Coroner Jacques Ramsay released a report today on the death of Radil Hebrich, 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 as the train left the station moments later, he leaned across the yellow warning line at the edge of the platform and was hit in the head by a passing train.
He fell onto the platform and was bleeding profusely.
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.
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.
"As for the indifference of the passengers," coroner Jacques Ramsay writes, "it says a lot about citizen apathy in our society. There is not much positive to write about this operation."
Ramsay only made one recommendation in his report. He suggests Montreal's public transportation authority, the STM, review its safety protocols.
The STM declined to be interviewed, but said it takes the recommendation in the report seriously.