British Columbia's coroner system questioned by forensic pathologist

May 6, 2010
By Carlito Pablo, The Georgia Straight

Forensic pathologist John Butt wants B.C. to introduce a medical examiner system; currently, the chief coroner isn’t required to have a medical background.
A renowned forensic pathologist says B.C. should change its system for investigating sudden deaths.

John Butt is recommending a shift from the current coroner setup to a medical examiner system, which is used in a number of other provinces, namely Alberta, Manitoba, Nova Scotia, and Newfoundland and Labrador.

“In the investigation of sudden death, there are five questions that have to be answered,” Butt explained to the Georgia Straight in a phone interview. “The question that carries the greatest responsibility and is commonest and costs the most money is the question ‘Why?’, which is the medical cause of death.”

Butt is a former chief medical examiner for Alberta and Nova Scotia. He now works in Vancouver as a private consultant in forensic medicine, and specializes in providing expert testimony.

B.C.’s Coroners Act doesn’t require the chief coroner to have a medical background. For almost 30 years, between 1981 and 2010, the post was held by ex–police officers. Robert Galbraith was followed by Vincent Cain; Larry Campbell, who later became Vancouver mayor and is now a Liberal senator; and Terry Smith.

On April 1, Diane Rothon took over the B.C. Coroners Service, becoming the second physician to head the death investigation agency since the province’s first chief coroner, William McArthur, who held the position from 1979 to 1981.

Although Butt is pleased that the new chief coroner is a doctor, he suggested that the province consider introducing a medical examiner system.

“The medical examiner system is led, governed by an expert in forensic pathology,” he said. “That means that they have to be a forensic pathologist, not just a doctor. Just like the operating room is the tool of the surgeon, the tool of the forensic pathologist is the autopsy.”

Butt pointed out that the B.C. Coroners Service doesn’t have forensic medical expertise. As such, it contracts out autopsies to hospitals.

The Ministry of Public Safety and Solicitor General didn’t make Rothon or any other official available for comment. However, in a statement e-mailed to the Straight, a ministry spokesperson asserted that there is no compelling reason to switch to a medical examiner system.

Like Canada, the U.S. employs a mix of coroner and medical examiner models in different jurisdictions. However, a report released last year by the National Academy of Sciences, a Washington, D.C.–based private advisory body, recommended Congress earmark funds to set up “medical examiner systems, with the goal of replacing and eventually eliminating existing coroner systems”.

The report cited the need for unbiased death investigations in sensitive cases like police shootings and those occurring in jails, as one of the reasons for having a medical examiner. “The medical examiner is first and foremost a physician, whose education, training, and experience is in the application of the body of medicine to situations that have a legal dimension that must be answered by a practitioner of medicine,” the document states.

For many years in B.C., deaths in police custody were automatically subject to coroners’ inquests. However, in March of this year, the provincial government passed legislation giving the chief coroner the discretion to waive inquests in these cases, a move that civil-liberties advocates like lawyer Cameron Ward argue will weaken police accountability.

How this new legislation will be implemented is one of the issues the B.C. Civil Liberties Association intends to raise with Rothon in a meeting scheduled for June 1, BCCLA executive director David Eby told the Straight.

Powerful police lobby likes cops investigating cops

January 29, 2010
Allen Garr, Vancouver Courier

Dr. John Butt was clearly annoyed. Butt is Alberta's former chief coroner and the former chief medical officer for Nova Scotia. At the moment of his annoyance, Butt was taking part in a panel discussion last week on deaths that have occurred while people were in police custody. The object of his annoyance was B.C. Solicitor General Kash Heed.

In an audience made up of senior members of the RCMP, the Office of Police Complaint Commissioner, aboriginal leaders and advocates on the issue of in-custody deaths, neither Heed nor anyone from his office, which is responsible for policing, turned up.

The sponsor of the panel discussion was the B.C. Civil Liberties Association. The location was the VanCity Theatre.

Butt was joined on stage by three other panelists: the chair of the panel Dr. David MacAlister with Simon Fraser University's department of criminology; expert in police accountability and in-custody deaths, lawyer Cameron Ward; and filmmaker Leonard Cunningham, an expert in aboriginal in-custody deaths.

Behind them was a floor-to-ceiling projection on the theatre's screen, a mosaic of now familiar faces, some of the more prominent members of that tragic fraternity who have died in police custody: Frank Paul, Robert Knipstrom, Kevin St. Arnault, Clayton Willy, Ian Bush and Robert Dziekanski.

Sitting in the front row and bearing witness were the mothers of St. Arnault and Bush.

In-custody deaths are no small matter. Over the past several years in B.C. we have averaged two per month.

For those of you who have followed this debate, you will know it always gets down to the same point. There can be no confidence in a system where police investigate themselves. The RCMP, more than any other police force, has been battered repeatedly in recent years over the incredulous conclusions their own investigations into these matters have produced.

Ward, who has represented a dozen families who have suffered in-custody deaths, told the audience that we can't trust police nor can we trust the crown prosecutors who regularly work with police.

"The solution is really simple," Ward pointed out. "We have to have a body of independent civilian investigators respond immediately."

This is happening in Ontario. Ward also wants independent lawyers deciding if charges should be laid.

