Erick Meyer was speeding erratically along Highway 401 when he plowed his car into the back of another, killing a female passenger and injuring two others.

His vehicle had been travelling up to 140 kilometres an hour; the car ahead had slowed to below 40 before entering a construction zone.

Witnesses said they’d seen the then 43-year-old driving dangerously, veering in and out of lanes. After the crash, he appeared disoriented and confused. To emergency responders, he seemed drunk.

Last month, Meyer was acquitted of serious criminal offences. He instead pleaded guilty in a Belleville, Ont., courtroom to the Highway Traffic Act charge of careless driving, for which he received a $2,000 fine and avoided prison time.

What happened?

According to evidence prepared for his defence, Meyer was on a job site around 8 a.m. on Sept. 20, 2017, when he felt the sensation of his blood sugar dropping.

The welder had been living with Type 1 diabetes since he was seven, so this in itself would not have been unusual.

He stopped what he was doing, tested his blood-glucose level, drank a can of soda, rested and felt fine, according to a summary prepared by Dr. Ileana Lega, a Toronto endocrinologist.

People with Type 1 diabetes produce no insulin, a hormone that lets their bodies use glucose — sugar — for energy or store it for future use. Without it, Type 1 diabetics, such as Meyer, must pay close attention to the level of glucose in their blood, and know how to regulate it with diet and insulin.

If a Type 1 diabetic’s blood-sugar drops — a condition called hypoglycemia — he or she will typically feel a range of symptoms, such as shaking, sweating, extreme hunger or dizziness.

(Hypoglycemia is not normally a problem for most people with Type 2 diabetes, which is typically acquired later in life and controlled through careful diet and exercise. Some Type 2 diabetics who take insulin or drugs to increase the body’s production of the hormone may be at elevated risk.)

About an hour later, Meyer ate a sandwich and banana. He did the same at lunch. Before driving home, he drank a coffee with sugar and reported feeling fine, without any symptoms whatsoever.

Other than the fact it was hot and Meyer was tired, Lega noted, it was an ordinary day.

The crash happened on the way home, around 3 p.m. in the westbound lanes of Highway 401 near Quinte West. Meyer jammed on the brakes at the last second, then slammed into a car that had slowed in a highway work zone

Sometimes, a diabetic won’t notice.

A condition called hypoglycemia unawareness occurs when blood sugar drops severely but without triggering the typical symptoms. With no obvious signs of hypoglycemia, a diabetic may fail to take the steps to raise his or her blood sugar, and may become disoriented and confused.

In Canada, blood sugar levels are measured in millimoles of glucose per litre, or mmol/L. Hypoglycemia begins below 4 mmol/L and severe hypoglycemia, which can threaten a person’s life or make them lose consciousness or have a seizure, occurs below 2.8 mmol/L.

At around 4:15 p.m., an ambulance attendant tested Meyer’s blood at 2.6 mmol/L. He was given glucose paste, and his reading soon improved to 3.1 mmol/L. He said he was feeling better, and mentioned his blood glucose levels usually fall in the range of 3-5 mmol/L.

Diabetes Canada recommends that people do not drive unless their blood sugar is above 5 mmol/L.

Meyer also told the attendant he typically feels symptoms when his blood sugar is low but “he did not experience them while driving on the highway pre-collision,” Lega noted after reviewing preliminary hearing transcripts, ambulance and hospital records, and Meyer’s historic medical records, and meeting with him.

Despite first responders’ suspicions, a breath test found no alcohol in Meyer’s system.

Hypoglycemia unawareness can be particularly dangerous behind the wheel as a diabetic may not know they’re driving erratically, according to a 2018 study in the Canadian Journal of Diabetes.

“Severe hypoglycemia impairs the ability to drive, but the affected individuals may not be aware that they are driving erratically or even dangerously,” it said.

And while governments have created laws, rules and regulations to help lower the risk of hypoglycemia-related crashes, they are still occurring regularly, the Diabetes journal article states.

The rate of the disease in Canada is a growing “epidemic,” Diabetes Canada says on its website, with 11 million Canadians living with either type of diabetes or prediabetes “and another diagnosed with diabetes every three minutes.”

So, too, the number of diabetic drivers has risen significantly in Ontario.

In 2010, there were fewer than 18,000 diabetic drivers in the province, 7,336 of whom were insulin-dependent, according to the Ministry of Transportation.

By 2018, there were nearly 60,000 diabetic drivers overall, 25,105 of whom were insulin-dependent.

The Belleville court case, therefore, has “enormous public significance” because it brings into focus the danger that hypoglycemia unawareness poses to road safety, said Richard Posner, the Toronto defence lawyer who represented Meyer, arguing in court that his client had been experiencing hypoglycemia unawareness.

“Many Canadians suffer from Type 1 diabetes and these individuals pose a significant risk on the road if they do not have proper education on hypoglycemic avoidance,” Posner wrote in an email.

“Tragic accidents will continue to plague our roads until such education becomes absolutely mandatory. It is incumbent on our legislature to address this problem and to do so on a most urgent basis.”’

If Meyer had felt his blood sugar dropping, Posner said, he would have “pulled over straight away, tested his blood sugar, and, if low, would have ingested a sugary snack,” which he kept in his vehicle.

Meyer was taken to hospital where he was treated by the emergency room physician, Dr. Allan Bell. According to Lega’s summary, Meyer told the doctor he felt his blood sugar start to drop after the crash.

Based on reports by emergency responders, witness accounts, Meyer’s diabetic history, and his blood sugar readings, the Toronto physician concluded he was in a hypoglycemic state at the time he rear-ended the car ahead, killing Irene Buenavida, 70, and injuring her husband and son.

