Report to the Minister of Justice and Attorney General Public Fatality Inquiry

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1 CANADA Province of Alberta Report to the Minister of Justice and Attorney General Public Fatality Inquiry Fatality Inquiries Act WHEREAS a Public Inquiry was held at the Provincial Court Criminal Division in the City of Calgary, in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 1 st day of December, 2009, (and by adjournment year on the 2 nd and 3 rd days of December, 2009 ), year before Judge C. M. Skene, a Provincial Court Judge, into the death of Woodrow James Three Suns 41 (Name in Full) (Age) of NFA and the following findings were made: (Residence) Date and Time of Death: Place: June 3, 2007 at 4:38 a.m. Peter Lougheed Hospital Medical Cause of Death: ( cause of death means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization The Fatality Inquiries Act, Section 1(d)). Chronic Ethanol Abuse Manner of Death: ( manner of death means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable The Fatality Inquiries Act, Section 1(h)). Unclassifiable (as per Certificate of Medical Examiner)

2 Report Page 2 of 8 Circumstances under which Death occurred: On June 2, 2007, at approximately 7:05 PM, LRT Community Peace Officer Robert Vande Bunte (Vande Bunte) was at the Southland LRT Station bus loop in Calgary, Alberta. He was there to investigate a report of graffiti in a large bus shelter. As he entered the bus shelter, Vande Bunte observed a male person lying on the floor in the corner of the shelter on his left side in a semi-prone position. Vande Bunte was able to rouse this person who identified himself as Woodrow Threesuns (Threesuns) in a mumbled, almost inaudible tone. Despite his mumbling speech, Vande Bunte found Threesuns to be responsive. Vande Bunte queried Threesuns on CPIC at 7:11 PM and discovered that Threesuns had two outstanding warrants for his arrest on charges under the Calgary Transit Bylaw for failure to produce proof of fare on the LRT. Based on his observations of Threesuns, Vande Bunte formed the opinion that Threesuns was intoxicated in a public bus shelter and was incapable of taking care of himself. His state of intoxication and the two outstanding warrants for his arrest caused Vande Bunte to arrange to have Threesuns taken into custody. Vande Bunte contacted two other LRT Community Peace Officers who were operating an LRT transport van and asked them to attend the scene to take custody of Threesuns. LRT Officer Cook Wright (Cook Wright) and LRT Officer Wong (Wong) arrived at the bus shelter and took custody of Threesuns, assisting him to his feet and to the van and into the prisoners cage in the rear of the van. Threesuns was able to walk with assistance, and stepped up and into the van with minor assistance. He responded appropriately to the Officers directions. Threesuns was known to Cook Wright as over the previous six months, Cook Wright had occasion to deal with Threesuns an estimated three to four times per week for public intoxication on transit property. Threesuns was described by Cook Wright as a very nice, gentle man who was always under the influence of drugs or alcohol during their encounters, but yet was always cooperative and followed the officer s direction. Cook Wright recalled that Threesuns had a garbled manner of speech and was always difficult to understand. When the officer encountered Threesuns at the bus shelter on June 2, 2007, he found Threesuns heavily intoxicated. Wong arrested Threesuns and read him his Charter rights and standard police caution. Wong had also encountered Threesuns during his tenure as an LRT officer, although with less frequency than Cook Wright. Wong recalled that in past encounters, he had transported Threesuns to Alpha House, a shelter in Calgary for men and women who are under the influence of alcohol and other drugs. Usually a mat is offered for sleep and the stay is overnight. After leaving Southland Station with Threesuns in the back of the van, Cook Wright and Wong attended the Chinook LRT station. They took custody of another male person who was under the influence of alcohol and placed that person in the rear cage area of the van with Threesuns. Cook Wright and Wong left the Chinook LRT Station at approximately 7:40 PM with Threesuns

