IACOLE CONFERENCE
Speech Delivered By

Shirley Heafey
Chair
Commission for Public Complaints Against the RCMP

Deaths in Custody

Sydney, Australia
September 8, 1999

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Good morning,

Somewhere in the annals of history, a wise person has said:

"Our society will be measured not only by achievements in the arts and sciences but also on how we have treated the weakest and most vulnerable members of our society.  That is a measure of the greatness of a nation."

In the modern, grass roots policing context, the weakest members are generally those who suffer from a mental illness, those who have a drug or alcohol problem AND so often they are the people who suffer from all of the above.

These are the people that the street cops deal with on a daily basis.

I'd like to talk to you today about a man named BOB.  BOB was born in the mid-1950s and grew up in a fairly small city called Whitehorse, which is the capital city of the Yukon, one of Canada's northern territories.  Life wasn't easy growing up in Whitehorse in the 50s and 60s.  Whitehorse is located in a remote region of northern Canada, and even today, only has a population of about 23,000 people.  In those years, it certainly wasn't a sophisticated municipality.  Jobs were difficult to find and one of the most common diversions was.drinking alcohol.  As far as I know, BOB never got married but he had a lot of friends.

As he became an adult, BOB grew physically large and tall, a big bear of a man with longish dark bushy hair and a dark beard.  Anyone who has ever met BOB has only good things to say about him.  He's been described as friendly and gentle, a kind man, easygoing and cooperative.  Whitehorse being a small town, he was known and liked by many of the town's people.

What you saw was what you got, with BOB.  One person who knew him at the time claimed never to have seen him angry.  In fact, they used to call him "Basic BOB", because of his uncomplicated ways.  Like many others in his community, he took pleasure in having a drink now and then.  Soon, it became more often than that.  And, at some point over the years, he started to abuse alcohol.  Eventually, BOB was living on the fringes of society, even passing out in the homes of friends who cared about him.

BOB also developed a serious medical condition brought on by the excessive use of alcohol, which caused him to suffer from seizures.  Ultimately, the seizures led to the suspension of his driver's license.  Faced with little else to provide stimulation or recreation, BOB slipped into occasional drug use.

Four years ago, on March 30, 1995, BOB was picked up by the police for being impaired.  Around suppertime on that day, BOB was seen stumbling on one of the downtown streets in Whitehorse.  He was barely able to walk, lifting his legs high in the air as though it was a great effort just to take one step.  Seeing that he was in such poor shape and fearing that there was something seriously wrong with BOB, a couple of acquaintances came to his aid and helped him in into a nearby hotel lounge.

Meanwhile, a pair of RCMP officers was patrolling the streets of Whitehorse.  When they observed BOB and his companions heading to the lounge, they assumed that BOB was just drunk -- very drunk.  As a result, they entered the lounge and proceeded to take BOB into custody for his own protection in order to allow him to sober up, as the law permits them to do.

BOB's acquaintances, as well as others in the lounge where BOB had been taken, tried to warn the RCMP officers that BOB was ill.  They repeatedly insisted that he might be suffering from one of his seizures.  Even those who did not know him suspected that there was more to his poor condition than simply too much alcohol. 

In spite of all these warnings, the police chose to believe that BOB had merely had too much to drink.  BOB's breath reeked of alcohol and the police felt confident he was just drunk and so they carried him to a police lock-up to sleep it off.  Sure enough, BOB did go to sleep but unfortunately, he never awakened.

Sometime that evening, BOB was found in his cell, not breathing.  Although the police made every effort to resuscitate him and save his life, it was too late.  BOB was dead.  He was 41 years old.

As it turned out, BOB had desperately needed medical attention much earlier.  A coroner's inquest was called to try to determine the cause of his death.  The focus of the coroner's investigation was the events which followed the RCMP's discovery of Bob, in his cell and not breathing.  After much inquiry, the coroner determined that BOB had died from acute alcohol intoxication and acute morphine overdose.  In the end, the coroner attributed no wrongdoing to the police officers or the cell guard.  In fact, they were congratulated for their considerable efforts to try to save BOB.  I have no doubt that the coroner's finding was honest and reasonable, given the focus of his investigation.

