Chair-Initiated Complaint Regarding the In-Custody Death of Mr. Raymond Silverfox

RCMP Act Paragraph 45.42(3)(a)

September 7, 2010

File No.: 2008-3266

Table of Contents

Overview

On the night of December 1, 2008, Mr. Raymond Silverfox of Carmacks, Yukon Territory, was celebrating his 43rd birthday. He and his girlfriend secured a drive to Whitehorse, a 2.5-hour drive away. Upon arrival in Whitehorse in the early hours of December 2, 2008, the two found lodging at the Salvation Army shelter. They had continued to drink until that time.

Once at the shelter, Mr. Silverfox began to vomit. Shelter staff called Emergency Medical Services (EMS), knowing that Mr. Silverfox would not be taken into custody by the RCMP without first being medically cleared. Shortly before 5 a.m., the EMS personnel attended and cleared Mr. Silverfox, determining that his vital signs and responses were within the normal range despite his intoxication. However, Mr. Silverfox could not remain at the shelter due to his vomiting, so the EMS personnel called the RCMP in the hope that Mr. Silverfox could be incarcerated for the night, as it was extremely cold outside.

Constable Len Van Marck and Constable Daniel Bulford attended the shelter. Mr. Silverfox was arrested for public intoxication and booked into Cell 3 at the RCMP Detachment shortly after 5 a.m. Watch Commander Corporal Calista MacLeod checked on Mr. Silverfox at approximately 8 a.m. after beginning her shift. She was the Watch Commander and senior member on duty throughout Mr. Silverfox's incarceration. During that period, three different guards and matrons were responsible for the cell block.

Mr. Silverfox remained in RCMP cells throughout the day while he continued to be sick. Some of those instances were noted by the guards and/or matrons and members present in the guardroom, but most were not. However, Mr. Silverfox's cell became increasingly contaminated with his bodily fluids. Throughout this time, members and guards may be heard discussing Mr. Silverfox's condition on the audio recording of the guardroom. Few physical checks were conducted in respect of Mr. Silverfox, although he continued to be monitored through use of the closed-circuit video equipment (CCVE).

Near 4 p.m., Mr. Silverfox requested a mattress and was refused. At approximately 6 p.m., another prisoner was brought in who, due to combativeness, required the attendance of several members, including Corporal MacLeod. After the unruly prisoner had been lodged in cells, at approximately 6:34 p.m., Corporal MacLeod checked on Mr. Silverfox and noted that he did not appear to be breathing. The cell door was opened and Constable Mike Muller checked Mr. Silverfox for vital signs. Finding none, the members pulled Mr. Silverfox out of his cell and called EMS. They also began chest compressions.

EMS personnel arrived in the cell block at approximately 6:47 p.m. and took over care of Mr. Silverfox, who was transported to the Whitehorse General Hospital a short time later. Although the paramedics were successful in briefly regaining a pulse, efforts to resuscitate Mr. Silverfox ultimately failed and he was pronounced dead at 9:15 p.m. A subsequent autopsy determined that Mr. Silverfox had died of sepsis and acute pneumonia, and the autopsy findings suggested aspiration pneumonia.

The investigation into Mr. Silverfox's death was begun by the "M" Division Major Crimes Unit, but turned over to "E" Division North District Major Crime Unit on December 3, 2008. The Commission for Public Complaints Against the RCMP (the Commission) dispatched one of its independent observers to conduct an impartiality assessment, and no material concerns were identified. The criminal investigation was forwarded to Crown counsel, who determined that no charges were warranted.

An administrative review of the incident was subsequently conducted by Inspector Yvon de Champlain of the RCMP's "K" Division Commercial Crime Section in Alberta, and a number of recommendations were made in his report, issued May 26, 2009. On June 16, 2009, Inspector Mark Wharton, the Commanding Officer of the Whitehorse RCMP Detachment, responded to those recommendations.

Shortly before the coroner's inquest into Mr. Silverfox's death in custody, which ran from April 15 to 23, 2010, it was realized that audio tape of the cell block guardroom had not been transcribed. The audio track captured members, guards and matrons commenting on Mr. Silverfox, the condition of his cell, and his illness. Two weeks after the conclusion of the inquest, the RCMP announced that a Code of Conduct investigation had been initiated in respect of this matter.

Chair-Initiated Complaint

In recognition of the concerns expressed about deaths of persons in RCMP custody, the Commission will on occasion exercise its authority on behalf of the public to examine in depth the facts that give rise to the public's concern.

On December 12, 2008, the then-Chair of the Commission initiated a complaint (Appendix A) into the in-custody death of Mr. Raymond Silverfox in Whitehorse, Yukon, pursuant to subsection 45.37(1) of the RCMP Act. The complaint focused on the conduct of all RCMP members or other persons appointed or employed under the authority of the RCMP Act involved in the incident, as well as matters of general practice applicable to situations in which persons are held in the custody of the RCMP, specifically:

  1. whether the RCMP members or other persons appointed or employed under the authority of the RCMP Act involved in the events of December 2, 2008, from the moment of initial contact and arrest to the subsequent detention and death of Mr. Silverfox, complied with all appropriate training, policies, procedures, guidelines and statutory requirements relating to persons held in RCMP custody and, in particular, to providing access to medical treatment;
  2. whether the RCMP members at the Whitehorse RCMP Detachment provided adequate supervision and direction to the guard or guards who were charged with the care and handling of prisoners in the custody of the Whitehorse RCMP during the period of Mr. Silverfox's detention and subsequent death; and
  3. whether the RCMP national, divisional and detachment-level policies, procedures and guidelines relating to the provision of medical treatment to persons detained in RCMP custody, in particular relating to those who are detained where the consumption of alcohol is a factor, are adequate to ensure their proper care and safety.

As required by the RCMP Act, the RCMP investigated the complaint. The public complaint investigation was conducted by Staff Sergeant Tom Caverly of the RCMP's "E" Division in British Columbia. On February 16, 2010, the RCMP issued its Final Report into this matter (Appendix B)[PDF, 793Kb].

Pursuant to the RCMP Act, the Commission reviews the RCMP's disposition of each Chair-initiated complaint. To this end, the Commission requested the material relevant to its review from the RCMP and received such information on March 16, 2010. The Commission received the transcripts of the coroner's inquest on June 15, 2010.

Commission's Review of the Facts surrounding the Events

It is important to note that the Commission for Public Complaints Against the RCMP is an agency of the federal government, distinct and independent from the RCMP. When conducting a public interest investigation, the Commission does not act as an advocate either for the complainant or for RCMP members. As Chair of the Commission, my role is to reach conclusions after an objective examination of the evidence and, where judged appropriate, to make recommendations that focus on steps that the RCMP can take to improve or correct conduct by RCMP members. The Commission's role is not to make findings of criminal or civil liability. Although some terms used in this report may concurrently be used in the criminal context, such language is not intended to include any of the requirements of the criminal law with respect to guilt, innocence or the standard of proof.

My findings, as detailed below, are based on a careful examination of the extensive investigation materials, the closed-circuit video and audio footage of the cell block, the RCMP's criminal investigation report and administrative review, and the applicable law and RCMP policy.

As noted above, a coroner's inquest into the death of Mr. Silverfox was held in Whitehorse from April 15 to 23, 2010. The purpose of an inquest is to ascertain how, when, where and by what means the deceased died. Although the mandate of an inquest is quite limited, I considered the evidence heard to be an important part of the fact-finding process related to Mr. Silverfox's death. It is for this reason that the Commission carefully reviewed the inquest transcripts.

It should be noted that the RCMP's "M" Division provided complete cooperation to the Commission throughout its review.

First Issue: Whether the RCMP members or other persons appointed or employed under the authority of the RCMP Act involved in the events of December 2, 2008, from the moment of initial contact and arrest to the subsequent detention and death of Mr. Silverfox, complied with all appropriate training, policies, procedures, guidelines and statutory requirements relating to persons held in RCMP custody and, in particular, to providing access to medical treatment.

Events occurring prior to the RCMP's involvement

Mr. Silverfox's 43rd birthday occurred over the weekend of November 30, 2008. Mr. Silverfox and his friends marked the occasion with heavy drinking over a period of approximately two days. Mr. Silverfox did not habitually drink heavily, but was known to "binge drink" occasionally, and from all appearances, he did so on this occasion. Mr. Silverfox, a labourer in Carmacks, Yukon Territory, was known as a diligent worker and a passive person, even when drinking.

Late in the evening of December 1st, Mr. Silverfox and his girlfriend, Ms. Jill Skookum, decided to travel to Whitehorse from Carmacks, a 2.5-hour drive. As is the custom in the area, Mr. Silverfox offered Mr. Ray Hartling $120 to drive him and Ms. Skookum to Whitehorse. Mr. Hartling, who was accompanied by his girlfriend, Ms. Jennifer Skookum (Ms. Skookum's second cousin), agreed. Mr. Silverfox paid Mr. Hartling an initial $60 and the foursome set off towards Whitehorse between 9 and 10 p.m.

The drive to Whitehorse was relatively uneventful. It was apparent that Mr. Silverfox was intoxicated, and he urinated on himself at one point. Mr. Hartling said that such behaviour was not unusual for Mr. Silverfox. Mr. Silverfox and Ms. Skookum continued to drink during the drive, with Mr. Silverfox consuming vodka.

Upon arrival in Whitehorse, Mr. Silverfox attempted to retrieve money from an ATM to pay Mr. Hartling. He was unable to, saying that his bank card did not work, and Ms. Skookum and Jennifer Skookum began arguing. Mr. Silverfox and Ms. Skookum left the car, and Mr. Hartling drove away with Jennifer Skookum. The two doubled back several minutes later but could not find Mr. Silverfox or Ms. Skookum. Jennifer Skookum said that when she last saw Mr. Silverfox, he did not seem incapacitated, as he was joking, able to walk and able to speak without slurring.

Mr. Silverfox and Ms. Skookum attempted to find accommodation, and at 12:30 a.m. they arrived at the Salvation Army shelter, where Ms. Judy Lightening and Mr. James Kayotuk were on duty. Mr. Silverfox and Ms. Skookum left for a brief period and returned at approximately 12:45 a.m. The two were noted to be intoxicated, and both slept for a period of time. Upon Mr. Silverfox awakening, Ms. Lightening noted in the shelter log book that Mr. Silverfox was vomiting on himself and on the floor and was unable to focus. Ms. Lightening described Mr. Silverfox's demeanour as being like that of a "zombie." Ms. Skookum mentioned that at some point during the night, Mr. Silverfox had drunk an entire bottle of vodka.

Ms. Lightening noted that Mr. Silverfox's vomit appeared to consist solely of alcohol. She indicated that Mr. Silverfox was a "mess" and could not even handle the bucket he had been given to vomit in. Worried that Mr. Silverfox might have alcohol poisoning and concerned about his vomiting in the dining area, where breakfast would shortly be served, Ms. Lightening called 9-1-1. She informed the dispatcher that she would call the RCMP, but since Mr. Silverfox was in a "highly intoxicated state," she knew that they would tell her to call an ambulance first. She noted that Mr. Silverfox was vomiting and barely conscious.