At least initially, Bell also assumed Meyer would have been experiencing the typical symptoms of hypoglycemia, and therefore should have known better than not pulling over.

A day after the crash, Ontario Provincial Police charged Meyer with criminal negligence causing death and dangerous operation of a motor vehicle causing death.

The Crown’s theory was that Meyer was either not in a hypoglycemic state or, if he was, he showed criminally poor judgment by not pulling over.

During cross-examination at the preliminary hearing, Posner’s associate asked Bell if he knew about hypoglycemia unawareness. He told court he had heard of it, and that he didn’t think it was common. He added it was outside his area of expertise as an emergency physician. (Bell confirmed the content of his court testimony to the Star.)

After he left court, Bell went home and studied hypoglycemia unawareness. It was more common than he believed.

“It was humbling for me,” he told the Star. “I’m not sure how many emerg physicians would be aware it was that common.”

It is estimated that 25 per cent of Type 1 diabetics treated with insulin will experience one or more episodes of hypoglycemia unawareness, the Canadian Council of Motor Transport Administrators wrote in 2017.

The guidelines say anyone who has a history of recurring severe hypoglycemic episodes or hypoglycemia unawareness must measure his or her blood glucose immediately before and at least every two hours while driving or wear a real-time continuous blood glucose monitoring device.

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The trial began in early January, and Crown attorney Lee Burgess once again called Bell to testify about examining Meyer.

This time during Posner’s cross-examination, Bell testified he had a better understanding of hypoglycemia unawareness and said that although he could not say definitively if Meyer was suffering from it at the time of the crash, he could not rule it out.

Looking at the evidence, it would have been possible, Bell told the Star, paraphrasing what he had said in court.

“It would be a hard thing to prove one way or another,” he said.

After Posner’s cross-examination — and receiving Lega’s report — Burgess decided to halt the prosecution.

“I was of the view that I could no longer prove that Erick Meyer was not suffering an episode of hypoglycemia unawareness,” Burgess wrote in an email. “There remained evidence of aggressive driving in the moments preceding the collision and I accepted a plea to careless driving.”

In addition to the $2,000 fine, Meyer received a probation order for one year and was ordered not to operate a vehicle without first testing his blood sugar level to ensure it is above 4.0 mmol/L. He declined to comment.

Things should not have gone as far as they did, Posner said.

“The Crown never retained or consulted with an endocrinologist, which they should have done from the beginning,” Posner wrote in an email. “Had they done so, I really doubt this case would have proceeded to trial.”

Posner believes hypoglycemic education should become a mandatory condition for all Type 1 diabetics to obtain their driver’s licence.

Meyer has since learned more about hypoglycemic avoidance and “now always checks his blood sugar levels before driving,” Posner said.

That makes him a rarity.

“Studies have shown that the vast majority of such individuals do not test their blood sugar before driving. This is the direct result of a lack of education on hypoglycemic avoidance,” Posner said.

In an email to the Star, Dr. Ian Blumer, who was not involved in the Meyer trial but testified in another diabetic driving case, said that while he is “an incredibly strong proponent of diabetes education,” he’s not sure about making it mandatory.

“I am not aware of any research studies that have been done to advise (and therefore prove) that mandatory education is superior to strongly encouraging and promoting diabetes education in achieving successful behaviour change.”

But Blumer, who co-authored the 2018 journal article, agrees hypoglycemia unawareness is potentially a very serious problem, and not just while driving.

In the paper, Blumer and his co-authors argue that judges and lawyers need to understand that “patients with insulin-treated diabetes are a) likely to be insufficiently aware of the need for hypoglycemia avoidance when operating a motor vehicle and b) in nearly all cases, these patients are highly unlikely, when driving while hypoglycemic, to be aware that they are driving in a matter that is objectively dangerous.”

From a legal standpoint, “their conduct must be understood to be potentially excused under criminal law because they lack the intent necessary to commit the offense of either dangerous driving or criminal negligence, both of which require people to have subjective awareness of the nature of their acts.”

The Ministry of Transportation collects data on how many fatal accidents are caused by medical conditions but does not identify what condition contributed to the crash. In 2018, the province reported a total of 1,191 collisions involving medical conditions.

A ministry spokesperson did not directly respond to the Star’s question on whether hypoglycemia unawareness education should be mandatory for diabetic drivers.

“As with all types of medical conditions (diabetes, seizure disorders, etc.) the ministry relies on the individual’s primary health care provider to educate their patients about their medical condition and its effect on safe driving.”

Victor and Irene Buenavida and their son Ron were driving from Montreal to Toronto to visit family for Rosh Hashanah when Meyer smashed into their vehicle.

Irene, a well-known philanthropist in Montreal’s Jewish community and Victor’s wife of 43 years, was killed. She was 70. Victor, who was behind the wheel, and Ron were taken to hospital, treated and released.

Ron Buenavida had just flown in from Israel to see his parents for the Jewish holidays.

“I only had one day to spend time with my mom, and this terrible thing happened,” he told the Star in a telephone interview from his father’s home in Montreal.

Both Victor and Ron continue to undergo treatment for their physical injuries and psychological scars. “We’re dealing with a loss, completely unexpected, I still to this day — I just don’t understand how this happened. We’re very nice people. My mom was an amazing woman,” Ron told the Star.

Neither he nor his father is happy with how the case ended. They both reject that Meyer was unaware of the way he was driving — “like a maniac,” in Ron’s words.

Ironically, Irene was a Type 2 diabetic, as is Victor. It’s not that they don’t believe hypoglycemia unawareness exists; they just don’t think it was proved to be a factor in this case.

“A million other things could have happened in that car,” Ron said. “We just don’t know.”