Specialized team to respond to people in crisis could prevent future deaths: inquest report

The judge who oversaw an inquest into the deaths of five men who died while being restrained by officers within the span of a year has recommended police and paramedics create a specialized joint team to respond when people are in crisis.

"I fully support this initiative as being one which could prevent deaths in the future," Manitoba provincial court Judge Lindy Choy wrote in a roughly 70-page report released Friday, following the inquest into the 2018 and 2019 deaths of Matthew Fosseneuve, Patrick Gagnon, Michael Bagot, Sean Thompson and Randy Cochrane.

In each case, the men who died had either methamphetamine or cocaine in their system and were exhibiting "hyperactive agitated" behaviour that required medical attention and led to police being called, the report said.

All five men who ranged in age from 30 to 41 needed to be "safely brought under control and physically restrained" before they could get medical help, but became unresponsive before ambulances arrived.

The inquest heard expert testimony that use of drugs such as cocaine and methamphetamine can create a massive stress response in the body and increase the probability of a serious cardiac event during a situation where a person is being restrained by police.

While substance use was a contributing cause in all five incidents, there was evidence two of the men also had mental health issues. The official causes of death included cardiac arrhythmia, brain damage and mixed drug intoxication.

The inquesthad its first hearings last November and wrapped up in June. Over 19 days of hearings, itheard from 45 witnesses, including three experts in the areas of police use of force, pharmacology and forensic psychiatry.

A forensic psychiatry expert who testified said while there was imminent risk of harm that made physically controlling the men a fitting response for police, taking more time to de-escalate the situation could have made a difference in two of the cases.

'Excited delirium'

The autopsy report on one of the men also listed what's known as "excited delirium" linked to cocaine use as a contributing cause of death.

Thereport noted that has become a controversial term describing "a collection of signs and symptoms thought to be caused by chronic stimulant use." Manitoba's chief medical examiner said at the inquest the language has evolved over time, andhis office no longer uses that term.

"The practice today would be to either leave the term excited delirium out, recognizing that it just describes the behaviour prior to collapsing, or to say that there was cocaine-associated hyperactive delirium," the report said, adding when a death is attributed to "excited delirium," other potential contributing factors might go uninvestigated.

"Another alternative would be to simply state that the cardiac arrest was due to cocaine use."

The report said the term refers to what the judge called a "constellation of behavioural traits" including pain tolerance, "superhuman" strength and lack of fatigue.

WATCH | Partner of man who died hopes for change as inquest begins in November 2023:

Partner of man who died in Winnipeg police custody hopes inquest into 5 deaths leads to change

1 year ago

Duration 1:55

A lengthy inquest into the deaths of five men, all of whom died while in Winnipeg police custody, is underway after years of delays. A Manitoba judge is examining the circumstances around the deaths of Patrick Gagnon, Michael Bagot, Randy Cochrane, Matthew Fosseneuve and Sean Thompson in a group inquest expected to occur over 17 days.

The inquest judge recommended all levels of government commit resources to support people living with substance abuse issues, given what she said was described in the inquest as a "profound" increase in similar incidents to those that led to the men's deaths.

"It cannot be denied that further resources to address these challenges are critically required going forward to prevent further deaths. We cannot ignore the root cause of the problem," the report said.

Review training, keep funding new safety team

The judge also recommended the Winnipeg Police Service review its policy and training on responding to similar incidents, and that the police force, the Winnipeg Fire Paramedic Service and the 911 response team train members on transitioning a person from one service to the next.

In response to the death of one of the men, which happened after he boarded a bus and was taken off and restrained by police, the report also recommended Winnipeg Transit change its communications system to let drivers communicate directly with 911 call takers.

It also recommended the City of Winnipeg continue supporting and funding its community safety team, a relatively new initiative the report said "has the potential to create effective ways of helping people before they reach a crisis point" because of its focus on de-escalation and taking a trauma-informed approach.

"It represents a forward-thinking and compassionate way of assisting unhoused individuals and persons suffering from addictions or mental health issues," the judge wrote.

A city spokesperson said funding for that program is continuing, while a statement from Mayor Scott Gillingham said the team was one of his campaign promises"because it was clear we needed a new way to make our transit system safer and get vulnerable people the help they need."

The report also recommended victim services support for the families of people whose deaths lead to inquests.

"I heard from the families of the deceased men, and it is clear that many are left struggling to make sense of what has happened to them and their loved one," the report said. "It is especially hard on the children who have lost a parent."

Justice Minister Matt Wiebe said in a statement he was "carefully reviewing" that recommendation, and that the province is "committed to looking at ways we can support families and ensure they can meaningfully participate in inquest processes."