One point of clarification: What Ward is proposing should not be confused with what Heed and the Liberals in B.C. are promoting in their new police act, a beefed-up version of "civilian oversight." They draw support for that position from a report they commissioned from former B.C. Court of Appeals Justice Josiah Wood. But it still means police investigate themselves, albeit with a civilian occasionally looking over their shoulders. Wood came to this recommendation even though he found at least one in five police investigations seriously flawed.

There has, in fact, been a seismic shift in RCMP thinking in the past few months thanks largely to the beating they've been taking from the public and the media. Assistant RCMP Commissioner Alastair MacIntyre confirmed that in comments he made before the panel discussion began. The Mounties will accept what ever the government decides, including independent civilian investigation.

If you are wondering why Heed and his government aren't leaping at this, particularly given that they are in the midst of re-negotiating the province's contract with the RCMP, MacAlister offered this opinion, one shared by his fellow panelists.

We are captives in this province of a "very powerful police lobby" which likes things the way they are. Ex-cop Kash Heed is aware of that just as his predecessor, ex-cop Rich Coleman, was.

While that persists, nothing will change the shameful incidents of in-custody deaths.

RCMP urged to release arrest tape of man who died

November 17, 2009
Mark Hume, Globe and Mail

Clayton Alvin Willey died of a heart attack several hours after police knocked him to the ground, hog-tied him, kicked him in the chest, pepper sprayed him and used a taser on him repeatedly.

Although the incident took place in 2003 and the arresting officers were cleared of any wrongdoing, an aboriginal leader and civil rights critics called yesterday for the release of an RCMP video they say shows police used excessive force.

“I had an opportunity to see an edited version of the video and I can tell you it was sickening, it was very, very difficult to watch and it stirred a deep anger within myself,” Grand Chief Stewart Phillip, president of the Union of British Columbia Indian Chiefs, said at a news conference.

Mr. Phillip said the video shows Mr. Willey, a Métis, with his hands cuffed behind his back and tied to his feet, being dragged into the police station while RCMP officers repeatedly taser him.

“I was very disturbed, very emotional … in many ways it was worse than watching the Dziekanski tape,” he said, referring to a video shot at Vancouver International Airport in 2007, when RCMP officers used a taser on Robert Dziekanski, a Polish immigrant who died while being arrested after making a disturbance in the arrivals area.

The Dziekanski video generated worldwide media coverage and led to a public inquiry that recommended police adopt tougher rules on the use of tasers.

“The point of this press conference is to draw public attention to this horrific incident,” said Mr. Phillip, who hopes to trigger an “outcry across this country similar to the Dziekanski case.”

David Eby, executive director of the B.C. Civil Liberties Association, and John Butt, a forensic pathologist, echoed Mr. Phillip's views, and said there will be public anger if people get to see the video.

The video was entered in evidence in an October, 2004, coroner's inquest, which did not find fault with the police officers. The video was brought to the attention of Mr. Phillip recently by Leonard Cler-Cunningham, a writer researching aboriginal deaths in custody.

Mr. Cler-Cunningham said Mr. Willey's family has signed an authorization asking the RCMP to release the video, but the police have declined to do so.

“The reason the RCMP in Ottawa refused to release it is because it would be a violation of Clay Willey's right to personal privacy. I've encountered this in every single aboriginal death in custody under investigation. It's insulting. It's disgusting. Do not use an individual's right to personal privacy to shield yourself from investigation,” he said, directing his comments to police.

Mr. Cler-Cunningham said Mr. Willey was treated brutally.

“I believe it meets the standard of torture,” he said. “Do you need to taser a man who is handcuffed and hog-tied, seemingly immobile and prone?”

RCMP Sergeant Tim Shields said the video is not being released because of privacy concerns, but he said police are “more than happy to share all file details with the family and first nations leaders.” The RCMP could not be reached later for comment on Mr. Cler-Cunningham's remarks.

The findings of the coroner's inquest state that several people made 911 calls to the RCMP in Prince George in July, 2003, after frightening encounters with Mr. Willey, who was reportedly armed with a knife.

The coroner's report states that when police confronted Mr. Willey, he refused to lie on the ground and, with blood and foam coming from his mouth, advanced on a female officer.

One officer drew his handgun, but put it away when he saw Mr. Willey was not armed. Police tackled Mr. Willey and one officer kicked him “in an attempt to gain ‘pain compliance.'”

Police testified they also used pepper spray and that even after he was hog-tied, Mr. Willey “continued to thrash around and attempt to free himself.”

Police said they used tasers at the cellblock in an attempt to subdue Mr. Willey.

A pathologist's report found evidence of two apparent taser burns, numerous abrasions, contusions, six broken ribs and brain swelling from a head injury.

The pathologist, D.J. McNaughton, testified that Mr. Willey died of a heart attack brought on by a cocaine overdose and said that “in his opinion the use of the taser did not contribute to Mr. Willey's death.”

Mr. Willey was arrested at about 5:15 p.m. Police called an ambulance at 5:36, after he was “touch stunned” by a taser at the jail cell. He had a heart attack in the ambulance, and was pronounced dead the next morning at 9:05.

Police taser video 'worse than Dziekanski' says chief

These images were borrowed from a Facebook site set up by Clay Willey's family in his honour - see the Facebook Group "PLEASE HELP THE WILLEY FAMILY PUT A STOP TO TAZER DEATHS IN OUR COUNTRY".

