No video monitoring in cell where Winnipeg man died in custody: inquest report

A man who died by suicide in Winnipeg police custody was kept in a holding room without video monitoringat the oldest police building in the city, the inquest into his death found.

The officers who checked on David Norbert also said while he joked about suicide during his risk assessment, they didn't think he was a high risk, the inquest reportreleased Friday said.

Norbert, who was 56, was arrested on April 16, 2019, after he was accused of threatening his former roommate and assaulting him with a frying pan, a broken light bulb and steel-toed boots, Manitoba provincial court Judge Murray Thompsonsaid in the report.

The roommate told police Norbert was evicted for not paying rent, the report said.

Police found Norbert later that evening, walking down a median on Main Street with a black Labrador retriever he had taken from the home.

Officers said Norbertwas co-operative as they arrested him and let them take the dog to return it. Healso had glossy eyes and smelled like alcoholbut had no problems walking, the report said.

Officers took him to the police station on Hartford Avenue, which the report said is the oldest Winnipeg Police Service building. It's in the process of being replaced with a new one that will have more modern facilities, including cells monitored by video.

Police told Norbert he was being charged with assault causing bodily harm, assault with a weapon and uttering threats, the report said.

When they got to the holding room, police took Norbert's handcuffs off and removed his shoes and clothing down to one layer, as required by police policy.

Norbert was still co-operative, but his reactions were a bit delayed and slow, the report said.

One of the officers asked him the required risk assessment questions, including whether he was suicidal.

The report said Norbert smirked, laughed and replied, "Sometimes yes and sometimes no," then said, "No, of course I'm not."

The officer completing the report told him it wasn't a laughing matter, then circled "unknown" on the form "because he was going back and forth," the report said.

The officer also asked whether Norbert needed any medications and if he had taken any drugs.

Norbert told officers he'd had 11 beers since 2 p.m. that day.

His toxicology report later revealed several medications used to treat anxiety or insomnia in his system.

A forensic specialist in toxicology said that combination of drugs "would result in greater impairment than would be expected following their individual use," the report said.

Checks every 15 minutes

Norbert was assessed as a medium risk, which required face-to-face checks every 15 minutes while he was in custody, the report said. He was noted to be either sitting or sleeping during the first four checks, beginning at 8 p.m.

There was no record of the next three required checks, though one of the officers involved said he did them but didn't note it anywhere, the report said.

Police said they determined they could release Norbert if they could find a sober adult willing to take him but the first two people they called couldn't do it, and they couldn't find a phone number for the third name Norbert gave them.

Officers told Norbert about those attempts, the report said.Shortly after 10 p.m., they said they'd decided to move him to the Winnipeg Remand Centre and that he couldn't be released because he'd been drinking and couldn't give police a fixed address.

Police said they didn't notice any change in Norbert's demeanour. When he learned he was being moved, he responded by saying, "OK."

About five to 10 minutes later, another officer looked inside the holding room and noticed Norbert looked like he was standing in the middle of the room.

One of the officers who had been checking on Norbert earlier went inside and found him hanging by his shirt from a ceiling ventilation grate, the report said.

Police rushed into the room, got him down and started doing CPR. Paramedics soon arrived and took Norbert to Seven Oaks General Hospital, where he was pronounced dead.

All three officers who dealt with Norbert that night said they didn't think he was a high risk for suicide based on his responses to them, and that if they thought he was suicidal they "would have maintained a continual observation," the report said.

Since Norbert's death, all the holding room ventilation grates at the Hartford Avenue stationhave been replaced with new ones that don't have holes big enough to use as ligature points, the report said.

Because those changes have already been made and the building will soon be replaced, Thompson made no recommendations in the inquest report.

An investigation by Manitoba's police watchdog also found the officers were not at fault for Norbert's death.

If you're experiencing suicidal thoughts or having a mental health crisis, there is help out there. Contact the Manitoba Suicide Prevention and Support Line toll-free at 1-877-435-7170 (1-877-HELP170) or the Kids Help Phone at 1-800-668-6868. You can also text CONNECT to 686868 and get immediate support from a crisis responder through the Crisis Text Line, powered by Kids Help Phone, or contact Canada Suicide Prevention Service: 1-833-456-4566 (phone),45645 (text, 3 p.m. to 11 p.m. CT only), orcrisisservicescanada.ca