She needed medical help. Instead she died in police custody. 10 years later, her family wants accountability

It was just after 10 p.m. on a Wednesday when the 911 call came in to RCMP inGods Lake Narrows, Man.

A young woman had taken pills, the caller said. She was drinking, possibly suicidal andneeded to be checked on.

That began a series of events that ended with the death ofTracy Okemow, 31. By then, she'dspentnine hours in an RCMP jail cellin the town about 550 kilometres northeast of Winnipeg, slowly overdosing on diabetes medication.

"They brushed her off and let her be sick in the cell all night long ...being tormented," said Ralph Okemow, Tracy's brother.

Tracy Okemow's death in 2012 is one of61CBC has documented across the countryinvolving people who died in police custody after being arrested whilebelieved to be intoxicated.

More than a dozenof those stories aresimilarto Okemow's,in that the people who died were in medical distress and in need of health carebuthoused in a jail cell instead.

Unlike some others, Okemow'sdeath wasn't investigated by a police watchdog or through a judicial death review. Such reviews lookinto the circumstances of deaths in custody and makerecommendations to prevent similar incidents.

Her death was reviewed by the Brandon Police Service, which detailed herfinal hours in an 11-page investigative review obtained by CBC through freedom of information laws.

That report said decisions on Okemow's medical care were madethrough a phone consultation with an on-call doctor in Thompson, Man., more than 250 kilometres away.

Empty pill bottles found

When RCMP officers went to check on Okemowafter that 911 call on Nov. 28, 2012,they found two empty pill bottles at her home. Initially, she admitted to ingesting too much metformina commonly prescribed Type 2diabetes drug. She then backtracked and said she hadn't taken anything.

She voluntarily went with police to the Gods Lake Narrows nursing station, which provided the only medical care available in the northeastern Manitoba fly-in community.

Nursestested her blood and an on-call doctor gavetwo options for Okemow'smedical treatment: medically transportherto Thompson for further observation or keepher in RCMPholding cells for the night.

When the nurse hesitated and asked again if she should sendOkemowto Thompson, the doctor said, "send her to the cells," according to the report

Okemow was not accused of, or charged with, a crime, but under provincial legislation, police can detain an intoxicated person if they feel they are a danger to themselves or others.

WATCH | Ralph Okemow speaks at a 2012 news conference afterhis sister's death:

First Nation blames RCMP for in-custody death

12 years ago

Duration 1:45

Northern Manitoba First Nations leaders accuse RCMP and Health Canada of being negligent in their handling of a Gods Lake Narrows woman who died in custody.

Guards and people who had been in nearby cellslater told investigators Okemow was moaning throughout the night.

Based on witness accounts, "it sounded like Okemow wanted medical attention and was in agony all night," the Brandon police review said.

When officers checked on her in the morning, she was barely conscious. She was transported by medevac to Winnipeg but died the next day.

At the time of her death, the Independent Investigation Unit of Manitoba the province's police watchdog had yet to be established.

RCMP assigned Brandon police to conduct theseparate investigation, but that report was not made public. Although Okemow'sdeath happened while she was in police custody,there was never an inquest.

"It's just ridiculous," said Ralph Okemow,who had not read the report until CBC obtained it.

Charges for in-custody deaths rare

In-custody deaths of this nature haveresulted in criminal charges only twice since 2010,according to a CBC analysis.

A London, Ont.,police officer was found guilty in November 2019 of criminal negligence causing death and failing to provide the necessaries of life to Debralee Chrisjohn, 39, of Oneida Nation of the Thames, who died following her 2016 arrest.

A court heard that while transferring Chrisjohn into OPP custody, Const. Nicholas Doeringlied, saying she'dbeen medically clearedby paramedics.

He has appealed the court's decision.

That same month, two special constables in Halifax were convicted of criminal negligence in the 2015 death of Corey Rogers, 41. He choked on his own vomit while wearing a spit hooda device police can use if they believe the person in custody might spit or bite themafter his arrest.

The convictions wereoverturned on appeal and a new trial is scheduled for next year.

In Manitoba, public inquests are called by thechief medical examiner and presided over by a provincial court judge.Up until legislativechanges in 2017, they were mandatory when someone died in police custody.

Now, when a death has beendeemed the result of natural causes, the examiner has the option not to call one.

It's not clear why there wasn't an inquest for Okemow's death, which happened before the new legislation. The office of the current chief examiner said it could notcomment.

Justice Minister Cameron Friesen has the power to order an inquest in Okemow's death, but has refused to do so, telling CBC News he has confidencein the chief medical examiner's decision.

Wayne Okemow, Tracy Okemow's uncle, says he wants more than an inquest. He wants a publicinquiry into her death.

Family members of Tracy Okemow want an inquest into her 2012 death

3 years ago

Duration 3:19

Over 60 people in Canada have died in police custody since 2010 after being arrested while intoxicated. In dozens of those cases, the person in custody wasn't properly monitored or their deteriorating health condition wasn't addressed.

More complex and costly than aninquest, a public inquirywould aim toestablish the facts around whathappened, why it happened andwho may be accountable under government-mandated terms of reference.

"No one was held accountable about what happened to her," said Wayne Okemow. "They can't sweep it under the rug. The [Brandon police] investigation is too one-sided."

Cases showracism, Grand Chief says

Arlen Dumas, the Grand Chief for the Assembly of Manitoba Chiefs, said the deaths of Tracy Okemow and John Ettawakapow who died in The Pas in 2019 are examples of systemic racism and institutional bias within the criminal justice system.

"I think it's complete negligence," said Dumas, whoused to work as a guard at the RCMP detachment in his home community in Pukatwagan, Man.

"I think that these losses that you have identified arean example of systemic race and racism that still continues."

He said Indigenous people, especially when suspected of being intoxicated, are not assessed fairly by police or medical professionals.

"This racism has fatal consequences," he said. "I will reiterate that thisis a health issue and not a criminal issue."

RCMPthought Okemow was 'sobering up'

Manitoba RCMPsays the Thompson doctor's medical assessment isthe reasonOkemow did not receive any further medical care during her nine hours in the Gods Lake Narrows cell.

"RCMP members and civilian guards had no reason to believe harm would come to Okemow after being medically cleared to be in cells," a spokesperson wrote in a prepared statement. "It would be reasonable to believe that Okemow was only suffering the effects of sobering up."

Okemow's autopsy found she died of a metformin overdose. Several other prescription pills were found in her system, including diazepam (sometimes marketed as Valium).

The Brandon police report cleared RCMPof wrongdoing but recommended areview ofpolicies on monitoringprisonersand seekingmedical attention for someone who appears to be unconscious.

The report assigns some blame to medical staff, stating "the threat of overdose should have been taken more seriously" by those whomedically cleared her.

Red flags missed:endocrinologist

Dr. David Lau, an endocrinologist and University of Calgary professor, reviewed Okemow's death report and suggested the best course of action would have been taking her to ahospital, not a holding cell.

There were many red flags indicating her diabetes was not under control, and she should have received a series of blood tests while being closely medically monitored, Lau said.

Caitlyn Kasper, a senior lawyer with Aboriginal Legal Services in Toronto, says a person detained by policeno longer has theability to care for themselves.

"They are solely reliant on police," she said.

"That is a responsibility and a duty of those police officers."