November 16, 2009
By Colleen Kimmett, The Tyee

Aboriginal and civil rights groups are demanding RCMP release a video of man who died after being tasered in a police holding cell in 2003.

The video reportedly shows Clay Willey, an aboriginal man, being tasered while hog-tied on the floor of the cell at a Prince George RCMP detachment. The officers involved in the incident have not been identified.

At a press conference this morning, Grand Chief Stewart Phillip of the Union of B.C. Indian Chiefs said the four-minute long clip was "sickening" and "very, very difficult to watch."

"Clearly, they were trying to shut him up by using a taser."

David Eby, executive director of the B.C. Civil Liberties Association said he hopes media attention will pressure RCMP to release the video. "We believe it will cause an outcry," Eby said.

Writer Leonard Cler-Cunningham, who uncovered the video during the course of a five-year investigation on aboriginal deaths in custody, brought it to the attention of Eby and Phillip about six months ago. He thanked the RCMP for making the video available to him, but said police refuse to release to the public in order to protect Willey's privacy.

"They're using the right to privacy to protect themselves," he said.

A coroner's inquest into Willey’s death conducted in October of 2004 determined that he died of a cocaine overdose. According to the report, Willey had been acting erratically in the parking lot of a Prince George mall when police picked him up. He was handcuffed and taken to the local detachment, where police said they "touch stunned" him with a Taser after he continued to struggle and kick. Less than 45 minutes passed between the time he was picked up at the mall and the time an ambulance arrived at the detachment. Willey died en route to the hospital.

Dr. John C. Butt, a specialist in forensic pathology, noted that touch stun is a less debilitating mode on the Taser gun and said it wasn't clear how many times it was deployed. He questioned why police would taser a man who was already tied up and face down, and called it a "cruel and unnecessary act."

A media relations officer for the Prince George RCMP detachment said he was not aware of any internal investigation into the officers' actions.

Community demands release of videotape of in-custody death

Union of BC Indian Chiefs and BC Civil Liberties Association

Nov 16, 2009 14:32 ET

Attention: Assignment Editor, News Editor, World News Editor, Government/Political Affairs Editor

VANCOUVER, BC, PRESS RELEASE--(Marketwire - Nov. 16, 2009) - Representatives of a leading aboriginal and civil society group, along with a forensic pathologist and a journalist gathered yesterday to demand the release of security footage taken in an RCMP lockup that shows the Taser-related death of Clayton Alvin Willie, an aboriginal man.

Willie was arrested in 2003 for creating a public disturbance in Prince George, British Columbia, and died that same day following his interaction with police with a head injury and multiple broken ribs. RCMP officials acknowledge he was repeatedly Tasered while hog tied at the Prince George RCMP detachment.

Security camera footage from the jail of the incident was edited by the RCMP, and the RCMP retains a copy of the edited footage. Representatives of the UBCIC and BCCLA, along with Dr. John Butt and Leonard Cler-Cunningham, the independent journalist who uncovered the existence of the video, have viewed the edited footage.

"Even the edited footage shows Mr. Willie hog tied and being dragged around the Prince George RCMP detachment and being Tasered while lying helpless on his stomach," said Grand Chief Stewart Phillip of Union of BC Indian Chiefs. "If you treated any animal the way Mr. Willie was treated, there is little doubt that you would be facing criminal cruelty charges. Astonishingly, the officers involved here are still on active duty."

The original footage may be lost, or may be in the custody of the RCMP or Coroner's Office. Both offices have refused to release the edited or the full video to the public citing privacy concerns, despite receiving a notarized release from Clayton Willie's family.

"This video must get out to the public, in the same way that the Dziekanski video was released, so that there can be some justice for Clayton Alvin Willie," said David Eby, Executive Director of the BCCLA.

=================

Backgrounder

Who was involved in this incident?
In January, 2009, two of the RCMP officers involved in the Willie case were found by Provincial Court Judge Micheal Brecknell to have taken deliberate steps to ensure the loss of Prince George detachment videotape of another Taser abuse allegation. RCMP will not confirm whether those officers are still on active duty, but media reports indicate that investigative action was taken by the RCMP into that finding.

What is the content of the video?
* There are no date or time codes in the edited videotape.
* The video shows an RCMP SUV arriving at the Prince George Detachment garage.
* The video cuts away before RCMP say Clayton is pulled, hog tied, from the back seat of the SUV and allowed to drop, full weight, on his chest and possibly on his face.
* Clayton is then dragged down a hallway, with his hands bound behind his back and tethered to his feet, into an elevator. His head hits the doorway on his way into the elevator and he does not register any response.
* In the elevator, an RCMP officer can be seen targeting his Taser on Clayton's back and kneeling down and applying the device to Clayton's back.
* Clayton is then dragged out of the elevator into the booking area of the detachment. A number of RCMP officers, including senior officers are seen observing while the two male officers handling Mr. Willie Taser him at least twice more.
* Mr. Willie appears to lose consciousness, and an ambulance attends the scene.
* The RCMP advise that ambulance attendants ask the officers present to loosen Mr. Willie's handcuffs because his hands are "black". The video shows officers loosening his handcuffs.
* Still hog tied, Mr. Willie is loaded onto the stretcher, wrapped in blankets, and taken to the local hospital.
* He has a massive heart attack en route to the hospital and dies, which is not shown on the video.

