Interim Report on Chair-Initiated Complaint Regarding In-Custody Death of Charlene Danais in Assumption, Alberta, on August 7, 2011

Royal Canadian Mounted Police Act
Paragraph 45.42(3)(a)

File No.: PC-2011-2645

Related Links

• Chair-Initiated Complaint
  August 11, 2011
• Final Report
  September 24, 2014

Overview

On August 6, 2011, Constable Rob Boon of the Assumption RCMP Detachment in Alberta responded to the third complaint that day concerning Ms. Charlene Danais. Ms. Danais and her common law husband, Mr. Brent Providence, were intoxicated and kicking at the front door of her mother, Mrs. Marilyn Danais. Upon attending Mrs. Danais' home, Constable Boon learned that Ms. Danais was no longer there and had gone to another residence. Constable Boon was permitted to enter that other residence and told that Ms. Danais was hiding in a bedroom closet. He arrested Ms. Danais for mischief and instructed her to get out of the closet. He observed signs of intoxication. Ms. Danais was cooperative, and she was arrested without incident. Mr. Providence was also arrested for mischief.

Constable Boon then transported Ms. Danais and Mr. Providence to the detachment to detain them until they were sober. Prior to lodging Ms. Danais in cells, Constable Boon inquired how long she had been drinking and she replied three days. Constable Boon did not ask Ms. Danais if she had any illnesses or was taking any medications.

Mr. Matthew White, the cell block guard, was responsible for the prisoners detained in the cells. He began his shift at 5:00 p.m., approximately the same time that Ms. Danais was brought into the cell block area. Mr. White monitored her by conducting physical checks and through the use of the closed‑circuit video equipment (CCVE). At 5:17 p.m., Mr. White left his post for 55 minutes, during which time no one was monitoring the prisoners. At 7:21 p.m., Mr. White requested that Constable Boon check on Ms. Danais because her clothing was in disarray. Constable Boon looked through the cell window and then closed it to protect Ms. Danais' privacy. Throughout her incarceration, Mr. White observed movement from Ms. Danais until the last five minutes of his shift, when he believed she was asleep.

At 1:00 a.m., cell block guard Mr. Carlito Somera began his shift, replacing Mr. White. He initially conducted a physical check of the prisoners and observed that Ms. Danais was lying on her stomach. He unsuccessfully attempted to rouse her and immediately summoned help from Constable Erika Laird, an on-duty RCMP member.

Constable Laird determined that Ms. Danais was unresponsive and directed Mr. Somera to call 911 for emergency medical help. She then requested that Constable Tanner Wills return to the detachment to assist her. Constable Laird began cardiopulmonary resuscitation (CPR) but was unsuccessful in her efforts to revive Ms. Danais. Nonetheless, both Constables Laird and Wills conducted CPR on Ms. Danais, as they were instructed, for a period of 75 minutes until the emergency medical responders (EMR) arrived from the town of High Level.

The EMRs attempted CPR themselves and then determined that nothing further could be done. Ms. Danais was transported to the High Level Hospital, where she was pronounced dead. A subsequent autopsy determined that the cause of death was bupropion toxicity.

The investigation into Ms. Danais' death was conducted by the Peace River RCMP Major Crimes Unit and Forensic Identification Services. The Major Crimes Unit investigation report and file were subsequently reviewed by the Alberta Serious Incident Response Team (ASIRT), which completed its report on May 16, 2012. ASIRT determined that the RCMP's criminal investigation was conducted thoroughly and reported accurately.

An Incident Review was conducted by Staff Sergeant Mike Brandford of the Grande Prairie RCMP Detachment, and a number of recommendations were made in his report, completed February 7, 2012. On March 20, 2012, Superintendent Arlen Miller, District Commander, Western Alberta District, responded to those recommendations.

A Code of Conduct investigation was also ordered in relation to Constable Boon's actions. Informal discipline was recommended as a result of that investigation.

The Public Fatality Inquiry into Ms. Danais' death has not yet been scheduled.

Chair-initiated Complaint

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

On August 11, 2011, the Interim Chair of the Commission for Public Complaints Against the RCMP (Commission) initiated a complaint into the in‑custody death of Ms. Charlene Danais in Assumption, Alberta, pursuant to subsection 45.37(1) of the Royal Canadian Mounted Police Act (RCMP Act). The complaint focused on the adequacy of the conduct of all RCMP members or other persons appointed or employed under the authority of the RCMP Act involved in the arrest and detention of Ms. Danais, 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 RCMPAct involved in the events of August 6 and 7, 2011, from the moment of initial contact and arrest, through to the subsequent detention and death of Ms. Danais complied with all appropriate training, policies, procedures, guidelines and statutory requirements relating to persons held in RCMP custody;
2. whether the RCMP members at the Assumption 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 Assumption RCMP during the period of Ms. Danais' detention and subsequent death;
3. whether the RCMP national, divisional and detachment-level policies, procedures and guidelines relating to persons detained in RCMP custody are adequate to ensure the proper care and safety thereof; and
4. whether the actions taken by the RCMP in response to the incident were taken in accordance with all applicable policies, procedures, guidelines and statutory requirements for the conduct of such an investigation and whether such policies, procedures and guidelines are adequate.

As required by the RCMP Act, the RCMP investigated the complaint. The public complaint investigation was based upon the results of the Peace River RCMP Major Crime Unit (MCU) sudden death investigation, the Alberta Serious Incident Response Team (ASIRT) review and the RCMP's Incident Review. On August 9, 2012, the RCMP issued its Final Report into this matter.

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 September 25, 2012. Absent from the material initially provided by the RCMP was the MCU sudden death investigation report and the investigation notes and documentation. The Commission requested this further information, and it was forwarded on December 31, 2012.

Commission's Review of the Facts Surrounding the Events

It is important to note that the Commission 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 thorough examination of the extensive investigation materials, the closed-circuit video footage of the cell block and the guardroom, the MCU sudden death investigation report, the RCMP Incident Review, the ASIRT report, and the applicable law and RCMP policy.

First Issue: Whether the RCMP members or other persons appointed or employed under the authority of the RCMP Act involved in the events of August 6 and 7, 2011, from the moment of initial contact and arrest, through to the subsequent detention and death of Ms. Danais complied with all appropriate training, policies, procedures, guidelines and statutory requirements relating to persons held in RCMP custody.

Events surrounding the arrest of Ms. Danais

Ms. Danais was a member of the Dene Tha' First Nation and lived in the remote northern Alberta community of Assumption. Ms. Danais and her common law husband, Mr. Brent Providence, had two young children, aged 6 and 7 at the time of the incident. Ms. Danais had a large extended family living close by, including her mother, grandmother, brothers, aunts and cousins. Ms. Danais suffered from depression but she sought help and was taking prescription medication for its treatment. Family members recalled that when Ms. Danais was a child she underwent heart surgery and thereafter was required to attend annual check-ups for her heart. However, according to family members, in 1999 she stopped attending check-ups. Finally, while Ms. Danais was familiar to police because of repeated incidents involving intoxication, she did not have a criminal record.

By all accounts, Ms. Danais and Mr. Providence had been drinking for an extended period of time beginning on August 5, 2011, and continuing throughout the night and into the following day. Mrs. Marilyn Danais, Ms. Danais' mother, called the Assumption RCMP Detachment at 9:56 a.m. on August 6, 2011 to report that her daughter was intoxicated and knocking on her door. She requested that police attend and pick up Ms. Danais. Constable Chris Massicotte responded to the call and learned that Ms. Danais had gone to the residence of her grandmother, Mrs. Helene Talley. When Constable Massicotte attended there, he was told by Mrs. Talley that Ms. Danais could stay. Constable Massicotte left the scene.

