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The emergency room at Toronto's Scarborough Grace hospital was, as usual, overwhelmed and understaffed when a man arrived the night of March 7. The triage nurse who first looked at Tse Chi Kwai, 43, immediately escorted him into the E.R. "He had a fever and a cough, and he was having a hard time catching his breath," says Jane Eckersall, 26, the principal nurse who treated Tse that evening. "And he looked scared." Tse had reason to be. On March 5, his mother died at home after suffering what had been diagnosed as a chest infection. A day before her death, Tse had come down with the same symptoms she had, and now the mysterious illness seemed to be spreading to the rest of his family.

Tse had SARS, from which he died on March 13, and he was about to set off a chain reaction that would infect 138 Ontario residents, leave a total of 20 dead and force more than 10,000 people into quarantine over a four-week period. How could the situation in Toronto—a center of advanced medicine—have gone so wrong so quickly? Bad luck explains most of Toronto's tale, but not all of it. As a TIME investigation has found, medical staff members early on missed key opportunities that, if taken, might have drastically slowed the spread of the disease.

The story begins with an elderly Toronto couple who spent 10 days in Hong Kong. Kwan Sui-chu, 78, and her husband began a visit to the city on Feb. 13 and stayed one night at the Metropole Hotel. Kwan almost certainly had a chance encounter there with a retired Chinese nephrologist named Liu Jianlun, who, it turns out, had SARS. After her return to Toronto on Feb. 23, Kwan passed the disease to members of her family, including her son Tse. At Scarborough Grace, he was placed in a corner bed of the E.R.'s observation ward. Next to him was Joseph Pollack, 76, who had been complaining of an irregular heartbeat. That night Pollack almost certainly got SARS, as did another man in the room, a coronary patient whom authorities refer to as Mr. D., 77. Both Pollack and Mr. D. would infect many others.

Could the spread of SARS in Toronto have been stopped that first night? Tse spent almost 24 hours in Scarborough Grace before he was placed in isolation. Says Dr. Sandy Finkelstein, who was on call that day: "His mother had died of a respiratory illness, and his background was Asian, and until proven otherwise, that's tuberculosis in my book. At which point I put him in the isolation room." Finkelstein also told the rest of the family members to isolate themselves, which they did. But he did not order the isolation of any of the patients and healthworkers with whom Tse had already been in contact. Should he have done so? "No," says Dr. Andrew Simor, a microbiologist and a member of the team coordinating Toronto's SARS response. "At that point there was no concept of how infectious (Tse) was."

If there had been, Pollack and Mr. D. might have been treated differently. After leaving the hospital, Mr. D. returned to Scarborough Grace complaining of shortness of breath. He probably had SARS by then, but because no one had connected him to Tse, he was sent to cardiac care before being transferred to York Central Hospital, north of Toronto. Mr. D. was finally linked to SARS on March 28, the day before he died. York Central was then shut down, and more than 3,000 staff members, patients and visitors were isolated. "In hindsight," says Dr. Allison McGeer, a Toronto infectious-disease specialist, the transfer of Mr. D. to a previously uncontaminated hospital "was the worst miss of the early days of the investigation."

Pollack was found when authorities started to trace people who may have been exposed to Tse. By that time he was already on his way back to Scarborough Grace with a burning fever. Pollack was isolated, but the E.R. staff apparently didn't check his wife Rose, 73. She was getting sick too. (Both would soon die from SARS.) When she took her husband into the E.R.'s waiting room, she sat near a man who was accompanied by two sons; all three were members of the 500-strong Toronto chapter of a largely Filipino Roman Catholic group, the Bukas-Loob Sa Diyos (B.L.D.) Covenant Community. The sons may have infected 30 other members of the B.L.D. Worse, B.L.D. members would expose an unknown number of people outside their circle to possible infection. On April 12, for example, one of the sons who had been at Scarborough Grace went to a conference in Montreal attended by about 450 people, including many from New York State.

Is SARS under control in Toronto? Authorities claimed last week that it was. Still, many questions about the handling of the outbreak remain. Don't put them to Carol Tough, a Scarborough Grace nurse who had to care for eight of her colleagues leveled by SARS and then spent 10 days isolated from her family. "I'd like to see someone else have done a better job," says Tough, defending the staff. "Walk a mile in our shoes and then tell me what you would have done different. And all the time you're wondering, When is it my turn?"

—With reporting by Daffyd Roderick, Cindy Waxer and Leigh Anne Williams/Toronto

• Steven Frank