What is the video?
The video reviewed by the representatives at the press conference is an edited compilation of the surveillance videotape taken at the RCMP Prince George detachment. It, and possibly the full, unedited footage, is in the possession of the RCMP and the B.C. Coroners Service.

What were the consequences of these actions?
The RCMP investigation found that all interactions with Mr. Willie were "routine" and there was no discipline as a result.

=================

Grand Chief Stewart Phillip, President of the Union of British Columbia Indian Chiefs (UBCIC).
Grand Chief Phillip has been married for twenty-two years to his wife Joan. They have four grown sons, two daughters, four granddaughters and four grandsons. Grand Chief Phillip was elected to a fourth consecutive term as Chief of the Penticton Indian Band and is Chair of the Okanagan Nation Alliance.
Office: (604) 684-0231
Cell: (250) 490-5314
http://www.ubcic.bc.ca/

David Eby, Executive Director of the British Columbia Civil Liberties Association (BCCLA)
David Eby is the 33-year-old Executive Director of the B.C. Civil Liberties Association. An adjunct professor of law at the University of British Columbia, David is also the President of the Canadian HIV/AIDS Legal Network and a research associate with the Canadian Centre for Policy Alternatives.
Phone:778.865.7997
Email: david@bccla.org
Website: http://www.bccla.org/

Dr. John C. Butt is a highly-qualified specialist in forensic medicine and pathology, having served as Chief Medical Examiner for the Canadian provinces of Alberta and Nova Scotia, and also as president of the National Association of Medical Examiners in the United States.
Office: 604.738.0878
Email: pathfinderforum@gmail.com
Website: www.pathfinderforum.com

Leonard Cler-Cunningham is a writer. He lives with his daughter Hailey in Vancouver BC. His book and documentary on Aboriginal deaths in custody is due out next year.
Phone: 604.298.7585
Email: lencler@gmail.com

/For further information: Grand Chief Stewart Phillip, President of the UBCIC - (250) 490-5314; David Eby, Executive Director of the BCCLA – (778) 865-7997; Dr. John C. Butt, Forensic Pathologist – (604) 738-0878; Leonard Cler-Cunningham, writer - (604) 298-7585/

Dziekanski's death linked to Tasering: Pathologist

April 29, 2009
Suzanne Fournier, The Province

An eminent forensic pathologist told the Braidwood inquiry Wednesday morning that Robert Dziekanski’s death — after five Taser jolts and restraint by the RCMP — was likely a “cardiac-related” death linked to the Tasering.

Dr. John Butt, a forensic pathologist with almost 40 years’ experience who was awarded the Order of Canada in 2000 for his work, disagreed with the report by pathologist Dr. Charles Lee that failed to mention use of the Taser but did conclude “chronic alcoholism” contributed to Dziekanski’s death.

Nor did Lee make any mention of marks on Dziekanski’s back — which were photographed by homicide detectives present at Lee’s autopsy of Dziekanski — that were consistent with the puncture marks of Taser probes.

Butt said that Lee’s failure to mention the Taser and traces of it on Dziekanski’s body were significant oversights.

Butt also disputed Lee’s conclusion that Dziekanski’s heart showed signs of alcohol-related damage and disagreed that with Lee that “chronic alcoholism” could be said to be a “contributory factor” to Dziekanski’s death.

“I think this is probably a cardiac-related death 'de novo,' a new event unheralded by previous symptoms,” said Butt, noting that he reviewed Dziekanski’s health records back to 1994 and found “no indication” of heart problems or high blood pressure.

“Dr. Lee concluded, in part, that alcoholic heart disease ‘would have put (RD) at increased risk for development of an arrhythmia and sudden death,’” noted Butt. “After finding the microscopic slides of the heart to be essentially normal, I was unable to conclude that the features that I saw represented alcoholic cardiomyopathy.

“Nothing in those [health records] suggests that he was a drinker, either,” said Butt, although he said he did agree with Lee that Dziekanksi’s fatty liver and a partly deteriorated section of his brain were serious signs of alcoholism.

Butt’s report, released by the inquiry Wednesday, questioned why Lee, who viewed a bystander video of Dziekanski crashing to the floor and screaming in pain after being Tasered, mentioned Dziekanski’s agitation but not the Taser.

“Given the circumstances of the death of Dziekanski, in my experience it would be uncommon for the role of a weapon (e.g. Taser) to be left without a discussion as was so in Lee’s report,” noted Butt’s report.

Butt also urged that “caution is advisable about use of the term ‘excited delirium,’” which has often been cited as a cause of death following Taser use. Butt said that “diagnosis” is “questioned by those practicing psychiatry . . . often is defined by persons who have neither training in nor experience with aberrant behaviour.”

Walter Kosteckyj, the lawyer for Dziekanski’s mother Zofia Cisowski, replayed the bystander video shot by Paul Pritchard and Butt agreed that Dziekanski can clearly be seen clutching his heart and howling with pain after being Tasered.

Butt also agreed that Cpl. Benjamin Monty Robinson can be seen on the video kneeling on Dziekanski’s upper back and neck with considerable force.

Dziekanski began turning blue shortly after that “restraint,” which Butt told Kosteckyj is an indication he may also have been in respiratory distress.

