A Quebec coroner says a man who was seriously injured by a subway train and collapsed on a Metro platform in Montreal might have had a chance to survive, if only someone had helped him.

Coroner Jacques Ramsay released a report today on the death of Radil Hebrich, 59, who was hit and killed by a Metro car in January 2014 at Langelier station in Montreal's east end.

Hebrich had been drinking and stumbled across the yellow warning line at the edge of the platform and was hit in the head by the side of a passing train.

He fell onto the platform and was bleeding profusely.

The entire incident was caught on security cameras.

"It's very provocative, because for 16 minutes you see Mr. Hebrich on the platform with nobody that tries to provide help," Ramsay told CBC News.

The coroner writes that dozens of people and three Metro trains passed by as he bled from the head.

No one intervened to help Hebrich.

"Some people actually turn and look at what's happening, but nobody goes to give him help," said Ramsay. "People coming into the station do not know what happened and consequently, don't feel involved."

It took 16 minutes before emergency services arrived and another three minutes before they began to try and revive the man. He died shortly afterwards.

Ramsay said it is not certain whether an earlier intervention could have improved Hebrich's chances of survival, because of the seriousness of his head injury.

"If you're 19 minutes without CPR … it does not help your chances," he said.

"As for the indifference of the passengers," Ramsay wrote in his report on the incident, "it says a lot about citizen apathy in our society. There is not much positive to write about this operation."

Ramsay said that he did not think that people were intentionally not helping Hebrich, however, the collective inactivity could have caused him to not receive help as quickly as possible.

"It's sort of a case where people expect their neighbours will do something," he said. "I think as a rule the Quebec society is a very caring society, so I think this is very pertinent in the sense that it makes us question 'what would I have done in a situation like this' because it could happen to anyone."

Ramsay only made one recommendation in his report. He suggests Montreal's public transportation authority, the STM, review its safety protocols.

"I was hoping this could serve as a sentinel event," he said.

The STM declined to be interviewed, but said it takes the recommendation in the report seriously.