That might have been the end of BOB's story, if not for a young woman named Donna.  Donna was a friend of BOB's.  Troubled by the feeling that BOB's death could have been avoided, she came to our Commission to make a formal complaint against the RCMP officers.  At the time, I was a member, though not yet the Chair, of the Royal Canadian Mounted Police Public Complaints Commission.

The Chairman, at the time, decided to hold what is known as a Public Interest Hearing.  He hoped the hearing would shed light on BOB's tragic death.  I happened to be one of the members sitting on the 3-member panel hearing this case and, so, heard first-hand the details of BOB's death.

When we considered the circumstances surrounding BOB's death, especially what occurred prior to his placement in the police holding cell, the Commission arrived at a different conclusion than had the coroner.  The Commission found that the police officers were, sadly, inadequately trained to recognize BOB's medical problems when they picked him up for his own protection.

At this juncture, let me remind you about the important differences between police holding cells on the one hand and correctional facilities on the other.  As in most countries, correctional facilities, such as prisons, are generally equipped to accommodate long-term tenants.  Staff at these facilities normally receive a file setting out the history of the prisoner, which includes the medical, criminal and personal information about the inmate.  As a result, they generally have a fairly good idea of who they are dealing with.

They have information they can rely on to assess the prisoner.  They have employees to look after the various needs of their charges - for one, the guards are normally highly trained, and they also typically have specialized back-up assistance such as medical specialists, psychiatrists, counsellors and ministers on hand to handle medical or emotional crises that may arise.

By contrast, police lock-ups are quite different.  When police officers pick up an impaired person on the street, or in a drinking establishment, they are at a disadvantage.  They often know little or nothing about the person, other than what they are able to detect, using the skills they have acquired through police training.  The police must rely on statements made by the person being taken into custody and those of any witnesses.

THERE IS NO FILE to resort to.  Without additional clues, they may not know the medical problems this person may be suffering from.  And, if they do detect signs of impairment, they can't know for sure the substance or combination of substances that were used to lead to the impairment.  Of course, if the individual has consumed alcohol, that you can generally smell.  BUT even then, that can be misleading and relying on smell alone is risky.  Without knowing what substances have been ingested, the police can't predict how the individual might respond and, more importantly, the police may not know what medical treatment may be necessary for this person.

With that in mind, and after reviewing the particular details of BOB's final hours, the Commission made a number of recommendations, including the following:  that existing RCMP training be reviewed to ensure that members are aware of the common symptoms of alcohol and drug overdose; that members receive refresher courses in this area; that trained medical professionals be made available to provide advice to RCMP officers; that a system of monitoring and re-testing of first aid qualifications be implemented; that the training of civilian guards be re-examined; and that the policy relating to the detention of intoxicated persons be reviewed for clarity and consistency.

The police officers who provided evidence at the hearing into BOB's death were very clear about one thing.  They admitted that they honestly had no idea what to look for in order to determine if someone was suffering from alcohol poisoning, acute drug intoxication or some other illness.  In BOB's case, there were definite indicators as to the presence of drugs and alcohol.  Granted the symptoms of some drug overdoses may be subtle, but you DON'T have to be a trained medical doctor to recognize signs as obvious as BOB was exhibiting.

For instance, the exaggerated way that BOB had been walking, as described by his friends, was one of the glaring signs of being under the influence of certain "hard" drugs.  Indeed, one of the known effects of morphine use is slow and deliberate movements.

I know that it is entirely possible that BOB would have died no matter what medical attention he might have received on March 30, 1995.  However, like my colleagues on the panel, I believe that he did not receive the degree of care he should have received from the police officers and the cell guard who dealt with him.  NOT because the officers or the guard didn't care, but RATHER, because they were NOT adequately trained to recognize the warning signs.

In BOB's case, it became painfully clear to those of us who heard all the evidence that more could have been done to help him.  The RCMP agreed with our Commission's findings and accepted almost all of the hearing panel's recommendations.  In the end, Donna, the complainant for Bob, was satisfied that her complaint had resulted in positive improvements to the way people are treated in RCMP custody.