Snoring noises emitted by Dziekanski, as he lay facedown in handcuffs, may have been “agonal breathing,” a feature Butt said is common in deaths that he has reviewed.

Concluded Butt, whose testimony continues Wednesday afternoon: “I believe that increasing exertion and stress seen following the dischrage of the Taser likely contributed to the death of Robert Dziekanski.”

Dziekanski would still be alive if not for RCMP confrontation: pathologist

April 29, 2009
The Canadian Press

VANCOUVER, B.C. — Robert Dziekanski would likely still be alive if he hadn't been stunned multiple times with a Taser and restrained on the floor of Vancouver's airport by four RCMP officers, says an expert pathologist.

Dr. John Butt, who has served as chief medical examiner in Alberta and Nova Scotia, told a public inquiry into Dziekanski's death that the stress of the confrontation - including the use of the Taser - likely caused the Polish man's heart to stop.

He said it was a death that could have been avoided.

"Is it fair to say that, in your opinion, had Mr. Dziekanski not been Tasered, not been restrained on the floor, that he would still be alive today?" asked Walter Kosteckyj, the lawyer for Dziekanski's mother.

"I suspect that, yes," Butt replied during his testimony Wednesday.

"Is that a strong opinion?" asked Kosteckyj.

"Yes," replied Butt.

The inquiry has heard widely differing opinions on how much, if at all, the Taser is to blame for Dziekanski's death.

Butt and the pathologist who conducted the autopsy on Dziekanski say the weapon may have contributed, while two experts paid by the company that makes Tasers insist it played no role at all.

Butt, who reviewed slides from Dziekanski's autopsy, said the stress of his agitation, multiple Taser stuns and being restrained by police on the airport floor likely contributed to his heart stopping.

Still, he couldn't say how significant a factor the Taser played.

Butt was called in to review several reports provided to the inquiry, and he agreed with the autopsy's finding that Dziekanski's cause of death could be described as "sudden death during restraint."

It's a little-understood term used for deaths in custody when there is no clear, anatomical cause of the death.

Butt disagreed with several findings in the autopsy report and in other reports provided to the commission.

For example, he said he could find no evidence that Dziekanski's heart was damaged due to chronic alcoholism. That's a contributing factor listed in the autopsy report.

Butt said Dziekanski's liver and brain showed classic signs of alcoholism, but the man's heart didn't appear to be affected.

"I just don't agree with that," said Butt. "I don't think there is alcoholic heart disease so I don't think that it has any role (in Dziekanski's death)."

He acknowledged that he didn't have an opportunity to examine the heart himself, but he said it would be a finding that could only be confirmed through microscopic slides, which he had access to.

A lawyer for the federal government told the inquiry Dziekanski may have been on heart medication, however Butt said there was no indication of that in his medical records, including from a mandatory health exam required to immigrate to Canada.

Butt, who worked on a report about Tasers for the B.C. Police Complaints Commission four years ago, said he was also concerned the autopsy report barely mentions the fact that Dziekanski was stunned with a Taser.

Dr. Charles Lee, who conducted the autopsy, told the inquiry earlier in the week that the Taser may have contributed to Dziekanski's death. But his report makes one mention of the weapon, only to explain marks on Dziekanski's body.

"I don't see how one could possibly not mention the Taser in the commentary in this case," said Butt. "Whether or not that's going to say that it's hugely relevant to the cause of death, it's enormously relevant to the events in this case."

Lee has told the inquiry that while he knew Dziekanski had been shocked by a Taser, he was not aware he was shocked multiple times.

His autopsy report, along with two others provided to the commission, also mention excited delirium, a controversial term often used in in-custody deaths that has since been removed from RCMP training manuals.

Butt acknowledged the controversy surrounding the term, and also noted that in most cases where it is used, subjects are on drugs or suffering from mental illness such as paranoid schizophrenia.

Neither was the case with Dziekanski.

While he couldn't say whether Dziekanski was suffering from any type of delirium, he said it's not something that could be detected in an autopsy, and the video of the confrontation doesn't provide enough information to make that determination.

Braidwood Inquiry

Scheduled Witnesses (Subject To Change)

Tuesday, April 28, 2009

Dr. Charles Lee (Pathologist) Continued
See CBC's coverage of Dr. Charles Lee's testimony on Monday, April 27th.

Dr. Charles Swerdlow (Cardiac Electrophysiologist)(video/teleconference)
Dr. Swerdlow gave a presentation on sudden deaths after use of taser at the Braidwood Inquiry in June 2008.

Dr. Dorin Panescu (Electrical Engineer)(video/teleconference)
Dr. Panescu has has been retained as an expert witness by Taser International in a wrongful death suit (see here).

Wednesday, April 29, 2009

Dr. John Butt (Pathologist)
Dr. Butt, pathologist and a former chief coroner, told the Braidwood Inquiry in May 2008 that there are no obvious features on a body to indicate to a pathologist that a Taser has directly caused a death and said he believes Tasers can contribute to a sudden death(see here).

