B.C.'s police watchdog won't be recommending charges after a person was found dead of an overdose while in custody, but it did raise concerns about how intoxicated prisoners are housed. 

Interim chief civilian director Sandra J. Hentzen said she will be referring the case to the RCMP and the Civilian Review and Complaints Commission to decide if policy or training changes are necessary to prevent similar situations in the future. 

A female, referred to as AP (affected person), died in Burnaby RCMP custody in March after being arrested and placed in jail cells two nights in a row, according to the latest Independent Investigations Office of B.C. report on Thursday (Sept. 5).

The first arrest

On the evening of March 6, a person called 911 to report that a female was in a restaurant allegedly bothering patrons by yelling, panhandling and "appeared to be intoxicated." The caller also asked that officers do a wellness check as she "was not dressed appropriately for the weather conditions."

Two Burnaby RCMP officers went to the restaurant and arrested AP for causing a disturbance. She wasn't charged, but officers brought her to the jail cells "because she was intoxicated and unable to care for herself." She was also provided with a forensic suit because she had urinated on herself. 

The report says that surveillance footage from the evening of March 6 and the morning of March 7 show AP being "restless for the first several hours," before settling down around 2:20 a.m. and sleeping for about four hours. 

A third officer, who dealt with AP in the morning, told the police watchdog that she was "yelling and screaming from her cell for the police to 'let her go.'" The officer said that in order to be released, "she needed to be calm."

A fourth officer said she told them that she "wanted to go home and also that she wanted to look for drugs."

She left the cells around 8:25 a.m. on March 7, about 12 hours after being arrested. She chose to not re-dress in her original clothes and instead left in the forensic suit. 

The second arrest

Within the hour, RCMP received a call from the public that AP was intoxicated and at a local high school. She was allegedly asking students whether they had drugs and it was reported that she was "trying to fight someone."

The fourth officer went to the school and re-arrested her. On the ride back to the cells, she begged the officer to take her home or to the hospital. The officer refused, believing she "did not require medical assistance, and only wanted to go to the hospital to avoid going to jail." He did not inform the third officer 91ÂãÁÄÊÓƵ“ the jail supervisor 91ÂãÁÄÊÓƵ“ of their conversation. 

She was booked into the cells at 9:30 a.m. and stayed awake until 1:24 p.m. when she was interviewed. When the fourth officer removed her from the cell, he noticed feces on the floor. 

During the interview, she asked the officer again to take her to the hospital. He asked if she was "dope sick," and she said yes. The officer 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."

He didn't inform his supervisor of the conversation, which was captured on video. In the video, she "would go from putting her head on the table in a drowsy state to sitting upright conversing and sometimes getting agitated" with the officer. 

She was put back into her cell at 2:08 p.m., where she laid down. Video footage showed her last visible movement at 3:18 p.m.

Jail guard's actions leading up to her death

RCMP policy is that prisoners need to be checked every 15 minutes, generally from outside the cell. A civilian jail guard did in-person checks 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. 

On a fourth check at 4:15, the jail guard noticed he wasn't getting a response. He kicked the door of her cell, attempting to wake her.

The jail guard and supervisor opened the cell door to give her Narcan and use an automated external defibrillator. Paramedic continued trying to revive her for 45 minutes until a doctor determined no further attempts would be successful.

She was pronounced deceased at 4:55 p.m.

An autopsy determined her cause of death to be a drug toxicity 91ÂãÁÄÊÓƵ“ an overdose. The report adds that no drugs were found in her cell or the police vehicle she was transported in and she wasn't seen to be consuming drugs while in custody. 

AP's requests to go to hospital not communicated

Hentzen said in her report that AP's actions were largely captured on video, including through the booking-in process and while in the cell. The investigation also included statements from five witnesses, two witness officers, 911 calls, RCMP radio transmissions, AP's statement in the interview room and the jail guard's logbook. 

Hentzen said that the visual checks were only three to 11 seconds in length, and "one wonders whether the checks could have been more fulsome."

The jail guard told the IIO that he looks for a prisoner's chest rising and falling, and that sometimes a video doesn't provide the same view as his in-person checks. His logbook showed that he believed her to be breathing on all three checks between 3:31 and 4 p.m.

Hentzen said that AP had also asked the fourth officer twice to go to the hospital and had "soiled and urinated herself," adding there was no indication that AP's requests were communicated to the supervisor.

She said that AP was experiencing a reaction to drug toxicity, "not simply symptoms of withdrawal," and "one wonders whether this information would have resulted in more careful monitoring."

"Officers and jail guards are not trained medical personnel, and jail cells are not the best place for such prisoners."

Hentzen added that in other places in the province, sobering centres or having health professionals on site are used as alternate options, as the care of intoxicated people "should not fall solely to police."