Two paramedics, Ms. Gillian Smith and Mr. Andrew McCann, arrived at the shelter at 4:59 a.m. Mr. Silverfox was conscious and responsive. They conducted an examination of Mr. Silverfox that included taking his vital signs and checking his blood pressure, blood glucose, respiration and pupils. They confirmed that Mr. Silverfox's responses were in the normal range despite his intoxication and noted that he was ambulatory. He did not vomit in the presence of the attendants, although there was vomit on the floor, and he indicated that he had consumed a bottle of vodka but had stopped drinking at approximately midnight. Mr. McCann described Mr. Silverfox as answering questions "appropriately and correctly" and rated his intoxication as between 4.5 and 5.5 on a 10-point scale. Ms. Smith rated his intoxication as a 5 on a 10-point scale. There is no evidence that the EMS attendants measured Mr. Silverfox's blood alcohol concentration (BAC).

Ms. Lightening wanted Mr. Silverfox removed from the shelter due to his vomiting. Given that the outside temperature was approximately -16°C and Mr. Silverfox did not require medical attention or wish to go to the hospital, Mr. McCann decided to call the RCMP in the hope that Mr. Silverfox could be incarcerated rather than turned out into the cold. Ms. Smith noted that Mr. Silverfox was not dressed for sleeping outside, as he was wearing only a jacket, some jeans and a sweater. At 5:05 a.m., the Whitehorse Ambulance Service called RCMP dispatch to request that members attend the Salvation Army. RCMP dispatch was told that there was an "unruly gentleman" that was intoxicated and had been assessed by EMS. Mr. McCann called dispatch, which in turn called the RCMP at 5:07 a.m.

Initial contact and arrest of Mr. Silverfox

Constable Van Marck and Constable Bulford of the Whitehorse RCMP responded to the call and arrived at the shelter at 5:10 a.m. Mr. McCann told them that there were no medical problems with Mr. Silverfox, but he needed somewhere to "sleep [it] off," as the EMS attendants did not want him outside in the cold. Constable Bulford arrested Mr. Silverfox under section 175 of the Criminal Code for causing a disturbance. His contemporaneous notes indicate that Mr. Silverfox had been getting sick, that the Salvation Army staff did not want him to stay at the shelter, and that EMS had said he was clear to go to cells. Mr. Silverfox walked to the police vehicle unassisted and sat in the back seat, and he was driven to the detachment.

The relevant portion of section 175 of the Criminal Code,Footnote 1 which codifies the offence of causing a disturbance, reads:

(1) Every one who
(a) not being in a dwelling-house, causes a disturbance in or near a public place,
[...]
(ii) by being drunk, [...]
is guilty of an offence punishable on summary conviction.

The Criminal Code includes in its definition of "public place" any area accessible to the public by right, or by implied or express invitation.

The threshold for meeting the requirements of the offence of causing a disturbance is relatively low. In this instance, there is no dispute that Mr. Silverfox was intoxicated or that he was located in a public place, namely the Salvation Army shelter, an area by implication open to all members of the public in need of assistance or lodging. There were other individuals in the dining area. Accordingly, Constable Van Marck and Constable Bulford had the requisite reasonable and probable grounds to arrest Mr. Silverfox for causing a disturbance.

Apart from having reasonable and probable grounds to believe that a criminal offence has been committed, members must also satisfy the elements of section 495 of the Criminal Code in order to effect a warrantless arrest, as occurred in this instance. That section provides that a peace officer may arrest an individual for a summary conviction offence only in cases where he or she believes on reasonable grounds that it is necessary in the public interest in order to establish the person's identity, secure or preserve evidence, or prevent the continuation of the offence. In addition, the peace officer must have reasonable grounds to believe that the individual will fail to attend court if he or she is not arrested.

In the present case, it is apparent that Mr. Silverfox's intoxication in a public place was continuing. Given that fact, and acknowledging that Mr. Silverfox was not a Whitehorse resident and was unknown to the police, I find that it was reasonable for the members to determine that his arrest was necessary.

I believe that it is incumbent upon me to note as well that although Mr. Silverfox's arrest and subsequent detention were reasonable pursuant to the Criminal Code, it is apparent that compassion guided the decision to take him into custody. The desire of the EMS personnel and the members to avoid Mr. Silverfox being left outdoors in the extreme cold was the main factor leading to his arrest, and despite the tragic events that would ensue, Constable Van Marck and Constable Bulford should not be faulted for their decision, which was reasonable in the circumstances.

Finding: The warrantless arrest of Mr. Silverfox was reasonable and consistent with the Criminal Code.

The RCMP's national operational policy in effect at the time of this incident read:

19.2.3.6 If medical assistance was necessary and the person is to be released into your custody:

19.2.3.6.1 Inform the medically trained professional that the individual will be incarcerated.

19.2.3.6.2 When possible, obtain written documentation from the medically trained professional certifying the person is fit to be incarcerated.

19.2.3.6.3 If you cannot obtain this documentation, ensure you make detailed notes and put a copy on the investigative file.

19.3.4.4.1 Document the date, time and name of the medically trained professional who certified the prisoner fit for incarceration on form C-13-1.

The EMS personnel called the RCMP so that Mr. Silverfox could be incarcerated and out of the cold. Accordingly, they were aware that he would be placed in cells. However, Constable Van Marck and Constable Bulford failed to obtain written documentation from the paramedics certifying that Mr. Silverfox was fit for incarceration, or to note any information regarding EMS attendance. The relevant portion of the C-13, or Prisoner Report, consists of a box reading "Medical Examination by" followed by an option to check "Yes" or "No" to the statement "Fit for incarceration." Following those boxes are date and time boxes. All of those boxes were left blank.

The policy provides for the inclusion of detailed notes on the investigative file if it is not practicable to obtain documentation from EMS. In this instance, there is no information to suggest that it would not have been possible to obtain EMS certification: no emergent situation existed, Mr. Silverfox was placid and cooperative, and there was no particular urgency that would have precipitated the members' dispensing with the step of obtaining certification. In any event, only Constable Bulford took notes regarding the members' initial contact with and booking in of Mr. Silverfox; they read as follows: "EMS says he's cleared to go to cells."

Even if I were to accept that obtaining EMS certification would have been impractical, it is apparent that the notes are insufficiently detailed to meet the requirements of the relevant policy as reproduced above. Neither the results of the EMS examination nor the names of the EMS personnel are included. Accordingly, I find that Constable Van Marck and Constable Bulford failed to obtain documentation from EMS certifying that Mr. Silverfox was fit for incarceration, failed to complete the relevant section of the Prisoner Report, and failed to make detailed notes to that effect as required by policy.

Finding: Constable Van Marck and Constable Bulford failed to obtain documentation from EMS certifying that Mr. Silverfox was fit for incarceration, failed to complete the section of the Prisoner Report dealing with EMS examination, and failed to make detailed notes to that effect as required by policy.

Recommendation: That the Detachment Commander conduct regular "spot checks" of Prisoner reports to ensure that the proper notations are being made as required by RCMP policy.

In his response to the administrative review, Inspector Wharton stated that he would ensure that members document the proper information on Prisoner reports.

In addition to the above, I would emphasize that Constable Van Marck does not appear to have taken any notes in relation to his interaction with Mr. Silverfox on the date in question. As this Commission has done numerous times in the past, I must reiterate the importance of members' notes in describing contemporaneous events, which provide invaluable assistance both for those charged with investigating past events and for the member, who may refresh his or her memory and explain his or her actions at the earlier time. It is often difficult to recall particular details, and members' notes are the best record of their interactions with the public. RCMP national operational policy at the relevant time read:

2.1. The member's notebook is a fundamental investigative tool. It is essential that notebooks be properly compiled, complete and accurate in order to support investigations, corroborate evidence and increase the credibility of a member's testimony in court. Properly recorded entries (notes) may also prove to be invaluable in substantiating information years after an investigation.

2.2. You may use notebook entries to refresh your memory for court if the notes were made at or near the time of the occurrence.

2.3. If you are performing operational duties, use and maintain an up-to-date notebook. Record the date for any operational assistance in your notebook.

Constable Van Marck failed to make any notes regarding this incident.

Finding: Constable Van Marck failed to make any notes regarding his interaction with Mr. Silverfox.

Recommendation: That a senior officer review with Constable Van Marck the importance of maintaining detailed notes as required by RCMP policy.

Booking into RCMP cells

Mr. Silverfox was booked into Cell 3, colloquially known as one of two "drunk tanks" at the Whitehorse RCMP Detachment, at 5:13 a.m. The members did not take a breath sample with an alcohol screening device (ASD), as Mr. Silverfox had just been examined by EMS and cleared for incarceration. Mr. Silverfox was lodged in the cell, which was occupied by two other men. Mr. Silverfox's interaction with Constable Van Marck and Constable Bulford was cooperative, and he responded to their questions appropriately.

Constable Bulford stated that he did not use the ASD in respect of Mr. Silverfox because he had already been cleared by EMS. Constable Bulford elaborated that ASD readings are done for the safety of prisoners, and in this case, he had already been dealt with by emergency medical staff and there were consequently no safety concerns. Constable Van Marck agreed that there was no need to administer the ASD, as Mr. Silverfox had already been assessed by EMS.

In recognition of the issues that may arise from acute intoxication, the Whitehorse RCMP Detachment policy in effect at the time of this incident read as follows:

19.2.1.1 As part of the booking in process, all prisoners suspected of being under the influence of alcohol shall be asked to provide a breath sample in the (digital) approved screening device.

19.2.1.2 A prisoner with a BAC of 350 mg % or greater shall be taken to Whitehorse General Hospital for examination/treatment before being lodged in cells.

Constable Van Marck and Constable Bulford stated that they did not believe they needed to follow the policy in this instance, as Mr. Silverfox had been medically cleared for incarceration by the EMS personnel. However, it is of note that the policy is prescriptive in terms of the needs to administer the ASD; it does not provide an exception for circumstances in which an individual has been seen by medical personnel. Nonetheless, it may have been reasonable for the members to decide, given the short time between the medical examination and Mr. Silverfox's incarceration, that it would not serve any useful purpose to readminister a BAC test since one had already been performed.

Despite the foregoing, there is no evidence suggesting that the EMS personnel checked Mr. Silverfox's BAC: it was neither noted on Mr. Silverfox's medical reports nor raised by Ms. Smith and Mr. McCann in their statements. Accordingly, there does not appear to have been any basis on which the members could reasonably rely on the medical assessment in the matter of Mr. Silverfox's BAC as opposed to complying with the existing detachment policy.

Finding: Constable Van Marck and Constable Bulford failed to comply with detachment policy requiring that intoxicated prisoners be asked to provide a breath sample prior to incarceration.

Recommendation: That members of the Whitehorse RCMP, as well as all guards and matrons working at the Whitehorse RCMP cells, be given further training regarding signs and symptoms of impairment, and medical conditions that may arise therefrom.