Thursday, April 30, 2009

Dr. Jeffrey Ho (Emergency Medicine)(teleconference)
Dr. Ho, an ER doctor whom Taser pays to conduct studies and testify—he got $70,000 during a recent 12-month stretch (see Mother Jones - Taser's Delirium Defense)

Dr. Walter Martz (Toxicologist)

Veteran pathologist says he believes tasers can contribute to sudden death

May 21, 2008
The Canadian Press

VANCOUVER — There are no obvious features on a body to indicate to a pathologist that a Taser has directly caused a death, a former chief coroner told a B.C. public inquiry Wednesday.

But Dr. John Butt, who was the former chief coroner in Alberta and the chief medical examiner in Nova Scotia, said he believes Tasers can contribute to a sudden death. "There is no specific pathology related to death by Taser," Butt told the inquiry into Taser use.

He told retired judge Thomas Braidwood that when the anatomical cause of death is elusive, a pathologist must turn to so-called "proximate" events, such as intoxication from alcohol or cocaine, heart disease, or the force involved in the takedown by police.

"Often there is no hard-core, pathological information from the autopsy," Butt told reporters after he delivered his submission. In terms of what you see with your naked eye, nothing there."

He was reminded that Taser International's opinion of its stun gun is that it does not kill.

Butt noted the company says the weapon doesn't kill "directly." "But when you have a pre-existing cardiac condition and you deploy the Taser and the death occurs instantly, then I don't think it's an easy thing to dodge the responsibility."

Butt told the inquiry that he took it upon himself last year to try to become an expert in Tasers and has read on the subject widely. He said his research suggests Tasers are being used about 600 times a day in North America. "I would have concerns about the number of times it's deployed knowing that some of the rules for engagement are not sound."

The inquiry has already heard that police forces in B.C. don't have a uniform policy on Taser use and the training regimen varies from force to force, as do policies surrounding its deployment.

"The issue is rules of engagement," said Butt. "What are they? Are they the same for the Vancouver police department as they are for the RCMP?

"Have they been looked at as an ethical concern? I think one would want to look at them as an ethical concern knowing that there have been issues of sudden death associated with them."

Butt also expressed concern about the widespread marketing of the weapon, noting that it is being bought not only by more and more police forces but also by citizens for personal protection.

The inquiry heard Tuesday that the New Westminster police department has 20 Tasers and informs its trainees that injury or death could result. But it also provides no first-aid or cardiopulmonary resuscitation training.

Butt suggested that issue would come up in the second part of the Braidwood inquiry, which will look at Tasers and their connection in the death last fall of Polish immigrant Robert Dziekanski at the Vancouver airport. Dziekanski had spent many hours in the airport and was agitated and throwing things. When four RCMP officers arrived to deal with him, he appeared confused and agitated. He was hit with a Taser almost immediately after police arrived and died shortly afterwards.

"I think you're going to hear a lot in the second part of the inquiry," said Butt. "I join with most of the people that they are very happy there is a video to look at (of Dziekanski' death) and I join most people in their concern if police don't have proper training in CPR."

My submission to the House of Commons Committee on Public Safety and National Security

Here is what I said to the House of Commons Standing Committee on Public Safety and National Security in Ottawa (Canada) on April 16, 2008:

Good afternoon, Chairman and members of the committee.

I'm relieved to be here today. For me and my family, this is an extremely important destination in what has been a very, very long journey.

As I'm sure you know, my brother, Robert Bagnell, died on June 23, 2004, moments after he was tasered by Vancouver police. Two days after his death, the Vancouver Police Department contacted my family to inform us that Bob died of an apparent drug overdose.

I know you won't be able to answer these questions, but my questions have always been as follows: If using tasers on my brother was the right thing to do, would the police not have disclosed the fact of their use immediately? Would they have concealed the fact that they used tasers, for an entire four weeks, before announcing to the media, not to us, that they used tasers the night my brother died? Would they have waited a further three weeks before coming up with a burning building from which Bob needed to be rescued?

No, I believe the police knew immediately that the force they used on my brother was excessive. They needed those seven weeks to pull together a plausible explanation to justify their use of the weapon whose manufacturer had aggressively marketed it to them, misleading them into believing that the taser could cause no harm.

More than two years after Bob died, a coroner's inquest was finally convened in September 2006. The inquest, in our opinion, was about saving the taser, not about the changes that might be made to prevent similar deaths in the future. No one, least of all the lawyer for the police and the two lawyers who had standing at the inquest for Taser International, was prepared to conceive of the possibility that the taser may not be the perfect weapon, that there may even exist the possibility that the taser could cause or in some way contribute to death.

We learned some interesting facts at the inquest. We learned that the four ERT members who were in physical contact with Bob when he stopped breathing delivered their mostly identical statements to investigators 17 days after the incident, after seeking legal advice. We learned from the advanced life support staff who attended to Bob right after he stopped breathing that every muscle in his body was spasmed. They said they had only ever seen that in rigor mortis, which they normally would not see until hours later.

We learned that it was possible that Bob had less than half the lethal amount of narcotics in his system, not nearly enough in and of themselves to kill him. We learned that the data download feature on both tasers that were used on Bob conveniently failed, so that the number, duration, and mode of uses were impossible to verify. We learned that police attended the autopsy. The pathologist testified that the cause of death was partly determined by information she was given. The cause of several taser-like marks on Bob's body were inconclusive and the pathologist was unable to determine whether Bob's heart underwent any electrical arrhythmia.