3 Report Page 3 of 8 and the other male. The other male was transported to Alpha House at 15 Avenue SE Calgary, Alberta. The officers then continued to transport Threesuns to the Calgary Police Service Arrest Processing Unit (also referred to in this Report as APU) located at Avenue S.E. Calgary, Alberta, arriving at approximately 7:57 PM. Had Mr. Threesuns not had the two outstanding warrants for his arrest, the LRT Officers may have dropped him off at the Alpha House. Instead, they transported Threesuns to the APU to execute the warrants for Threesuns arrest. At no time did any of the LRT Officers form the opinion that Threesuns was in medical distress or required transportation to a hospital or medical clinic. Threesuns activities while at APU were monitored and recorded on surveillance equipment and the recording was recovered and entered as an Exhibit in this Fatality Inquiry. At APU, the booking of prisoners, reception of their property, escort to the paramedic, releasing prisoners, attending to their bail hearing appearances, feeding the prisoners and the monitoring of prisoners are handled by four staff Commissionaires each shift. Threesuns was searched. He was booked into APU, with the permission of Acting Staff Sergeant Lomore and the assistance of a Commissionaire, without incident by Cook Wright, while Wong attended to the paperwork. His clothing was removed down to one layer. Cook Wright helped him remove his boots, all of which were placed in a bag for safe-keeping pending his release. He was then taken to the APU paramedic office by Officer Cook Wright where he was examined by paramedic Will Gibson. Will Gibson (Gibson), EMR, EMT, Paramedic was working at APU when Threesuns was presented to him for medical assessment at 8:16 PM, prior to placing him in a cell. The initial assessment of Threesuns included taking his vital signs, including blood pressure, oxygen levels, heart rate and respiration rate and assessing his level of consciousness on the Glasgow Coma Scale. Although noticeably intoxicated, Threesuns was able to identify himself to Gibson as Woody when asked and he scored 13 out of 15 on the GCS, causing no concern to Gibson. Other questions by Gibson were responded to by Threesuns with grunts or mumbles. Cook Wright referred to this as Threesuns typical speech pattern in his experience. Once assessed and determined to be fit, Threesuns was delegated to a cell in the Drunk Tank. Threesuns was placed into cell #3 at 8:20 PM, one of three cells commonly referred to as the Drunk Tank. There are twenty-two cells at the Arrest Processing Unit, including cells for women, youths, men and isolation cells. Once placed in cell #3, Threesuns settled down on the floor of the cell and went to sleep. There was no interaction with any of the other occupants of the cell. All three of the Drunk Tank cells, as well as the other 19 cells, are monitored and recorded with cameras and television type monitors in the main office, containing the Staff Sergeant s desk and a Commissionaire s desk. The main Arrest Processing Unit office and that office s occupants have a direct and clear view of the Drunk Tank cells through large glass windows. The proximity of the Drunk Tank cells to the Staff Sergeant s office allows the Commissionaires to also hear prisoners, should the prisoners raise their voices or make noise within their cell.

4 Report Page 4 of 8 Threesuns was described as a regular or frequent flyer in the APU cells, specifically the Drunk Tank cells by at least one Commissionaire. Police records show that he had been detained in cells over 80 times since February In seventy of these bookings Threesuns was listed as drunk. There were 245 entries on the Police information management system. His criminal record shows 96 criminal convictions since The Calgary Police Services intention that evening was to detain Threesuns until he was sober enough to care for himself. At that time, the APU staff was intending to release him on a Promise to Appear. Should the APU paramedic have concerns over a prisoner s health or well being, the paramedic can request that the prisoner be placed in a specific medical cell for special monitoring. Also, the APU paramedic can check on any prisoner at any time and also has access to all of the cell monitors, including the Drunk Tank monitors on cells #1, 2 and 3. An unfit or unwell prisoner would be transported by ambulance to the hospital or suitable inner city medical clinic. Further, the Drunk Tank cells often experience a lot of prisoner traffic, whereby prisoners are placed in and out of the three cells frequently, providing an informal monitoring of the prisoners remaining in the cells. In addition to the video recording and monitoring of all APU cells, the CPS have a system in place and written policy for the care of prisoners in custody, and a specific system for the monitoring of prisoners at APU. The four Commissionaires present at each shift at APU are assigned the duty of monitoring the prisoners in the cells at APU every fourth hour on a rotational basis. The Commissionaires refer to this assignment as Lights. At the start of each hour, the Commissionaire whose turn it is signs into the Log Book showing that he or she is starting to perform his or her assignment of Lights or monitoring the prisoners directly by looking into every cell every 10 minutes, and indirectly by looking at the monitors of the cell cameras. The one hour shift, every four hours, is referred to as Lights because a strobe light goes off every 10 minutes in the Staff Sergeant s office, which also is the office where the cell monitors are placed. The Commissionaire is then required as part of his or her assignment for the hour to physically look into each and every one of the 22 cells in APU to ensure that each prisoner is safe. If a prisoner is asleep, he or she is to ensure that the prisoner is breathing, by looking for signs of life or breathing. Placed at five strategic locations there are electronic computerized card readers. As the Commissionaire on Lights views the occupants of each cell, he or she then swipes their computer chip card over the card reader and then walks to the next set of cells, and the next card reader. Once all five card readers are swiped, the strobe light in the Staff Sergeant s office goes off, indicating that the Commissionaire has completed his round of prisoner monitoring. The Commissionaire then returns to his or her desk in front of the cell monitors and watches the cells and the occupants of those cells, until the strobe light goes on again 10 minutes after the light went on at the start of the prior round.

