Specialized team to respond to people in crisis could prevent future deaths: inquest report

The judge who oversaw an inquest into the deaths of five men who died while being restrained by officers within the span of a year has recommended police and paramedics create a specialized joint team to respond when people are in crisis.

"I fully support this initiative as being one which could prevent deaths in the future," Manitoba provincial court Judge Lindy Choy wrote in a roughly 70-page report released Friday, following the inquest into the 2018 and 2019 deaths of Matthew Fosseneuve, Patrick Gagnon, Michael Bagot, Sean Thompson and Randy Cochrane.

In each case, the men who died had either methamphetamine or cocaine in their system and were exhibiting "hyperactive agitated" behaviour that required medical attention and led to police being called, the report said.

All five men — who ranged in age from 30 to 41 — needed to be "safely brought under control and physically restrained" before they could get medical help, but became unresponsive before ambulances arrived.

The inquest heard expert testimony that use of drugs such as cocaine and methamphetamine can create a massive stress response in the body and increase the probability of a serious cardiac event during a situation where a person is being restrained by police.

While substance use was a contributing cause in all five incidents, there was evidence two of the men also had mental health issues. The official causes of death included cardiac arrhythmia, brain damage and mixed drug intoxication. 

The inquest had its first hearings last November and wrapped up in June. Over 19 days of hearings, it heard from 45 witnesses, including three experts in the areas of police use of force, pharmacology and forensic psychiatry.

A forensic psychiatry expert who testified said while there was imminent risk of harm that made physically controlling the men a fitting response for police, taking more time to de-escalate the situation could have made a difference in two of the cases. 

The autopsy report on one of the men also listed what's known as "excited delirium" linked to cocaine use as a contributing cause of death.

The report noted that has become a controversial term describing "a collection of signs and symptoms thought to be caused by chronic stimulant use." Manitoba's chief medical examiner said at the inquest the language has evolved over time, and his office no longer uses that term.

"The practice today would be to either leave the term excited delirium out, recognizing that it just describes the behaviour prior to collapsing, or to say that there was cocaine-associated hyperactive delirium," the report said, adding when a death is attributed to "excited delirium," other potential contributing factors might go uninvestigated. 

"Another alternative would be to simply state that the cardiac arrest was due to cocaine use."

The report said the term refers to what the judge called a "constellation of behavioural traits" including pain tolerance, "superhuman" strength and lack of fatigue.

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