Constable Boon attended Mrs. Talley's residence later that morning when Mrs. Danais again called the RCMP, this time on behalf of Mrs. Talley, requesting that Ms. Danais be removed from Mrs. Talley's residence. However, upon attending Mrs. Talley's residence, Constable Boon was told that Ms. Danais had departed and her whereabouts were unknown. Constable Boon told Mrs. Danais to call the police if Ms. Danais returned.

At some point that afternoon, Ms. Danais ingested an unknown quantity of her prescription medication. According to Mr. Providence's statement, he and Mr. Kevin Talley attempted to stop Ms. Danais from taking a handful of pills. He knocked the pills from her hand. Mr. Providence stated that Ms. Danais had pills in her mouth but he did not know if she swallowed any of them. He noted that her pill bottle that had been half full was empty. Mr. Talley's statement is largely consistent with that of Mr. Providence on this point. Mr. Providence stated that he told Mrs. Danais that Ms. Danais had taken pills. Mr. Talley stated that they had told Mr. Edmund Danais about the incident.

Later that same day, at 4:40 p.m., Mrs. Danais called the Assumption RCMP Detachment and reported to Constable Boon that Ms. Danais and Mr. Providence had returned to her home and Ms. Danais was kicking at her front door. When Constable Boon arrived at Mrs. Danais' residence, she told him that Ms. Danais was intoxicated but had left and gone to the nearby home of Ms. Paula Talley. Constable Boon recalled that Mrs. Danais had told him that Mr. Providence had tried to get her to go home. According to Mrs. Danais' statement, she told Constable Boon that she wanted Ms. Danais put in jail until she was sober.

From a review of the statements, it is apparent that either Mr. Kevin Talley or Mr. Providence also told Mr. Robert Ahkimnachie that Ms. Danais had ingested pills. Mr. Ahkimnachie^{Footnote 1} had a clear recollection of what he was told about the pills. He stated that at approximately 5:00 p.m., he informed Mrs. Danais of what he had been told about Ms. Danais ingesting pills. The information provided by Mr. Ahkimnachie is consistent with that of Ms. Paula Talley on this point. Ms. Talley also stated that she told Mr. Ahkimnachie to call police. It should be noted that Mr. Ahkimnachie does not communicate verbally, and he did not call the police.

During her statement, Mrs. Danais did not state that she had been told her daughter had taken pills.^{Footnote 2} According to Mrs. Talley, she was told by Mr. Ahkimnachie that her granddaughter, Ms. Danais, had a pill bottle and he thought she may have taken some pills. Mrs. Talley stated that she told her daughter, Mrs. Danais, to tell the police to take Ms. Danais to the nursing station, but she was unaware of whether Mrs. Danais did so.

In his statement to the MCU investigators, Constable Boon related that when he arrived at Ms. Paula Talley's home, a teenage boy opened the door. Constable Boon asked him if Ms. Danais was in the house, and the boy pointed down the hall towards the bedrooms. Constable Boon walked back towards the bedrooms and quickly found Ms. Danais hiding under a pile of clothes in one of the bedroom closets.

Constable Boon recounted that he pulled the loose clothes off of Ms. Danais and recognized her from prior interactions. He told her that she was under arrest for mischief, and instructed her to get out of the closet, which she did. Constable Boon recalled that Ms. Danais was cooperative, very friendly and intoxicated. He noted that her eyes were bloodshot, her speech was slurred and she had a strong odour of liquor on her breath. He did not handcuff her. She walked unaided to the police truck.

Upon Constable Boon telling her that she would have to go out to the police truck and then go to jail, Ms. Danais asked why she was being arrested. Constable Boon explained that it was for mischief, because she kept going over to her mother's house and kicking the door. He also informed Ms. Danais that she could speak with a lawyer once she was sober. His police notes reflect that he advised her of her constitutional rights and that she understood those rights.

Constable Boon proceeded to arrest Mr. Providence for mischief as well, and placed him in the back of his police truck with Ms. Danais. Constable Boon told them that he was not going to charge them but simply hold them in custody until they were sober. Constable Boon recalled that both were cooperative and asked how long they would remain in custody.

Prior to leaving the area, Ms. Danais and Mr. Providence asked Constable Boon if he could stop by Mrs. Danais' home to ask her to lock up their house. Constable Boon recalled that he drove to Mrs. Danais' home and that she came out onto her front step. He sat in his truck and relayed the information about locking up Ms. Danais and Mr. Providence's home to Mrs. Danais. She replied, "No problem."

In his statement, Constable Boon recounted that while he was transporting Ms. Danais and Mr. Providence to the Assumption RCMP Detachment, the former appeared to be in a good mood and happy. He related that Mr. Providence was joking around and calling him "Baby Face."

There is no information on file to suggest that Constable Boon spoke to any other person during the arrest of Ms. Danais and Mr. Providence, aside from the teenage boy and Mrs. Danais. A review of the statements of Constable Boon, the teenage boy and Mrs. Danais reveals that at no time during any of their interactions did either Mrs. Danais or the youth claim to have informed Constable Boon that Ms. Danais had ingested pills.

Finding No. 1: During his arrest of Ms. Danais, Constable Boon was not told that she had ingested pills earlier in the day.

Reasonableness of the arrest of Ms. Danais

Constable Boon arrested Ms. Danais for the offence of mischief. Section 430 of the Criminal Code provides that the offence includes destroying or damaging property and interfering with the lawful use or enjoyment of property.

In this instance, there is no dispute that Ms. Danais repeatedly attended her mother and grandmother's homes that day, resulting in Mrs. Danais calling the RCMP on three different occasions for assistance. Each time, Mrs. Danais told the responding member that Ms. Danais was intoxicated and that she wanted her removed. When Mrs. Danais called the RCMP a third time, Ms. Danais was kicking at her mother's front door. However, she had departed by the time Constable Boon arrived and had gone to Ms. Paula Talley's residence. Constable Boon attended that residence, where he was directed to the bedrooms by the teenage boy.

Accordingly, I find that Constable Boon possessed reasonable grounds to believe that Ms. Danais had committed the offence of mischief, as she was clearly preventing Mrs. Danais from the lawful enjoyment of her own property by kicking and knocking at the front door. Furthermore, I am satisfied that Constable Boon had consent to enter Ms. Paula Talley's home.

Apart from having reasonable grounds to believe that a criminal offence has been committed, the police must also satisfy the elements of section 495 of the Criminal Code in order to effect a warrantless arrest, as occurred in this instance. The Criminal Code provides that a police officer shall not arrest a person without warrant for an offence such as mischief:

...

in any case where

(d) he believes on reasonable grounds that the public interest, having regard to all the circumstances including the need to

• (i) establish the identity of the person,
• (ii) secure or preserve evidence of or relating to the offence, or
• (iii) prevent the continuation or repetition of the offence or the commission of another offence,

may be satisfied without so arresting the person, and

(e) he has no reasonable grounds to believe that, if he does not so arrest the person, the person will fail to attend court . . .^{Footnote 3}

In the present case, it is apparent that Ms. Danais' behaviour was continuing. Simply having the police attend Mrs. Danais' residence had not been a sufficient deterrent to Ms. Danais, as she continually returned, resulting in further calls to the police. There was no indication that this pattern of conduct would stop until Ms. Danais was sober. In light of this continuing behaviour and as requested by Mrs. Danais, it was reasonable for Constable Boon to locate Ms. Danais and arrest her for mischief.

