An incident, captured on video by CBC News, in which a funeral home employee dragged a body along the floor of a refrigerated trailer breached protocol but was a "one-time incident" that occurred at an overwhelmed Office of the Chief Medical Examiner, an Alberta Justice investigation concluded.

The investigation report said the incident occurred as the understaffed Edmonton Office of the Chief Medical Examiner (OCME) struggled with an influx of bodies that exceeded its storage capacity.

The report was completed more than three months ago but was not publicly released.

"My investigation found that sliding a decedent on his back was a one-time incident by someone outside of OCME," wrote investigator Don Smallwood, former director of the Alberta Human Rights Commission.

An investigation is underway after CBC News recorded this video showing a man dragging a body bag across the floor of a refrigerated truck being used as a temporary storage unit. 1:00

"The CBC video clearly showed a decedent being moved by a Calgary funeral home employee in a manner that was unprofessional and contrary to standard operating procedures of the OCME and the Alberta Funeral Services Association," Smallwood wrote, adding the body "was the only decedent in the trailer that was moved in an unprofessional or inappropriate manner."

In September, CBC News learned the OCME had taken the unusual step of renting a refrigerated semi-trailer to store an influx of bodies.

Acting on a tip, CBC News recorded video of a funeral home employee dragging a dead person in a body bag along the floor of the trailer, parked in a lot behind the OCME's office in south Edmonton.

The employee grabbed the foot end of the body bag and dragged the body on its back about half the trailer's length to an elevated gurney where an OCME staff member stood waiting.

The trailer and its interior, which held 17 bodies on the floor, was clearly visible from a nearby street.

The video caused national outrage and spurred an apology from Justice Minister Doug Schweitzer, who directed his ministry to open an investigation.

Mass fatality plan

Smallwood's investigation found the chief medical examiner, Dr. Elizabeth Brooks-Lim, rented the trailer in accordance with her office's mass fatality plan to handle the influx of bodies, which he noted cannot be turned away by the OCME.

He found contributing factors to the office reaching storage capacity may have included understaffing and fatigue in the Edmonton Investigation Unit, ongoing delays in hiring new investigators, and the fact several employees were in acting roles at the time.

"In effect, the trailer was set up as one continuous gurney/body storage rack," Smallwood wrote, adding the trailer was clean, kept at the proper temperature, and monitored by security.

He acknowledged, however, that "the positioning of the trailer, coupled with the initial lack of privacy screening, left the back end of the trailer exposed to passers-by on Belgravia Road and beyond."

CBC News subsequently learned the decedent in the body bag was Bryce Sather, a 25-year-old man who died after a long struggle with kidney disease. Sather's family was distraught by the treatment of his body. (Submitted by Raymond Pizzey)

The operations manager for the Calgary funeral home, McInnis and Holloway, admitted the OCME had directed funeral homes to send two employees to retrieve bodies from the trailer but the funeral home decided to only send one "due to the distance and cost."

The operations manager said the lone employee had been directed not to move the body himself but instead was supposed to seek the assistance of a colleague from an Edmonton funeral home.

The report noted the OCME employee present during the incident, a morgue technician, said he told the funeral home employee "not to move the decedent by himself" but the funeral home employee refused the instruction.

"The challenge the morgue technician had in the moment was understanding his authority to stop the funeral home employee from proceeding with the pick up," the report continued, "as he was in a unique situation he had never encountered before and it transpired within a few seconds."

In an interview, McInnis and Holloway's operations manager, Jeff Hagel, told CBC News the OCME had asked his funeral home to send two employees to transfer the body, though he could not recall what, if any, explanation the OCME gave for this. He said in his experience, OCME staff have often assisted funeral-home staff when required.

Hagel said rather than send two employees from Calgary, the funeral home decided to let the one employee use his discretion about whether to call in a staff member from an Edmonton funeral home to help him move the body.

Smallwood recommended the OCME develop an additional standard operating procedure, or expand existing ones, to more formally outline how to handle bodies in a respectful and professional way.

Body was 'desecrated,' brother says

Following the broadcast of the video, CBC News learned the person in the body bag was 25-year-old Bryce Sather. His brother, Raymond Pizzey, said Sather died quietly in his sleep in Edmonton following a long struggle with kidney disease.

Pizzey said he found out about the video the day of Sather's funeral. Chief medical examiner Elizabeth Brooks-Lim and another pathologist examined Sather's body to ensure it had not been harmed, and both Brooks-Lim and Hagel personally apologized to the family.

But that apology provided little comfort for Pizzey.

"I feel like my brother's body was desecrated and I have to live with that for the rest of my life," he said in an October interview. He is now suing the funeral home for emotional distress.

The brother of a man who was dragged in a body bag on the floor of a semi-trailer rented for storage by the Office of the Chief Medical Examiner of Alberta expresses his hurt and outrage at his brother's treatment. 0:43

Staff concerns brushed aside

Smallwood's report does not reference internal emails, obtained by CBC News, that showed an OCME staff member previously raised concerns with Brooks-Lim about the propriety of storing bodies on the floor of a trailer.

"I feel that this might not be something that families will find acceptable," the employee told Brooks-Lim in an email sent Sept. 5, four days before CBC News recorded the video. "How do I approach this when speaking to families?"



In an email sent to all OCME staff, Brooks-Lim responded: "The floor is clean, the bodies will be in body bags and the families do not need to be informed of the storage procedures."

The report also doesn't reference that Alberta Justice launched an internal investigation to try determine who tipped CBC News to the body storage issue.

Smallwood's investigation found the OCME has asked for more body storage racks for the past two fiscal years and will soon receive them, to reduce the likelihood of needing the refrigerated trailer for storage in future.

Two MEs leaving understaffed office





Internal emails obtained by CBC News showed Alberta chief medical examiner Dr. Elizabeth Brooks-Lim brushed aside an OCME employee's concerns about storing bodies on the floor of a refrigerated trailer. (Supplied) Brooks-Lim recently resigned from her position. In a statement, she said it was a personal decision to leave the job and that she is looking forward to the next chapter in her career. Alberta Justice confirmed she will stay on in her role until the ministry can appoint an acting chief medical examiner.

CBC News also confirmed earlier this week that another Edmonton medical examiner, Dr. Mitchell Weinberg, is leaving the chronically understaffed OCME. Weinberg said in a statement he has accepted a position that is closer to his family and that his decision is not related to Brooks-Lim's resignation.

"The OCME has made arrangements to ensure uninterrupted service delivery during the recruitment period, including bringing in qualified temporary service physicians to assist, and rotating Calgary and Edmonton medical examiners between sites as necessary," an Alberta Justice spokesperson said in a statement.

The statement said the ministry has already begun to fill the vacancies.

In an emailed statement about the investigation report, Justice Minister Doug Schweitzer apologized to the public and said he will ensure the new chief medical examiner incorporates the report's findings to ensure an incident like this doesn't happen again.

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