Woman who died in B.C. jail cell had asked to be taken to hospital twice, report shows

An undated photo of a jail cell.

A woman who died from drug toxicity while in a B.C. jail cell asked to be taken to hospital twice in the hours after she was taken into custody in a case the province's police watchdog says again raises concerns over the treatment of intoxicated prisoners.

The Independent Investigations Office of B.C. issued a report into the March 2024 Burnaby death last week, finding no reasonable grounds to forward a report to Crown for consideration of criminal charges.

However, the results of the investigation were forwarded to the RCMP's Civilian Complaints Commission "to assess whether policy or training changes are necessary to prevent similar situations from happening in the future."

The woman, referred to as the affected person or "AP" in the report, was monitored by a civilian jail guard and the report notes that the IIO does not currently have jurisdiction to investigate the actions of people who are not sworn officers. Amendments to the province's Police Act will soon change that.

In this case, no member of the Burnaby RCMP was the subject of the investigation, and the two Mounties who were involved and interviewed are identified as witnesses.

What happened

On the evening of March 6, a member of the public called the RCMP to report a woman who appeared to be intoxicated and to request a "well-being check," the report says.

The officers who attended arrested the woman for causing a disturbance and took her to the detachment's cells. Officers did not pursue charges but did keep her in custody because she was "unable to care for herself," according to the report. Roughly 12 hours later, prior to her release, she told an officer her plan was to try to find drugs.

The report also notes that she left jail wearing a "forensic suit" she had been given after urinating on herself.

The AP's arrest on the morning of March 7, 2024, happened just 30 minutes after she was released after police were called to a high school where the woman was reportedly intoxicated and approaching students.

The officer who arrested her is referred to as "witness officer four" or "WO4" in the report.

"In the car on the way back to cells, the AP begged WO4 to take her home instead. When WO4 refused, the AP requested that she be taken to hospital instead of being taken to cells. WO4 did not take her to the hospital, believing that the AP did not require medical assistance, and only wanted to go to the hospital to avoid going to jail," the report says

The officer did not tell his colleague who was working as the jail supervisor about this conversation, according to the IIO.

Four hours later WO4 removed the AP from her cell, where she had defecated on the floor.

"The AP requested in her interview that WO4 take her to hospital. WO4 asked whether she was 'dope sick', and she said yes. WO4 said that he noticed she was ill but did not think it was severe enough to take her to the hospital as she was not throwing up or experiencing diarrhea," according to the report, which notes that the officer did not inform his colleague of this request either.

CCTV from the cell shows that the woman was last seen moving in her cell at 3:18 p.m.

In the hour that followed, the jail guard – referred to in the report as civilian witness three or "CW3" was responsible for conducting in-person checks on the woman every 15 minutes, per RCMP policy. These checks do not require entering the cell but are meant to supplement video monitoring and involve observing, for example, whether someone's chest is rising and falling.

"CW3 did in-person checks on the AP at 3:31 p.m. for approximately three seconds, 3:45 p.m. for approximately 11 seconds, and at 4 p.m. for approximately 10 seconds," the report says, adding that the guard believed that the woman was breathing all three times.

At 4:15, the guard kicked the cell door in an attempt to wake the woman. When she was unresponsive, the guard and an officer entered the cell where they administered Narcan and used an AED to try to rouse the woman.

She was pronounced dead 40 minutes later after paramedics determined that "no further attempts to save the AP's life would be successful," the report says.

An autopsy found AP's death was the result of drug toxicity. The IIO report says no drugs were found in the woman's cell.

What the IIO found

The brevity of the in-person checks was one of the things the report identified as a potential issue in the case.

"The visual checks that were performed were only three to 11 seconds in length. With the benefit of knowledge and hindsight, one wonders whether the checks could have been more fulsome," the report says.

W04's decision not to take the woman to the hospital and not to inform anyone else working in the jail that she had requested to be taken there was another.

"Again, with the benefit of hindsight, one wonders whether this information would have resulted in a more careful monitoring of the AP and/or provision of medical treatment," the report continues.

The conclusion of the report echoes those of previous ones issued by the IIO after the deaths of people who were intoxicated in the province's jails.

"Officers and jail guards are not trained medical personnel, and jail cells are not the best place for such prisoners. Other options are utilized within the province, including sobering centres and having health professionals on site to deal with intoxicated persons. The care of intoxicated persons should not fall solely to police, as it is a health-care issue," it reads.