BOB's story is one that will stay with me for a long time.  His life ended far too soon and he left behind many friends.  I know there are others, besides his friend Donna, who miss their friendly encounters with BASIC BOB.

Two years ago, shortly after my appointment to the position of Chair of the RCMP Public Complaints Commission, I was reading a Canadian newspaper when I was struck by a particular story.  The memories of BOB came flooding back.  The article told of the death of a man named KIM.  KIM also died while being detained in an RCMP cell.  There were many parallels in BOB and KIM's stories.  But, in KIM's case, no one complained.so I did.

Under our legislation, if the Chair deems it in the public interest to start an investigation into an incident that she feels needs to be aired -- she can do that.  And so I began a public interest investigation into KIM's death.

In 1997, KIM was living in a city called Kamloops, in British Columbia, Canada's most western province.  Some months earlier, KIM had gotten married.  His best man, Lyle, was a counsellor at the local street mission, which is something of a drop-in centre, catering to the physical, emotional and spiritual needs of residents of the community.

On the morning of May 21, 1997, Lyle was working at the mission.  Sometime that morning, an unidentified driver dropped KIM off at the mission, presumably because of the rough shape that KIM was in.  Lyle knew KIM to have been involved in alcohol and occasionally drugs, but had never seen him in this state before.  Lyle tried to have KIM placed in a drug and alcohol treatment centre, but that centre had a rule that incoming patients had to be sober for a day before being placed there.

Having no other alternative, Lyle contacted the police.  He later said he was unsure whether to call an ambulance, or call the police.  In his opinion, all KIM needed was to sleep off the effects of whatever substance he'd taken.  When an RCMP officer arrived shortly before eleven o'clock, he found KIM in very poor condition, indeed.

KIM was described as looking like a "zombie".  He needed help to walk.  His gaze was fixed.  He couldn't communicate except for the occasional grunt.  There was a strong odour of alcohol on his breath and so the police officer arrived at what he felt was a logical conclusion:  KIM was drunk.

As a result, Lyle and the officer picked up KIM, helped him out to the patrol car and the officer drove off to the nearby police holding cell.  Unable to respond verbally to the simplest questions, KIM was booked and placed in a cell.  Like Bob, he was placed there for his own protection.  Shortly after 3 p.m. that afternoon, a guard discovered that KIM was not breathing.

As with Bob, efforts were made to resuscitate KIM.  These efforts were successful and he was rushed to the hospital where he remained comatose for ten days, before life support was finally turned off and he died.  The cause of death was found to be accidental brain damage and cardiac arrest as a result of alcohol and substance overdose.  KIM's blood/alcohol level had been measured six hours after being picked up by the police, and was at that time found to approach life-threatening levels.  On top of that, there was evidence that KIM had also ingested cocaine.

It was later confirmed that KIM had a drug addiction problem, which was compounded by a mental health problem.  Our Commission's investigation revealed that there were definite warning signs prior to incarceration which indicated that KIM had consumed drugs and was probably in need of urgent medical attention.

Most of us are familiar with the signs of excessive alcohol consumption.  However, there are also unique side effects of cocaine use, which are readily detectable with the proper training.  Evidence of a high consumption of both alcohol and another drug signals almost certain danger.

Signs associated with alcohol consumption include relaxation, drowsiness, impaired balance and coordination, slurred speech, increased risk-taking and something called horizontal gaze nystagmus (which is an involuntary jerking of the eyeballs).  Symptoms of cocaine use, on the other hand, include dilated pupils, elevated vital signs, hyper-alertness, agitated body movements, and a deterioration of the individual's ability to filter environmental stimuli.  People can be taught to decipher these symptoms and predict what the expected consequences will be.

I have learned that the police officer who picked KIM up was a gentle and caring person who did everything he was trained to do.  But that was just not enough.

Unfortunately, neither he nor the jail guard were trained to recognize the clues that were screaming out at them:  that KIM was in dire need of medical help, but they did what they thought was right and left him in a cell to sleep it off for a few hours.  As they know now, that was not the right decision.  I am presently preparing a report on KIM's death, in which I will make several recommendations, the main one being that appropriate training for the police and cell guards must be made a priority.

