Chair's Final Report After Commissioner's Notice Regarding In-Custody Death of Charlene Danais in Assumption, Alberta, on August 7, 2011

Royal Canadian Mounted Police Act
Subsection 45.46(3)

File No.: PC-2011-2645

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The Complaint

On August 11, 2011, pursuant to subsection 45.37(1) of the Royal Canadian Mounted Police Act (RCMP Act), 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.

On August 6, 2011, after a number of calls to the police regarding her conduct, Ms. Danais was arrested, charged with mischief, and placed in cells at the Assumption RCMP Detachment to be detained until she was sober. Unbeknownst to police, Ms. Danais had consumed an amount of medication. Shortly after 1 a.m. on August 7, 2011, Ms. Danais was discovered unresponsive in her cell, and, despite first aid, including cardiopulmonary resuscitation (CPR), Ms. Danais was pronounced dead. An autopsy determined that the cause of death was bupropion toxicity (Ms. Danais had a prescription for Wellbutrin, which is the brand name for the generic drug, bupropion).

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 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;
  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.

The RCMP's Final Report

As required by the RCMP Act, the RCMP investigated the complaint and issued a Final Report. 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. The RCMP found that:

  1. RCMP members were compliant with all appropriate training, policies, procedures, guidelines and statutory requirements relating to persons held in RCMP custody.
  2. Overall adequate supervision and direction was provided to the guards involved in the incident. While areas of concern did surface with respect to one guard's supervision earlier in the day and limited documentation, it did not affect the tragic outcome for Ms. Danais, and appropriate corrective action was taken.
  3. National and divisional policy is adequate to ensure the proper care and safety of persons taken into custody. The frequency of prisoner checks at the detachment was amended to every ten (10) minutes, with a fifteen (15)-minute maximum.
  4. Members acted upon becoming aware of Ms. Danais' medical distress, and contacted emergency medical responders, performed CPR for an extended period until the emergency medical responders arrived, promptly contacted the Detachment Commander, and reported the incident to a supervisor at the "K" Division NAOCC (Northern Alberta Operations Communication Centre). Further, "K" Division Criminal Operations was promptly advised, resulting in the proper notification, according to section 46.1 of the Alberta Police Act, to the Office of the Director of Law Enforcement, Solicitor General's Department, Alberta. In addition, the investigation of the incident followed all requirements. Finally, since this tragedy, several steps have been taken to enhance the level of awareness within "K" Division to the care and handling of prisoners and arrest of intoxicated persons.

The Final Report advised that a Code of Conduct investigation had also been ordered in relation to Constable Boon's actions, and that informal discipline was provided to him. The RCMP, in its Final Report, supported the finding that Constable Boon should have been more thorough in the completion of the Prisoner Report form and should have asked questions of Ms. Danais, including if she had consumed any medications.

The Commission's Review and Interim Report

The Commission concluded its Interim Report on July 25, 2013. In this report, the Commission made a number of findings, including:

  1. During his arrest of Ms. Danais, Constable Rob Boon was not told that she had ingested pills earlier that day.
  2. The warrantless arrest of Ms. Danais by Constable Boon was reasonable.
  3. When booking her into cells, Constable Boon did not properly search Ms. Danais or complete the "Prisoner Screening" section of the Prisoner Report, and failed to conduct a Canadian Police Information Centre (CPIC) check, as required by RCMP policy.
  4. During the booking in of Mr. Providence,Footnote 1 Constable Boon was not informed that Ms. Danais had ingested pills earlier in the day.
  5. The entries into the prisoner log book by the cell block guard, Mr. Matthew White, were deficient, and some of the notations were false.
  6. Mr. White derogated his duties by leaving his guard post for extended periods of time.
  7. Constable Boon and Constable Tanner Wills failed to record in the prisoner log book their prisoner checks of Ms. Danais, as required by RCMP policy.
  8. Constable Boon failed to assess the responsiveness of Ms. Danais, contrary to RCMP policy.
  9. Constable Erika Laird and Constable 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.
  10. Constable Brad Noss acted in accordance with the requirements of national and divisional policies respecting sudden deaths in RCMP custody.
  11. Mr. White was provided with adequate direction.
  12. Mr. White was not adequately supervised.
  13. The Detachment Commander did not ensure compliance with RCMP policies regarding guarding prisoners, the prisoner log book and cell block procedures.
  14. The members and Mr. White did not comply with RCMP policies respecting guarding prisoners and cell block procedures.
  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.
  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.
  17. The sudden death investigation and Incident Review were thorough and unbiased.

