RCMP Watch

RCMP officers failed to follow their own policies and were guilty of a “critical delay” in getting medical help for a northern Manitoba man who died in their care, an inquest has found.

Provincial court Judge Brian Colli released a 22-page report Wednesday on the October 2003 death of Sherrill Forbister in Norway House.

Colli said police should have seen Forbister was taken immediately to hospital after finding him passed out inside a home, fresh blood near his eye and “growling or moaning” when they tried to rouse him.

Instead, the officers got him to their cruiser car, laid him in the back seat and headed for their detachment to put him in a holding cell.

They discovered he wasn’t breathing after carrying him out of their vehicle. He was taken to hospital by ambulance but pronounced dead.

“The decision to detain Mr. Forbister without seeking a medical opinion contributed to the risk of death in this case,” Colli wrote in his report.

Thambirajah Balachandra, the province’s chief medical officer, conducted Forbister’s autopsy and told the inquest he could have been saved had he got to hospital while still breathing and with a pulse.

Tests showed Forbister’s blood-alcohol level was .415, more than five times the legal limit for driving.

Colli noted the two officers who dealt with Forbister admitted they hadn’t read their own policies regarding assessing responsiveness and obtaining medical help.

If they had, the officers would know they were required to seek “immediate” medical help based on Forbister’s “copious” consumption of alcohol combined with his inability to even walk or sit up on his own.

“I have no doubt that the officers made the decision they did because they believed Mr. Forbister was not in crisis and that medical intervention was not required,” said Colli.

“While this opinion was formed honestly and in good faith, it was erroneous. More to the point, the decision reached to lodge Mr. Forbister in cells was not in accordance with the policy of the RCMP.”

Colli said it likely would have been a “close call” if police had summoned immediate medical help.

The judge also took aim at the provincial and federal governments, saying there is clearly a “lack of support for members working in the field and the extreme working conditions” in Norway House.”Officers do not have sufficient time to read and learn policy,” said Colli.
He cited the cutting of the band constable program — which has since been restored — as putting additional pressures on officers working in the northern detachment. Other factors include a sharp rise in drug and alcohol abuse and general lack of respect towards police.

Colli was also critical of the delay in getting an ambulance to respond to the police call. It took 22 minutes for paramedics to arrive at the police station, about double the expected response time in the community.

The inquest was told government budget cuts have left only one full-time ambulance being staffed in the community, and they were already tied up with another call related to the same drinking party Forbister had been at.

That meant volunteers had to be located and called in to drive the community’s second ambulance.

“These matters concern me because they… suggest that the emergency service program in the community is operating at the edge,” said Colli.

The judge said the ambulance delay likely wasn’t the difference between life or death in this case because Forbister’s condition had already worsened too much in the company of police.

One final target of Colli’s gavel was a lack of public awareness about the hazards of drinking to excess. He noted that from 2000-2004, 75 people in Manitoba died from excessive drinking.

Balachandra testified the frequency of drinking deaths is not well-publicized because his office is constrained from releasing much information because of privacy laws.

Colli said that must change.

Changes urged
* Approx. 8:40 a.m.: time police arrived on scene and discovered an unresponsive Forbister
* 9 a.m.: time police left the scene with Forbister in their back seat
* 9:10 a.m.: time police discovered he wasn’t breathing
* 9:11: time medical call made to ambulance
* 9:33: time ambulance arrived
* 22 minutes: time it took for ambulance to arrive at Norway House police detachment following police call for help
* 10-15 minutes: the normal average paramedic response time in Norway House
* 9 minutes: the normal average response time in Manitoba
* 1: number of ambulances in Norway House with full-time staff

JUDGE’S RECOMMENDATIONS
Provincial court Judge Brian Colli has made the following recommendations:
* The “core” policies of RCMP must be identified and made the subject of formal training for all police cadets and field officers.
* No future cadet should enter the field without verification of his/her understanding of “core” policies.
* The Department of Justice should work with the office of the Chief Medical Examiner to develop a policy of maximum disclosure pertaining to deaths caused by alcohol poisoning, subject to existing privacy concerns.
* The Department of Health and Manitoba Liquor Control Commission should jointly develop a strategy for publishing information about deaths from alcohol poisoning to ensure its “broad dissemination”.
* The province of Manitoba and MLCC should consider providing funding to Norway House to further the community’s alcohol strategy.