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Weighill personally apologized to Buxton’s family, according to the report. Buxton appears to have had a medical emergency which caused him to swerve off the road. The report does not say whether the delays were a factor in the death.

Vicky Buxton said she’s “in shock” over the situation, but declined to say whether the action taken is enough.

Buxton got his first horse at age three growing up in Innisfail, Alberta. His father raced and bred horses. So did his mother — a rarity in those days, Vicky Buxton said. Buxton would go on to become a jockey as well, racing across North America. In recent years, the father of two boys worked at Marquis Downs.

On Aug. 28, Buxton left his house before dawn. He was heading to Marquis Downs to exercise the horses, said his wife. At 5:19 a.m., a call came in to a 911 dispatcher regarding a crash on the 900 block of 20th Street East, according to the report. The caller said the driver of the vehicle appeared to be passed out. The call taker classified the incident as “Priority 4,” meaning it would only be responded to when a car in the district became available.

Further calls came in at 5:34 a.m., 5:40 a.m., 6 a.m. and 6:02 a.m., with the 6 a.m. call being made to the non-emergency administrative line at the station. During the 6:02 a.m. call, the caller said the driver appeared to be dead. It was then the incident was upgraded to “Priority 2,” prompting an immediate transfer to MD Ambulance.

Police officers were dispatched to the scene at 6:21 a.m. By the time they arrived at 6:26 a.m. the driver had been taken to hospital by paramedics, the report says. Officers then went to the hospital, where Buxton had been pronounced dead by staff.

The report states that in each of the first four calls to 911, the operators should have asked enough questions to reclassify the incident as Priority 2.

All communications staff will undergo additional training due to this event, the report says.