Inspector Wharton indicated that he had implemented a recommendation stemming from the administrative review of this incident that required that he ensure compliance with the policy. He also indicated that he had reviewed the relevant policy and added clauses requiring members to consider all circumstances and indications of impairment and consider medical attention even if a prisoner's BAC did not exceed 350 mg per 100 mL of blood according to the ASD.

Members booking prisoners into cells are also responsible for noting the individual's level of responsiveness. The relevant RCMP national operational policy stated:

19.2.3.8 Assessing prisoner responsiveness results must be noted on form C-13-1 before lodging the person in a cell and regularly thereafter by the guard on duty until release.

19.3.2.2 You must assess prisoner responsiveness and note the information on form C-13-1 before lodging the person in a cell. Instruct the guard on duty to assess responsiveness regularly and document the results in the prisoner log record book.

Although Constable Van Marck was noted to be the "investigator" on the Prisoner Report, Constable Bulford in fact completed the report. Constable Bulford noted on the report that he had checked Mr. Silverfox's responsiveness, and it is apparent on the cell block video that Mr. Silverfox was responding to questions and the members' instructions during the booking process. Constable Bulford noted on the Prisoner Screening section of the Prisoner Report that Mr. Silverfox's breath had a strong odour of liquor, that he was vomiting and fumbling, that he was wobbling and sagging, that his speech was confused, that he was sleepy, and that he was placid in demeanour. Under "illnesses/medications," he wrote, "none noted." Given the information noted on the Prisoner Report completed during booking, I am satisfied that Constable Bulford adequately assessed Mr. Silverfox's responsiveness and completed the relevant section of the Prisoner Report as required.

Finding: Constable Bulford adequately assessed Mr. Silverfox's responsiveness at the time of booking and completed the associated section of the Prisoner Report as required.

Craig MacLellan's guard shift

Craig MacLellan was the guard on duty at the time that Mr. Silverfox was booked into cells. Guards and matrons at the Whitehorse RCMP Detachment are employees of the Canadian Corps of Commissionaires, the RCMP Guard Program Coordinator for which is Mr. Harry Elliott. Constable Paul Brisley and Constable Jeff Kalles were the designated Guard coordinators for the Whitehorse Detachment. The guard training, delivered by Mr. Elliott, was consistent with the RCMP's Course Training Standard (CTS) for guards.

Essentially, RCMP policy requires guards and matrons to have up-to-date CPR and basic first aid certification, and to take an annual recertification course every year once they have completed their initial training.Footnote 2 Craig MacLellan possessed current CPR and basic first aid certification, and had taken his guard training course on June 24, 2008. His training was complete and up to date.

Finding: Guard Craig MacLellan's training was complete and up to date.

During the booking-in process, Craig MacLellan remembered Mr. Silverfox being reasonable and cooperative, although "pretty drunk." He described him as "pretty drunk" in that he was shuffling and seemed unsteady, but "not too bad." Craig MacLellan stated, "[...] it almost seemed just a, another, another drunk really [...] like I mean I've dealt with hundreds of them probably eh so." He remarked that Mr. Silverfox had urinated on himself, but did not recall Constable Van Marck or Constable Bulford giving him any information about Mr. Silverfox, apart from the fact that he may have defecated in his pants.

RCMP national operational policy requires that persons having been certified fit for incarceration be placed in their cells in a recovery position, with their faces in plain view, "[w]hen appropriate and possible."Footnote 3 This was not done, as Mr. Silverfox was simply admitted to the cell and left to position himself. However, Mr. Silverfox was walking by himself at that point, and it is clear from the cell block video that he was able to enter the cell, where he interacted briefly with its other occupants and proceeded to lower himself to the ground. As that was the case, and the members had observed Mr. Silverfox's ability to both walk and speak at that point despite his obvious indications of impairment, it was not necessary or appropriate to intervene to place him in the recovery position.

Finding: It was not necessary to place Mr. Silverfox in a recovery position when he first entered Cell 3.

Although Craig MacLellan did not do a physical check of Mr. Silverfox until 7:05 a.m., he took note of some of his actions by way of the detachment's closed-circuit video and recorded them in the cell log book. He saw Mr. Silverfox tossing and turning and believed that it was likely due to his intoxication. He also noted Mr. Silverfox dry heaving, although he did not vomit.

One of the individuals lodged with Mr. Silverfox stated:

Raymond SILVERFOX was fucking hyperventilating pretty bad. He couldn't stop getting sick and he shit his pants and pissed his pants and he couldn't stop puking. It was pretty obvious he needed help but they didn't, they didn't do nothing about it.

He also remarked Mr. Silverfox dry heaving after he had vomited. He indicated that Mr. Silverfox was too sick to talk to him or to the cell's other occupant. That individual concurred that Mr. Silverfox was extremely intoxicated and also stated that he had told the guard upon release that something was seriously wrong with Mr. Silverfox. Neither Craig MacLellan nor any of the members present recalled this occurring, and it does not appear on the video.

At 6:55 a.m., Constable Dennis Connelly released the other men in Cell 3, at which time he spoke briefly to Mr. Silverfox. He again checked on Mr. Silverfox at 7:22 a.m., asking if Mr. Silverfox was all right. Mr. Silverfox did not respond, although his eyes were open and he continued to move about. Constable Connelly checked on Mr. Silverfox again at 7:57 a.m.

Note: Corporal Gale was the senior member and not the "Watch Commander" as originally identified.

Corporal Gale, the senior member at the time of Mr. Silverfox's booking into cells, attended the cell block at approximately 7:51 a.m., likely shortly before going off shift. RCMP national operational policy in effect at the time stated:

19.3.1.11 At the commencement and conclusion of a member's or guard's shift, the senior member on duty, accompanied by the guard, will assess each prisoner in every cell and record same.

19.3.2.1 You and the guard on duty are responsible for determining the responsiveness of each prisoner in cells and must be familiar with the requirement to assess prisoner responsiveness and conduct assessments as required.

19.11.12.3 The incoming Watch Commander will check C13's and confirm the status of each prisoner and will ensure that a prisoner is being lawfully detained.

Although Corporal Gale was present in the cell block, there is no evidence that he took any steps to check or assess Mr. Silverfox at the conclusion of his shift.

Finding: Corporal Gale failed to check or assess Mr. Silverfox at the conclusion of his shift.

Recommendation: That the Detachment Commander conduct regular "spot checks" of cell log books to ensure that Watch commanders are checking and assessing prisoners at the beginning, end and throughout their shifts as required by RCMP policy.

In response to the administrative review conducted, Inspector Wharton ensured that Watch commanders understood their responsibilities towards the detachment cell block facilities and prisoners, as well as the need to assess prisoners and record same. Unit supplements were updated to reflect national policy.

Corporal MacLeod, the Watch Commander at the time of Mr. Silverfox's death, began her shift at 7 a.m. It would end at 7 p.m. Corporal MacLeod first attended the guardroom at 8:03 a.m., but did not conduct a physical check in the cell block.

Although Corporal MacLeod did recall reading over the Prisoner reports (C-13s) as required by policy, which at that time consisted only of that of Mr. Silverfox, there is no indication that she performed a physical check or assessed Mr. Silverfox's condition as required by the policy. There is no evidence that she questioned why Mr. Silverfox had not been administered an ASD and his BAC recorded. Mr. Silverfox's vomiting was not covered in detail on his Prisoner Report, nor was his examination by EMS, and there is no indication that any member or Craig MacLellan gave her any further information regarding Mr. Silverfox.

Corporal MacLeod stated at the coroner's inquest that she had not performed the physical check, as Mr. Silverfox was using the washroom. The cell block video shows that she arrived in the cell block at approximately 8:03 a.m. She reviewed the Prisoner Report approximately one minute later, and at 8:09 a.m. began to assist with searching and booking in a resistant prisoner, which appeared to take her some time, as she did not reappear and leave the guardroom until 8:20 a.m. Mr. Silverfox began using the washroom at 8:17 a.m. and was not finished until 8:29 a.m.

Although Corporal MacLeod's explanation for not performing a physical check of Mr. Silverfox is consistent with the events as seen on the cell block video, the policy in respect of checks at the beginning of the senior member's shift does not provide that such checks will be conducted only "where possible"; the policy is prescriptive in that such checks must be performed. Finally, there is no indication that Corporal MacLeod attempted to wait or returned to determine whether Mr. Silverfox would be available, and as above, she did not appear to have asked any questions or received any information in respect of Mr. Silverfox.

Finding: Corporal MacLeod did not perform a physical check of Mr. Silverfox or assess him at the beginning of her shift as Watch Commander.

Finding: Although Corporal MacLeod did review Mr. Silverfox's Prisoner Report, she did not question the lack of a BAC reading.

Recommendation: That Watch commanders review Prisoner reports at the beginning and end of their shifts, and that they identify and remedy or direct the remedying of any deficiencies.

I also reiterate my previous recommendation that the Detachment Commander conduct regular "spot checks" of cell log books and Prisoner reports to monitor compliance with RCMP policy. Also, as previously stated, Inspector Wharton indicated in response to the administrative review that he had ensured that Watch commanders were better aware of their responsibilities.

Craig MacLellan remembered speaking to Constable Connelly about Mr. Silverfox and telling him that Mr. Silverfox had been sick at the Salvation Army and was dry heaving. He also remembered that Mr. Silverfox had urinated in his pants. Craig MacLellan noted that Mr. Silverfox did not say anything and continued, "[...] and that was strange too because I know like if people are sick or not feeling well they're usually pounding on the door like you know [...] saying call EMS over like lots of minor things [...]." He did not recall the other two prisoners saying anything about Mr. Silverfox. In the cell log book, Craig MacLellan noted Mr. Silverfox dry heaving on two occasions.

The RCMP's national operational policy at the time of Mr. Silverfox's death provided the following with respect to duties of RCMP members in regard to prisoners:

19.2.3.2 Assess responsiveness regularly.

19.2.3.3 Transfer this information, e.g. quantity of alcohol/drugs consumed, evidence of liquor bottles/drug paraphernalia observed, to form C-13-1 and the investigative file.

19.2.3.4 Relay this information and the results of the responsiveness assessment to the member or guard responsible for his/her custody until the prisoner is released. The information must also be relayed to any medically trained professional [which includes a medical practitioner, nurse, paramedic and ambulance attendant].

19.2.3.5 Ensure the information regarding the assessment of responsiveness is communicated to the relief members and guards until the time of the person's release. Regularly assess and communicate the results.

[...]

19.2.3.8 Assessing prisoner responsiveness results must be noted on form C-13-1 before lodging the person in a cell and regularly thereafter by the guard on duty until release.

As previously determined, Constable Bulford adequately assessed Mr. Silverfox's responsiveness at the time of booking. Although Craig MacLellan stated that he could not recall the booking members providing him with any information in respect of Mr. Silverfox, he later stated that he told Constable Connelly that Mr. Silverfox had been vomiting at the Salvation Army. As that information was not detailed on the Prisoner Report, it is apparent that he must have been provided with at least some information regarding Mr. Silverfox's circumstances by either Constable Bulford or Constable Van Marck. However, it is equally apparent that the transfer of information between the members and the guard was not formalized to such a degree that it was either recorded or specifically recalled by Craig MacLellan. Certainly, there was no indication from either member or from Craig MacLellan that the importance of transferring information regarding those in RCMP custody was recognized. The evidence available to me is such that it does not lead to the conclusion that information regarding Mr. Silverfox's particular situation was comprehensively communicated to Craig MacLellan by Constable Bulford or Constable Van Marck, as required by policy.