Finding No. 2: The warrantless arrest of Ms. Danais was reasonable.

Booking into cells and completion of the Prisoner Report

Upon arriving at the Assumption RCMP Detachment, Constable Boon removed Ms. Danais from the rear of the police truck. According to the Incident Review and Constable Boon's statement, Ms. Danais walked unaided to the prisoner processing area. Constable Chris Massicotte and Mr. Matthew White, the cell block guard, were present in the processing area but not involved in booking in Ms. Danais.

Constable Boon stated he conducted a "visual search" of Ms. Danais because he knew "she was wearing just a pair of pants and a loose top."Ms. Danais removed her shoes. In his police notebook, Constable Boon noted that he asked Ms. Danais how long she had been drinking, to which she replied three days.^{Footnote 4} Constable Boon then lodged Ms. Danais in cell no. 5, colloquially known as the female drunk tank, located directly across from the guard desk. She was alone in the cell.

The RCMP's national operational policy requires that all prisoners be thoroughly searched prior to being incarcerated.^{Footnote 5} The relevant supplemental Assumption RCMP Detachment policy states as follows:

C.1.a. The member booking in the prisoner will conduct a physical search of the individual and his/her effects.

Contrary to RCMP policy, Constable Boon failed to conduct a thorough search of Ms. Danais when he lodged her in cells. A visual search is inadequate for the purposes of ensuring the safety of the incarcerated individual, other prisoners, RCMP members and guards/matrons. In this instance, Ms. Danais could have had pills in her pockets which would have gone undetected by a visual search.^{Footnote 6}

Members booking prisoners into cells are required to complete Form C-13, Prisoner Report, which includes details concerning an individual's injuries, illnesses or medications. The relevant "K" Division operational policy in effect at the time of this incident read as follows:

19.3.1.2 Complete form C-13-1. Biographical data is not mandatory on repeat offenders where there are no charges.

1. Show the full name of the prisoner on the form.
2. Complete Canadian Police Information Centre (CPIC) query and check off on form.
3. In addition to any other observations, indicate:
   1. If the prisoner is a security risk.
   2. If the prisoner is sick, injured, or has been subjected to:
      1. Oleoresin Capsicum Spray (OCS)
      2. Conducted Energy Weapon (CEW); or
      3. Significant physical force.
   3. If the potential exists for:
      1. Escape;
      2. Violence;
      3. Suicide;
      4. Self-injury; or
      5. Sexual offence.

The relevant supplemental detachment policy^{Footnote 7} at the time stated as follows:

C.2 Ensure form C-13 is completed filling out all available information.

C.2.g. Conduct a CNI/CPIC query on the prisoner to determine if he/she had any previous history of suicide. If the prisoner has a history, ensure the guard/matron is made aware of it and indicate it visibly on the C-13 in red marker/ink and highlight on C-13 and prisoner log book.

In completing the Prisoner Report, Constable Boon noted that Ms. Danais was impaired by alcohol but responsive. He duly checked off the responsiveness box on the form. He indicated that she was placid, sleepy and essentially had poor balance. He also noted that she had slurred speech. In the "Prisoner Screening" section of the form, Constable Boon wrote "N/A" under injuries and illnesses/medications. He stated that "N/A" stood for not applicable. According to his supplementary occurrence report, Constable Boon wrote "N/A" in both instances based on his observations of Ms. Danais and the fact that she did not disclose anything to him about injuries or drugs. Constable Boon did not specifically ask Ms. Danais if she had any injuries or illnesses or if she was taking any medications.

In my view, Constable Boon's inquiries fell short of what is required by RCMP policy. While Constable Boon stated that Ms. Danais was talking "gibberish" as he booked her in, this did not absolve him of his duty to ask the appropriate questions. Constable Boon's observation that Ms. Danais was impaired by alcohol was correct; however, it is now apparent that another substance was likely contributing to her impairment, namely, the pills she had earlier ingested. In failing to inquire about medication and other health issues, Constable Boon did not properly complete the "Prisoner Screening" section of the form.

In addition, the notation "N/A" used by Constable Boon is imprecise and could lead to confusion. In completing the form, he should have accurately reflected that he did make inquiries or was not aware of any injuries or medications.

Furthermore, Constable Boon did not conduct a CPIC check, as required by RCMP policy.^{Footnote 8} In his statement, Constable Boon indicated that the only policecheck that he conducted on Ms. Danais was on the RCMP's PROS system.^{Footnote 9} In reviewing the Prisoner Report, there appears to be an "X" marked beside the CPIC box and letters written over the word "hit". It is confusing and difficult to determine what is meant by these notations.

Finally, as noted in the Incident Review, within one minute of arriving at the prisoner processing area, Ms. Danais was lodged in the "female drunk tank." A review of the video recording of the prisoner processing area at the relevant time discloses that Ms. Danais' processing or "booking in" was conducted in a perfunctory and informal manner. The fact that she was not properly searched, not asked questions on the prisoner screening section of the form, and a CPIC check was not conducted, are all indicative of the summary manner in which she was lodged in cells.

The RCMP's national operational policy states that the RCMP is responsible for the well-being and protection of persons in its custody.^{Footnote 10} Proper screening of prisoners prior to incarceration is essential to ensuring the safety and well-being of individuals in custody. The required screening procedures, including searches and CPIC checks, are vital assessment tools that may serve to alert members to underlying issues with a prisoner. When a step is missed in the process, so is potential information.

Accordingly, I find that Constable Boon did not properly search Ms. Danais or complete the "Prisoner Screening" section of the Prisoner Report. I also find that Constable Boon failed to conduct a CPIC check, as required by RCMP policy.

The Incident Review concluded as follows:

Constable BOON did not ask [Ms.] DANAIS directly if she was suffering from any injuries, illnesses and or taking medication. The completion of the Prisoner Report C-13-1 in regards to injuries/illnesses/medications is not in accordance with "K" Div. 19.1.2.

As a result of this finding in the Incident Review, on February 17, 2012, a Code of Conduct investigation was initiated in respect of Constable Boon for the purpose of further examining his actions in this regard. The RCMP's Final Report related the following:

The allegation of, "a member shall not knowingly neglect or give insufficient attention to any duty the member is required to perform", was substantiated against Constable Boon. I support the finding that Constable Boon should have been more thorough in the completion of the Prisoner Report form and actually asked questions of Ms. Danais, including if she had consumed any medications. Informal discipline in the form of "counselling" was provided to Constable Boon at the conclusion of this investigation. It will never be known if asking this question would have resulted in Ms. Danais actually responding that she had ingested a quantity of pills, as if it was truly her intent to commit suicide, she likely would have withheld this information from the police. Regardless, it is clearly my expectation that our employees will perform their duties as thoroughly as possible to reduce the risk to the public.

I recognize that Constable Boon's actions with respect to completing the Prisoner Report have been addressed by the Incident Review and the Code of Conduct investigation. However, the issues of the search and the CPIC check have not been addressed. Accordingly, I recommend that a senior RCMP officer provide Constable Boon with operational guidance concerning the importance of completing a thorough search of a prisoner and conducting a CPIC check when processing prisoners, as required by RCMP policy.

Finding No. 3: Constable Boon did not properly search Ms. Danais or complete the "Prisoner Screening" section of the Prisoner Report and failed to conduct a CPIC check, as required by RCMP policy.