Without fail, I have found the Canadian police to be acting in good faith and merely doing what they feel is necessary.  At the same time, the police must gain a better understanding of the people and problems they are dealing with and undergo specialized training to give them the tools to recognize the complex problems they are faced with.

As we can see, the common thread in these three situations is the need for adequate TRAINING.  Police officers on the street have to deal with drugs, alcohol and mental illness everyday.  This is a phenomenon that has grown in the past few decades.  Historically, the police have not been trained to respond to such problems.  But, today, they NEED to know how to deal with drug and alcohol impairment.  The irony is that, in many cases, the police are in the best position to assist the vulnerable population.  I think the police need to realize how pivotal their role is in saving lives.

You might ask why our Commission would even concern itself with the matter of cell deaths when coroners in Canada are generally required to conduct inquests in the case of every death in a police cell.  The answer is that the scope of inquiry does not necessarily overlap.  While the coroner's examination is generally confined to the actions taken or not taken by jail cell staff during the period of incarceration, the Commission backtracks to the point where the police had a choice to make.

In that way, the Commission can look at the decisions made by the officer in choosing to incarcerate the individual in the first place, choices which dictate the care the individual will ultimately receive.  Furthermore, the coroner's mandate is limited to determining the cause of death.  The Commission's inquiry takes on a broader focus, concentrating on the role of the RCMP.

The Commission's investigations into the deaths of BOB and KIM have left me with some theories on cell deaths.  In my view, a little bit of effort will go a long way toward reducing the number of deaths in police cells.  What is called for is a shift in priorities among police officers - from a strictly law and order approach to a caring approach for those at risk.

Currently, there are too many policies regarding the care and handling of prisoners.  This is a criticism echoed in many police forces, in many countries.  In an effort to resolve the problem of deaths in custody, policy has proliferated and this overabundance of policy has only backfired.

Proper training assists police officers to know when incarceration is not appropriate and when medical help is necessary.  Drug recognition training for police officers is becoming more and more pervasive in North America.  It provides police officers with the essential tools to detect the hallmarks of alcohol and drug consumption.

Drug Recognition Expert (or DRE) programs began in Canada a little over ten years ago, having been imported from the United States.  Police forces are coming to realize that this type of training is invaluable.  In Canada, the style of DRE training is called "cascading" since the trainer is trained first, and he or she, in turn, offers training to others in his or her detachment.

Two American states claim to have virtually eliminated cell deaths as a result of DRE training.  The specialized training generally involves an intensive 2-week course, followed by a series of evaluations where the student must recognize the symptoms of a combination of drugs.  More advanced training is also offered, as well as an instructor course.

DRE training is not available throughout all of Canada, primarily due to its high cost.  Partnering with the private sector, therefore, is becoming a necessity.  Thus, the DRE program in the province of British Columbia is sponsored by the British Columbia Insurance Corporation, a governmental motor vehicle insurer that realizes that dollars can be spared when DREs are on the road using their skills.  Despite the large price tag for this type of training, the potential it holds for saving lives far outweighs the cost.  RCMP forensic toxicologist advises us that even a one-day course would significantly improve awareness.

Before I finish, I would like to comment on the relationship between our Commission, which has been around for ten years now, and the Royal Canadian Mounted Police, that is, the police force we monitor.  There is necessarily a delicate balance between these two entities because of our respective roles.  HOWEVER, there is a growing cooperation and mutual respect and a grudging understanding that we are there to help them do their job more effectively.  I am confident that we are succeeding in that regard.

And for fear of giving you the wrong impression, I am glad to say that cell deaths in police custody are not at epidemic proportions in Canada.  However, my goal would be to have NONE.  For as long as I remain the Chair of the Royal Canadian Mounted Police Public Complaints Commission, I plan to continue fighting for the required improvements to the way people in custody are treated.  I want to see a marked change in direction.  I won't be happy until the RCMP are better equipped to provide the proper care and treatment to the BASIC BOB and KIM.

We can help the police do their job but not in the context of constant criticism. We should not replace one tyranny for another. Consequently, my Commission maintains good credibility with Canadians and this cordial relationship has enhanced the confidence that the Canadian public has in the RCMP.