Finding: Information regarding Mr. Silverfox was not comprehensively communicated to Craig MacLellan by Constable Bulford or Constable Van Marck.

Recommendation: That the Detachment Commander review with all members and guards the importance of and the need for meaningful, thorough and consistent communication with respect to persons in custody at the Whitehorse RCMP Detachment.

In addition, I reiterate my recommendation that Watch commanders review cell log books to ensure compliance with policy regarding the checking and monitoring of prisoners, as well as recording same.

During Craig MacLellan's guard shift, he made a number of notations in the cell log book regarding Mr. Silverfox. RCMP national operational policy regarding the requirements for on-duty guards provides:

16.4.4.5 Video surveillance cameras should be used to increase cell-block security but they do not replace physical security checks.

19.3.3.1 All checks of a prisoner will be recorded in the prisoner log record book.

19.3.3.2 The prisoner log record book [...] must include columns for date, time, prisoner number, cell number, observations, type of check completed, e.g. CCVE or physical check where the guard or matron attends the area outside the cell to observe the prisoner, and the guard's initials.

19.3.5.1 Check prisoners frequently and at irregular intervals to ensure their security and well-being. Ensure the intervals are no more than 15 minutes apart.

19.3.5.2 Document all checks of a prisoner in the prisoner log record book. Detail prisoner activities, the type of check completed and the status of a prisoner at the time of the check. Ensure these entries can be clearly read and understood if reviewed at a later date.

In addition, "M" Division operational policy regarding the monitoring of prisoners states:

19.1.1.3 The guard/matron shall check all prisoners on an intermittent basis, e.g. 5, 8, 10, 7 minutes, but no longer than 15 minutes apart and continuously if they are sick or injured. The guard/matron must ensure there is physical movement observed during each and every check and that these movements are documented.

19.1.1.4 In detachments with monitoring equipment the guard/matron shall indicate in the guardroom log book if the check was done physically or by way of a monitor. This will be done by writing either "M" (monitoring) or "P" (physical) in the log beside each entry.

The applicable policy specific to the Whitehorse RCMP Detachment provides:

19.3.3.1 The video monitor is in place to allow for an increased level of monitoring and does not constitute a check of the prisoner.

Craig MacLellan made notations regarding Mr. Silverfox at intervals of between 2 and 15 minutes. The time intervals noted were irregular, as required by policy, but there were no notations indicating whether the checks performed were physical checks, or checks by way of the video monitor. This is contrary to divisional policy in this respect. The cell block video shows that only one of the checks performed by Craig MacLellan was a physical check. As national, divisional and detachment policy specifically state that a video monitor check does not constitute a check of the prisoner, there were an insufficient number of checks performed in respect of Mr. Silverfox during Craig MacLellan's guard shift.

Finding: The time intervals noted in the cell log book for checks of Mr. Silverfox during Craig MacLellan's shift were consistent with RCMP policy, as was the irregularity of those intervals.

Finding: Craig MacLellan failed to indicate whether Mr. Silverfox was subject to physical checks or checks by way of the video monitor.

Finding: As divisional policy specifically required that checks performed be physical checks, there were an insufficient number of checks performed in respect of Mr. Silverfox during Craig MacLellan's guard shift.

Recommendation: That Watch commanders review cell log books intermittently throughout and at the end of their shifts to ensure compliance with RCMP policy regarding checking and monitoring prisoners, as well as recording same.

Most of the notations made by Craig MacLellan stated only what position Mr. Silverfox was lying in at that particular time, although he noted three instances in which Mr. Silverfox appeared to be dry heaving or vomiting. The cell block video, however, shows seven instances in which Mr. Silverfox appears to be vomiting. None of those instances corresponds with times noted in the cell log book. Although it is impossible to conclude that physical checks would have resulted in the guard noting more of Mr. Silverfox's actions, it must nonetheless be concluded, as above, that Mr. Silverfox was inadequately monitored.

Physical vs. video checks

As stated, divisional and detachment policy require that checks on prisoners, which should be no more than 15 minutes apart, should also be physical checks as opposed to checks by way of the video monitor. The requirement that physical checks be conducted is consistent with the national policy in that respect.

Although physical checks may appear to be a cumbersome and often unnecessary process when video monitoring is in place, it is incumbent upon members and guards to recognize that physical checks are vital in assessing prisoner responsiveness, as is also required by policy, and in noting prisoner appearance and behaviour that may be missed due to the relatively low quality and resolution of most cell block video equipment. In addition, the cell block video in this instance was not equipped for audio transmittal from within the cells, and a video check would not indicate in every instance when a prisoner may be calling for help or otherwise acting unusually.

It is without question that a physical check and direct observation of prisoners provides more information than simply viewing a video monitor, and in my view, it is important that policy regarding the requirement to physically check prisoners be maintained and followed. Although the advent of new monitoring technology is useful, it should, as noted in policy, be used to supplement direct observation and not to replace it.

Beyond the requirement for physical checks, RCMP national operational policy provides:

19.3.5.4 Constantly monitor prisoners known to have, or suspected of having, suicidal tendencies, as well as the prisoners who have been examined by a medically trained professional [...] and certified fit to be incarcerated.

19.3.5.4.1 To constantly monitor means to watch or observe without interruption. Use of CCVE [closed-circuit video equipment] may augment but not replace physical checks.

In this instance, Mr. Silverfox was found fit to be incarcerated by medical personnel. According to the policy, he should have been subject to constant monitoring. A great deal of discussion at the coroner's inquest centred around the requirement for constant monitoring and what, exactly, was implied by constant monitoring. Although "constant monitoring" implies a heightened level of surveillance and increased alertness to any problems given what appears to be the predisposition of those who have been medically examined prior to incarceration, it would be impossible for the guards or members to physically monitor any prisoner, including Mr. Silverfox, constantly without significant resource implications. In my view, the requirements for frequent physical checks supplemented by video monitoring were sufficient in this instance, although their sufficiency is largely predicated on compliance with the policy. Accordingly, I find that the requirement of constant monitoring would have been satisfied through compliance with RCMP policy regarding physical checks of prisoners, supplemented with an enhanced level of awareness given that Mr. Silverfox had been medically examined prior to incarceration.

Finding: The requirement of constant monitoring would have been satisfied through compliance with RCMP policy regarding physical checks of prisoners, supplemented with an enhanced level of awareness given that Mr. Silverfox had been medically examined prior to incarceration.

Heather Balfour's guard shift

Ms. Heather Balfour took over from Craig MacLellan as matron at approximately 7:40 a.m. She would remain on shift until approximately 3:30 p.m. Ms. Balfour first took the guard training course on June 17, 2007, and subsequently completed refresher courses on January 14 and August 30, 2008. She also possessed valid first aid and CPR certification. Accordingly, her training was complete and up to date.

Finding: Ms. Balfour's training was complete and up to date.

At the beginning of her shift, Ms. Balfour walked to the window of Cell 3 to perform a physical check on Mr. Silverfox. RCMP national operational policy requires that such a check be performed at every shift change,Footnote 4 and Ms. Balfour acted in compliance with that policy.

Finding: Ms. Balfour properly conducted a physical check of Mr. Silverfox when she began her shift.

Ms. Balfour proceeded to conduct a number of physical checks throughout her shift: at 7:38 a.m., 8:56 a.m., 9:13 a.m., 9:32 a.m., 10:09 a.m., 10:59 a.m., and 1:02 p.m. In the interceding times, she would check the video monitor and make notes in the cell log book. According to Ms. Balfour, she "could see that [Mr. Silverfox] was actually moving ah in many different ways [...] and some of the members actually went and talked to him." She continued, "[...] in the afternoon he wasn't moving as much and I made some rounds then for sure and so and then I actually went and spoke to him a couple times too."

Ms. Balfour made a total of 41 notations in respect of Mr. Silverfox, mainly consisting of observations regarding where and how he was laying in the cell. The notations, and accordingly checks on Mr. Silverfox, were made at intervals of 15 minutes or less and at irregular times, as required by the policy detailed previously. Ms. Balfour, like the previous guard, failed to note whether the checks conducted were physical checks or checks by way of the video monitor. The cell block video provides further information in this regard, as detailed above. Ms. Balfour performed seven physical checks during the approximately eight-hour shift.

My comments with respect to the need for physical checks as opposed to checks by way of the video monitor are equally applicable here. Ms. Balfour specified that she would not necessarily have made her rounds every fifteen or twenty minutes if the prisoners were "up and moving." However, the policy does not allow for deviation; there is no provision for omitting to perform physical checks if it is apparent that individuals are moving about their cells. As alluded to previously, and as is tragically apparent in the case of Mr. Silverfox, the fact that prisoners are moving does not inexorably lead to the conclusion that they are not in any distress. Accordingly, I would once again reinforce the need for physical checks of prisoners, as they did not occur in this instance.

Finding: The time intervals noted in the cell log book for checks of Mr. Silverfox during Ms. Balfour's shift were consistent with RCMP policy, as was the irregularity of those intervals.

Finding: Ms. Balfour failed to indicate whether Mr. Silverfox was subject to physical checks or checks by way of the video monitor.

Finding: As divisional policy specifically required that checks performed be physical checks, there were an insufficient number of checks performed in respect of Mr. Silverfox during Ms. Balfour's guard shift.

I reiterate my previous recommendation that Watch commanders review cell log books intermittently throughout and at the end of their shifts to ensure compliance with RCMP policy regarding checking and monitoring prisoners, as well as recording same. I also note that Inspector Wharton spoke with Ms. Balfour on July 20, 2009, regarding the requirement to check prisoners frequently at irregular intervals no more than 15 minutes apart, the proper use of closed circuit video equipment, and properly recording checks in the guardroom log book.

In the cell log book, Ms. Balfour noted during her shift that Mr. Silverfox vomited on five occasions and could be seen dry heaving on six occasions. Nine of the instances she indicated coincided with the times at which Mr. Silverfox is noted to vomit on the cell block video. However, on the cell block video, Mr. Silverfox can be seen to vomit and/or dry heave approximately 22 times. Accordingly, between 11 and 13 instances of vomiting and/or dry heaving were missed or not noted in the only available record of prisoner activity.

Although Mr. Silverfox was not physically observed to have vomited the number of times he in fact did, it was apparent that the cell was becoming more and more contaminated. The cell block video clearly shows an increasing amount of fluid on the cell floor.

At one of those times, Ms. Balfour stated to Mr. Silverfox, "Why don't you go puke in the toilet instead of all over the floor. Go puke in the toilet. You're gonna have to clean, you're gonna have to clean this up." It is of note that the RCMP national operational policy provides:

19.3.4.5 Do not ask or direct a prisoner to clean or mop out his/her cell or a police vehicle.

Guards and matrons are required to familiarize themselves with all applicable RCMP policies. Accordingly, Ms. Balfour's threat, directed as it was towards Mr. Silverfox, was contrary to the stated policy in this regard.

