Prisoners continue to die in custody as fatality inquiry recommendations ignored

A blue binder, filled with the names of the dead, sits before Edmonton lawyer Tom Engel as he explains why for years he has tried, in some small measure, to do work the government will not.

Inside the binder are fatality inquiry reports of those who died while in police or prison custody. Marvin Redcrow, Vincent Beaudry, Edward Snowshoe sixteen in all.

"I track them because when I go and do a fatality inquiry, I want to show the judge that what he or she is dealing with has been dealt with before and recommendations were made," Engel said, "and this institution has not followed them and the government hasn't done a damn thing about it."

• READ:Family says Alberta fatality inquiry system failed them and their mother
• READ:Alberta's fatality inquiry system dysfunctional, says internal document

Engel has acted as legal counsel for families in at least 10 fatality inquiries since 1994. The province orders a public fatality inquiry in cases where a death was preventable, or requires greater public scrutiny or investigation.

At the end of an inquiry, a provincial court judge may issue recommendations to prevent similar deaths in future. But the province does not track the recommendations and, under the current legislation, it can't force institutions to comply with them.

"I think (judges) would be shocked to find out that the recommendations are not enforced at all," Engel said.

"There is no accountability for it, no transparency once the recommendations are made."

Recommendations repeated

Engel said, as a result, he sees the same recommendations over and over again.

Ken Buffalo died in a Wetaskiwin RCMP holding cell on March 29, 2002 from a drug and alcohol overdose, just hours after he was arrested. Police confiscated a bottle of pills from Buffalo before putting him in his cell.

In Buffalo's six-page fatality inquiry report, the judge recommended RCMP policy "should be reviewed to ensure recognition and awareness of the procedures when encountering arrests involving intoxication by alcohol, drugs, or (a) combination."

I think (judges) would be shocked to find out that the recommendations are not enforced at all.- Tom Engel, lawyer

The judge's statement almost could have been lifted from a fatality inquiry report into a death that had occurred eight years earlier. At the end of the 1994 inquiry into Chester Saddleback's death in Ponoka, another judge recommended RCMP officer training "should include a segment on decision making when encountering arrests involving intoxication by drugs, or drugs and alcohol, and whether medical intervention is warranted."

Engel said because the government does not track and enforce the recommendations from fatality inquiries, there is no one to coordinate a cross-provincial response.

"If it happened in an Edmonton Police Service lockup, that is relevant to all lockups in the province," he said.

No enforcement

Engeloften follows up fatality inquiries by asking the government to explain what it, or other institutions, have done to comply with the recommendations. He said the responses he receives have been "underwhelming."

In one Feb. 14, 2012 response, then justice minister Jonathan Denis told Engel: "Our practice in the fatality inquiry process is to review and then forward all police in-custody fatality related inquiry reports to Alberta's police services for their information.

"My ministry invites responses from the agencies but they are not required to provide them," Denis said.

Engel said the provincial government should not only table fatality inquiry reports in the legislature, it should task a legislative officer - like the ombudsman - with ensuring institutions comply with the recommendations made by judges.

"There has to be accountability on the part of the solicitor general and the government to enforce these things where the government agrees with them," he said.

The deaths of prisoners should trouble the public, Engel said, because at the time of their deaths, they were "at the mercy of the state".

"And so when prisoners die, everybody ought to be concerned about whether there was any responsibility on the part of the state for that death," he said.