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A "slap on the wrist," said the dead man's best friend.

"A joke," said his lover and partner.

It's hard to find other words to describe the limp disciplinary actions taken against the emergency services workers whose missteps and bad decisions destroyed James Hearst's chance of surviving a heart attack and fall at his downtown apartment building this summer.

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While Mr. Hearst lay dying, his face turning blue as horrified passersby tried to revive him, two paramedics sat parked in their ambulance just around the corner, lights off, doing nothing, for nearly half an hour. Dispatchers failed to inform them of the growing urgency of the call. A supervisor didn't bother to ask them why they were not on the move.

The penalty for the five workers: unpaid leave for between 10 and 17 days, plus six to 12 months of probation and training. For Alejandro Martinez-Ramirez, Mr. Hearst's partner of eight years, it is inconceivable that they should pay so small a price.

"We are all putting our lives in the paramedics hands," he said yesterday after Toronto Emergency Medical Services chief Bruce Farr released a report on the appalling events of June 25. "And for them to make such a poor decision when someone died and then they just need to go back school? I don't think that is good enough for me."

It shouldn't be good enough for any of us. The inquiry not only exposes an incredible series of blunders and rule-breaking that quite possibly cost Mr. Hearst his life. It tears the lid off a practice - staging - that could put many more lives at risk.

Since a 2005 Ministry of Labour order sparked by a union complaint about the safety of emergency workers, paramedics have the right not to come to your aid if they fear they may be putting themselves in danger. Instead, they are allowed to "stage" nearby while waiting for police to arrive and check things out.

It's easy to understand why paramedics might hang back on arriving on the scene of a shooting or a fight. But there was nothing remotely like that going on the night of June 25. This was not Fort Apache the Bronx. Mr. Hearst lived at 40 Alexander St., a neat 1960s-style apartment building on a quiet residential street of the city's gay village. He had passed out and was on the floor when a caller phoned 911. There was no news of violence from the scene, only a vague report that Mr. Hearst may have been drinking.

But the two paramedics dispatched to the scene were rookies, and shaky ones at that. One of them later admitted she may have been rattled by an incident earlier in the night when an aggressive patient thrust his arm through the ambulance window. The other said there were "tens of thousands of people out" - it was Pride Week in Toronto - as if that were a cause for dread.

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Deciding that discretion was the better part of valour, they parked way down the street at Yonge and Alexander and sat there. They didn't bother to drive by 40 Alexander to see if any of the awful things they feared were actually happening. Nor did they talk with a supervisor about what to do next. Even when they got an update from dispatch that Mr. Hearst was not breathing, they stayed parked for more than four minutes, only arriving at 40 Alexander after a fire truck had screamed by en route to the scene. Between the time they were first dispatched to help the stricken Mr. Hearst and the time they arrived, 36 minutes and 42 second had passed. By then it was too late.

A handsome, soft-spoken man with the accent of his native Spanish tongue, Mr. Martinez-Ramirez isn't seeking revenge for the loss of his lover. But he does want answers, and so should we all.

Why did emergency services pair up two rookie paramedics - one on the job for only a year or so, the other for just four shifts - despite an explicit policy of putting rookies with more senior workers? Was their failure to follow the rules on staging the cause of the tragedy, as Chief Farr claims, or is the staging policy itself at fault? Should paramedics really have the right to decide not to deliver their life-saving services if they happen, for whatever reason, to feel threatened?

Did the fact that the City of Toronto strike was on and that emergency workers were a part of it (though forced to provide adequate service) have anything to do with the two paramedics reluctance to act? Incredibly, the inquiry does not even touch on that question.

Until something changes, says Mr. Martinez-Ramirez, "This could happen to any other paramedic." Without answers, "who says they are not going to make the same mistake again and someone is going to die?"

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