A coroner’s inquest is recommending the creation of a wellness centre for people struggling with mental health and addictions in Port Alberni in the wake of a teenager’s death.
The BC Coroner’s Service held a public inquest into the death of Jocelyn George, 18, who died of heart failure in a hospital in Victoria on June 24, 2016 after transfer from police custody at the Port Alberni RCMP detachment. She had spent a day and a night in custody.
The inquest took place at the Capitol Theatre in Port Alberni from June 21-30, 2021. Presiding coroner Margaret Janzen and a jury heard testimony from approximately 30 witnesses, including paramedics, doctors and RCMP. A coroner’s inquest is designed to establish facts and not faults surrounding a death.
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Now, five years after George’s death, the jury has come up with 24 recommendations to various agencies in order to prevent future deaths from occurring. Recommendations from an inquest are suggestions; the agencies involved are not compelled to address them.
One of the jury’s recommendations, which was directed to Vancouver Island Health Authority, First Nations Health Authority, Ministry of Children and Family Development, USMA, Nuu-chah-nulth Tribal Council, Maa-nulth Nations and the Alberni-Clayoquot Regional District, proposes collaborating and creating a holistic wellness centre within the regional district.
This centre ideally would include a safe place for youth, a sobering centre, mental health and addictions beds, certified health-care professionals, an on-call physician, certified security guards and appropriate cultural and spiritual supports.
“The jury heard evidence from multiple witnesses that there is a gap in services for youth facing mental health and addictions issues who are often detained in RCMP’s cells because there is no alternative safe place for them to go,” stated the jury foreperson on June 30.
On June 28, the jury heard testimony from George’s mother Claudette Lucas, who questioned why her daughter was left in a police cell overnight without being offered any food or water, even though her behaviour was not combative, abusive or destructive.
“My daughter was stripped of her inherent right to be treated fairly, with respect and with dignity,” said Lucas. “My daughter was a child.”
Earlier medical intervention may not have saved George’s life, said Lucas, but it would have given her family a chance to say goodbye.
“We were robbed of having that opportunity,” she said.
The jury came up with 24 recommendations overall.
To the deputy commissioner of the Royal Canadian Mounted Police’s E-Division, the jury recommended the following:
1. Provide training for all members regarding the definition of the age of majority in B.C. and relevant legislative requirements regarding minors.
2. Create policies to ensure prisoners’ access to water in cells is recorded and can be confirmed by supervisory staff.
It was unclear from testimony and CCTV footage whether or not George was able to obtain water while she was in custody.
3. Create policies to ensure that when food is offered, accepted, refused or consumed by prisoners it is recorded in the guard log book. Reasons for withholding food or water should also be detailed in the log book.
Guards and RCMP members testified that George was not offered food because she was intoxicated, despite an RCMP policy that states all prisoners must be provided with food—even those who are intoxicated.
4. Ensure members’ and guards’ training includes mental health and addictions awareness, local cultural awareness and how to access employee trauma counselling.
5. Ensure that job descriptions and responsibilities for members and guards regarding prisoners are listed and available for all staff to access.
6. Install audio monitoring in cell block corridors of all RCMP detachments in B.C. within five calendar years.
7. Develop a policy requiring a release plan to ensure safety of minors upon release from custody.
The jury heard testimony that George was released from custody in wet clothes and no shoes, with no communication with her family or other agencies.
8. Require members to transport persons in detention to local health facilities for assessment when their health status is unclear.
9. Share a copy of this verdict with detachments throughout “E” division.
To the deputy commissioner of the RCMP’s E-Division, the City of Port Alberni, Minister of Public Safety and Solicitor General, Nuu-chah-nulth Tribal Council, First Nations Health Authority and Vancouver Island Health Authority, the jury recommends the following:
10. Provide an on-call health care professional to assess detainees in cells.
11. Develop a program to provide appropriate cultural support for detainees.
To Vancouver Island Health Authority, the jury recommended the following:
12. Ensure that a Crisis Response Team is available in Port Alberni on nights and weekends. The CRT is currently only available during business hours, and response is “sporadic” due to workloads.
13. Ensure an internal medicine specialist is available onsite at West Coast General Hospital in Port Alberni.
To the Ministry of Public Safety and Solicitor General and Ministry of Mental Health and Addictions, the jury recommended the following:
14. Provide permanent funding to the Port Alberni Indigenous Safety Team for a full-time social worker and youth advocate.
Testimony stated that since the Indigenous Safety Team has been in place, there has been a “decline” in people needing to go to cells due to earlier intervention.
To the City of Port Alberni and Port Alberni RCMP Detachment, the jury recommended the following:
15. Implement annual performance reviews, certifications and training for city employees working as guards at the Port Alberni RCMP detachment.
16. Implement measures to diversify work force.
To the Ministry of Mental Health and Addictions, the jury recommended the following:
17. Give special priority to youth facing addiction and mental health issues and the establishment of First Nations operated treatment centres.
To Nuu-chah-nulth Tribal Council, the jury recommended the following:
18. Provide RCMP with cultural diversity supports and support for release planning for Indigenous detainees.
To Quu’asa, the jury recommended the following:
19. Offer trauma-informed practice and seek funding for permanent harm reduction staff including a harm reduction youth worker.
To Nuu-chah-nulth Tribal Council, the City of Port Alberni, Vancouver Island Health Authority, Tseshaht First Nation, Hupacasath First Nation and the First Nations Health Authority, the jury recommended the following:
20. Collaborate to make an application to “Foundry” to provide services in Port Alberni for local, then regional populations. Foundry offers young people ages 12-24 health and wellness resources, services and supports.
To Nuu-chah-nulth Tribal Council and the City of Port Alberni, the jury recommended the following:
21. Advocate for a Justice Centre in Nuu-chah-nulth territory to address the over-representation of First Nations people in custody.
To the Independent Investigations Office, the jury recommended the following:
22. Appoint a First Nations civilian monitor in all cases where the affected person is Indigenous.
To the City of Port Alberni, Nuu-chah-nulth Tribal Council, and deputy commissioner of the Royal Canadian Mounted Police E-Division, the jury recommended the following:
23. Seek membership on the board of directors of the Port Alberni Shelter Society.
To the Vancouver Island Health Authority, First Nations Health Authority, Ministry of Children and Family Development, USMA, Nuu-chah-nulth Tribal Council, Maa-nulth Nations and Alberni-Clayoquot Regional District, the jury recommended the following:
24. Collaborate and create a holistic wellness centre within the regional district that includes a safe place for youth, a sobering centre, mental health and addictions beds, certified health-care professionals, an on-call physician, certified security guards and appropriate cultural and spiritual supports.
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