A Manitoba judge is calling for the creation of a specialized team of police and paramedics to respond when people are in crisis and may need medication.
The recommendation is made in an inquest report released Friday that looks at five men who died in police custody in Winnipeg over 12 months in 2018 and 2019.
The inquest determined Matthew Fosseneuve, Patrick Gagnon, Michael Bagot, Sean Thompson and Randy Cochrane died while being restrained by police and waiting for medical assistance.
Judge Lindy Choy called their deaths tragic.
“I hope that through the process of this inquest, their loved ones have gained some insight into what happened, and that my recommendations will someday assist in preventing another untimely death,” Choy wrote in her report.
In each of the unrelated cases, the judge said the men had methamphetamine or cocaine in their systems and displayed erratic behaviour, requiring medical attention. They had to be physically restrained.
“In the course of being restrained, each of them suffered a medical incident and sadly passed away,” wrote the judge.
She made six recommendations, including that an officer and a medical professional jointly respond to a call when a person is in distress and may need medication.
She also suggested Winnipeg police review their policy and training on responding to events where someone is agitated.
Police said in an email they need time to review the report and couldn’t provide immediate comment.
The report detailed the deaths of the men.
Family told the inquest that 34-year-old Fosseneuve was an intelligent man who struggled with his mental health and later a drug and alcohol addiction.
In July 2018, he called 911 for help getting to detox. When paramedics arrived, he became agitated and aggressive, the report said. Police were called and used a stun gun to subdue the man.
While police restrained and pinned down Fosseneuve, he suffered a cardiac arrest and died.
“Other significant conditions contributing to death but not causally related were identified as methamphetamine toxicity and physiologic stress of recent physical struggle and restraint,” the report said, adding the stun gun was not considered to have contributed to the death.
Gagnon, 41, died in October 2018. The inquest heard he was with his partner and, after consuming some substances, became highly agitated and wandered off.
He walked to nearby railway tracks and attempted to climb onto a train. Operators called police.
Officers guided Gagnon to a grassy area, where they pulled him to the ground face down, the report said. Gagnon resisted and struggled. Shortly after, officers put handcuffs on him, he went limp and had no pulse.
The medical examiner’s office determined the cause of death as brain damage due to cardiac arrest, with cocaine use a contributing factor.
In May 2019, police were called to a transit bus after Bagot boarded in a frenzied state.
The 40-year-old was under the influence of drugs and had previously been seen acting erratically.
Police took him off the bus and multiple officers held him down. While he was restrained on the ground, he suffered cardiac arrest from complications of cocaine toxicity and stopped breathing.
Thompson was located by police on the front steps of a home In June 2019.
He was a suspect in nearby break-ins, and officers arrested him and pinned him to the ground.
They applied handcuffs when he became unresponsive and stopped breathing.
An autopsy said mixed drug intoxication from cocaine, methamphetamine and ethanol was the immediate cause of death.
Cochrane, 30, ran into a police car in July 2019. Police chased him and pinned him down and waited for an ambulance. Before paramedics arrived, Cochrane went limp.
An autopsy determined the immediate cause of death as the toxic effects of methamphetamine, cocaine and ethanol. An enlarged heart, and physiological stress associated with the pursuit and restraint were listed as contributing factors.
The inquest heard from medical experts that a sedative could be used with agitated people to counteract stimulants.
Medical experts told the inquest that research is lacking to understand these kinds of deaths but that the use of stimulant drugs results in high levels of adrenalin to the bloodstream, which can result in cardiac arrest during violent and prolonged interactions with police.
Choy said the common contributing factor in the deaths is the detrimental effects of stimulant drug use and that more addiction supports are needed.
“We cannot ignore the root cause of the problem,” the judge said.