An ambulance was requested at least four times before first responders arrived about 25 minutes after a participant in Montreal's half-marathon event collapsed and later died, sources tell Radio-Canada.

The Quebec coroner's office has launched an investigation into the death of Patrick Neely, 24, who collapsed about two kilometres from the finish line Sunday.

A police officer on the scene called three different times on her radio asking for an ambulance, and her partner called a fourth time, according to Radio-Canada sources.

Watching from the sidelines, spectator Josée Gagnon was one of the first to rush to Neely's side, offering him water and comfort until, finally, an ambulance arrived.

She said others, including a nurse, performed CPR on Neely while awaiting the ambulance.

By looking over her phone's history, Gagnon was able to figure out precisely how much time had passed.

"I wondered if it was me who had lost track of time and that it had just taken four minutes. But that's not it. Finally, it was 25 minutes. It was not in my head," she said.

"Why was the first call [from police] not heard?"

25 minutes before first responders arrived

Watching Neely turn blue with people crowding around, Gagnon eventually called 911 to ask what was taking so long, and an operator told her they had not yet received any calls about the incident.

Radio-Canada has since learned that the runner collapsed at 9:38 a.m.

Urgences-santé says it received the call at 9:55 a.m. First responders then arrived eight minutes later — by which time a full 25 minutes had passed.

Urgences-santé spokesperson Véronique Tremblay said the first call it received came from a female police officer, at 9:55 a.m. The officer had radioed in the incident to a police dispatcher, who in turn advised Urgences-santé.

Tremblay said two calls from citizens came after 9:55 a.m., but there is no report of any other calls before that time.

"It is not known if people have tried to call for help before that," she said.

The agency is investigating the incident, meeting witnesses and looking into what happened.

"We will have to meet everyone, and we will ask each other questions because we do not know. We have no idea," said another Urgences-santé spokesperson, Stéphane Smith.

Both spokespeople reiterated that race organizers had first-aid teams posted along the race route and ambulances on standby, ready to respond as needed.

Marathon organizers defend response time

Rock 'n' Roll Montreal Marathon race organizers issued a statement Monday afternoon offering "sincere sympathies" to Neely's family and friends while, at the same time, defending the medical response.

Medical personnel arrived at the scene with "state-of-the-art" rescue equipment and supplies within approximately eight minutes of the 911 call, the statement said.

Race organizers say they reached that conclusion based on timing and Neely's race pace data, as well as event logs and eyewitness accounts.

Rock 'n' Roll Montreal Marathon race director Dominique Piché told CBC News Monday morning he focus was on the athlete's family and friends, extending his condolences to them. (Isaac Olson/CBC)

Organizers say everything was ready during the event to help runners in distress, and nearly a year has gone into planning medical support.

"All resources were in place appropriately on race day, including more than 50 defibrillators and more than 80 health professionals on the course, as well as eight ambulances dedicated to the event," read the statement.



Race director Dominique Piché told CBC on Monday morning that his focus was on Neely's family and friends, extending his condolences to them. Piché declined to talk to CBC after a further request Tuesday.

Government reviews sporting event organization

On Monday, Quebec Health Minister Danielle McCann said that the government will review the way major sporting events are organized in the province.

Aside from having defibrillators available, there are other steps that can be taken to minimize risks, McCann said. She stressed that there will never be zero risk, however.

Studies have shown medical emergencies are most likely to occur near the finish line of long course events like the marathon.

Urgences-Santé says ambulances were stationed nearby, but witnesses say help was requested four times before an ambulance arrived 25 minutes after the victim collapsed. (Al Bello/Getty Images)

"Nearly 80 per cent of cardiac arrests occur within 1.5 kilometres of the finish line," said Dr. Martin Juneau, a cardiologist who called it "curious" that it took so long to get help to Neely.

Vincent Thibaudeau, an experienced marathoner who competed in Sunday's event, said there should always be medical teams posted along the last couple of kilometres of races.

"It is necessary to plan to have more than one respondent at these locations and/or more defibrillators," said Thibaudeau, who routinely runs in marathon races across North America.

"The organization failed in its responsibilities."