Recommendation No. 1: That a senior RCMP officer provide Constable Boon with operational guidance concerning the importance of completing a thorough search of a prisoner and conducting a CPIC check when processing prisoners, as required by RCMP policy.

Booking in of Mr. Providence

In his statement, Mr. Providence claimed that he advised Constable Boon that Ms. Danais had taken some pills. He stated: "I told him I think she took some pills, check on her, uh."

In his statement, Constable Boon unequivocally denied that Mr. Providence informed him that Ms. Danais had taken pills. Constable Boon stated that the only thing that Mr. Providence spoke about during his booking in was when he would be released from jail and that "he didn't seem concerned about anything else." He stated that if Mr. Providence had told him this information, he would have questioned Ms. Danais but "there was no indication at all."

Mr. White, the cell block guard, was present during Mr. Providence's booking in. He is also Mr. Providence's brother-in-law. During one of his interviews, Mr. White was asked if Mr. Providence had mentioned anything "like where he got picked up or what they were doing prior or anything."Mr. White responded that Mr. Providence had not. Mr. White was not asked if Mr. Providence had specifically mentioned pills.

The evidence elicited from Mr. White on this point is not helpful. Accordingly, I am left with the conflicting evidence of Mr. Providence and Constable Boon.^{Footnote 11} Mr. Providence may genuinely believe that he told Constable Boon about Ms. Danais' pill consumption. However, I note that Mr. Providence was highly intoxicated at the time he claims to have told Constable Boon about the pill incident. I also note that Constable Boon unequivocally denies being told about it. Accordingly, based upon my weighing of this evidence, I am unable to conclude that Constable Boon was apprised of this information.

Finding No. 4: During the booking in of Mr. Providence, Constable Boon was not informed that Ms. Danais had ingested pills earlier in the day.

Prisoner log book and monitoring

Mr. White was the guard on duty at the time that Ms. Danais was lodged in her cell. Guards and matrons at the Assumption RCMP Detachment are employees of the Canadian Corps of Commissionaires.^{Footnote 12} When new guards or matrons are hired at the Assumption RCMP Detachment, they are required to read and fully understand all policy regarding prisoner handling and cell block operations. Furthermore, RCMP policy requires guards and matrons to have up‑to-date cardiopulmonary resuscitation (CPR) and basic first aid certification, and to take a recertification course every year once they have completed their initial training.^{Footnote 13} At the time of the incident, Mr. White possessed current CPR and basic first aid certification. Finally, Constable Boon^{Footnote 14} was the designated guardroom supervisor for the detachment.

The RCMP's national operational policy regarding the requirements for on-duty guards and monitoring prisoners provides:

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

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.

. . .

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

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.^{Footnote 15}

In addition, the relevant supplemental detachment policy required that guards conduct visual checks at least every ten minutes^{Footnote 16} and defined the guards' responsibilities as follows:

Guards/Matrons are to visually check the prisoners. Checks are to be made continuously on a frequent basis. These checks must be staggered (not predictable intervals) but no more than 10 minutes should take place between checks as per [KOM Appx. III-3-3].

. . .

Record, in the log book the exact time the check was made, i.e.: 10:13 hours; 10:19 hours, 10:24 hours, etc.; also indicate the prisoners activity (IE: sleeping; reading; etc.).^{Footnote 17}

Further, the detachment policy provides detailed examples of prisoner log book entries, including the level of detail expected to be recorded for the observations of prisoners.

The MCU investigation revealed an issue with the conduct of Mr. White. Upon comparing the video recording of the guardroom and Mr. White's entries in the prisoner log book, it became apparent to the RCMP investigators that Mr. White had been absent from the cell block area for approximately 55 minutes^{Footnote 18} but had noted in the prisoner log book that he had checked on Ms. Danais and Mr. Providence during the time he was absent. During one of his interviews, Mr. White admitted he falsified the entries in the log book for those times.

In addition, the Incident Review determined that Mr. White's entries in the prisoner log book were "consistently poor with limited information" and not in accordance with RCMP policy. Mr. White was released from his duties as guard at the Assumption RCMP Detachment.

The Commission's review of the prisoner log book reveals that Mr. White's entries were limited to essentially two notations, "All ok" or "ok." Furthermore, Mr. White did not record that he gave water to Mr. Providence several times throughout the evening or that Ms. Danais' clothes were dishevelled on two occasions and that he asked members on duty to check on her. RCMP policy requires that prisoners' activities are to be detailed and all checks of prisoners are to be recorded.

Furthermore, during the time when Mr. White was absent from the cell block purportedly talking with the members in the bullpen, Ms. Danais hit her head on the edge of the toilet. As a result, no one was aware that Ms. Danais hit her head. As the guard on duty, Mr. White was responsible for Ms. Danais' safety and well-being. While there is no indication that Ms. Danais' death was as a result of this incident, Mr. White's absence resulted in it going unnoticed and unrecorded in the prisoner log book.

A review of the cell video reveals that Mr. White had another lengthy absence from the cell block from 7:49 p.m. to 8:17 p.m., and he repeatedly left the cell block area in the direction of the detachment office area during the course of his shift. He neglected his duties when he left his post for lengthy periods of time and frequently left the prisoners unmonitored.

In light of the above, I find Mr. White's entries in the prisoner log book to be deficient and some to be false. As well, he abdicated his responsibility to properly monitor the prisoners in his care. Given that Mr. White has been dismissed as a guard, I am satisfied with the RCMP's disposition in this regard.

I note that there are other issues regarding the prisoner log book and prisoner checks which are not specific to Mr. White or the members. The pages of the prisoner log book which were provided to the Commission do not specify the type of check performed, in terms of whether it was a physical check or CCVE monitoring, contrary to the RCMP's national operational policy. Moreover, the entries in the log book reveal that the guards, except Mr. White, appeared to be rigidly adhering to a 15-minute interval for checks unless there was a specific reason for them to attend a cell. The RCMP's national operational policy states that time intervals shall be irregular but no more than 15 minutes apart.

The Commission has raised similar concerns in the context of other Chair‑initiated complaints^{Footnote 19} involving in-custody deaths. Furthermore, I note the RCMP Commissioner's commitment to amend RCMP national policy with respect to prisoner log book documentation.

Findings 5 and 6: Mr. White's entries in the prisoner log book were deficient and some of the notations were false. In addition, Mr. White derogated his duties by leaving his guard post for extended periods of time.

In terms of the members' conduct, the information reveals that Constables Boon and Tanner Wills each conducted separate prisoner checks of Ms. Danais; however, they did not record those checks in the prisoner log book, as required by RCMP policy.

In addition, supplemental detachment policy requires members to perform periodic checks of the cell area. It states as follows:

Members during the course of their duties when in the cell block will do periodic checks of the cell area and make a notation of such checks in the guards log to indicate this has been done. This should be done in Red Ink. This will include a physical count of the prisoners.^{Footnote 20}

At approximately 7:20 p.m., Mr. White became concerned because Ms. Danais' clothing was dishevelled, leaving her breasts and genitals exposed, and he asked Constable Boon to check her. According to Constable Boon's statement, he conducted a visual check of Ms. Danais. He described Ms. Danais as "lying down on her back. Arms, legs spread apart and her pants pulled down to her thighs. Her shirt was pulled up to her shoulders . . ." Constable Boon advised that he did not feel he needed to go into the cell to conduct a physical check because there was no indication that Ms. Danais was unresponsive as opposed to simply sleeping.