Finding: Ms. Balfour's statement to Mr. Silverfox that he would have to clean up his cell did not comply with RCMP policy in that regard.

Recommendation: That the Detachment Commander or his delegate review with Ms. Balfour the RCMP policy regarding cell clean-up.

Ms. Balfour indicated that she thought Mr. Silverfox was getting better in the afternoon, as he started to get up and vomit into the cell toilet.

Ms. Balfour did not find it odd that Mr. Silverfox continued to vomit, as: "...we have people that vomit all the time [...]. So I didn't really think that it was you know particularly odd." Constable Jeffrey Kalles, a Whitehorse provost member present in the guardroom at various points throughout Mr. Silverfox's incarceration, indicated that Ms. Balfour had told him at approximately 3 p.m. that Mr. Silverfox had urinated, defecated and vomited, and that he was still intoxicated after being in cells for ten hours. Constable Heather Kaytor, another provost member intermittently present in the guardroom, stated that Mr. Silverfox's vomiting was apparent, "[b]ut there was never any indication or questions or voices of concern that it was anything else but intoxication and vomiting as a result of his intoxication." Tellingly, Constable Kaytor stated: "[...] there's nothing unusual about that day except for what happened later in the day."

Hector MacLellan's guard shift

Just before 3:30 p.m., Hector MacLellan began his shift as cell guard. Hector MacLellan first completed his guard training on June 16, 2007. He subsequently completed a refresher course on January 14, 2008. Although it is desirable that refresher courses be taken every six months, he nonetheless met the standard for annual recertification as required by policy. He possessed current first aid and CPR certification. Accordingly, his training was complete and up to date.

Finding: Hector MacLellan's training was complete and up to date.

Mr. Silverfox had knocked on his cell door at the time of the shift change, which was noted by Ms. Balfour, but no one responded and he returned to lying down in the cell. Ms. Balfour told Hector MacLellan that Cell 3 was a mess and that Mr. Silverfox had been vomiting. She stated: "[...] he's been throwing up all day so he'd sooner just throw up and not move." Hector MacLellan asked, "Did he shit himself?" and Ms. Balfour responded that she did not think so. Hector MacLellan proceeded to physically check Mr. Silverfox, who was awake at that time, at the beginning of his shift, as required by RCMP national operational policy.

Finding: Hector MacLellan properly conducted a physical check of Mr. Silverfox when he began his shift.

Hector MacLellan stated: "There was no sign of any trouble whatsoever with him." He could not recall seeing Mr. Silverfox vomit while he was on shift. He did not note any vomiting or dry heaving by Mr. Silverfox in the cell log book. Mr. Silverfox in fact appeared to have vomited three times during Hector MacLellan's guard shift, specifically at 3:59 p.m., 4:34 p.m. and 5:08 p.m. None of those instances was noted by Hector MacLellan. Hector MacLellan made notes in the cell log book in respect of Mr. Silverfox at intervals of exactly 15 minutes-contrary to the policy previously noted-between 3:30 p.m. and 6:01 p.m. None of the checks performed, beyond the initial one, was a physical check. Accordingly, an insufficient number of checks were performed, at intervals that could not be termed irregular. The monitoring of Mr. Silverfox at this time was entirely inadequate.

Finding: Although the time intervals of exactly 15 minutes noted in the cell log book for checks of Mr. Silverfox during Hector MacLellan's shift were consistent with RCMP policy, they were not irregular, which violated RCMP policy in that respect.

Finding: There were an insufficient number of checks performed in respect of Mr. Silverfox during Hector MacLellan's guard shift.

I reiterate my recommendation that Watch commanders review cell log books intermittently throughout and at the end of their shifts to ensure compliance with RCMP policy regarding checking and monitoring prisoners, as well as recording same.

I note that Inspector Wharton spoke with Hector MacLellan on July 16, 2009, regarding the requirement to check prisoners frequently at irregular intervals no more than 15 minutes apart, the proper use of closed-circuit video equipment, and properly recording checks in the guardroom log book. Nonetheless, in my view, this guard's failure to comply with the minimal requirements for supervision of a prisoner was such that further remedial action should be considered by the RCMP in respect of his employment.

Recommendation: That the RCMP consider further remedial action in regards to Hector MacLellan's employment.

Hector MacLellan's impression was that Mr. Silverfox was gradually "sobering up" and getting restless as a result. As was the case with the other guards on shift, Hector MacLellan failed to indicate whether the checks were physical checks or whether he had simply checked the video monitor.

Finding: Hector MacLellan failed to indicate whether Mr. Silverfox was subject to physical checks or checks by way of the video monitor.

I reiterate my previous recommendations and note that Inspector Wharton spoke with Hector MacLellan in this regard.

Note: Members' names and attributed quotes have been corrected in the paragraph below.

Constable Kaytor, Constable Connelly and Constable Kalles, Whitehorse provost members, as well as Constable Geoff Corbett and Constable Shirley Telep, were in the guardroom at various times during Mr. Silverfox's incarceration. Constable Connelly noted that Mr. Silverfox had urinated on himself, saying: "He's definitely, he's definitely pissed himself because he's ah, he's opened up his pants and all that stuff to try and get it away from his body, short of taking them and the only reason he probably hasn't taken them off is he probably pooped in there." Constable Connelly further stated, "[...] it looks like a fucking smut in here." Constable Connelly later said: "[...] poopy, poopy mc poopy."

At 3:49 p.m., Constable Corbett checked on Mr. Silverfox after looking at the video monitor and remarking, "There's shit everywhere." Constable Corbett entered the cell block and spoke to Mr. Silverfox. Mr. Silverfox requested a mattress, but Constable Corbett responded: "No ... you can sleep in your own shit." He further stated to Hector MacLellan and Constable Kalles, who were in the guardroom: "Yeah you need a pizza too. What else can I get for ya?" Constable Kalles continued, "... get him some sausages [...] throws that up and eat it [...]." The members continued to talk about the cell's cleanliness, Constable Corbett referring to it as a "biohazard" and saying, "it's disgusting." Hector MacLellan advised that if there was anyone that someone didn't like in town, they should get them and put them in the cell with Mr. Silverfox.

Constable Corbett did not remark anything physically unusual about Mr. Silverfox during their interaction, but also stated that he had not dealt with Mr. Silverfox previously and accordingly had no basis for comparison. None of the subject members could recall dealing with Mr. Silverfox previously, and indeed, there were no recent files involving him at the Whitehorse RCMP Detachment.

In respect of Mr. Silverfox's medical condition, Constable Kalles continued once Constable Corbett had left. He stated: "Must be on some kind of drugs or somethin'. He can't, 'cause he can't get up like he's just rollin' around and -." A short time later, Constable Kaytor, Hector MacLellan and Constable Telep continued discussing Mr. Silverfox:

HK: Look just rolling around in that.
HM: Oh yeah, yeah -
HK: It's terrible to watch.
...
ST: Ew doesn't even have got his shirt on.
HK: Oh it's just gross.
...
HK: That is, that's is really disgusting.
ST: He must have got the flu. [laughs]
HK: Yeah (...) [laughs] but it's a terrible...
...
HK: Like there's a terrible stomach one going around.
ST: I know.
HK: (indiscernible) he's gonna poop his pants right away [...] Correct.

I have specifically addressed the contents of the guardroom audio recording later in this report.

The Watch Commander on duty, Corporal MacLeod, began her shift at 8 a.m. and checked in at the guardroom at that time. She did not check on the prisoners and did not return to the cell block until approximately 4 p.m. RCMP national operational policy provides:

19.3.1.11 At the commencement and conclusion of a member's or guard's shift, the senior member on duty, accompanied by the guard, will assess each prisoner in every cell and record same.

The applicable "M" Division operational policy states:

19.1.1.5 The guardroom and all prisoners are to be checked by the senior member on shift, at the beginning of each shift and intermittently during shift.

Finally, the relevant policies specific to the Whitehorse RCMP Detachment provide:

19.3.3.2 The Watch Commander or delegate shall ensure their inspections are noted in the prisoner log in red ink. [emphasis in original]

19.11.12.1 The Watch Commander or in his/her absence, the Senior Constable on shift, has overall responsibility for the Detachment cell block.

19.11.12.2 At the commencement of the shift, and periodically during the shift, the Watch Commander will physically check the cell facilities and prisoners and record any adverse findings in the prisoner diary book in red ink, inclusive of regimental number.

19.11.12.3 The incoming Watch Commander will check C13's and confirm the status of each prisoner and will ensure that a prisoner is being lawfully detained.

As previously determined, Corporal MacLeod did review Mr. Silverfox's Prisoner Report shortly after the start of her shift, but did not conduct a physical check of Mr. Silverfox. It is also apparent that Corporal MacLeod, as Watch Commander, did not return to the guardroom or the cell block intermittently during her shift, as required by policy. Corporal MacLeod stated at the coroner's inquest that she trusted that the guards on duty would inform her of any issues with the prisoners, and that she was "shocked" when she attended the cell block late in her shift and saw the condition of Mr. Silverfox's cell.

It is reasonable for a Watch Commander to expect to be notified if a prisoner's condition changes or if a problem arises in the cell block. However, Watch commanders should not substitute reasonable reliance on those individuals directly tasked with monitoring prisoners for the requirement that they also continue to intermittently check prisoners. It is understood that many issues arise during the course of a day or a shift; nonetheless, the requirement to check periodically remains. Watch Commanders should not find themselves surprised by a condition that has been developing over the course of some eight hours. It is doubtless to avoid such a situation that policy requiring intermittent checks was developed. The responsibility to ensure the well-being and fitness of prisoners and cells should not and cannot be devolved to the extent that a Watch Commander is unaware of what is occurring within the detachment. Corporal MacLeod failed to ensure that she was aware of emergent issues in the cell block, in large part because she failed to periodically check on Mr. Silverfox as required by RCMP policy.

Finding: Corporal MacLeod failed to periodically check on Mr. Silverfox during her shift as Watch Commander.

I reiterate my recommendation regarding regular "spot checks" of cell log books to ensure that Watch commanders are checking and assessing prisoners at the beginning, end and throughout their shifts as required by RCMP policy. In addition, and as previously noted, Inspector Wharton ensured, in response to the administrative review, that Watch commanders understood their responsibilities to the detachment cell block facilities and prisoners, and updated unit supplements to reflect national policy.

At approximately 6 p.m., Constable Mike Muller arrived at the detachment cells with an unruly and combative prisoner, and several members arrived to help him. Corporal MacLeod attended the guardroom in response to Constable Muller's request for help, as did Constable Kendra Hannigan.

At 6:34 p.m., Corporal MacLeod learned from Hector MacLellan that Mr. Silverfox had been sick throughout the day, and she decided to go to Cell 3. Constable Hannigan checked on Mr. Silverfox at 6:36 p.m., (Timeline) followed by Corporal MacLeod at 6:41 p.m. Corporal MacLeod looked inside, where Mr. Silverfox was lying prone, mainly on his stomach, and shirtless. Corporal MacLeod could not see Mr. Silverfox breathing and called out to him, as did Hector MacLellan. Mr. Silverfox did not respond.

