DYING TO BE HEARD
Police often slow to act on repeated recommendations for preventing fatalities
When Saskatoon police came across Brandon Daniels outside the Galaxy Theatre on July 2, 2010, he was slumped over on a bench next to his own vomit. Officers assumed the 19-year-old was drunk, and took him to the police lockup.
About 12 hours later, he was dead in his cell.
Daniels hadn’t been drinking; rather, he had overdosed on Tylenol. At a coroner’s inquest into his death last fall, a jury recommended “mandatory” drug-recognition training for all police in the city.
Seven years earlier, a different jury — probing the death of another inmate in that city — had made a similar recommendation.
Among the public agencies most often under scrutiny at death inquests or inquiries are police. Yet they are often slow to act on recommendations, a Postmedia News investigation found.
For example, inquests have repeatedly called for better training and clearer policies for handling detainees whose state of consciousness is unclear. Inquests have also called for dashboard cameras in police cars, clarification of pursuit policies, better responses to emotionally disturbed individuals, and a database related to the use of stun guns.
“They say it’s already been done or it’s not practical, but we find that the same kinds of recommendations are made over and over without any appreciable improvement,” said Josh Paterson, executive director of the B.C. Civil Liberties Association, which tried unsuccessfully to get the Saskatchewan Public Complaints Commission to review a trio of Saskatoon jail deaths.
“(Police) are authorized by government to use force, including deadly force. And that requires a very high degree of oversight and a lot of care and responsibility. … It’s really important that police take those recommendations very seriously.”
Jail-cell deaths
Daniels, of the Mistawasis First Nation, was in Saskatoon to visit his cousins and friends. In the late afternoon, he purchased about 650 Tylenol tablets and apparently ingested most of them over the next few hours, according to a coroner’s summary.
Police found him “slumped forward with vomit between his feet and on his clothing.” At the station, he had to be taken to the booking area in a wheelchair. He was placed in a cell in a recovery position and “remained prone until his death more than 11 hours later,” according to the coroner’s summary.
“At no time” was he medically assessed.
An inquest jury in November recommended that all Saskatoon police watch an educational video on recognizing symptoms of drug use. It also recommended a paramedic be present in the jail 24/7, an expansion of the 12-hour coverage from 7 p.m. to 7 a.m. that was implemented in 2011.
The jury also called on the city to expand its 12-bed detox unit, which is frequently at capacity, and create a health-and-wellness centre that includes a detox unit.
The city had heard such recommendations before. In 2006, an inquest looked at the death of Dona Sanderson. She was arrested after police found marijuana and drug paraphernalia inside the vehicle in which she was riding.
What police didn’t know was that she had a bag of cocaine concealed in her vaginal area. The drug began to leach into her system. She complained to jail staff that she needed to go to the hospital. “My heart, my heart,” she said.
Even as a call was made to 911, a special constable chuckled when the operator asked if Sanderson was conscious. “When she wants to be,” the officer said.
The jury recommended that “all police personnel participate in a drug addictions awareness program.” It also called on the city to set up a detoxification facility with long-term care accommodations and counselling.
At an inquest last June into yet another death at the Saskatoon jail, a jury recommended the 24/7 presence of a paramedic and a higher level of first aid training for detention staff.
Saskatoon police Chief Clive Weighill told Postmedia News the force will add drug-recognition training for all front-line personnel this year. Police are also talking with the Saskatoon Health Region about expanding the presence of jail paramedics.
But Sandra Blevins, vicepresident of integrated health services at the health region, said they don’t have enough provincial funding to expand the presence of paramedics. She admitted that the city’s detox facility is frequently at capacity but said a recently opened federally funded 25-bed emergency shelter for people with addictions could ease the pressure.
Police and health officials are discussing developing a wellness centre to help people with addictions and mental health issues. They may also renew a pilot project that teamed a mentalhealth worker with patrol officers.
Enough talk, said Sherry Bird, Daniels’ mother. The same recommendations keep coming up; surely authorities should be able to support them.
“There are good recommendations coming out of these (inquests),” she said. “Why can’t they come up with the money? It’s obvious there’s something that needs to be done.”
Inquests into jail deaths elsewhere in the country have repeatedly called on police to revamp protocols for how often sleeping or intoxicated inmates should be checked, how to confirm whether they’re breathing and how often to wake them. For instance, several inquests have recommended that the RCMP protocol for “rousing” sleeping inmates every four hours should be modified to one or two hours. So far, there has been no change.
Police cameras
Another repeated recommendation has been for police to install video and audio recording devices in vehicles, or have officers wear them.
In Saskatoon, the police service completed installing in-car cameras in its fleet of vehicles one year ago. Each patrol unit has a front- and rear-facing camera to capture the area in front of the car and the back seat, where prisoners are held.
In Prince George, B.C., last fall, a coroner’s inquest began into the death of Greg Matters, a former Canadian peacekeeper shot by an RCMP emergency-response team member. The team had been sent to his rural home to arrest him in an assault investigation.
