Manitoba man likely wouldn't have died in holding cell if proper procedure was followed: inquest report
John Ettawakapow's 2019 death in holding cell in The Pas was preventable, judge says
A provincial court judge says a Manitoba man likely wouldn't have died if proper policy had been followed when he was placed in an RCMP holding cell in The Pas.
Following an inquest into the 2019 death of John Ettawakapow in an RCMP holding cell, the judge is also recommending the province look to create an alternative place to house intoxicated people in the northern Manitoba town.
Ettawakapow, 54, died in the cell after being arrested for public intoxication on Oct. 5, 2019, in The Pas, after another inmate's leg inadvertently rolled onto his neck.
A five-day inquest into his death was held in June, during which a provincial court judge heard testimony from the officers who arrested Ettawakapow, the civilian guards who were supposed to be monitoring him and the province's chief medical examiner.
Security video played at the inquest showed the inmate's leg stayed on Ettawakapow's neck for 40 minutes, and no one came to move it. It was another five hours before anyone noticed Ettawakapow wasn't breathing.
Chief Medical Examiner Dr. John Younes testified in June the leg likely contributed to Ettawakapow's death, and he likely was dead for hours before he was found.
WATCH | 2019 security video shows John Ettawakapow in RCMP cell (WARNING: video is disturbing):
"Knowledge of this fact cannot be comforting to the family," wrote provincial court Judge Brian Colli in a 50-page report released Thursday.
"Mr. Ettawakapow died in police care from a preventable cause. He needed help but he did not receive it."
An inquest, which is called whenever someone dies in police custody, does not make a finding of criminal responsibility, but determines the circumstances surrounding the death and whether anything can be done to prevent similar incidents in future.
Colli wrote the checks done by the guards on Ettawakapow were insufficient, and they relied on "glancing" at a video monitor rather than physical checks. RCMP policy requires physical checks every 15 minutes for someone detained in a holding cell.
"In my assessment, if police policy had been followed, it is likely that Mr. Ettawakapow would not have died that night," wrote Colli.
The judge said guards seemed confused by the policy and that proper training of guards would prevent future deaths. He also noted a training course for guards is currently being developed by RCMP, which he hoped will emphasize the importance of monitoring people in custody.
The judge also wrote Ettawakapow's life could have been saved if he was assessed by medical personnel, rather than relying on the observations of a police officer.
Safe shelter for intoxicated people recommended
Colli also recommended RCMP and government work together to implement a program that gives officers quick and easy access to a medical assessment to determine if someone is fit to be lodged in a cell. That could be a nurse or a paramedic, and doesn't have to be a doctor, Colli wrote.
"The recommendation would, where the resources exist, eliminate the need for police, who often have no medical background, to make the decision without knowledge of underlying health conditions," wrote Colli.
Jamil Mahmood, the executive director of Winnipeg's Main Street Project, also testified at the inquest, where he talked about the organization's protective care facility. Police are able to drop off people arrested for public intoxication at the facility, where they are monitored 24/7, with a paramedic on site.
Colli recommended the provincial government partner with stakeholders in The Pas to form a working group that would study establishing a safe shelter for intoxicated people in the area, and should look at Main Street Project and similar facilities in Canada when considering the shelter.
"Such a program would in my estimate, if well designed, eliminate the type of death that Mr. Ettawakapow suffered and would also free up police resources to deal with other threats to community safety," he wrote.
Justice Minister Matt Wiebe said in an email statement the inquest report would help inform The Pas' community safety and well-being plan and what steps need to be taken.
"My heart goes out to the family of John George Ettawakapow and I want to express my sincere condolences for their loss," he wrote in the statement.
In the inquest report, Colli noted that Ettawakapow's son, Jeremy, sat through all five days of the inquest, and Colli thanked him for his "calm and resolute presence."
The judge concluded his report by emphasizing that all human life has value, writing that everyone who knew John Ettawakapow said he was a joy to be around and always smiling.
"Mr. Ettawakapow and others like him are human beings and in my assessment intrinsically valuable," he wrote.
"I only need to recall the words that Mr. Jeremy Ettawakapow used in summing up his dad to confirm my view. He was a good man; he was more than just his addiction. He was loved by his family."
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