It was just after 10 p.m. on a Wednesday when the 911 call came in to RCMP in Gods Lake Narrows, Man.
A young woman had taken pills, the caller said. She was drinking, possibly suicidal and needed to be checked on.
That began a series of events that ended with the death of Tracy Okemow, 31. By then, she’d spent nine hours in an RCMP jail cell in 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 of 61 CBC has documented across the country involving people who died in police custody after being arrested while believed to be intoxicated.
More than a dozen of those stories are similar to Okemow’s, in that the people who died were in medical distress and in need of health care — but housed in a jail cell instead.
Unlike some others, Okemow’s death wasn’t investigated by a police watchdog or through a judicial death review. Such reviews look into the circumstances of deaths in custody and make recommendations to prevent similar incidents.
Her death was reviewed by the Brandon Police Service, which detailed her final 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 made through 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 Okemow after that 911 call on Nov. 28, 2012, they found two empty pill bottles at her home. Initially, she admitted to ingesting too much metformin — a commonly prescribed Type 2 diabetes 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.
Nurses tested her blood and an on-call doctor gave two options for Okemow’s medical treatment: medically transport her to Thompson for further observation or keep her in RCMP holding cells for the night.
When the nurse hesitated and asked again if she should send Okemow to 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 after his sister’s death:
Guards and people who had been in nearby cells later 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 the separate investigation, but that report was not made public. Although Okemow’s death 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 have resulted 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 Doering lied, saying she’d been medically cleared by 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 hood — a device police can use if they believe the person in custody might spit or bite them — after his arrest.
The convictions were overturned on appeal and a new trial is scheduled for next year.
In Manitoba, public inquests are called by the chief medical examiner and presided over by a provincial court judge. Up until legislative changes in 2017, they were mandatory when someone died in police custody.
Now, when a death has been deemed 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 not comment.
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 confidence in the chief medical examiner’s decision.
Wayne Okemow, Tracy Okemow’s uncle, says he wants more than an inquest. He wants a public inquiry into her death.
More complex and costly than an inquest, a public inquiry would aim to establish the facts around what happened, why it happened and who may be accountable under government-mandated terms of reference.
“No 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 show racism, 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, who used 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 are an 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 this is a health issue and not a criminal issue.”
RCMP thought Okemow was ‘sobering up’
Manitoba RCMP says the Thompson doctor’s medical assessment is the reason Okemow 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 RCMP of wrongdoing but recommended a review of policies on monitoring prisoners and seeking medical 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 who medically 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 a hospital, 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 police no longer has the ability to care for themselves.
“They are solely reliant on police,” she said.
“That is a responsibility and a duty of those police officers.”