up and she would
press the Lifeline’s button. Each time the Lifeline button was activated, ERC would have Hieb
respond and/or an ambulance would attend and ensure that Bell received proper medical
attention. These events was recorded in Philips’ own records.
Notwithstanding the above, Bell was in relatively good health in the days before her death. Hieb
planned on travelling to Red Deer in mid-February 2013 and advised Bell that she wouldn’t be
home to receive a telephone call for a short period of time. When Hieb returned to Ponoka, she
did not receive a telephone call from Bell as expected. Hieb then called Bell at 9:00 a.m. and
there was no response. HIeb made another phone call shortly thereafter. When there was no
response to this second call, Hieb attended Bell’s residence.
Upon entry, Hieb saw no sign of a disturbance. She immediately noted Bell lying virtually prone in
the doorway separating the kitchen and pantry. Bell was dressed in her night clothing (a longsleeved T-shirt and full-length pant) with her head suspended approximately one foot off the floor.
The neck of Bell’s shirt was tightly tangled in her ‘walker’ handle and around her neck, causing
her head to be suspended. Hieb lightly ‘flicked’ the garment off the handle and Bell fell to the
floor. Hieb immediately called 911.
In her initial statement to police (dated February 19th, 2013), Hieb made no mention of Bell’s
Lifeline pendant. In a statement taken the next day, she was questioned about the pendant in the
following exchange:
Q. Ok. Did you notice whether she was wearing her - her Lifeline or anything?
A. No. I didn’t see. I didn’t see it.
Q. Ok. And when you flicked the T-shirt off, you didn’t feel the Lifeline or anything flick off
with it?
A. No, I didn’t. No.
Q. Ok.
A. Just the seam from the – the nightshirt.
Q. The seam from the nightshirt, ok.
A. Yeah.
Police responded to Bell’s residence shortly after Hieb’s call. They noted that the residence was
neat and orderly. Both Taylor and Hieb noted that, although there were empty wine bottles in the
kitchen cupboard of Bell’s residence, there were no liquor bottles otherwise visible. Taylor noted
no sign of a struggle or any evidence indicating foul play. He suspected that Bell may have risen
in the night and fell.
Like Hieb, Taylor saw no sign of the Lifeline pendant as he viewed the scene. He obtained
permission from the Medical Examiner to move the body. Even when lifting the body for
transportation to the Funeral Home, Taylor did not make note of the Lifeline.
It was the Funeral Home Director who first noticed the Lifeline. He contacted Taylor the next day
and advised of concerns about marks to Bell’s neck area. Examination revealed what appeared
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to be ligature marks on the neck. Visual inspection of those marks revealed a deep impression in
the skin around Bell’s neck area corresponding to the configuration of the Lifeline cord. One of
the sliders on the Lifeline cord precisely matched the contours of the deep impression in the skin
of Bell’s neck. Taylor contacted the Medical Examiner, photographed the body and arranged for
its transport for examination.
Bell’s death sparked swift and significant action by the staff at FCSS. McLellan testified that their
first concern was for Bell and the members of her family. Their second concern was prevention of
similar occurrences. Saunders ordered 50 new breakaway cords for the pendant Lifelines. FCSS
had 82 Lifeline clients at that time, 56 of which had pendants. Each was phoned and
appointments made. At meetings with them, they were shown the new breakaway cord and
advised that it was safer than the non-breakaway cords. They were shown Philips’ warning that a
fall while wearing the non-breakaway cord could lead to strangulation. At the end of the day,
every client with a Lifeline with a non-breakaway cord obtained a Lifeline with a breakaway cord.
The non-breakaway cords were discarded.
McLellan was asked about the reaction of clients to the warnings and encouragement to
exchange cords. She testified that it was a non-issue with them. They understood what was
being said and simply opted for the new breakaway cords.
Recommendations for the prevention of similar deaths:
It has been recommended by Philips that I recommend mandatory autopsies and toxicological
testing in cases such as this. Inquiry Counsel does not dispute the fact that an autopsy may have
provided more information relating to the cause of death. This submission is akin to one that
more information is always better than less information. I was impressed by Grofton’s evidence
relating to the efficacy of an autopsy in cases such as this, however. He was of the firm view that
an autopsy is not usual in cases of strangulation. I share his view that an autopsy would have
been of little value, if any, on the facts of this case. I decline to make the recommendation
suggested.
Counsel for Philips has also cautioned against recommending a recall of non-breakaway cords
used with the Lifeline. It has been noted that Philips has an otherwise good safety record and
operates in a highly regulated environment. Subscribers have been notified of risks associated
with the non-breakaway cord and should be permitted to exercise their own choice in that regard.
I have already noted earlier in these reasons why Philips chose not to replace non-breakaway
cords with breakaway cords even though the cost of doing so was minimal. And Philips
discouraged those distributing Lifelines from strongly recommending breakaway cords for fear
that consumers would be unnecessarily alarmed; they may elect not to use the Lifeline.
Fortunately, we have some empirical evidence that, if this is in fact the concern, it is probably
unfounded. Following Bell’s death, FCSS immediately and proactively worked in their community
to replace non-breakaway cords with breakaway cords. I commend them for that. Importantly, the
evidence before me is that, from the perspective of the consumer, replacement was a non-issue
to them. Given the risk described by FCSS (based upon information supplied by Philips),
replacement was undertaken quickly and effectively.
Accordingly, my sole recommendation arising from this Fatality Inquiry is as follows:
THAT Alberta Health Services and/or Health Canada, acting in conjunction with Philips
immediately and proactively take such steps as are necessary to replace all non-breakaway
cords used in conjunction with the Lifeline with breakaway cords.

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DATED
at

,
, Alberta.
A Judge of the Provincial Court of Alberta

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