Hector MacLellan opened the cell door at 6:43 p.m., and Constable Muller and Constable Hannigan checked Mr. Silverfox's vital signs. Constable Hannigan noted that "his mouth [was] slightly open, his eyes [were] glazed and wide open. His eyeballs were rolled back into his head." Finding none, Corporal MacLeod told Hector MacLellan to call an ambulance, which he attempted to do, but the line was busy. He then asked Constable Hannigan to call for an ambulance on her radio. The ambulance was contacted at 6:43 p.m. and advised that there was an unresponsive prisoner in cells. Dispatch was subsequently told that the prisoner was not breathing.

RCMP national operational policy requires that if a member is unable to establish the responsiveness of a prisoner, medical assistance shall be immediately requested.Footnote 5 Immediately upon determining that Mr. Silverfox was unresponsive, Corporal MacLeod directed that an ambulance be called. Her actions were consistent with policy in this respect.

Finding: Medical assistance was immediately requested once it had been determined that Mr. Silverfox was unresponsive.

Corporal MacLeod began chest compressions on Mr. Silverfox, who had been pulled into the cell block hallway following the check of his vital signs: "This was done as cell was contaminated [with] feces and urine and there was an overpowering stench." Constable Hannigan then took over chest compressions. Constable Muller was meanwhile performing artificial respiration. Several other RCMP members were present by that time, including Constable Benjamin Douglas and Constable Chris Pratte, who also rotated in to perform chest compressions, as well as Constable Dean Hoogland, Constable Craig Hughes and Constable Jade Stewart.

EMS arrived at 6:47 p.m. and took over care of Mr. Silverfox. Ms. Kathy Donnelly, one of the responding EMS attendants, described Mr. Silverfox's initial appearance as cyanotic, meaning that he lacked oxygen, and stated that his pupils were fixed. She also stated that he smelled of vomit. Mr. Shane Skarnulis, another paramedic in attendance, described his skin colour as "greyish." Mr. Silverfox was transported to the hospital and arrived in the emergency room of Whitehorse General Hospital at 7:16 p.m., where efforts to resuscitate him continued. Mr. Silverfox was pronounced dead at 9:15 p.m. A toxicological screen did not reveal elevated levels of alcohol or the presence of drugs.

An autopsy was conducted on Mr. Silverfox on December 5, 2008, by Dr. Charles Lee at the Vancouver General Hospital. The autopsy report, released on February 12, 2009, concluded that Mr. Silverfox had died of sepsis and acute pneumonia. The report added that, "[p]ostmortem cultures grew several bacterial organisms suggestive of aspiration pneumonia." The report noted that an "overwhelming infection" likely led to Mr. Silverfox's death. It also noted that chronic alcoholism was a likely contributory factor.

The investigation

The investigation into Mr. Silverfox's death was initially conducted by the "M" Division Major Crimes Unit; however, it was quickly turned over to RCMP "E" Division North District Major Crime Unit in British Columbia. On December 3, 2008, that team, led by Team Commander Staff Sergeant Glen Krebs and including File Coordinator Corporal Randy Bosch and Primary Investigator Sergeant Gary Heebner, began its work.

The Commission also dispatched an independent observer, and impartiality questionnaires were completed by the involved members. No material concerns were identified. The Independent Observer Program is an initiative arranged between this Commission and the RCMP whereby Commission staff are assigned to observe and assess the impartiality (not the adequacy) of RCMP investigations that examine the conduct of RCMP members who are involved in high-profile and serious incidents, such as in-custody deaths.Footnote 6

The RCMP investigators were conducting a criminal investigation into the actions of the members and guards, specifically to determine whether sections 219 (criminal negligence), 220 (causing death by criminal negligence) and 222 (homicide) of the Criminal Code applied in this situation so as to warrant charges. Following the investigation, the investigative report was forwarded to Crown Counsel Elizabeth Miller of the Office of the Director of Public Prosecutions Nunavut Regional Office. In her opinion, no charges were warranted in the circumstances. Solicitor-client privilege applying in this instance, the Crown's opinion was not provided to the Commission as part of the relevant materials.

The administrative review

An administrative review was conducted by Inspector de Champlain of the "K" Division Commercial Crime Section. That review, completed on May 26, 2009, identified a number of areas of non-compliance with policy and recommendations for improvement (Detachment Commander, outlined his responses to the recommendations on June 16, 2009 (Appendix E) [PDF, 523Kb]. Those responses are included throughout this report where relevant.

Issue Surrounding the Duty of Care Owed to Persons in RCMP Custody

Under the rubric of the general duty of care owed by the RCMP to persons in its custody are the provision of medical attention and the conditions in which prisoners are incarcerated. Both issues resonate strongly in the case of Mr. Silverfox.

Provision of medical assistance

The RCMP's national operational policy provides:

19.3.1.2 The RCMP is responsible for the well-being and protection of persons in its custody [...].

19.3.2.4 Document any unusual behaviour exhibited by a prisoner, e.g. suicidal tendencies, violence, real or feigned illness or conditions verified by a medically trained professional. Instruct guards to document any unusual prisoner behaviour in the prisoner log record book.

The Whitehorse RCMP Detachment operational policy further expands on the requirement set out in the national policy:

19.2.2.1 If a prisoner is suspected of having an injury or illness requiring medical attention, arrangements for such attention is to be made forthwith.

19.2.4.2 In the event a prisoner's medical condition worsens, seek medical treatment.

Mr. Silverfox was in the Whitehorse RCMP Detachment cells for almost 13 hours at the time of his death. He had been ill for virtually the entire length of his stay. However, as was demonstrated in the cell block video, he was left virtually alone as a number of individuals—members, guards and civilians—entered and exited the guardroom of the Whitehorse RCMP Detachment. Many of those individuals commented on Mr. Silverfox: his state of sobriety, his illness, the condition of his cell. However, as was stated by many of them, they did not think to seek medical assistance for Mr. Silverfox, as they assumed that he was simply "sobering up," or that he continued to be intoxicated.

It must be remembered that illness due to intoxication, while perhaps self-inflicted to some degree, does not obviate the need for medical attention and the provision of proper medical care. The policy does not provide an exception to the need to seek medical care for ill prisoners in cases where those prisoners are suspected or known to be intoxicated.

Mr. Silverfox vomited over 20 separate times in the span of 13 hours. He had been vomiting prior to incarceration, a fact that was communicated to the members by Salvation Army staff and subsequently recorded on the Prisoner Report. He continued to vomit at regular intervals, and the frequency and severity of his sickness did not diminish during his time in cells. Despite all of this, no medical assistance was sought for Mr. Silverfox prior to the determination that he was no longer breathing. It is glaringly apparent that the members and guards on duty failed to seek medical assistance for Mr. Silverfox as his illness continued.

Finding: The members and guards on duty throughout Mr. Silverfox's incarceration failed to seek medical assistance.

In response to the public complaint investigation and administrative review, Inspector Wharton was to provide operational guidance to all guards and matrons and RCMP members who came into contact with Mr. Silverfox during his incarceration. He was to ensure that those individuals were aware of their responsibilities pursuant to policy.

Inspector Wharton developed and enacted a policy within the detachment directing members and guards to seek medical attention for intoxicated persons who vomit while in custody in a prone position or vomit excessively considering the possibility of aspiration and the possible development of aspirated pneumonia. Finally, Inspector Wharton ensured that members would seek medical assistance for persons in custody if there were any indication that a person is ill or suspected of having alcohol poisoning, among other conditions.

Given the severity of the potential consequences of a failure to comply with the policy as amended, I recommend that the Commanding Officer of the Whitehorse RCMP Detachment establish a tracking and monitoring system for member and guard responses to incidents involving acutely intoxicated individuals. In addition, in an effort to address public concerns regarding these issues, I recommend that the RCMP work with the Commission to facilitate a yearly review of files concerning such incidents by Commission staff, for a period of at least three years following this report.

Recommendation: That the Commanding Officer of the Whitehorse RCMP Detachment establish a tracking and monitoring system for member and guard responses to incidents involving acutely intoxicated individuals.

Recommendation: That the RCMP work with this Commission to facilitate a yearly review of files concerning such incidents by Commission staff for a period of at least three years following this report.

I am satisfied with the specific action taken regarding the subject members, namely the guidance provided in respect of ensuring that policies regarding the provision of medical assistance are complied with. The adequacy of such policy and further recommendations flowing therefrom are discussed below.

Condition of Mr. Silverfox's cell

The RCMP's national operational policy provides:

19.1.2.1.1 The member on duty is responsible for ensuring cells are safe and habitable.

The operational policy specific to "M" Division provided:

19.11.12.1 The Watch Commander or in his/her absence, the Senior Constable on shift, has overall responsibility for the Detachment cell block.

The Whitehorse Detachment's unit supplements stated:

19.3.9 Guard responsibilities [include] [e]nsuring the overall cleanliness of the guard room, cell block and security bay; [b]ringing a deficiency or omission in the completion of C13's to the attention of personnel [...]

It is clear from the cell block video that the condition of Mr. Silverfox's cell deteriorated rapidly throughout the day as he continued to be ill. The condition of the cell was noted by Ms. Balfour and by Hector MacLellan and commented upon at length by both the guards and the members. However, it is equally clear that there were no efforts made to address the fact that Mr. Silverfox was incarcerated in what amounted to deplorable conditions.

As has been consistently noted throughout this report, the policy does not allow deviation from the minimal standard of safe and habitable cells. It is an established fact that cells are to be safe and habitable prior to being used to lodge a prisoner; however, the minimal standard continues to apply during a period of incarceration. If, as in the case of Mr. Silverfox, an individual has become so violently ill as to contaminate a cell to the degree that it is difficult to find a clean area in which to sit or lie down, the cell is neither safe nor habitable, and the situation must be addressed in order for policy compliance to be achieved.

There was clear abdication of responsibility and accountability, as both members and guards saw cell cleanliness as either within the purview of the other group of individuals, or an issue to be addressed only once a prisoner is released. However, it is apparent that both members and guards bear responsibility for complying with the requirement that cells be appropriately maintained, although the ultimate accountability for the condition of the cell block rests with the senior member on duty, in this case Watch Commander Corporal MacLeod. As addressed previously, intermittent checks throughout a shift would quickly reveal that the physical condition of a cell was not in compliance with RCMP policy. Corporal MacLeod failed to ensure that the cells were safe and habitable. Compounding this lapse, neither the members present in the cell block throughout Mr. Silverfox's incarceration nor the guards and matrons responsible for his care took any steps to ensure that his cell was safe and habitable.

Finding: Corporal MacLeod failed to ensure that Mr. Silverfox's cell was safe and habitable.

Finding: The members present in the cell block and the guards and matrons responsible for Mr. Silverfox's care throughout his incarceration failed to ensure that his cell was safe and habitable.

