Raymond Silverfox spent the last 13 hours of his life moaning in pain while lying in a vomit and filth-covered police cell before succumbing to toxic bacteria he’d sucked into his lungs.
It was a natural death, ruled a coroner’s jury after hearing seven days of disturbing testimony in a Yukon court.
The decision was rendered Friday night after the jury heard from Deanna Charlie, Silverfox’s only daughter and the last of more than two dozen witnesses.
She read a victim-impact statement.
“I miss my dad so much,” she said with tears in her eyes.
“He was always there for me. He is gone; I cannot believe he is not here with me now.”
On December 2, 2008, Silverfox was taken to the RCMP drunk tank after vomiting several times at the Salvation Army shelter.
The rest of his life was spent in police custody, most of it lying on the floor, sometimes in the fetal position, in a puddle of his own urine, feces and vomit.
Silverfox vomited 26 times that day.
The 43-year-old Carmacks man received no help from RCMP and guards until he stopped moving and had to be transferred to the hospital, where he later died.
A forensic pathologist found the cause of death to be acute pneumonia and sepsis – a toxic lung infection probably caused from inhaling his own vomit.
Charlie has lost faith in a system that’s supposed to protect people in need, she said.
“I pray and wish that the right decision be made at this inquest, so no other families will encounter the devastation I had over the loss of my dad.”
Three hours later, the six-member jury issued its decision.
The scant, two-page document recommended the RCMP establish a community group to review the issue of public intoxication.
This group would include Yukon First Nations, the medical community, the Yukon government and the Salvation Army.
The jury wants the group to provide possible alternatives to incarceration for intoxicated people and to examine the medical care they receive.
It also recommended the RCMP hold monthly joint health-and-safety committee meetings, which include guards.
Guard staffing levels should be increased in the cell block, the jury wrote.
And guards should be paid more, and be trained better.
The RCMP is not compelled to implement any of these findings.
On Monday, Liberal Leader Arthur Mitchell urged the Yukon government to conduct a public inquiry into Silverfox’s death.
It would determine whether there were steps that should have been taken to prevent his death.
It would also examine whether the changes already made to RCMP procedures since the death are sufficient to prevent similar incidents in the future.
Silverfox family lawyer Susan Roothman welcomes such an inquiry.
A broader inquiry could look at systemic problems and other incidents, she said.
Silverfox is the 10th person to die in police custody in the past 20 years.
Some of those other deaths occurred under similar circumstances.
In 1995, Robert Keddie died while in RCMP custody.
Despite definite indicators that he was ill, suffering from acute alcohol poisoning and was not fully conscious, he was not given access to medical treatment.
In March 2000, Fred Stewart died of “accidental death from acute alcohol poisoning.”
And three months later, Madeleine Henry died in the drunk tank after having a seizure.
She was taken to Whitehorse General Hospital in a coma, where she died two weeks later due to complications relating to pneumonia.
Henry was carrying seizure medication at the time, but police refused to supply them to her, according to her partner Arthur Joe.
After each of these incidents, inquests were held and recommendations were made.
It was suggested an alarm bell be used in an emergency and it should be easily accessible by a guard.
The day Silverfox died, this emergency button was pushed twice, but didn’t work.
It was recommended police and guards receive more education on recognition of medical conditions of prisoners, including alcohol poisoning and drug overdose.
But guards and police never realized that Silverfox was anything other than intoxicated until he became unresponsive.
Guards were to document in their log notes whether they have completed a physical or monitor check on a prisoner.
This wasn’t done the day Silverfox died.
And the Henry inquest also recommended a committee be formed with representatives from the government, police, medical workers and the Salvation Army to develop care and prevention for individuals who are addicted to alcohol and other substances.
Seven years later that hasn’t been done.
The jury at the Silverfox inquest recommended a nearly identical committee be formed to look at public intoxication.
During the last day of the inquest, the jury heard that there would be no criminal charges laid against anyone involved.
The RCMP primary investigator, Sgt. Gary Heebner, looked into two specific charges: duty to provide care and causing death by criminal negligence.
No one rose to the level of criminal negligence, he said.
There was not an attempt to deprive nor wanton behaviour that would raise to a criminal level.
However, Const. Geoff Corbett is under a code of conduct investigation for his “sleep in your own shit” comment.
The RCMP has made a number of changes since Silverfox’s death.
A confusing and contradictory policy has been tightened up.
And police now call emergency medical services more often.
In 2008, the ambulance was called to RCMP holding cells 174 times.
In 2009, it was called 417 times.
Also on Monday in the legislature, NDP MLA Steve Cardiff urged the government to establish a medical detoxification unit.
It would provide patients with flexible and appropriate care and alleviate the overuse of hospital and ambulance services for substance abuse problems.
It would also prevent needless deaths, Cardiff said.
Contact Chris Oke at