When asked by the investigator about Ms. Danais' level of consciousness, Constable Boon replied as follows:

Boon: She was over in the back lefthand [sic] corner so I...to my understanding she was con' or she was sleeping...

Taylor: Sleeping?

Boon: ... at the time. The guard would be keeping record of whenever the last time she was moving around or anything like that.

Furthermore, Constable Boon stated that he only checked Ms. Danais in terms of the safety of her clothing. He stated that he did not check on her responsiveness because he was not asked to, and he did not observe her long enough to see if she was breathing.

The RCMP's national operational policy provides the following with respect to the responsibility to determine responsiveness of a prisoner:

You and the guard on duty are responsible for determining the responsiveness of each prisoner in the cells and must be familiar with the requirement to assess prisoner responsiveness and conduct assessments as required.^{Footnote 21}/p>

The Incident Review stated the following with respect to Constable Boon's conduct:

Prisoner responsiveness is a continuous effort. Although it is known that DANAIS was alive after this check, members should be aware that prisoner checks include the responsiveness of that prisoner. Entries are to be made in the prisoner logbook. This is not in accordance with O.M. 19.3.3.1 and O.M. 19.3.5.2.

I echo the findings of the Incident Review in this regard. Constable Boon expended minimal effort in terms of his responsibilities to ensure Ms. Danais' well-being. He did not assess Ms. Danais' responsiveness because he stated that he was not asked to do so by Mr. White. Moreover, he assumed Ms. Danais was sleeping when he checked her; however, he was unable to say that she was breathing.

In this instance, Constable Boon briefly observed Ms. Danais, although not long enough or thoroughly enough to assess whether she was breathing. The RCMP's national operational policy provides that determining responsiveness of prisoners is the responsibility of both members and guards. It is not a mutually exclusive responsibility. Accordingly, Constable Boon should have made his own determination in terms of whether it was necessary to assess Ms. Danais' responsiveness, as opposed to relying on a request to do so or assuming that a guard had done it. Moreover, it is difficult to determine how Constable Boon was able to fully satisfy himself that Ms. Danais' clothing was not a safety issue when he did not observe her long enough even to ensure that she was breathing. Accordingly, I find that Constable Boon failed to assess Ms. Danais' responsiveness, as required by RCMP policy.

Finally, contrary to his assertions, Constable Boon was required by RCMP policy to record his check of Ms. Danais in the prisoner log book. Furthermore, according to the supplemental detachment policy, Constable Boon was also required to do a periodic check of the cell area and a prisoner count when his duties took him into the cell block. He was then to make a notation in the prisoner log book in red ink. He did none of this.

A short time after Constable Boon checked on Ms. Danais, Constable Wills did so as well, at approximately 7:44 p.m. In his police notebook, Constable Wills made the following entry:

Earlier, as I came on shift, told to check prisoner in female tank and other PNS [sic] looked at videoscreen female, native on her back, shirt up exposed. Pants down . . . alone. Other prisoners fine. Later on evening informed she had made herself decent.

Constable Wills did not record his check of Ms. Danais in the prisoner log book. The Incident Review concluded that Constable Wills was not acting in accordance with the RCMP's national operational policy with respect to documenting checks on prisoners in the prisoner log book. Although Constable Wills noted the prisoner check in his police notebook, I find that he should also have recorded it on the prisoner log book, in accordance with RCMP policy. Furthermore, Constable Wills did not check the cell area, conduct a prisoner count or make a notation in red ink in the prisoner log book that this was done, contrary to supplemental detachment policy.

During his statement, Constable Wills was not asked about his prisoner check of Ms. Danais and whether he assessed her responsiveness. I note that he concluded that the other prisoners were "fine" but did not make a similar notation in his police notebook for Ms. Danais. However, given the limited information, I am unable to make a determination with respect to whether Constable Wills properly assessed Ms. Danais' responsiveness.

A number of recommendations arose from the Incident Review, and steps were taken to implement those recommendations, including the institution of a process to ensure that members and guards/matrons of the Assumption RCMP Detachment review national and divisional policy and unit supplements on cell block operations, and track same.^{Footnote 22} I am satisfied that this measure will sufficiently address the failure of Constables Boon and Wills to record their checks of Ms. Danais in the prisoner log book and accordingly, I decline to make a recommendation in this regard.

I am not satisfied, however, that such a measure will adequately address Constable Boon's failure to assess Ms. Danais' responsiveness. I recommend that a senior member of the RCMP provide operational guidance to ensure that the subject member understands his responsibilities regarding assessing prisoner responsiveness pursuant to the RCMP's national operational policy.

Finding No. 7: Constables Boon and Wills failed to record in the prisoner log book their prisoner checks of Ms. Danais, as required by RCMP policy.

Finding No. 8: Constable Boon failed to assess the responsiveness of Ms. Danais, contrary to RCMP policy.

Recommendation No. 2: That a senior member of the RCMP provide Constable Boon with operational guidance with respect to his responsibility to continually assess responsiveness of a prisoner according to the RCMP's national operational policy.

Cell video

A review of the cell video reveals that upon entering the cell, at 4:49 p.m.,^{Footnote 23} Ms. Danais sat down at the cell door and looked out the open meal slot in the door for approximately 40 minutes. She occasionally shifted position from sitting with her legs to the side to sitting cross-legged. There is nothing unusual in her behaviour during this time. At 5:30 p.m., Ms. Danais moved away from the door and rolled onto her back. After what appear to be several attempts, she sat back up again in a cross-legged position, although she appeared somewhat unsteady. While still seated, she lurched to her right, falling over and hitting her head on the edge of the stainless toilet and fountain in the cell.^{Footnote 24} Ms. Danais then appeared to make an attempt to stand. She was finally able to get to the seated position and move to the cell door, where for approximately eight minutes she looked out the meal slot again. At 5:47 p.m., Ms. Danais lay on her back. She did not sit up or stand again. However, while lying down Ms. Danais appeared to be restless. She was moving and attempting to sit up at times. At other times, she turned from side to side, and brought her arms over her head. During the last hour of her life, Ms. Danais lay on her stomach on the right side of the toilet near the cell door. She continued to move her upper body and head. After 12:37 a.m., no further movement can be detected from Ms. Danais. At no time does it appear that Ms. Danais is in distress. She did not vomit or shake at any point. The video has no audio component.

I note that the MCU investigation report states that Ms. Danais' cell video was examined. The report provides as follows:

Three (3) minutes after entering, she can be seen rolling to the right and striking her head against the toilet on the right side. This would almost have the appearance of a "switch" being turned, for lack of a better term. She appears to attempt recovery into a seated position, but never does.

The available information does not support the description of this portion of the video provided in the MCU investigation report. The CCVE video discloses that Ms. Danais hits her head on the toilet seat 40 minutes after entering the cell and for an eight-minute period she regained a seated position at the cell door. While the inaccuracy in the report is not determinative, the correct timing of this event reveals the fact that Mr. White was not in the cell block area when Ms. Danais hit her head.

Provision of medical assistance

According to the Final Report and Incident Review, which are consistent with the Commission's review of the available information, at 12:35 a.m., Mr. Carlito Somera, another detachment guard, arrived to replace Mr. White. They had a brief discussion and Mr. White left. Mr. Somera immediately conducted physical checks of the prisoners, including Ms. Danais. According to Mr. Somera's statement, his normal practice is to ensure that the prisoners in his care are breathing when he conducts his physical checks. When he observed Ms. Danais lying on her stomach he could not see any movement that would indicate she was breathing. He then kicked the door in the hopes that this might rouse her, but it did not. Mr. Somera stated that he then retrieved a yardstick and stuck it through the meal slot to touch her leg in an attempt to get a response. At that point, Mr. Somera said he was alarmed and went to inform the member on duty.

