Better monitoring of police cells needed, says coroner’s jury

Recommendations come from inquest into death of Terrace, B.C. woman

PRISONERS at the Terrace RCMP detachment, especially if they are known to have substance-abuse problems, should be more closely monitored, a coroner’s jury has concluded following a three-day inquest last week into the death of a 25-year-old woman.

Alyssa Josephine Talina George fell into distress in the detachment cells approximately 14 hours after her Sept. 3, 2013 arrest for outstanding warrants.

She was then taken to Mills Memorial Hospital and later flown to Vancouver General Hospital for more treatment but died September 10, 2013.

Evidence presented at the Oct. 19-21 inquest centered around George’s time in custody at the detachment.

Through replaying of video surveillance at the time of her arrest, George appeared to be able to walk without problem or assistance and to communicate with the booking guard. Once put in her cell she flipped through a magazine and laid down for a sleep.

But footage shown of the 45 minutes before paramedics removed her showed her in what appeared to be distress, laying on the bench in the cell, then sitting up and rocking back and forth, then sliding off the bench onto the floor where she sat, rocked some and laid down on her side, then her back and later facedown.

Dr. Robert Saunders, emergency physician and coroners service medical consultant, said George died of many factors.

Saunders testified that she had been quite ill for months prior to her death as she was not eating much but had been drinking.

People with a severe alcohol dependence that goes on for a long time have this happen, he said.

A person’s liver filters toxins including alcohol out of the body and can be damaged by alcohol, which also affects glucose metabolism, he said.

A person’s brain needs energy in the form of glucose so if you don’t have any in your body, you starve, Saunders said.

George’s glucose levels were down low enough to cause unconsciousness, plus she was dehydrated and in respiratory distress when brought to the hospital, he said.

She also had metabolic acidosis which is when lactic acid forms from burning cells without proper oxygen, and all of these factors led to multi-organ death, he said. Saunders had seen parts of the video and said George was certainly ill by 9:42 p.m. – she had been arrested and taken to cells at about 11 a.m. – when she got her food tray and struggles to pick it up.

However, he said that training guards or police officers to identify complex medical issues takes too long and needs practice so training for them wouldn’t be beneficial. Saunders said that if a person gets worse over time, that’s a sign that can be taken for medical distress.

“I don’t expect police and guards to be paramedics but if [a person] gets worse, call paramedics who can come and say ‘they’re ok’ or ‘we have to take the person to hospital,’” he said.

George’s immediate cause of death was multiple organ and system failure due to metabolic acidosis and respiratory depression as a consequence of acute and prolonged ethanol (alcohol) and substance abuse, and her death was classified as natural.

The jury heard that George had gone to Dr. Lennox Brown here for help to get off heroin and he prescribed methadone for her for a while. He said he believed she had been referred by her regular doctor to alcohol and drug counsellors and mental health services.

In May 2013, she expressed a desire to go to a detox centre to get off drugs and alcohol but there was no place here in Terrace and the centre in Prince George was full, he said.

Brown testified the area wasn’t adequately served for drug and alcohol detox services.

He also said that contrary to what people might think, there are no detox beds at Mills Memorial.

The following are the 16 recommendations made by the jury following the inquest into the death of Alyssa George.

They’ll be forwarded to the chief coroner who will send them out to the specific organization named in each recommendation.

To the RCMP

1. The RCMP C13 form (filled out when a person is being booked by the police cells guard and arresting officer) requires additional space for initial medical info/questioning/survey/screening, such as when was last intake of alcohol or drugs; taking any medication/what/ dosage; pre-existing medical condition; and allergies.

2. Consider all policies/procedures and standards as mandatory, not best practices.

3. Ensure RCMP watch commander performs and is accountable for physical (in cell) checks every four hours of all prisoners in all cells.

To the RCMP/City of Terrace

4. Guards must follow/adhere to existing policies/procedures (in their operational manual) concentrating on: the four Rs of rousability, watch command four-hour prisoner check, guard “physical” check every 15 minutes.

5. Use of closed-circuit TV should be used as a secondary backup to physical check.

6. RCMP/guards should use the cell check log appropriately (follow all blocks of the form and fill out completely).

7. To assist the guards doing the physical cell checks, the hall lighting could be reduced, or a matte coating on cell door window to reduce the glare from the above lights.

8. Consider reducing medical assessment time to eight hours.

9. A committee should be established to discuss the possibility of and paying a second guard on duty at all times.

10. Investigate upgrading the existing closed-circuit TV system to include larger monitors, with the ability to select the video feed to focus on one cell, ability to zoom and pan video feed while maintaining the source feed for the recording, audio microphones at each end of the hallways free of background noise.

11. Install a two-way non-recording intercom system into all cells, other than cell 1 and cell 7, (drunk tank and youth cell) for rousability checks, a loud buzzer noise in cell to precede actual two-way communication for prisoner privacy.

12. Ensure that all guards and RCMP members take the existing training as required and investigate increasing some training cycles to ensure retention of information, policies and procedures.

13. First aid training should be enhanced to include medical information and scenario training more conducive to alcohol and drug addiction, and community level training such as the intergenerational effects of residential school on First Nations, as well as cultural sensitivities of other minorities.

To the provincial Ministry of Health

14. Must keep blood samples taken from patients who are gravely ill for 14 days for testing and follow patient if transporting to alternative medical facilities.

To Northern Health/First Nation Health Authority/ Ministry of Health/ City of Terrace

15. A committee/focus group should be established to investigate the construction of a proper medically staffed substance abuse/detox centre in the City of Terrace to service all outlying areas. This should include one or more substance abuse doctors and counsellors.

To the Ministry of Health/Northern Health/RCMP/Mills Memorial Hospital/ BC Ambulance Service:

16. Investigate having a better and more accurate means of transmitting urgent/non-confidential medical information from one agency to another.