Death of northern Manitoba man in RCMP custody was preventable: medical examiner

The death of a 54-year-old man in RCMP custody could have been prevented if the leg of another detained person that fell on his neck while he was in a holding cell was removed, Manitoba’s chief medical examiner said Thursday.

At an inquest into the 2019 death of John Ettawakapow, Dr. John Younes testified that Ettawakapow had a very high blood alcohol level and signs of heart disease.

However, Younes said he couldn’t ignore the role of the other man’s leg in the cause of death.

“There’s every reason to believe he [Ettawakapow] would have survived his period in his cell” had the other man’s leg been removed, Younes told court in The Pas, where the inquest is being held before provincial court Judge Brian Colli.

He pointed to the security video which showed Ettawakapow make motions to remove the leg several times before he stopped moving all together. 

“The video evidence clearly shows Ettawakapow respond to that,” he told the court.

Younes’s testimony came on the fourth day of hearings at the inquest into Ettawakapow’s death in The Pas.

Ettawakapow was arrested for public intoxication on Oct. 5, 2019, and placed in a holding cell, along with two other men, just after 7 p.m. He was pronounced dead more than seven hours later.

Court heard no one physically checked on Ettawakapow for five hours, during which time one of the other inmates moved and his leg fell on Ettawakapow’s neck, possibly smothering him.

If Ettawakapow had been taken to a hospital, he would have been kept there and constantly monitored, Younes told court.

A portrait of a man in a dark blue suit jacket behind a bookcase.
Younes said it was evident from the security video that the leg on Ettawakapow’s neck was bothering him, as he tried to remove it. (Trevor Brine/CBC)

Two Mounties and one civilian guard admitted during the inquest they weren’t aware of the RCMP’s policy, which is to physically check on inmates every 15 minutes.

“It was my impression from the jail guard and from officers that there is a misunderstanding on the policy,” Judge Colli said Thursday.

“There is an impression that you are not constantly monitoring them, which in itself increases risk to those in detention.”

Officer says he didn’t know about policy

Const. Joel Hardes, Cpl. Eryin Wiita and Rebecca MacDonald, a former civilian guard, all told the court they believed the policy was to physically check on an inmate every 30 minutes, and in the interim monitor them through video surveillance.

“Would it surprise you to know that RCMP policy requires … in-person checks every 15 minutes?” Judge Colli asked Hardes Thursday.

“I didn’t know that,” the constable replied. 

A man wearing glasses holding a framed photo of a man.
Jeremy Ettawakapow holds a picture of his father, John, who died in 2019 while he was detained in a cell in the RCMP detachment in The Pas, Man. Court heard that John was never aggressive with police and always had a smile on his face. (Jaison Empson/CBC)

Earlier testimony from MacDonald, the guard on shift when Ettawakapow was brought in, and Wiita revealed they also didn’t know the policy. 

CBC first told Ettawakapow’s story in 2021, as part of its death in custody project. It found that he was just one of dozens of Canadians who have died in custody after being arrested for public intoxication.

Judge Colli pointed to the problem of intoxicated people dying in police custody on Thursday.

“One is too many, several events is overwhelming, and that is what I get from some of the events that have occurred across Canada of people dying in police detention,” he said.

“So maybe it is time to look at an alternative format.”

Ettawakapow never aggressive with police

Ettawakapow was so intoxicated, Hardes testified, that he had to be wheeled into the detachment using a chair and carried into the cell.

It was typical for Ettawakapow to have trouble walking, Hardes told the court, as he frequently was brought into the detachment for being intoxicated.

He was never aggressive and always had a smile on his face, Hardes said. 

Wiita, who was the watch commander at the time, told court on Wednesday part of her job was to do physical checks on inmates three times a shift. Civilian guards were responsible for the other monitoring.

It was Wiita who found Ettawakapow unresponsive around 1:30 a.m., when she did a physical check. 

“Would it surprise you to know the video shows you checking the prisoner by opening the window at 1:30 in the morning and no other physical checks were done?” Judge Colli asked the officer.

“That would shock me, yes,” she replied, adding “if they [the guards] couldn’t confirm his rousability in another way, they should be doing a physical check.”

New training for guards coming

The RCMP has declined to comment on the proceedings, saying the force will wait until it has reviewed the final inquest report.

Brenna Dixon, the legal counsel for the federal Department of Justice, said in court that new training for guards is underway, and a new policy says a senior officer must refresh all guards on current policies every six months.

A portrait of a man sitting at a desk with glasses and a long beard.
Winnipeg’s Main Street Project sees about 8,000 people a year who are brought in by police for public intoxication, executive director Jamil Mahmood told court. Main Street Project’s protective care facility is staffed 24 hours a day with two paramedics. (Holly Caruk/CBC)

Jamil Mahmood, executive director of the Main Street Project in Winnipeg, also testified Thursday morning about how Winnipeg police handle people who are intoxicated. 

They are taken to Main Street Project’s protective care facility by police, where they are supervised around the clock by staff and two paramedics. Main Street Project takes in about 8,000 people a year, he said.

While the facility isn’t perfect, “the model is the safer model” instead of police detention, he told the court.

The inquest is scheduled to last until Friday.

An inquest does not make a finding of criminal responsibility, but determines the circumstances surrounding the death and whether anything can be done to prevent similar deaths in the future.