Constable Erika Laird was working at the detachment and she responded immediately to Mr. Somera's request for assistance. According to the Incident Review and Constable Laird's statement, Constable Laird was unable to detect a pulse and Ms. Danais felt cool to the touch. Constable Laird called Constable Wills on the police radio to return to the detachment. She noted other signs of lividity and believed Ms. Danais was dead. Constable Laird directed Mr. Somera to call 911, which he did. Constable Laird then attempted resuscitation and CPR on Ms. Danais. Within minutes Constable Wills returned to the detachment. Based on his observations, he too believed that Ms. Danais was deceased.

Constable Wills contacted Sergeant Dickinson, who was the supervisor on shift performing "K" Division Member Operational Support Section (KMOSS) duties, to inform him of the sudden death of Ms. Danais. Sergeant Dickinson instructed Constable Wills to commence resuscitation and CPR and to call out the local medical responders. Upon contacting the local emergency responders, Constable Wills was told no one was on duty or on call.

Constable Laird contacted Constable Brad Noss, the Acting Detachment Commander for the Assumption RCMP Detachment. Constable Noss instructed her to contact the local emergency responders. After being contacted, Constable Noss attended the detachment. He then contacted Sergeant Dickinson and Staff Sergeant Henley, the Western Alberta District Advisory NCO, to inform them of the situation.

Constables Laird and Wills alternated performing CPR on Ms. Danais until an ambulance from High Level, Alberta, arrived at approximately 2:13 a.m. Shortly thereafter, the emergency responders directed the members to stop resuscitation efforts. Ms. Danais was transported to the High Level Hospital, and she was subsequently pronounced dead. Constable Laird accompanied the ambulance to the High Level Hospital to ensure continuity of the deceased for the purposes of the medical examiner.

In his statement, Constable Noss indicated that after the ambulance left the detachment, he secured the scene. He then notified the MCU and the Forensic Identification Section of the incident and he updated Staff Sergeant Henley. Based on a review of the MCU investigation report and the Incident Review, I am satisfied that the incident was properly reported within the RCMP, and that the protection of the scene and evidence was in accordance with RCMP national and divisional policies^{Footnote 25} respecting in-custody deaths.

On August 8, 2011, an autopsy was performed which concluded that there was no evidence of trauma or natural disease to account for the cause of Ms. Danais' death. The toxicological analyses revealed bupropion toxicity.

The RCMP's national operational policy regarding assessing responsiveness and providing medical assistance, in effect at the time,^{Footnote 26} stated the following:

2.2. If you locate a person who is not able to walk or talk and the person cannot be roused by speaking to or touching him/her, check for:

2.2.1. airway blockage,
2.2.2. irregular breathing,
2.2.3. erratic pulse or no pulse,
2.2.4. injuries,
2.2.5. medic alert bracelet,
2.2.6. responsiveness to a mildly noxious or painful stimulus, e.g. reaction to pressure applied just behind the ear.
2.3. If you observe any conditions outlined in sec. 2.2., initiate first responder first aid/CPR and seek immediate medical assistance. If possible, bring medical assistance to the scene.

When Mr. Somera was unable to rouse Ms. Danais, he immediately alerted Constable Laird. The member was unable to detect a pulse and immediately began resuscitation and CPR. Constable Laird was unable to get any air into her lungs. The member then called for Constable Wills to return to the detachment, which he did immediately. Both Constables Laird and Wills obtained further instructions from senior RCMP officers and notified them of the event. The two members maintained resuscitation and CPR efforts for approximately 75 minutes, until after the ambulance arrived and they were instructed to stop. Notwithstanding a brief interruption in the efforts to resuscitate Ms. Danais, I find that the actions of Mr. Somera and the conduct of the members in responding to this medical emergency were consistent with RCMP policies respecting assessing responsiveness and providing medical assistance, and in-custody deaths. I note the laudable efforts of Constables Wills and Laird in attempting to resuscitate Ms. Danais for an extended period of time.

Finding No. 9: Constables Laird and Wills applied resuscitation efforts and CPR to Ms. Danais in compliance with RCMP policy, and medical assistance was immediately sought once it was determined that she was not responsive.

Finding No. 10: Constable Noss acted in accordance with the requirements of national and divisional policies respecting sudden deaths in RCMP custody.

Second Issue: Whether the RCMP members at the Assumption 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 Assumption RCMP during the period of Ms. Danais' detention and subsequent death.

I have made several findings with respect to Mr. White's lack of compliance with RCMP policy pertaining to the prisoner log book and the proper monitoring of prisoners. Mr. White's entries in the log book were poor and contained limited information and he had repeated unexplained absences from the cell block, two of which were for an unreasonable amount of time.

I note that the Final Report advised that guard refresher training had occurred on May 10, 2011, at the Assumption RCMP Detachment. The refresher course included a review of applicable policy and a walkthrough of the cell block area, as well as training on the CCVE. This is consistent with the information reviewed by the Commission which discloses that on a form entitled "Read and Initial Assumption Detachment" regarding operational requirements for prisoners, Mr. White initialled beside his name.

Accordingly, notwithstanding that Mr. White did not comply with RCMP policy with respect to properly monitoring prisoners and prisoner log book entries, he was provided adequate direction, by means of the guard refresher training course in this regard. The provision of direction is determined irrespective of whether or not that direction is properly followed; ensuring compliance with training programs and policies is a component of the adequacy of supervision.

Finding No. 11: Mr. White was provided with adequate direction.

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.

It is the member in charge or shift supervisor who is responsible for ensuring that all prisoners are cared for and handled appropriately and to ensure that all prisoners have been searched before being placed in cells.^{Footnote 27} Furthermore, the Detachment Commander must ensure that all personnel responsible for prisoner care read and initial applicable policies, including national, divisional and detachment/unit supplements to acknowledge their understanding of same. This should be repeated every six months. The initialled record must be maintained.^{Footnote 28}

In my view, there were obvious gaps in the supervision of Mr. White, the cell block guard on duty during the majority of the time that Ms. Danais was alive in RCMP custody. Mr. White neglected his responsibilities as cell block guard on two occasions when he left the guardroom for extended periods of time. Mr. White provided an inadequate explanation for the first absence. He was not asked to explain the reason for his second absence. While these two occasions are the longest absences, a review of the CCVE guardroom recording reveals Mr. White departing the cell block area frequently for short periods of time during his shift.

In this instance, it is apparent that no RCMP member, including the senior member on duty, sought to correct Mr. White's lengthy absences from the cell block. Moreover, Mr. White's deficient and falsified prisoner log book entries were neither noted nor corrected by any RCMP member on duty, including the senior member. Accordingly, Mr. White was not provided with adequate supervision while on guard duty.

It is evident that Mr. Somera acted in compliance with RCMP policy throughout this incident, including assessing Ms. Danais' responsiveness and alerting Constable Laird to the fact that Ms. Danais was unresponsive.

Finding No. 12: Mr. White was not adequately supervised.

Recommendation No. 3: That the Detachment Commander conduct regular reviews of the prisoner log book to ensure compliance with RCMP policy regarding appropriate recording of monitoring and checking of prisoners.

Recommendation No. 4: That the Detachment Commander conduct regular audits of the cell block video to ensure compliance with RCMP policy regarding monitoring prisoners.

