First responders did nothing wrong in dealing with man on meth who later died: judge

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An inquest judge said nothing more could have been done to save a man who died one week after he was restrained by police while he was high on meth and acting out on the Assiniboine Riverwalk.

“There is no evidence that the police or medical personnel could have done anything more than they did,” wrote provincial court Judge Sandra Chapman in a report released Friday that gave no recommendations from the review of the case.

The death of Aaron Ross, 27, in hospital on Sept. 30, 2019, was “untimely” and “tragic,” the judge said.

Provincial law requires an inquest be held when a person dies while in custody of police or corrections staff, and make recommendations to prevent similar fatalities.

Chief medical examiner Dr. John Younes determined Ross’s cause of death was a brain injury caused by lack of oxygen due to cardiac arrest linked to meth toxicity.

A contributing factor was the physical stress of struggle and restraint by police, the report said.

Chapman wrote that an official working group should be formed to examine whether blood samples can be taken from patients who appear to be suffering from drug toxicity, in case it’s needed for autopsies.

In Ross’s case, no blood sample was analyzed and the urine sample that was taken never made it to medical examiner’s office. Younes only became aware of the methamphetamine found in Ross’s urine at the inquest.

On Sept. 23, 2019, Ross was observed behaving erratically near the riverbank at Assiniboine Avenue and Kennedy Street.

Police responded after residents had reported Ross was yelling and taking his clothes off, then fell back and hit his head on a curb on the riverwalk.

He continued to flail, so an acting patrol sergeant got a RIPP hobble device, a kind of belt used to restrict movement of ankles, knees or elbows.

While restrained, Ross then stopped yelling and possibly stopped breathing, so officers rolled him onto his back, gave him chest compressions as they waited for paramedics. He began to breathe and speak nonsensically again, as he was placed on his side.

Paramedics arrived at about 1:12 a.m. and eventually gave Ross sedatives to calm him down. Police removed the cuffs and he was placed on a backboard, but Ross’s breathing and heart rate ceased.

It took two minutes of chest compression for Ross to regain a pulse and he was rushed to hospital, but he experienced cardiac arrest. Within days, doctors determined he had suffered a catastrophic brain injury and he later died.

In his 2021 autopsy report on Ross, Younes used the term “excited delirium” — a controversial term that has been debunked.

He has since said he will avoid using the term in future autopsy reports.

Chapman’s inquest report noted the concept is no longer in vogue with the medical community and isn’t used by city police or the Winnipeg Fire Paramedic Service. It was in use locally at the time of Ross’s death and though city police no longer use the term, that’s what officers suspected was happening upon finding Ross.

Younes told the inquest “the difficulty” with the term from a medical standpoint is that it was listed as a cause of death without further explanation of the underlying causes.

Winnipeg police told the inquest they’ve stopped using the term.

The situation Ross was found in would now be described as an “agitated chaotic event,” said Chapman, which is typically caused by drug use or mental health issues.

“Basically, an agitated chaotic event is one where an individual’s behaviour suggests to the first responders that this could be a medical event, requiring police intervention, only to the extent that they are required to ensure the safety of the individual or the public,” said Chapman.

erik.pindera@freepress.mb.ca