Cameron Ward, the family’s lawyer, suggested that the jury recommend police use body-worn video and audio devices during potentially serious encounters. Seven other inquests had made similar recommendations, he noted. RCMP spokeswoman Sgt. Julie Gagnon said the force has tested body-worn video devices in B.C. and New Brunswick.
It is still assessing their performance, as well as the privacy and legal implications, she said.
Meanwhile, the installation of video cameras in police cars was a recommendation of an inquest in 2012 in Kamloops, B.C.
Wilbert Bartley, 50, was parked at a gas station on July 30, 2010, when two plainclothes RCMP officers pulled up beside him in an unmarked minivan. The officers later testified that they approached Bartley because they wanted to talk to him about returning a laptop. They said he appeared nervous and seemed to be trying to shift gears. One officer standing outside the minivan drew his firearm.
Bartley began to reverse; the second officer backed the minivan perpendicular to Bartley’s vehicle. They collided.
Then, just as Bartley’s vehicle apparently lurched forward — or was about to (there was conflicting witness testimony) — the officer fired three shots, hitting Bartley in the head. Bartley was later found to have cocaine and methamphetamines in his system.
In May 2012, an inquest jury called on the RCMP to install video cameras in its unmarked vehicles; to use the shooting as a case study in lethal-force training; and to strive to pair up more senior officers with junior ones (one of the officers had six years of experience; the other, four).
The RCMP later wrote to the coroner’s office saying the installation of cameras was “not practical” and does not guarantee that police interactions will be captured. Pairing senior and junior officers also would “not be practical or desirable,” it said.
Nor was the case adopted for study. “Some situations are very specific and do not necessarily meet the criteria to be used as a training scenario,” the RCMP’s Gagnon said.
Wanda Doubt, Bartley’s sister, said the recommendations provided “a little bit of solace … a bit of hope that my brother dying would help someone in the future.
“But it didn’t,” she said. “No one learned anything from it.”
The 2010 annual report of the B.C. Coroners Service says the RCMP was the subject of the most recommendations that year. However, it also notes that police were among “the least likely to implement recommendations,” with 60 per cent of recommendations not put into practice.
Gagnon said recommendations might not be implemented because they might “already exist in policy” or might contradict existing policies, procedures or laws.
Police pursuits
Deadly police pursuits have prompted numerous inquests. For instance, the Ontario Provincial Police pursuit policy came under scrutiny during an inquest in 2011 into the death of Phillip Jeffrey Charbonneau.
On July 3, 2009, Charbonneau, 35, whose licence was suspended, sped away from a police roadside check. Police used a “rolling block” technique — sandwiching a fleeing driver between two police cars — to slow and stop him. Officers, guns drawn, then ordered Charbonneau to get out.
But Charbonneau steered his truck to push the police cars around him. With batons and firearms, the officers tried to smash the driver’s-side window or windshield. The pickup started moving toward a gap between police vehicles and two officers fired their guns, hitting Charbonneau in the head.
The jury’s 10 recommendations, in October 2011, included that the OPP develop a new training module on “suspect apprehension pursuit” to deal with non-compliant drivers and dangerous situations. It also recommended the OPP clarify when it is appropriate to engage in a pursuit, and develop policies for using rolling blocks and other means of stopping vehicles.
The OPP later wrote to the coroner’s office indicating that a new 14-minute training video had been created on how to prevent pursuits, as well as how to bring a pursuit to an end safely. But the OPP said existing policies adequately addressed pursuits and techniques for stopping vehicles.
Lawrence Greenspon, the lawyer for Charbonneau’s family, hadn’t seen the written responses until Postmedia News provided copies.
“They still don’t outline, as the jury wanted, the guidelines and the circumstances under which you use each of those approaches,” Greenspon said. “By constantly going back to … the officer’s discretion, that’s exactly what the jury didn’t want to have happen. You almost get the impression when you look at the response to the recommendations the OPP is saying, ‘Yeah, yeah we hear you, but we know what we’re doing.’ ”
Stun guns
Canadians know of the high-profile 2007 death of Robert Dziekanski at Vancouver’s airport, but there have been several other fatal encounters in which police fired conducted-energy weapons — stun guns — on emotionally disturbed people who were in severely agitated states.
In one instance, the OPP used stun guns on 27-yearold Aron Firman, who suffered from schizophrenia and had been seen pushing a woman over in her chair. Firman was growling and flexing his muscles.
In another case, Calgary police investigating a breakand-enter used their stun guns on 30-year-old Gordon Bowe, who had been grunting, flailing his arms and running or jumping inside a residence.
At least four inquests have recommended that such cases be treated as medical emergencies and that police and paramedics do a better job of co-ordinating responses to people displaying such erratic behaviour, which is sometimes referred to as “excited delirium.” At least two inquests have also called for a nationwide database to collect information on the use of stun guns.
Mike Federico, a member of the Canadian Association of Chiefs of Police, said the association has created an advisory committee that is discussing the need for a national database on all useof-force incidents.
“However, it is not the intention to recommend that the CACP establish and maintain the database, but rather that an appropriate government supported agency take on the responsibility,” he said.