Third Issue: Whether the RCMP national, divisional and detachment-level policies, procedures and guidelines relating to persons detained in RCMP custody are adequate to ensure the proper care and safety thereof.

I have noted throughout this report the existing RCMP policies regarding searching prisoners, proper screening of prisoners, completion of the Prisoner Report, CPIC checks of prisoners, monitoring of prisoners, prisoner checks, prisoner log books, and assessing responsiveness. I have found that with the exception of Mr. Somera and Constables Laird's and Wills' actions with regard to assessing and responding to Ms. Danais' unresponsiveness, RCMP policies were not complied with.

The Commission often makes recommendations with respect to policy requirements in fulfilling the remedial aspects of its mandate. In this case, it is primarily adherence to numerous fundamental RCMP policies regarding the screening and guarding of prisoners which is problematic. In my view, this points to a fundamental failure on the part of the senior members to ensure compliance with RCMP policy regarding guarding prisoners and cell block operations at the detachment.

While, it may appear that many of the transgressions of policy by the members and Mr. White were insignificant and did not impact on the final outcome for Ms. Danais,^{Footnote 29} such transgressions risk having a cumulative effect. Such an effect may manifest itself in the situation which existed surrounding this incident; namely, that certain key operations and practices, outlined in comprehensive policy, were conducted in a casual and careless manner with respect to Ms. Danais, including prisoner searches, screening and monitoring.

Furthermore, what may seem to be a routine task or responsibility can have serious consequences if neglected. In this instance, the members were not recording their checks of Ms. Danais in the prisoner log book. This resulted in there being nothing to refer back to in the log book. Members requested to check on Ms. Danais would have been unaware that other members had also been called to check on her. Proper member documentation in the prisoner log book is essential as a means of communicating to other members a prisoner's condition and also serves as an "early warning system" for potential issues.

As a result of recommendations arising from the Incident Review, steps were taken by the RCMP to address policy compliance with respect to cell block operations. In a memorandum dated March 20, 2012, Superintendent Arlen Miller, District Commander, Western Alberta District, informed Assistant Commissioner Marianne Ryan, Officer in Charge, "K" Division Criminal Operations, that based on discussions and communications with the Detachment Commander, measures had been taken at the Assumption RCMP Detachment to mitigate the risk of another in-custody death and to ensure accountability of RCMP members. These measures included the following:

The Detachment Commander has implemented a process to ensure members and guards/matrons review National, Divisional and Unit Supplements on cell block operations and track same.^{Footnote 30} This will be an ongoing process. All guards have been re-certified in First Aid/CPR by the Corps of Commissionaires as of March 2012.

. . .

The Detachment Commander will ensure that prisoners-cellblock continues to be an area of review, subject to the 2012/13 ULQA process. In addition, Assumption Detachment has been selected by K Division for a Management Review during the same period.

In my view, these measures will address many of the underlying issues with respect to policy compliance. However, I reiterate my recommendation that the Detachment Commander conduct regular audits of the prisoner log book and the CCVE cell block video to continue to ensure policy compliance.

Finding No. 13: The Detachment Commander did not ensure compliance with RCMP policies regarding guarding prisoners, the prisoner log book and cell block procedures.

Finding No. 14: The members and Mr. White did not comply with RCMP policies respecting guarding prisoners and cell block procedures.

Finding No. 15: The RCMP has taken comprehensive measures to address and correct many of the issues of non-compliance by members and guards at the Assumption RCMP Detachment.

One of the most serious issues in connection with this incident is the failure by Constable Boon to ask Ms. Danais about her consumption of any prescription drugs. I note that this case is strikingly similar to another RCMP in-custody death involving Mr. Arthur Lafrance from the Ermneskin Reserve in Alberta which occurred in 2007. Mr. Lafrance had taken an overdose of a painkiller he was being prescribed. He was arrested and taken into custody. The RCMP members did not ask him or question family or friends about ingestion of medication. In the Fatality Inquiry Report, Mr. Justice B. Rosborough recommended that family and friends of intoxicated individuals be questioned to determine substances ingested and changes to the C-13 to provide for separate inquiry about possible impairment by alcohol, drugs, illness/injury, mental illness and state of consciousness/health, or a combination of any of these.

Following Ms. Danais' in-custody death, and in an effort to enhance policy compliance with respect to prisoner screening, Assistant Commissioner Ryan distributed a communiqué to all employees of "K" Division on August 18, 2011. In the communiqué, Assistant Commissioner Ryan highlighted the need to enhance "our efforts to identify drug and alcohol consumption by prisoners as a good police practice as this is an extremely high risk area that requires vigilance." Assistant Commissioner Ryan also communicated that the recommendations arising from the Fatality Inquiry Report regarding the death of Mr. Lafrance had been forwarded to the policy centre in Ottawa and "will be addressed in due course."

On January 5, 2012, Assistant Commissioner Ryan requested that all District Officers of "K" Division ensure that all RCMP members within their district read and initial the national operational policy with respect to guarding prisoners and the requirements of members and supervisors while individuals are in the care of the RCMP. In addition, Assistant Commissioner Ryan mandated that all detachment policy echo the provisions of the national operational policy with respect to guarding prisoners.Finally, she recommended that detachments take advantage of a PowerPoint presentation concerning the arrest of intoxicated persons.

I acknowledge that the RCMP in "K" Division has recognized that the lack of inquiry into drug/medication consumption was not unique to this case. Furthermore, I am satisfied that the RCMP has adequately sought to address this issue by a direction from Assistant Commissioner Ryan requiring members to be vigilant in their effort to identify drug and alcohol consumption. This was later followed up by another direction from Assistant Commissioner Ryan that all members were required to read and in essence, refresh their understanding of the policy respecting guarding prisoners and their responsibilities flowing therefrom. Accordingly, I find that the RCMP has undertaken reasonable efforts to enhance policy compliance for screening prisoners and the responsibilities of members for prisoners in custody across "K" Division.

I recommend that the RCMP report to the Commission any changes to policy and the Prisoner Report resulting from recommendations arising from the Fatality Inquiry Report into Mr. Lafrance's death.

Finding No. 16: The RCMP has undertaken reasonable efforts to enhance policy compliance for screening prisoners and the responsibilities of members for prisoners in custody across "K" Division.

Recommendation No. 5: That the RCMP report to the Commission any changes to policy and the Prisoner Report resulting from recommendations arising from the Fatality Inquiry Report into Mr. Lafrance's death.

Fourth Issue: Whether the actions taken by the RCMP in response to the incident were taken in accordance with all applicable policies, procedures, guidelines and statutory requirements for the conduct of such an investigation and whether such policies, procedures and guidelines are adequate.

Three separate investigations were conducted into this incident by the RCMP, as previously noted: the sudden death investigation, an Incident Review and a Code of Conduct investigation. The public complaint investigation comprised a review of the information obtained during the criminal investigation and the Incident Review.

The sudden death investigation was initiated when "K" Division Criminal Operations notified^{Footnote 3`} the Director of Law Enforcement, Solicitor General's Department, Province of Alberta, of the in-custody death of Ms. Danais, who decided that the RCMP's "K" Division Major Crimes Unit would investigate the incident. The Peace River MCU was directed to undertake the investigation. Corporal S. Shott of the Peace River MCU was the lead investigator and prepared the investigation report. The RCMP's Forensic Identification Services assisted with the investigation as well as some members of the Assumption RCMP Detachment.

