The Montreal Marathon: the coroner notes several failures after the death of Patrick Neely

A series of boondoggles “compromised” the chances of survival of Patrick Neely, a 24-year-old runner who died during the Montreal marathon last year, concludes coroner Géhane Kamel in a report released on Monday where the organization of the event is skinned.

Patrick Neely was approaching the finish line when he collapsed on September 22, 2019, feeling unwell. He was competing in the half marathon, a 21.1 kilometer course. After “difficult” treatment, the young man was transported to Notre-Dame Hospital and then to the CHUM, where he died the same evening.

Due to illness, the Beaconsfield runner was at higher risk of fatal cardiac arrhythmia. He had it entered on his race bib as a precaution. However, his condition was “moderate and stable”, and he was followed up annually at the Montreal Heart Institute, notes Kamel in his report.

All in all, Patrick Neely was in “good physical shape”: he practiced several sports, including running. His “exercise tolerance” was “significantly above average for his age”. “He had no contraindications to physical exercise and his only restriction was not to do intensive weight training like weights, for the sole purpose of preventing dilation of the aorta”, can we also read.


At 9:51 a.m. on September 22, Mr. Neely collapsed near the Cherrier-Saint-Hubert intersection in the final kilometer of the race. An SPVM police officer who saw him stagger immediately assisted him. On the communication channel deployed for the event, she asked for the support of Urgences-santé at 9:54 am received.

The assignment of a team of paramedics is, however, hazardous. Two attempts were necessary to reach her, yet posted very close to Mr. Neely. They were not in their vehicle, but in a mobile marathon clinic, “as they were asked,” notes the coroner. They finally set off at 10 a.m.

Meanwhile, the police reiterate their request for help on the line three times. She also performs resuscitation maneuvers on the young man with a citizen, a nurse by profession. Luckily, the officer had been trained in cardiopulmonary resuscitation (CPR) before her arrival at the SPVM, notes Me Kamel. Another policewoman and another good Samaritan woman may help them.

Several precious minutes passed between the time the runner collapsed and the arrival of first aid, that is, the firefighters. They were warned by a police officer who decided to run to their barracks. The paramedics arrived two minutes later at 10:03 a.m.

According to their protocol, they transported Patrick Neely to the nearest hospital, Notre-Dame Hospital. But once there, the decision to transfer her to the CHUM, better equipped, was made because of her medical condition. “Several difficulties in the stages of the care of Mr. Neely have certainly compromised his chances of survival,” said the coroner.

According to her, the organizers of the marathon should also have planned a clear game plan if a participant had to make a cardiopulmonary arrest. No protocol provided for the systematic transport of marathon runners to the CHUM, which offers hemodynamic treatment.


The pitfalls identified by Géhane Kamel do not stop there. The organizers had to deploy 200 people throughout the course to help the participants, if necessary. Barely sixty were finally deployed, a lack made up by the SPVM. The police force thus dispatched 200 additional officers, having “to play a role which was not initially intended for them”, notes the coroner.

The organizers of the marathon had also promised a “cardiosecure” event. In other words: a defibrillation device (DEA) will be accessible within three minutes. A total of 52 AEDs were to be available, at fixed or mobile stations. However, the police officers on duty that day did not know their position.

It was the firefighters who, after 10 minutes, arrived at Patrick Neely’s with a defibrillator. “Access to an AED would have been essential and should have been administered within five minutes of Mr. Neely’s discomfort. We believe that the rapid administration of the DEA could have helped to save his life, “concluded Mr. Kamel.

In the seven-page document, the coroner recommends that the SPVM train its cardiopulmonary resuscitation (CPR) agents and equip its patrol vehicles with an automated external defibrillator (AED). Currently, CPR training is not mandatory, except on hiring.

Me Kamel also asks the City of Montreal to ensure that the “medical and organizational infrastructure” of a sporting event comply with standards. Otherwise, she must cancel it.

Other details will follow.

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