5 Report Page 5 of 8 Each round lasts two to three minutes, unless there are prisoner questions, or other matters to deal with. Each time a Commissionaire swipes his or her card past a card reader, a computerized record is generated. The log of the hourly assignment, and the log of all the card swipes, showing which Commissionaire made each round or card swipe for all the relevant times on June 2 and 3, 2007, was entered as an Exhibit in this Fatality Inquiry. The card reader for the Drunk Tank cells, cells #1, 2 and 3 is located in the Staff Sergeant s office along the glass wall facing the Drunk Tank cells. On the other side of the glass is a narrow corridor in front of the cells. The Calgary Police Service has written policy and procedures referred to as Care in Custody. The Statement of Principles show that the Care in Custody policies appear to be focused on preventing prisoners from having opportunities to inflict self harm (suicide). Also, the policies would address the prevention and detection of one prisoner harming another where both were housed in the same cell. Further, the policy assists in the early detection of a prisoner in medical distress. A portion of the Care in Custody document is set out as follows: Care in Custody 4. Definitions 3. Prisoner Check: Satisfying oneself of a prisoner s well-being by: a. Observation: Observing the prisoner through a door peep-hole or on a video monitor; or b. Physical Check: Establishing close enough physical proximity to be able to determine if the prisoner is breathing 7. Arrest Processing Unit (APU) 4. Prisoner Monitoring a. The Staff Sergeant, APU, will ensure that APU members conduct regular prisoner checks to ensure the safety, security and welfare of all prisoners. b. All prisoners will be checked at ten-minute (10) intervals. These checks will be recorded electronically by the APU member swiping his or her card al all card-swipe stations in the cell block. c. When a prisoner appears to be sleeping, a physical check will be made to ensure the prisoner s well-being. When the prisoner is awake, an observation check may be made d. If the prisoner check reveals any abnormalities regarding any prisoner, the APU member will immediately intervene, as appropriate, and the Staff Sergeant, APU and medical staff will be notified as soon as possible. e. The Staff Sergeant, APU will arrange for transportation to a medical facility, where necessary.

6 Report Page 6 of 8 At 1:09 AM on June 3, 2007, Acting Staff Sergeant Mike Lomore (Lomore) had a brief conversation with Threesuns. Lomore asked Threesuns if he was ready to be released. Threesuns stated to Lomore that he was not ready to leave. Threesuns speech was described as sluggish, and Lomore agreed that it would be best if he stayed. Lomore s opinion was that Threesuns was intoxicated by alcohol, but otherwise seemed fine. He was awake and he was appropriately responsive to Lomore s inquiries. The video surveillance tape shows Threesuns, as stated above in this report, in cell #3 from 8:20 PM onward. Occasionally, Threesuns would turn over or otherwise adjust his sleeping posture. On a close review of the surveillance video tape, the last time Threesuns is shown visibly moving is at 2:26 AM on June 3, The checks of all prisoners in all cells continued every 10 minutes. At the shift change at 3:00 AM on June 3, 2007, the Commissionaire starting his shift on Lights noticed that Threesuns was positioned lying down, with his back to one of cell #3 s walls. His mouth was open. At 3:01, the Commissionaire entered cell #3 and determined that Threesuns was unresponsive to verbal and physical stimulation and was not breathing. The APU paramedic Gibson was called into the cell at 3:07 AM. Threesuns was removed from the cell, and CPR and other resuscitation efforts were commenced. Paramedic Gibson was assisted by a CPS officer who was also a trained paramedic. Gibson testified that Threesuns was warm to the touch, but also stated that the cells are kept warm. Gibson initially was unable to detect a pulse from Threesuns. Calgary Health Region paramedics responding to a 911 call arrived with Calgary Fire Department personnel who then assisted with the resuscitation efforts. Through their combined efforts, the paramedics were able to obtain a pulse from Threesuns for one minute at approximately 3:26 AM. Thereafter the pulse was lost. Dr. Bannach, Alberta s Chief Medical Examiner, testified that in his opinion, the ability of the paramedics to obtain a pulse from Threesuns through CPR and other methods, may indicate that Threesuns had been without a pulse and not breathing for no more than 15 minutes prior to the Commissionaire detecting that he was unresponsive at 3:01 AM on June 3, The evidence tends to show that Threesuns may have stopped breathing after the physical check at 2:50 AM and before the physical check at 3:01 AM. Threesuns, from the time he was placed in cell #3 of the Drunk Tank, to the time he was dragged out of cell #3 when found to be unresponsive at 3:01 AM, was checked every 10 minutes in accordance the Commissionaires on-the-job training and Calgary Police Service Care in Custody policy and guidelines. Threesuns was transported to the Peter Lougheed General Hospital, leaving APU at 3:35 AM. EMS and hospital staff continued to attempt to revive Threesuns but were not successful and he was declared dead at 4:37 AM at the hospital. All APU officers and staff testified that this was the first time in their work experience at APU that a prisoner died after being detained in a cell under similar circumstances. Dr. Singer, Deputy Chief Toxicologist for the Province of Alberta, conducted toxicology screens