In response to the public complaint investigation and administrative review, Inspector Wharton ensured that members on duty are responsible for making certain that cells are safe and habitable. Unit supplements were modified to include a clause stating that "habitable" is to be interpreted as being free of vomit, urine or any other bodily substances. Inspector Wharton was also to provide operational guidance to all guards/matrons and members with respect to their responsibility in relation to the policy.

I am satisfied that the Detachment Commander has taken adequate steps to achieve a common understanding of what is meant by the threshold of "safe and habitable" as respects the physical condition of the cell block.

Second issue: Whether the RCMP members at the Whitehorse RCMP Detachment provided adequate supervision and direction to the guard or guards who were charged with the care and handling of prisoners in the custody of the Whitehorse RCMP during the period of Mr. Silverfox's detention and subsequent death.

I have made several findings in respect of the guards responsible for Mr. Silverfox's care while in custody. It is apparent that the guards and matrons on duty failed to check on Mr. Silverfox as required by RCMP policy. Nonetheless, that policy was outlined in detail in the guard training program completed within the prescribed time limits by each guard and matron. Despite the fact that policy compliance was not achieved, the guards and matrons were provided with adequate direction, by means of the course training program, regarding the requirements for prisoner checks and notations in the cell log book. The provision of direction is irrespective of whether or not that direction is properly followed; ensuring compliance with training programs is a component of the adequacy of supervision provided.

Finding: The guards and matrons charged with the care and handling of prisoners including Mr. Silverfox were provided with adequate direction regarding their responsibilities.

An important distinction must be drawn between the responsibility of cell block guards and matrons, and final accountability for what occurs in the cell block. Although it is true that guards and matrons are responsible for prisoner care and the condition of the cell block, members on duty, and specifically, the senior member on duty, are ultimately accountable for both. Accordingly, adequate supervision and direction must be provided.

During Mr. Silverfox's detention, his physical condition and the condition of his cell were noted on numerous occasions. However, the notes taken by the guards and matrons in the cell log book did not adequately reflect the severity of Mr. Silverfox's illness and made no reference to the condition of the cell. No information regarding Mr. Silverfox was communicated to the Watch Commander, Corporal MacLeod, although she stated that she expected that she would have been informed of any problems. Numerous members were also aware of Mr. Silverfox's condition and that of his cell, but no member checked the cell log book to ensure that relevant information was being noted, and no member thought to inquire as to whether the senior member on duty had been apprised of the issues surrounding Mr. Silverfox and his incarceration.

Perhaps the most vital element of supervision is ensuring that relevant guidelines, directives and policies are complied with. It is beyond doubt both that the guards and matrons on duty did not comply with policy regarding checking on prisoners, and that this fact was not noted or corrected by any RCMP member, including the senior member on duty. Accordingly, the guards and matrons on duty were not provided with adequate supervision.

Finding: The guards and matrons on duty during Mr. Silverfox's incarceration were not provided with adequate supervision.

The Whitehorse RCMP Detachment, at the time of this incident, had no discernible system in place to ensure that relevant information concerning prisoners was communicated to members by guards and matrons. Although the desire of guards and matrons to avoid unnecessarily and repeatedly calling upon members with regard to prisoners is understandable to some degree, it is incumbent upon the RCMP to encourage the communication of information regarding prisoners.

The most effective and efficient way in which such communication may be accomplished is, in my view, appropriate use of the cell log book. Such appropriate use is predicated upon checks being completed in the prescribed manner and information being noted in a systematic and comprehensive way. To that end, I reiterate the following recommendations:

Recommendation: That the Detachment Commander conduct regular "spot checks" of cell log books to ensure that Watch commanders are checking and assessing prisoners at the beginning, end and throughout their shifts as required by RCMP policy.

Recommendation: That the Detachment Commander review with all members and guards the importance of and the need for meaningful, thorough and consistent communication with respect to persons in custody at the Whitehorse RCMP Detachment.

Recommendation: That Watch commanders review cell log books intermittently throughout and at the end of their shifts to ensure compliance with RCMP policy regarding checking and monitoring prisoners, as well as recording same.

Although these recommendations are aimed at ensuring that proper note-taking is done and that relevant observations are seen and considered by the relevant individuals, it is also, in my view, incumbent upon the RCMP to detail the type and substance of the observations recorded by guards and matrons. To that end, observations should include prisoner condition, both generally and where illness is possible and/or suspected, as well as cell condition when foreign matter or bodily substances are present.

Recommendation: That the RCMP implement directives concerning the requirement to note and communicate, by way of the cell log book, prisoner condition generally and where illness is possible and/or suspected, as well as cell condition when foreign matter or bodily substances are present.

Third issue: Whether the RCMP national, divisional and detachment-level policies, procedures and guidelines relating to the provision of medical treatment to persons detained in RCMP custody, in particular relating to those who are detained where the consumption of alcohol is a factor, are adequate to ensure the proper care and safety thereof.

I have noted throughout this report the existing RCMP policies requiring the provision of medical assistance for prisoners suspected of being ill. Notably, prisoners suspected of being intoxicated must be screened for BAC, responsiveness must be continuously monitored, illness (real or feigned) must be documented by both guards and members, arrangements must be made for medical attention when a prisoner is suspected of having a condition requiring medical attention, and medical attention must be sought if a prisoner's medical condition worsens. I found that with the exception of immediately seeking medical assistance when responsiveness cannot be established, the policies were not complied with.

The strict adherence to and consistent application of policies regarding the appropriate screening of prisoners and the immediate obtainment of medical assistance would likely be adequate to ensure the proper care and safety of prisoners suspected of having an illness, including those detained where the consumption of alcohol is a factor. However, the existing policies are difficult to apply, as they require a subjective assessment of a prisoner's condition, with no objective criteria provided in order that members, guards and matrons may evaluate that condition. For example, "unusual" behaviour or "suspected" illness, as well as a condition that "worsens" will vary according to personal opinion, which may be shaped by a host of factors including an individual's situation and experience. In my view, it is inadequate to allow the provision of medical assistance to depend solely on a subjective assessment of the need for such assistance.

Finding: RCMP policy concerning the provision of medical assistance is inadequate to the extent that it relies on subjective assessment of prisoner condition.

The dangers of relying on a subjective assessment of the need for medical attention are glaringly obvious in the case of Mr. Silverfox. Several of the guards and members pointed out that Mr. Silverfox's behaviour could be attributed to his perceived level of intoxication, and that vomiting was not unusual for persons deemed intoxicated. Although this is true, vomiting may also result from other conditions or, as in this instance, result in further complications. One condition may present virtually identically to another, and the temptation is to view situations as being analogous and thus expect the same outcome to flow from a similar set of circumstances. It is for this reason that objective criteria regarding the need to seek medical assistance are crucial.

As previously indicated, in response to the administrative review conducted by Inspector de Champlain, Inspector Wharton developed and enacted a detachment-level policy directing members and guards to seek medical attention for intoxicated persons who vomit while in a prone position or vomit excessively. In my opinion, this policy goes a considerable distance in excising the element of subjectivity from the decision to seek medical assistance for persons in custody. However, although it is without question whether or not an individual vomits while in a prone position, the question of how much vomiting may be termed "excessive" continues to rely on subjective assessment. Accordingly, I recommend that the policy be further refined in order to determine a measurable amount of how many instances of vomiting may be termed "excessive." Any such determination must be made in consultation with medical professionals having expertise in conditions that may arise from acute intoxication.

Recommendation: That the Detachment Commander, in consultation with medical professionals, further refine the policy requiring the immediate provision of medical assistance in cases of excessive vomiting in order to include an objective and measurable standard.

The administrative review also recommended that the Detachment Commander consider establishing a community consultative group, including the medical community, which would, in part, review the issues of public intoxication and the medical care of intoxicated persons in Whitehorse. The RCMP noted that such a group had already been established and that efforts continued to strengthen it.Footnote 7 Although I agree that such a group would be of great value to the Whitehorse community, the imperative to seek medical attention when necessary, based on an objective standard, is not unique to Whitehorse. I recommend that the RCMP create a consultative group at the national level that includes medical professionals in order to strengthen national operational policy regarding the provision of medical assistance. In my view, the policy would benefit from the inclusion of objective and measurable mandatory thresholds for seeking such assistance. Thresholds of the type described would be useful for both guards and members, as prisoner behaviour could be measured against a set of objective and defensible criteria.

Recommendation: That the RCMP create a consultative group that includes medical professionals in order to strengthen national operational policy regarding the provision of medical assistance for persons in RCMP custody.

Finally, I would add that the public does not expect its police officers to possess the same expertise with respect to the recognition of medical symptoms and issues as would a health professional. However, in my view, there is value in providing training beyond basic first aid regarding medical issues that may arise from particular behaviours present in our communities, specifically alcohol intoxication and drug impairment. I recommend that the RCMP leverage the expertise of medical professionals working within the community in order to provide an orientation session for members new to the area regarding the recognition of such medical issues, as well as their consequences and underlying causes. Members already working in the area should also be provided with similar training on a regular basis.

Recommendation: That the RCMP provide members new to the Whitehorse community with an orientation whereby local medical professionals may address the recognition of medical issues arising from alcohol or drug consumption. Members already working in the area should be provided with similar training on a regular basis.

Issue Concerning the Guardroom Audio

It is incumbent upon me to comment on issues that arose subsequent to both the criminal investigation and administrative review of Mr. Silverfox's death and that are linked to an audio recording of the guardroom during Mr. Silverfox's incarceration. As previously noted, the Whitehorse RCMP Detachment is equipped with closed-circuit video recording equipment. A number of camera views are available using the CCVE system, including recordings of the booking area, portions of the guardroom, the secure bay and each cell. Accordingly, one is able to view movements in and, to a limited degree, around Mr. Silverfox's cell from the time he was booked in until the time he was transported to the hospital.

Of the cameras recording the events in and around the cell block, the only one equipped with audio recording capabilities is the one recording a portion of the guardroom. That camera is motion-activated; accordingly, audio is recorded only while there is movement in the guardroom. The audio quality is also relatively poor. Nonetheless, a quantity of dialogue was captured on the audio track, namely the statements cited throughout this report made by guards, matrons and members within the guardroom. Included amongst those statements were several that may be described in their best light as lacking compassion for Mr. Silverfox and his situation. Those statements are cited above.

Two issues arise from the existence of the guardroom audio: first, the reason for which the audio recording was not made available during the administrative review or cited during the criminal investigation; and second, the content of the discussion regarding Mr. Silverfox. It is of note that the audio was the catalyst for the initiation of a Code of Conduct investigation in relation to the actions of the implicated members, which is ongoing.

Disclosure of guardroom audio

The existence of the guardroom audio was disclosed to the participants in the coroner's inquest only shortly before the inquest began. There is no evidence on file that Inspector de Champlain was aware of the existence of the audio while conducting his administrative review. There is equally no reference to the audio in the material pertaining to the criminal investigation; however, Corporal Wayne Gork notes in an early task report that there was audio available. Constable Kalles, who was responsible for copying the CCVE footage and going through it with Corporal Gork, would presumably also have been aware of the audio.

