The Alberta Serious Incident Response Team (ASIRT) released its findings Wednesday on the in-custody death of a man at an Edmonton detainee management unit on March 16, 2020.
In his investigation, ASIRT assistant executive director Matthew Block determined that the required checks were not done by the community peace officers (CPOs) on the detainee, who later died from fentanyl toxicity.
The report said peace officers are required to conduct walk-around physical checks every 15 minutes and arousal checks every hour.
The two peace officers told Edmonton Police Service detectives that they conducted certain checks in the time leading up to the detainee’s death, but video from the cell showed they hadn’t. The video showed the officers on duty that day did not conduct a single arousal check on the detainee between 8:30 a.m. and 1:42 p.m.
“The CPOs on duty that day did not follow EPS policy, and then… appear to have tried to hide this,” the ASIRT report said.
However, ASIRT doesn’t have the jurisdiction over community peace officers.
“Any further action regarding them is the responsibility of EPS.”
In a statement to Global News, EPS said the CPOs working at the detainee management unit that day are still employed by the EPS.
EPS also said it will be conducting an internal review into the circumstances pertaining to this in-custody death now that ASIRT has concluded its investigation.
“EPS policies relating to detainee care and checks are thorough; however, according to the ASIRT report, it appears regular policy and procedure weren’t followed in this case. This will also form part of the EPS’ follow-up investigation,” a police service spokesperson said.
The ASIRT report detailed the timeline of events that day.
At approximately 10:50 p.m. on March 15, 2020, a man with several outstanding warrants was arrested by police while riding a bike on a sidewalk in Edmonton. He was taken to the EPS detainee management unit, searched and processed. He was also assessed by a paramedic, who found him to be alert and responsive, with no injuries, and fit to be placed in a cell, which was done at 11:44 p.m.
The next morning at 7:10 a.m., another person was put in the same cell. According to ASIRT, the two talked and, at 7:42 a.m., the second person dropped a white object on the bench in the cell, went to the door to look out, returned to the bench, picked up the white object and “started doing something with it… moved his head down to the bench and from right to left.”
Then, ASIRT said the first detainee went over and “also moved his head down to the bench before getting up.”
“He appeared unsettled,” the ASIRT report explained. “He eventually laid down on the bench, facing the wall. At 8:13 a.m., (he) appeared to spasm twice. He moved slightly in the next two minutes, but no further movement was noticeable on the cell video after 8:15 a.m.”
Between 8:30 a.m. and 1:42 p.m., the video showed peace officers walking by the cells every 10 minutes and looking inside the cell. However, “they did not stop and look into the cell for any significant amount of time, and never entered it other than the times described below.”
ASIRT found that a peace officer brought food inside the cell at 12:14 p.m. but the first detained man didn’t move. At 1:29 p.m., a peace officer went and got the second detainee and left the cell but the first detained man again didn’t move. At 1:37 p.m., the second detainee came back, checked on the other detainee and moved away and stood by the cell door. At 1:42 p.m., another peace officer went inside the cell and “appeared to notice that something was wrong.” When the officer left, the other detainee picked up two objects from the floor.
The two peace officers came back with a paramedic.
“They began CPR… and naloxone was used,” the ASIRT investigation explained. “Emergency medical services was called, and CPR was continued until they arrived.
“Unfortunately, their efforts were unsuccessful and the (man) was not resuscitated.”
An autopsy done on March 17, 2020, determined the death was caused by fentanyl toxicity.
EPS policy states that in addition to walkaround physical checks done every 15 minutes, arousal checks must be done on detainees at detainee management units every hour. Those checks require that a detainee is “awoken and spoken to in order to confirm that they are responsive and not in need of medical assistance. Arousal checks can be done with the CPO outside of the cell but, if the detainee does not respond, the CPO must enter the cell,” ASIRT said.
As part of its investigation, ASIRT reviewed interviews done with three peace officers by EPS detectives. The first peace officer said they’d been conducting the required arousal checks every 40 minutes. That peace officer said they’d “done a check prior to lunch and had paused at the door since the (detainee) was in an odd position,” but said the man “made eye contact with him.”
The second peace officer said he’d done an arousal check at 12:40 p.m. “and did not remember having any concerns.”
However, “video from the cell showed that they had not actually done these checks. Further, the video showed that the CPOs on duty that day had not conducted a single arousal check on the (detainee) between 8:30 a.m. and 1:42 p.m.,” ASIRT said.
“The CPOs on duty that day did not follow EPS policy, and then CPO1 and CPO2 appear to have tried to hide this. Since ASIRT’s mandate does not extend to the CPOs, any further action regarding them is the responsibility of EPS,” the ASIRT report continued.
“No police officers were involved with the (detainee) once he was in cells, and there are therefore no grounds to believe any police officer committed an offence. The actions of the CPOs are outside of the mandate of ASIRT.”
Tom Engel, an Edmonton criminal lawyer, said EPS should have reported this death to the director of law enforcement has soon as it happened. EPS confirmed that the director was notified at the time of the death.
Engel thinks there could be reasonable grounds to believe that criminal offences were committed and EPS shouldn’t be leading the investigation because it’s a conflict of interest.
“I’m not shocked to see that people who are hired to look after prisoners and who are not police officers — be it in RCMP lockups or other lockups in this province or elsewhere in Canada — I’m not surprised to see… failure to comply with police service policy about checking on prisoners. It happens all too frequently.
“But brazenly lying to the Edmonton Police Service detective who interviewed them? They know that there’s CCTV there.”
The EPS also said that since this incident, several capacity and technology improvements were made to the main detainee management unit when it was moved to the new northwest campus police station.
1. With additional cells, detainees are kept alone in a cell, minimizing the chance of transferring contraband to each other.
2. A body scanner has been introduced to reduce contraband being introduced to DMU.
3. Each cell at the new NW Campus DMU has an individual station for physical/visual check reporting compared to the old DMU at police headquarters, which had a group station and paper reporting.
4. NW Campus DMU has additional staff for monitoring detainees.
5. When a detainee is not responsive to an arousal check, a supervisor is now notified for a decision.