MONTREAL -- A Quebec coroner says the quick use of a defibrillator could have helped save the life of a 24-year-old Beaconsfield man who ran in the Montreal Marathon last year, but that a lack of communication, organization and a series of missteps led to his death.

No defibrillator nearby, not enough marathon response teams on hand, transport to the nearest hospital instead of one specialized in cardiac arrest, more than 10 minutes before first responders arrived - those were just some of the things that went wrong the day Patrick Neely died last September 22.

Coroner Géhane Kamel said in her seven-page report it was only by chance that Neely got the help he did when he collapsed during the last kilometre of the marathon - lucky that the officer who tended to him knew CPR since it's not mandatory training for Montreal police; lucky that another officer was able to run to the nearest firehouse instead of waiting for the dispatch call.

But that wasn't enough to save him. It took more than 10 minutes from the first police call for first responders to arrive. Neely was brought to Notre-Dame Hospital, the closest hospital, instead of the CHUM, which specializes in cardiac arrest and only 300 metres away from Notre Dame.

Kamel said all of this happened because of the confusion surrounding communications and the way the marathon was organized - that the many problems in the way Neely's case was handled compromised his chances of survival.

Among the coroner's recommendations:

  • marathon organizers must make sure everyone knows where defibrillators are located
  • Urgences Santé must know where their ambulances are located so they can be dispatched quickly
  • Montreal police patrollers should be trained in CPR
  • the city of Montreal should refuse such events if safety and organizational measures aren't in place