It appears that the lack of reference to the audio was attributed to simple oversight, and there is no evidence of deliberate withholding of the audio. However, the reasons for which its existence was to all appearances unknown to Inspector de Champlain or to the Command Triangle responsible for the criminal investigation are unclear. Accordingly, I recommend that the RCMP appoint an independent, non-RCMP investigator from outside of "M" Division to review the circumstances surrounding the late or non-disclosure of the audio, and to report the findings of such review to both the RCMP and the Commission.

Finding: The reasons for which the existence of the guardroom audio appeared to be unknown are unclear.

Recommendation: That the RCMP appoint an independent investigator to review the circumstances surrounding the late or non-disclosure of the guardroom audio and to report the findings of such review to both the Commissioner and the Commission.

The content of the guardroom audio

The content of the guardroom audio, and specifically those portions relating to Mr. Silverfox, has been cited throughout this report. Apparent are instances in which his illness is noted and disregarded or, in the most egregious of cases, openly mocked by members, guards and matrons. The RCMP's national operational policy states that persons in RCMP custody will be treated with decency.Footnote 8 Equally, the basic standards required to be upheld by all members and enshrined in the RCMP Act require members to act in a courteous, respectful and honourable manner, and to maintain the honour of the RCMP. Indeed, the core values of the RCMP include professionalism, compassion and respect.

In my opinion, the members involved and whose statements are cited above, particularly Constable Corbett and Constable Kalles, as well as Constable Kaytor and Constable Telep, displayed conduct that fell far short of that required of a member of Canada's national police force.

A number of individuals made statements to the effect that they believed that Mr. Silverfox was, essentially, "just another drunk." This attitude, in my view, coloured each of their interactions with Mr. Silverfox, resulting in Mr. Silverfox's illness not being taken seriously and being seen as a natural consequence of his intoxication. However, this is an example of the dangers of "tunnel vision": in the same manner that it is possible to become so fixated on a certain theory of a case being investigated that one is blind to other possibilities, so was it a crucial mistake to believe that all of Mr. Silverfox's actions could be attributed to his intoxication, with no consideration of any other possibilities. There is great danger in failing to recognize that each person in custody must be treated as an individual and not simply as representative of a category of persons. Mr. Silverfox provides a tragic example of the dangers of classifying someone as "just another drunk." The failure of any member to address the behaviour of those involved in mocking Mr. Silverfox is also troubling.

Had the relevant policy been strictly complied with in respect of Mr. Silverfox, and had the proper steps been taken to address his illness, he may have succumbed regardless. However, the failure to follow policy did exist and was aggravated in the mind of the public by the callousness and disrespect shown to Mr. Silverfox. Public perception is paramount, and the fact that Mr. Silverfox was initially taken into custody out of a sense of compassion-because members did not want him out in the cold-is lost and generally irrelevant due to the end result of the incident, the very outcome that the responding members had tried to avoid. Unfortunately, it is the members' attitudes towards Mr. Silverfox in his final hours that will be remembered.

Finding: Constable Corbett, Constable Kalles, Constable Kaytor and Constable Telep failed to act in accordance with the RCMP Act and the RCMP's core values in respect of their interactions regarding Mr. Silverfox.

An internal RCMP disciplinary investigation, begun following the coroner's inquest, is already in progress in respect of this matter. However, in my view, such an investigation does not address the larger issue surrounding the requirement to treat members of the public in a way that reflects the core values of the RCMP. The importance of this requirement cannot be overstated, and a failure to abide by it is an institutional failure. Accordingly, I recommend that all members of the Whitehorse RCMP Detachment, as well as the guards and matrons employed by the detachment, be provided with training on creating a respectful environment and interacting in a manner consistent with the RCMP's core values, within both the detachment and the larger community. In order to develop and implement such training, it would be appropriate for the RCMP to consult with the variety of community organizations in place in the Yukon that deal with social and cultural issues.

Recommendation: That all members of the Whitehorse RCMP detachment, as well as the guards and matrons employed by the detachment, be provided with training on creating a respectful environment and interacting in a manner consistent with the RCMP's core values, within both the Detachment and the larger community.

Comment Regarding the RCMP Investigation Undertaken into the In-Custody Death of Mr. Silverfox

Three separate investigations were conducted into this incident by the RCMP, as previously noted: a criminal investigation, an administrative review and a public complaint investigation. The steps involved in each investigation bear mentioning, as the issue of the police investigating the police has frequently been an area of public concern, as well as the subject of a Commission report released in August 2009.

The criminal investigation began very shortly after Mr. Silverfox's death on December 2, 2008. Although initially begun by the "M" Division Major Crimes Unit, the investigation was turned over to the "E" Division North District Major Crime Unit the next day so that an independent investigation could be conducted as per RCMP policy. The investigation was conducted in accordance with Major Case Management principles and was led by Team Commander Staff Sergeant Glenn Krebs.

The investigative team proceeded to identify and obtain recorded statements where necessary from 8 civilian witnesses; 15 members involved in the events surrounding Mr. Silverfox's arrest, incarceration and attempted resuscitation; 3 civilian staff; and 5 EMS personnel. The team also obtained any relevant documentation, including members' notes, log books, medical records, and training records and standards.

The Commission assessed the impartiality of the criminal investigation with respect to line management, level of response, timeliness of response and conduct. The salient points of the impartiality assessment are as follows:

Line management: "M" Division members began the investigation into Mr. Silverfox's in-custody death at approximately 9:30 p.m. on December 2, 2008. A team was immediately structured following Major Case Management principles, and evidence such as guard logs and the cell block video was preserved. Members were advised of their duty to report. "E" Division was advised of the investigation at 7:30 a.m. on December 3, 2008, and Staff Sergeant Krebs arrived in Whitehorse to begin his investigation by 12:30 p.m. that day. By early the next day, all "M" Division staff had been removed from the investigation, and Staff Sergeant Krebs required all members of the investigative team to complete impartiality questionnaires prior to beginning work on the investigation. No potential conflicts of interest of concern were identified by either Staff Sergeant Krebs or the CPC Observer. In light of the foregoing, I have no concerns with line management.

Level of response: The initial response of "M" Division members, particularly Sergeant Mark London, was exemplary. Sergeant London was fully aware of his responsibilities, including the need to preserve evidence and ensure that members understood their responsibility to account for their actions. The "E" Division investigative team that subsequently assumed the investigation had extensive experience and skills, and the Major Case Management model was followed. I have no concerns with the level of response.

Timeliness of response: The investigation into the death of Mr. Silverfox commenced by "M" Division members approximately 15 minutes after his death and was taken over by the "E" Division team less than 12 hours later. In my view, the timeliness of the response to this incident was appropriate.

Conduct: The Commission noted the professionalism of the members involved in the criminal investigation, who fully realized the nature of their task and fulfilled their mandate. I have no concerns with respect to the conduct of the RCMP members involved in the criminal investigation.

Based on the assessment of the Commission Observer, the documentation acquired and my review of the investigative file, I find that there were no concerns relating to the impartiality of the criminal investigation into the in-custody death of Mr. Silverfox.

As stated, I have reviewed the statements taken and documentation accumulated in the course of the criminal investigation. It is apparent that the investigation was thorough and detailed. All relevant tasks were completed and the necessary information obtained. Although there is some discrepancy, as noted above, as to the use made of the audio recording of the guardroom, this does not affect my conclusion that the criminal investigation undertaken into the in-custody death of Mr. Silverfox was thorough and well documented. I would add that the investigation was completed in approximately three months, which is well within reason for an investigation into a serious incident.

Although not related to the death of Mr. Silverfox, the Commission's Final Report concerning Police Investigating Police (issued following both the death of Mr. Silverfox and the ensuing criminal investigation) concluded that in circumstances involving in-custody deaths, for example, an independent, external investigator should be used in order to address public perceptions surrounding the impartiality of the designated investigator. Although the investigative team in this instance was not external to the RCMP, other features of the model proposed by the Commission to ensure impartiality and enhance credibility were evident. Specifically, the investigators were of appropriately senior rank, many interviews were conducted by two members, the investigative team was appropriately qualified, and the investigation was timely.

It is also of note that the RCMP recently implemented an external investigations policy that would see criminal investigations such as the one into the in-custody death of Mr. Silverfox delegated to an external investigative body.

Finding: The criminal investigation undertaken into the in-custody death of Mr. Silverfox was impartial, thorough and well documented, and although the assigned investigators were not external to the RCMP, the measures taken to ensure their independence were appropriate in the circumstances.

Equally, an administrative review of the investigation was conducted by Inspector Yvon de Champlain of the "K" Division Commercial Crime Section. Inspector de Champlain was responsible for evaluating compliance with certain aspects of RCMP policy by those involved in the events surrounding Mr. Silverfox's death. Inspector de Champlain determined that the investigation into the incident was conducted in accordance with RCMP policy, and he had no concerns with issues of impartiality. Inspector de Champlain also identified a number of deficiencies in the application of national, divisional and detachment-level policy respecting cell block operations at the time of Mr. Silverfox's death. As noted throughout the report, Inspector Mark Wharton, the Whitehorse Detachment Commander, responded to these recommendations by taking actions designed to rectify the deficiencies noted. I find that Inspector de Champlain's administrative review, much like the criminal investigation, was thorough and well documented within the boundaries of his particular mandate.

Finding: The administrative review regarding the criminal investigation and cell block operations was thorough and well documented.

The third and final investigation undertaken in respect of the in-custody death of Mr. Silverfox was the public complaint investigation carried out in response to the Commission Chair's complaint. The RCMP assigned Staff Sergeant Tom Caverly, the Non-Commissioned Officer in charge of the "E" Division Legal Application Support Team in British Columbia, as the public complaint investigator. It is of note that Staff Sergeant Caverly is an experienced investigator who works within a specialized unit in a separate division, and it is clear that the need for an investigator with as high a degree of independence as possible was recognized and addressed.

In the course of his investigation, Staff Sergeant Caverly reviewed the materials already accumulated in support of the two preceding investigations, described above. He also further interviewed the members and civilian staff who interacted with Mr. Silverfox and examined relevant policy. Staff Sergeant Caverly took all reasonable investigative steps appropriate in the circumstances, and I find that his public complaint investigation was responsive to the Chair's complaint.

Finding: The public complaint investigator took all reasonable investigative steps appropriate in the circumstances.

Conclusion

The public expects a certain standard of behaviour from its police officers. Equally, the public expects those in RCMP custody to be treated with decency and respect, and their acute medical needs attended to. The RCMP members involved with Mr. Raymond Silverfox, in large part, fell short of these expectations. As has been noted by this Commission, public trust, once lost, is difficult to regain. The events surrounding the death of Mr. Silverfox have created a trust deficit in respect of the Whitehorse RCMP Detachment that will be healed, in part, by taking steps to prevent a repeat of this occurrence, by remaining continuously vigilant to policy and procedure, and by being mindful of the need for each interaction with the public to be guided by the core principles of the RCMP.

Having considered the complaint, I hereby submit my Interim Report in accordance with paragraph 45.42(3)(a) of the RCMP Act.

_____________________
Ian McPhail, Q.C.
Interim Chair

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