That's the thing about death that occurs after tasering. Even Dr. Butt testified recently to this committee that very uncommonly is there specific pathology with the taser. And I don't begin to understand the science behind the taser or how it affects the human body.

Coroners and medical examiners often choose to mention a condition they call “excited delirium” as the cause of death. They are influenced by Taser International to specifically not mention the taser. The manufacturer's aggressive approach against coroners and medical examiners explains why relatively few deaths have been found to be caused by tasers. Both so-called excited delirium and the taser are undetectable on autopsy, and therefore unprovable. However, as a friend of mine says, “Excited delirium doesn't sue coroners, Taser International does.” So drugs, psychosis, and excited delirium take the blame for these deaths despite the lack of any evidence to show that the taser did not cause or contribute to them in any way.

Tasers have not been safety-tested in this country, and nobody knows whether individual weapons match the manufacturer's specifications. The only truly independent testing I am aware of is what was done on the two tasers that were used on my brother the night he died. One of those two tasers was found to be 84.5 times more powerful than the manufacturer's specifications. Of course, Taser International reacted to those findings in its usual hostile manner, and the company that tested the tasers was made to resile from its findings. However, the author of the report, the man who tested the tasers, testified at my brother's inquest and stood steadfastly behind his methodology and his conclusions.

At this time the two tasers are still awaiting new testing protocols, protocols that are being developed by police. Today I learned that the two tasers used on my brother arrived in Ottawa this week.

Tasers urgently require expert and truly independent testing for safety on humans. Every time a police officer uses a taser they engage in a deadly game of Russian roulette with a potentially lethal weapon. Not so long ago, the past president of the Canada Safety Council urged that minimum standards for the efficacy and use of tasers be developed and noted that relying completely on specifications provided by the manufacturer of the taser is completely unacceptable. Since we are dealing with possible electrocution, it seems the Canadian Standards Association would be the most logical place to start. And if after the taser has been tested it is to remain in the police arsenal, then a much higher standard of necessity must be imposed upon its use in Canada so that police officers can better predict the potential for severe, unintended, and possibly deadly effects, and therefore consider their force options more carefully.

There has been a great deal of reluctance by law enforcement officials and coroners in Canada to admit that the taser may not be as safe as the manufacturer originally misled them to believe. This has only been exacerbated by the fact that the manufacturer has ingratiated itself into our law enforcement community by, for example, compensating individual police officers and at least one coroner, and spending thousands of dollars in sponsorship of Canadian law enforcement events. They have even recently announced that they'd like to be part of any inquests and reviews in Canada.

My brother Bob's death was the 58th in North America. According to my research, the number of dead now stands at 337. It's no coincidence that the taser is the common denominator in all of these deaths.

Canadians witnessed the last horrifying moments of Mr. Dziekanski's life as it was stolen from him. Had the events leading up to my brother's death been captured on video, Canadians would have been outraged in 2004, and perhaps many of those who have since died in Canada, including Mr. Dziekanski, might still be alive today.

What would we learn if we could bear witness to the last moments of the lives of Terry Hanna, Clayton Willey, Clark Whitehouse, Ronald Perry, Roman Andreichikov, Peter Lamonday, Robert Bagnell, Jerry Knight, Samuel Truscott, Kevin Geldart, Gurmeet Sandhu, James Foldi, Paul Saulnier, Alesandro Fiacco, Jason Dean, Claudio Castagnetta, Quilem Registre, Howard Hyde, and Robert Knipstrom?

Would we agree that taser use was justified during Clayton Willey's "altercation" at the mall? Were three taser jolts justified when Clark Whitehouse "tried to flee" from police on foot? What about when police arrived, tasers already drawn, to find Roman Andreichikov sitting on a couch rocking back and forth mumbling to himself? Was it okay to shock Peter Lamonday several times when he was already on the ground? How about Alesandro Fiacco, who "refused to cooperate" with police? These are but a few Canadian examples where the lives of these men and their loved ones went sideways in a heartbeat.

Would we agree that taser use was justified as my brother, all 136 pounds of him, lay on his back on a bathroom floor alone, unarmed, in extreme medical distress, resisting police attempts to drag him out by his feet by holding on to inanimate objects for dear life while 13 highly trained police officers stood by as the only witnesses to the last moments of Bob's life, watching as he was subdued to death?

No, I believe that if Canadians could see with their own eyes what really happened--not the police's tidy version of events, but what really happened when these 20 people died in this country--they would be outraged.

In the days leading up to today, I have wracked my brain trying to conjure up the words that might help you look at the issue of tasers from a different perspective: that of a person who has been deeply affected by the loss of a family member to this deadly weapon. I am but one grieving family member. Somewhere out there are thousands of other family members left behind to mourn the other 336 people who have died.

I know that the eyes of the world are on Canada at this pivotal point. They watch, and they wait. Those who know us know that we will do the right thing. Canada will take the lead and see these weapons finally and independently tested. Canada will set the standard and impose strict regulations that will not allow police unfettered access to this technology. And finally, they know that Canada will impose a much-needed moratorium on tasers until we know, beyond a shadow of a doubt, whether or not their use on human beings is safe. Canada will pay special attention to the studies that have found problems with tasers.

As the father of one taser victim said, "The issue is not whether or not the taser can be used in a high percentage of cases to reduce death and/or physical trauma to officers and civilians alike. The issue is whether or not it's OK to kill the rest through ignorance and rationalization just because it's a small percentage.... The successes aren't the problem--the failures are."