ASIRT was assigned to review the MCU investigation on August 12, 2011, pursuant to section 46.1 of the Alberta Police Act. In its Final Report, ASIRT determined that Major Case Management principles were employed for the investigation, and that investigative avenues and tasks were sufficiently identified and completed for the purpose of gathering and corroborating the available witness and physical evidence. ASIRT concluded as follows:

Overall, the investigation of this death in custody matter by members of the RCMP Peace River Major Crimes Unit and Forensic Identification Services was conducted thoroughly and reported accurately. Appropriate tasks were completed in order to try to determine the circumstances surrounding the events and the actions of all those involved. This included investigation in order to try and determine whether or not members of the Royal Canadian Mounted Police were advised that the Affected Person, (DANAIS) had taken a quantity of drugs prior to her arrest for intoxication.

While ASIRT did recommend some follow-up tasks^{Footnote 32} to clarify certain details of the investigation, the ASIRT Final Report stated that the recommendations did not affect the final conclusion that the RCMP investigation was thorough and accurate.

In light of the above, I am satisfied that the MCU sudden death investigation was completed in a professional, unbiased and thorough manner.

On August 11, 2011, Superintendent Miller directed Staff Sergeant Mike Brandford, Non-Commissioned Officer in charge of the Grande Prairie General Investigation Service, to conduct an Incident Review into the in-custody death of Ms. Danais. Staff Sergeant Brandford was asked to examine closely the actions of all RCMP members and any other personnel in terms of the care and handling of Ms. Danais while in RCMP custody and the proper compliance with RCMP policy.

The Incident Review Report, dated February 7, 2012, was based primarily upon a review of the evidence obtained during the MCU investigation, including the witness statements, police notebooks, the prisoner log book, and the cell block videos. The Incident Review identified 15 issues with member and guard conduct. Arising from the review, 7 recommendations were made to address areas of concern identified during the review.

The recommendations acted upon were: initiating a Code of Conduct investigation with respect to Constable Boon; dismissing Mr. White as a guard; directing the Detachment Commander to implement a process to ensure that members and guards/matrons review national, divisional and unit supplements on cell block operations and tracking same, and ensuring that prisoners/cell block areas continue to be an area of review, subject to the 2012/13 ULQA process; the Assumption RCMP Detachment being subject to a Management Review; ensuring that the time stamp on the CCVE has been fixed; replacing or fixing the food tray doors on cell doors; and providing operational guidance to Constable Boon regarding the arrest of Mr. Providence.

In a memorandum dated May 7, 2012, Assistant Commissioner Ryan stated that she was satisfied that all recommendations, except for a recommendation concerning equipping the detachment with an automated external defibrillator, had been adequately addressed.

Accordingly, based upon my review of the Incident Review and the RCMP responses thereto, I am satisfied that the Incident Review was reasonably thorough and unbiased.

Finally, as a result of the Incident Review, the RCMP initiated a Code of Conduct investigation to determine if Constable Boon, while on duty, adhered to policy regarding the proper completion of the Prisoner Report and placement of Ms. Danais in the detachment cells. The Commission was informed that the allegation of neglect of duty was substantiated against Constable Boon, and that he was provided informal discipline by means of counselling, pursuant to paragraph 41(1)(a) of the RCMP Act.

In conclusion, I am satisfied that the sudden death investigation and incident review that the RCMP undertook with respect to the in-custody death of Ms. Danais were thorough, fair and professional.

Finding No. 17: The sudden death investigation and Incident Review were thorough and unbiased.

Comment Regarding the Availability of Automated External Defibrillators

The Incident Review reported that the Assumption RCMP Detachment lodges approximately 1,000 individuals per year in its cells, but noted that the detachment does not have an automated external defibrillator (AED).

An AED is a small, portable device used to identify cardiac rhythms and deliver a shock to correct abnormal electrical activity in the heart. They have been used efficiently and effectively in community settings, such as casinos, airport terminals, airplanes, shopping malls, recreation facilities, office buildings and other public locations.^{Footnote 33} Approximately half of all federal departments, agencies and Crown corporations have AED programs.

In July 2011, the RCMP's Chief Human Resources Officer (CHRO) approved a limited AED program in three areas only: the Prime Minister's Protective Detail, the Division Fitness and Lifestyle Section, and the Emergency Medical Response Team.

In November 2012, the RCMP provided a response to an Inquiry of Ministry (official inquiry^{Footnote 34}) regarding the installation of AEDs within all federal departments, agencies and Crown corporations. In that response, the RCMP was unable to state with certainty the number of AEDs installed in its detachments or how many employees are trained at each location to use them, which may be due in part to the number of detachments located in municipally or provincially-owned premises.

The RCMP also stated in its response that there are no plans to expand the current limited AED program, although it noted that under the British Columbia Provincial Policing Standards effective January 30, 2013, the Commissioner must, in rural areas, provide AEDs to members assigned a Conducted Energy Weapon and, in urban areas, provide AEDs to all on-road patrol supervisors. I note that the Ontario Provincial Police purchased AEDs for all its detachments, and the Correctional Service of Canada (CSC) has adopted an AED program providing reasonable access to AEDs in all CSC institutions and facilities.

Recognizing that the diverse and disparate nature of RCMP operations is different from that of the CSC and the Ontario Provincial Police, equipping detachments with AEDs is nevertheless a desirable measure given the remote locations of many RCMP detachments and lack of access to emergency responders combined with the high-risk population detained in RCMP cells. In many cases, proper screening, monitoring and assessments may obviate the need for an AED, as medical assistance will be sought for prisoners long before the need for an AED arises. However, there will always be instances where this life saving intervention may be useful to members, civilian employees and those in custody alike.

Recommendation No. 6: That the RCMP evaluate the possibility of equipping all detachment with an Automated External Defibrillator.

Conclusion

Ms. Danais' death while in custody at the Assumption RCMP Detachment underscores the need for constant vigilance by members and guards in screening and monitoring prisoners. While the Commission often makes recommendations with respect to policy requirements in fulfilling the remedial aspect of its mandate, in this case it is primarily the application of the policy which failed.

Ms. Danais was lodged into cells without being questioned about medication consumption, and without being properly searched or a CPIC check conducted. While in cells, Ms. Danais was not properly monitored, as the guard left the cell block for long periods of time and failed to keep a proper record in the log book. Equally troubling were the actions of the members called to check on Ms. Danais. They failed to record their prisoner checks of her in the log book, resulting in there being nothing to alert other members that there may be an issue arising with Ms. Danais. When Ms. Danais was lying on the cell floor, her clothes partially removed, the member did not assess her responsiveness, in part because he was not asked to do so by the guard. The repeated lack of compliance with RCMP policies demonstrates a lack of diligence on the part of the Detachment Commander and supervisors to ensure that members understood their responsibilities pursuant to the policies.

In response to this specific incident, the RCMP's "K" Division undertook measures designed to address and correct the issues of non-compliance. However, the proper screening and monitoring of prisoners in RCMP custody continues to be an area of concern for the Commission. While the RCMP has established policies and procedures to ensure the health and safety of prisoners, it is apparent that compliance is inconsistent. The well-being and safety of prisoners in custody should be the foremost consideration for members while conducting their duties in the cell block. While this duty of care is owed to all prisoners, vulnerable individuals require members to be keenly aware of additional risk factors when conducting their assessments and monitoring of them. Finally, inattention to policy requirements and standardized procedures results in a potentially unsafe environment for both prisoners and those who work in the cell block, including members.

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

Interim Chair,
Ian McPhail, Q.C.