More than eight years after a woman died while in the custody of White Rock RCMP, officials with the Independent Investigations Office say a “negligent attitude” towards the woman’s deteriorating condition likely contributed – but not to the point of criminal negligence.
In a report released May 7, IIO chief civilian director Ronald MacDonald notes that while investigation found the negligence — displayed by “White Rock detachment staff, officers and civilian guards alike” towards Patricia Anne Wilson — did not meet the threshold for a criminal charge, “serious mistakes can be said to have been made.”
“It could quite reasonably be concluded in this case that (Wilson’s) death was the cumulative result of poor training, lack of adherence to established policies, the misinterpretation of her symptoms, and the established protocols that invited mistakes by those charged with her care, in particular the police officers and civilian guards,” MacDonald writes.
“The situation was undoubtedly further complicated by the stigma associated with drug addiction and the underappreciation of the risks associated with detoxification.”
Arrested March 25, 2016, Wilson was being held for an appearance in Surrey provincial court at the time of her death.
MacDonald’s report does not identify her as the deceased, however, Peace Arch News has reported on the 58-year-old’s demise since it was made public eight years ago. At the time, former classmates described the longtime Semiahmoo Peninsula resident as “a kind and gentle soul (who) had a hard life.”
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On the day she died, Wilson — who struggled with addiction throughout her adult life — was found unresponsive at approximately 10:30 a.m., less than four hours after having been assessed by paramedics.
According to the IIO report, she told officers who arrested her that she had last used drugs the day before and that she felt like she was “coming down with the flu.”
In a detailed day-by-day recounting, MacDonald states Wilson went from being described by jail guards and officers as “comfortable” and “restless” on the first day of custody, to yelling “need a nurse” on Day 3. The appeal was not investigated by the on-duty guard, the report notes.
On her fourth day in cells, Wilson complained of being in pain and asked for medication. Log notes indicate an officer was notified and that Wilson said she didn’t want to be seen by paramedics. The officer made note that she wasn’t eating and was sick, “likely from detoxing.”
Later that day, she was noted to be less coherent, not eating and restless. That night, she again complained of pain, but the guard “took no action,” according to the report.
Regarding her final night, MacDonald said CCTV footage from Wilson’s cell shows she was unsteady on her feet, crawling at times, holding her abdomen on several occasions and using the toilet multiple times over a period of minutes. Much of what was recorded on video, however, was not logged by the jail guard, the report notes.
Asked just after 7 a.m. on March 29 if she would like to be seen by paramedics, Wilson said she would, and a “routine” request was made, the report continues. The assessment took three minutes, and Wilson was told that paramedics said she would feel better after a bowel movement.
While one of the attending paramedics told the IIO that Wilson “needed to go to the hospital, but the decision was (up to the officers), as she had refused treatment,” the officers in question said they were advised that Wilson “would be fine.”
Log notes from 9:50 a.m. March 29 state things were “all good,” however, on CCTV, Wilson “appears distressed,” MacDonald writes.
At 10:19 a.m., prisoners were logged as “all breathing,” but on CCTV three minutes later, Wilson “no longer appears to be moving at all,” MacDonald continues.
“No medical intervention was ever administered after it was discovered that she had stopped breathing,” he adds.
The director notes policy at the White Rock detachment mandates measures including physical checks of prisoners every hour; that notes of medical issues and observations be logged; and for immediate notification of EHS (Emergency Health Services) “if there is any indication that a prisoner needs medical attention.”
Paramedics, he adds, must take a prisoner who appears to need medical attention to hospital.
MacDonald found “a combination of factors,” including a lack of adherence to such policy, contributed to officers not having a better understanding of Wilson’s deteriorating condition.
He notes “significant positive changes” at the detachment — including not to detain prisoners for more than four days — followed a February 2018 management review that identified deficiencies including in cell checks and documentation, compliance with guard-training requirements, and checking responsiveness of intoxicated prisoners.
Policy failures at the time of Wilson’s death included “clearly unsatisfactory” attention to the prisoner care and detachment policies by one officer, lack of guard adherence to mandated prisoner checks, irregular cell-block attendance by watch commanders, and insufficient documentation of prisoner activity and well-being.
The “negligent attitude” towards Wilson’s welfare, however, was most significant, MacDonald states.
“After all, the behaviours and actions of (Wilson), especially the symptoms of delusion, vomiting, unsteadiness, failure to eat, and incontinence ought to have been enough to lead to a conclusion that (she) was in need of medical attention earlier than the morning of March 29,” he writes.
He states there is “no doubt” that advice received from the paramedics who last assessed Wilson played a role in the inaction.
Ultimately, MacDonald said the inaction by officers did not show a wanton and reckless disregard for human life.
“Mistakes were made, but the behaviour was based on misunderstanding (Wilson’s) condition, being too quick to attribute it to drug withdrawal symptoms, and assuming those were not life-threatening.”
Responsibility for failures to adhere, review and follow policy flowed upwards through the RCMP system, MacDonald adds, “through progressively senior ranks, implicating the organization as a whole.”
While the possibility of “organizational criminal liability” made the investigation “rather unique,” it was ultimately ruled out.
“Rather, the evidence appears to show a significant degree of bureaucratic inadequacy — not so much wilful blindness to risk as failures of the organizational will to adequately minimize that risk through effective training, monitoring and quality control in the hiring, training and supervision of staff.”
Contacted by PAN for comment, White Rock RCMP Staff Sgt. Rob Dixon — who took on the role of detachment commander in November 2023 — said this week he could not “provide anything additional to what is contained in the report.”
Dixon did confirm that there have been no in-custody deaths at the detachment in the years since Wilson died.
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As of Friday (May 10, 2024), the coroner’s investigation into Wilson’s death was ongoing. MacDonald’s report notes that opiate abuse and withdrawal were likely complicating factors.
In 2021, Wilson’s daughter told PAN that the family had learned their mom died from blood poisoning. At that time, Ely Wilson — who was not available to comment prior to ʴ’s press deadline this week — said she and her siblings believed a lack of training and an inability “to understand the fact that drug withdrawals can be deadly to people,” may have played a role in their mom’s death.
“We just want to make sure this doesn’t happen to someone else,” she said.
IIO investigations are typically focused on determining whether police action or inaction contributed to an injury or death. In some cases, suggestions for improvement or change are made.
Wilson’s case, MacDonald states, provides an opportunity for additional discussion around a secure health-care facility being a more appropriate place than police custody for holding individuals with substance abuse and physical ailments.
He made the same suggestion — for what he called “sobering centres” — following a 2019 case in which an individual died in Kamloops cells.
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Other suggestions noted in MacDonald’s latest report include for regular audits of police lockup facilities, to confirm daily practices meet required standards; and for standardized training for jail guards and officers that includes the dangers of substance withdrawal, fulsome notes in prisoner logs and unconscious bias training.