The Commission made the following recommendations:

  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.
  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.
  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.
  4. That the Detachment Commander conduct regular audits of the cell block video to ensure compliance with RCMP policy regarding monitoring prisoners.
  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.Footnote 2
  6. That the RCMP evaluate the possibility of equipping all detachments with an automated external defibrillator (AED).

The Commissioner's Notice

Pursuant to subsection 45.46(2) of the RCMP Act, the Commissioner is required to provide written notification of any further action that has been or will be taken in light of the findings and recommendations contained in the Interim Report. On August 27, 2014, the Commission received the Commissioner's Notice dated August 20, 2014. The Commissioner agreed with all of the Commission's findings.

The Commissioner supported the recommendations that Constable Boon be provided with operational guidance,Footnote 3 but pointed out that this may have been a remedial aspect included in the informal discipline which was provided to Constable Boon.

The Commissioner also supported the recommendations that the Detachment Commander conduct regular reviews of the prisoner log book and regular audits of the cell block video to ensure compliance with RCMP policies regarding monitoring and checking prisoners and recording of such checks and monitoring.

The Commissioner informed the Commission that several changes had been made to the policy since 2007, as the RCMP continually reviews its policies. He added that he shared the Commission's concern that "there was an issue with respect to the lack of inquiry into drug/medication consumption" in RCMP members' dealings with both Ms. Danais and Mr. Lafrance. He added that, as a result of the incident involving Ms. Danais' death, the RCMP is currently reviewing the policy on assessing the responsiveness of prisoners.

Finally, the Commissioner wrote,

I generally support the recommendation that the RCMP evaluate the possibility of equipping all detachments with an [AED]. The RCMP is currently examining the issues surrounding the use of [AEDs] on members of the general public in delivering policing services.

The Commission's Findings and Recommendations

Having concluded that AEDs have been used efficiently and effectively in many community settings, that there are many federal AED programs, and that equipping detachments with such machines is desirable (given the remote locations of many RCMP detachments, the lack of access to emergency responders, and the high-risk population detained in RCMP cells), I find that the Commissioner could have provided unconditional direction that the RCMP at least evaluate the possibility that AEDs be available in all detachments. Rather, the Commissioner has used somewhat different language which appears to be generally favourable to undertaking this remedial action.

In light of the foregoing, therefore, I reiterate my findings and recommendations.

Findings:

  1. During his arrest of Ms. Danais, Constable Rob Boon was not told that she had ingested pills earlier that day.
  2. The warrantless arrest of Ms. Danais by Constable Boon was reasonable.
  3. When booking her into cells, Constable Boon did not properly search Ms. Danais or complete the "Prisoner Screening" section of the Prisoner Report, and failed to conduct a Canadian Police Information Centre (CPIC) check, as required by RCMP policy.
  4. During the booking-in of Mr. Providence, Constable Boon was not informed that Ms. Danais had ingested pills earlier in the day.
  5. The entries into the prisoner log book by the cell block guard, Mr. Matthew White, were deficient, and some of the notations were false.
  6. Mr. White derogated his duties by leaving his guard post for extended periods of time.
  7. Constable Boon and Constable Tanner Wills failed to record in the prisoner log book their prisoner checks of Ms. Danais, as required by RCMP policy.
  8. Constable Boon failed to assess the responsiveness of Ms. Danais, contrary to RCMP policy.
  9. Constable Erika Laird and Constable 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.
  10. Constable Brad Noss acted in accordance with the requirements of national and divisional policies respecting sudden deaths in RCMP custody.
  11. Mr. White was provided with adequate direction.
  12. Mr. White was not adequately supervised.
  13. The Detachment Commander did not ensure compliance with RCMP policies regarding guarding prisoners, the prisoner log book and cell block procedures.
  14. The members and Mr. White did not comply with RCMP policies respecting guarding prisoners and cell block procedures.
  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.
  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.
  17. The sudden death investigation and Incident Review were thorough and unbiased.

Recommendations:

  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.
  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.
  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.
  4. That the Detachment Commander conduct regular audits of the cell block video to ensure compliance with RCMP policy regarding monitoring prisoners.
  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.
  6. That the RCMP evaluate the possibility of equipping all detachments with an automated external defibrillator.

Pursuant to subsection 45.46(3) of the RCMP Act, I respectfully submit my Final Report and, accordingly, the Commission's mandate in this matter is ended.

Chair
Ian McPhail, Q.C.

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