7 Report Page 7 of 8 on ante mortem blood samples obtained from Threesuns. His blood alcohol level was 250 milligrams of alcohol in 100 millilitres of blood at approximately 4:00 AM. Threesuns had not been observed consuming alcohol or any other intoxicating substance since Officer Vande Bunte discovered him passed out in the Bus shelter at 7:01 PM, approximately 9 hours earlier. Dr. Bannach conducted an autopsy of Threesuns on June 5, 2007, and determined the immediate cause of Threesuns death to be Chronic Ethanol Abuse. His Autopsy Report is partially reproduced below. At autopsy, there are no acute natural diseases or injuries present to account for death. There is evidence of long-standing alcohol abuse with advanced cirrhosis of the liver, fatty metamorphosis of the remaining hepatocytes islands, atrophy of the testicles and brain, and enlargement and dilation of the heart. Blood and body fluids taken during the course of the autopsy are submitted to the toxicology laboratory for examination. The blood alcohol level was over 3 times the legal limit to operate a motor vehicle in the Province of Alberta. There was some acetone and isopropanol also present in the blood consistent with chronic alcoholism. These are as a result of metabolic conversion to these substances rather than ingestion. No drugs were detected. The vitreous glucose level is within normal limits. It is my opinion that the decedent, Woodrow James Three Suns, died as a result of chronic ethanol abuse. Individuals who chronically abuse alcohol can die suddenly and unexpectedly. In this case there is evidence of both liver disease as well as enlargement and dilation of the heart (i.e. alcoholic cardiomyopathy). Individuals with enlarged and dilated hearts can die suddenly and unexpectedly due to the development of lethal abnormal heart rhythms (i.e., cardiac arrhythmias). The levels of alcohol present in this case would not be lethal in and of themselves. There are no traumatic injuries present to cause or contribute to death. Dr. Bannach testified that Threesuns long-standing abuse of alcohol had toxic effects on his heart muscle. Alcohol abuse caused the enlargement and dilation of Threesuns heart, causing the development of heart arrhythmias leading to cardiac arrest. There would be no outward signs of pending or imminent death. Dr. Bannach testified that these types of deaths are not detectable, absent active cardiac monitoring. Although a death due to chronic alcohol (ethanol) abuse is not surprising, there is nothing that would or could tip off a paramedic, police officer or Commissionaire that Threesuns, or any other prisoner in cells may die during their detention. There is no indication of a criminal offence leading or contributing to Threesuns death. Neither is there evidence tending to show negligence on the part of the Calgary Police Service, the Calgary Health Region paramedics, or the Calgary Transit Officers.

8 Report Page 8 of 8 I have had the benefit of hearing Detective Keown s testimony and receiving his report (Exhibit 1, Tab H, Section 1, pg ) prepared for the Calgary Police Service investigation into Woodrow James Threesuns arrest and detention at the Arrest Processing Unit on June 2 and 3, The evidence in this Fatality Inquiry did not vary from the sequence of events set out in that report. Therefore, I have adopted and incorporated Detective s Keown s report into this Report to the Minister of Justice and Attorney General of Alberta. Recommendations for the prevention of similar deaths: I have no recommendations. DATE December 18, 2009 at Calgary, Alberta. Original signed by C.M. Skene A Judge of the Provincial Court of Alberta

Report to the Minister of Justice and Solicitor General Public Fatality Inquiry

Report to the Minister of Justice and Solicitor General Public Fatality Inquiry Fatality Inquiries Act WHEREAS a Public Inquiry was held at the Law Courts (North) in the City of Edmonton, in the Province