Death of man during well-being call on Winnipeg riverbank 'tragic,' but police acted reasonably: inquest

The inquest into the death of a man who went into cardiac arrest while police were responding to a well-being call near Winnipeg's riverwalk has determined police and medical personnel acted reasonably during the incident, and there was nothing they could have done differently to save the man.

Aaron Ross, 27, died on Sept. 30, 2019, several days after he suffered cardiac arrest on the riverbank. An autopsy confirmed he died from an anoxic brain injury — a lack of oxygen to the brain — due to complications of the cardiac arrest, which in turn was the result of methamphetamine toxicity, according to an inquest report dated July 15.

However, the report also identifies the "physiological stress of struggle and restraint by police" as a "significant" contribution to his death.

An inquest into his death was called in June 2021 after the Independent Investigation Unit of Manitoba, the province's police watchdog agency, cleared the officers who treated him during a well-being call of any wrongdoing.  

In the final inquest report, provincial court Judge Sandra Chapman said Ross's death was a "tragic incident," adding that "unfortunately, these types of incidents are more and more prevalent" in Manitoba.

However, she made no recommendations for first responders to prevent similar deaths from happening in the future.

"The police officers and the paramedics all performed in accordance with the relevant policies and their training. Their actions were reasonable in the circumstances," Chapman wrote in the 31-page report.

Winnipeg police responded to a well-being call just before 1 a.m. on Sept. 23, 2019, after getting a call about a naked man behaving erratically on the riverbank near Assiniboine Avenue and Kennedy Street, close to the Manitoba Legislative Building.

People living in the area told police they saw Ross take his clothes off and said he was yelling nonsensically before he fell backwards, hitting his head on what appeared to be the curb of the riverwalk, the inquest report said. 

Officers told the inquest they found Ross lying on his back, yelling randomly, and as they approached, he stood up and started walking toward the river.

The officers testified they feared for his safety, and tried to bring him down to the ground. After a struggle, they got him down on the ground, face-down, and handcuffed him. He continued to flail around while on the ground, the inquest heard.

Paramedics were called due to concern Ross's behaviour suggested he could be having a medical event. The first medic to arrive was unable to calm him down, so he was sedated.

Ross later became unresponsive and he was resuscitated before being taken to St. Boniface Hospital, where he died a week later.

Response time gap

Manitoba's chief medical examiner also initially said Ross's death was due in part to "excited delirium" — a term the inquest notes Winnipeg police have stopped using because "it is in fact a medical term and one that they may not be clinically trained to determine," the inquest report says.

A situation such as Ross's is now called "an agitated chaotic event," the report says.

Evidence at the inquest suggested Winnipeg police followed the appropriate protocols, including calling for paramedics and only intervening when Ross's safety was in question, and over the shortest amount of time possible, Chapman said. 

However, she noted there was a gap between when police arrived and the arrival of paramedics.

"I cannot say in this case that the attendance of the advanced care paramedic with the police would have made a difference, but possibly it may have," she said.

Recommendations from an inquest into the August 2019 death of Viengxay Chommany, who died after police subdued him with a stun gun, have already been made to reduce that gap, Chapman's report notes. Those include a review of the Winnipeg Police Service's policy and training to emphasize the use of de-escalation techniques.

The judge in the Chommany inquest also recommended that Winnipeg police and the Winnipeg Fire Paramedic Service establish a specialized unit specifically trained to respond to "agitated chaotic events," saying that sending out both a police officer and a medically trained person who could administer a sedative if required would "reduce the gap time" and get people in distress into care sooner.

Chapman's report said she has been told those recommendations are being looked into, and she opted not to not make new recommendations. 

She also said training of first responders has increased over the years since Ross's death.

Recommendation on blood samples

Chapman did, however, make a recommendation stemming from concerns around a blood sample in Ross's case.

Dr. John Younes, Manitoba's chief medical officer, told the inquest he couldn't initially determine with certainty whether Ross's behaviour was connected with substance abuse, because there was no blood sample analyzed that would give him that information.

Angela Ross, who spoke on behalf of the victim's family, told the inquest her family found it hard to understand how Aaron Ross died, given that no one in the family had any previous knowledge that he had used drugs.

Younes, in his testimony, asked the court to consider recommending that in situations like Ross's, the emergency doctor requests a blood sample when the person is admitted to hospital. He recommended that be stored until the patient's release or their death, saying those samples could be "significant" in determining a cause of death.

However, concerns were raised at the inquest on the ethics of that recommendation, since it would involve requesting blood for a purpose other than medical care, and could involve taking blood without a patient's consent.

Chapman recommended a working group be created — including the chief medical examiner, other medical leaders and a medical ethicist — to examine events involving drug toxicity and determine whether it's feasible to ensure a blood sample is available for toxicology analysis in an autopsy.