A five-member jury at a coroner's inquest that concluded in Saint John on Tuesday came up with a single recommendation to prevent another death like what happened to Steven Lutes.

They said all higher-risk workplaces should require safety supervisors dedicated to on-site safety compliance.

The jury also said it would be up to WorksafeNB to identify which workplaces would qualify as higher-risk. 

Earlier in the day, the jury heard that Steven Lutes was wearing a body harness the day he fell from the fourth floor of Fredericton's Hilton Garden Inn while it was under construction.

However, his harness wasn't anchored.

Instead, his lanyard was looped back into his harness to prevent it from dragging. 

That was determined by WorkSafeNB investigators who attended the scene the morning of January 30, 2017.

Michel Cyr, assistant director of investigations, also said there were no anchor points in the area where Lutes was working that would have passed the regulatory requirement to sustain 5,000 pounds of pressure.

Furthermore, Cyr said multiple trip hazards were identified on the floor where the 41-year-old father of two had been scraping down a concrete slab. 

A photo showed a ladder and a piece of wood that could have caused Lutes to stumble while he was likely looking upward at his task. 

Lutes was especially vulnerable at that moment because protective guardrails had been removed from the building's edge to allow concrete forms to be moved into position. 

Cyr said WorkSafeNB issued a stop work order on the project immediately. He also said the order was lifted on February 13. 

He testified that WorkSafe's accident review committee also recommended that Lead Structural Formwork, the company contracted to do the concrete work, be charged under the Occupational Health and Safety Act.

In 2019, Lead Structural did plead guilty to violating part of the Act that prescribed the proper use of fall arrest equipment and procedures. The company was fined $50,000.

At one point during Tuesday morning's testimony a member of the five-person jury, a man who described himself as having 41 years of experience in construction, asked about a substandard anchor point that had been photographed in another area on the site. 

The juror wanted to know, if inspectors had been on location and noticed that the steel bar screwed into a concrete wall was clearly inadequate as an anchor for a harness, then why did inspectors not order it changed. 

Cyr was unable to answer.

The juror also expressed his distaste for what happened to Lutes.

"He just walked right off the edge," said the juror. "It's sad."

The jury also determined that Lutes died as a result of multiple blunt force traumatic injuries, secondary to a fall.

That aligns with what they heard from the pathologist who conducted the autopsy.

Dr. Mohammed Hossain said Lutes died from multiple blunt force injuries to the head caused by his fall.

He said Lutes also had multiple rib fractures and one broken rib had punctured his lung.

On Monday, paramedic Corrie MacAdams told the inquest that his ambulance arrived on the scene and resuscitation efforts ceased within about 20 minutes. He described Lutes's injuries as not survivable.

David Pottier worked for Lead Structural in 2017, bidding on jobs and taking care of contracts from the Halifax office. He said he heard about the accident in a phone call from a company project manager who was on the site when the fall took place. 

The jury had already heard on Monday that Paul Crevatin had gone to Fredericton to work for Lutes because Lutes was short-staffed. 

"I didn't know what to do," said Pottier. "I was beside myself."

Pottier said he was so upset, he had to get his wife to drive him to Fredericton. 

Pottier told the jury that Lutes was the supervisor in charge on site and would have been expected to discuss safety issues with other workers related to their assigned tasks.

However, he could not answer exactly what safety issues had been discussed among Lutes and his crew because Pottier wasn't privy to the "toolbox meetings." He described toolbox meetings as a daily opportunity for Lutes to talk to his workers about their tasks and the safety measures related to those tasks. 

Pottier also could not say with certainty how many workers were on site. 

At about 11:30, presiding coroner Emily Caissy gave her instructions to the jury before releasing them to deliberate.

Caissy advised the jury to determine the facts surrounding Lutes's death. 

However, she said they were not to give their opinions about liability or fault and they were not to name any individuals or assign any blame.

Rachel Cave is a CBC reporter based in Saint John, New Brunswick.

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