Thank you.

Taser moratorium needed, committee told

April 5, 2008
Posted at Cameron Ward

Cameron Ward appeared before a House of Commons Committee Friday, urging it to recommend a moratorium on TASER use until rigorous independent scientific research has been conducted into the manufacturer's claims that the weapons do not kill people. Mr. Ward presented the committee with a list of the names of 336 North Americans who have died after being shocked by the TASER's 50,000 volt electrical output.

In response to a member's question, forensic pathologist Dr. John Butt confirmed that autopsies cannot detect the effect that TASER electricity may have on a human body.

Here is the summary of Mr. Ward's presentation:

For the reasons summarized below, I urge you to act in the public interest and make a recommendation that there be an immediate moratorium on the deployment of TASER weapons, so further unnecessary deaths like those of Robert Bagnell and Robert Dziekanski can be prevented.

According to media accounts, at least 336 North Americans have died since September 28, 1999 after being subjected to TASER shock(s). A copy of my list of these fatal incidents is enclosed. There have now been at least 20 reported deaths in Canada, including six here in the Province of British Columbia, with the most recent being that of Mr. Dziekanski on October 14, 2007 at Vancouver International Airport in Richmond.

TASER use is obviously very controversial. Police departments in Chicago, Illinois and Birmingham, Alabama have reportedly discontinued their use of the weapons due to safety concerns. Amnesty International, the American Civil Liberties Union, the National Association for the Advancement of Colored People and the Southern Christian Leadership Conference are some of the public interest advocacy groups that have been outspoken in their criticism of the weapons. However, the principal manufacturer, TASER International Inc. , has been very effective in persuading the law enforcement community that its products are safe, despite a significant body of evidence to the contrary .

Simply put, many people, including many experts, cannot accept that the deaths of at least 336 people after being subjected to the TASER’s 50,000 volt electrical output are purely coincidental. The manufacturer and many members of the law enforcement community have adopted the position that “excited delirium” causes the deaths, due to “psychiatric illness or the over use of street drugs, primarily methamphetamine or cocaine”, not the electrical trauma associated with the TASER. In my view, there simply has been insufficient independent research and study into these fatalities to reach any valid conclusions. If “excited delirium” is a “potentially fatal medical condition”, as the manufacturer asserts, one would expect that deaths would occur with similar frequency in incidents that did not involve law enforcement or in situations where TASER weapons had not been used. That is apparently not the case, as I have not yet seen any studies to that effect.

Although TASER International Inc. has commissioned some limited testing on animals, extensive independent testing of the lethality of the devices has apparently never been done in Canada, and was certainly not done before TASER weapons were first distributed to Canadian law enforcement personnel. Furthermore, although other electrical restraint devices like electric fences or cattle prods are subjected to Canadian Standards Association (CSA) testing and certification before distribution, the TASER weapons apparently are not.

You are undoubtedly aware of the TASER Technology Review Final Report prepared by members of the Victoria Police Department at the behest of the Police Complaint Commissioner of British Columbia. In my view, this report was clearly not independent as one of the principal authors, one Inspector Darren Laur, had earlier received payments and stock options from TASER International Inc. for his services to the company. The report failed to make the obvious recommendation, that is, that TASER use be discontinued until the health effects of the weapon are better understood.

There may be a place in the police use of force continuum for TASER technology. However, TASER use should be suspended until rigorous independent scientific research has been performed to properly assess the public safety risk. Unless that happens, more people will die like Mr. Dziekanski did, inexplicably and unnecessarily.

House of Commons committee "witnesses"

Canada's House of Commons Standing Committee on Public Safety and National Security is reviewing the use of tasers in Canada. To date, five meetings have been held (that we know of). With the exception of the two individuals from the University of Montreal, the list of witnesses who have appeared before the committee reads like a "Who's Who" of taser and "excited delirium" proponents:

Wednesday, March 12, 2008

John C. Butt, Consultant, Pathfinder Forum

Christine Alison Hall, Emergency Department Physician

Bernard Lapierre, Ethicist, philosopher and lecturer, École Polytechnique, U of Montreal (not a proponent)

Pierre Savard, Professor, École Polytechnique, U of Montreal (not a proponent)

Wednesday, March 5, 2008

Commission for Public Complaints Against the Royal Canadian Mounted Police - Paul E. Kennedy, Chair and Michael P. MacDonald, Director, Strategic Policy and Research

Office of the Police Complaints Commissioner of British Columbia - Dirk Ryneveld, Commissioner

Wednesday, February 27, 2008

Toronto Police Service - Michael Federico, Senior Officer, Staff Superintendent, Staff Planning and Community Mobilization

Toronto Police Services Board - Alok Mukherjee, Chair

Monday, February 25, 2008

Royal Canadian Mounted Police -

Richard Groulx, Sergeant, Tactical Training Section
Darrell LaFosse, Assistant Commissioner, Community, Contract and Aboriginal Policing Services
Troy Lightfoot, Inspector, Officer in Charge, Operational Program
Bruce Stuart, National Use of Force Coordinator, National Use of Force Program, Community, Contract and Aboriginal Policing Services

Vancouver Police Department - Joel Johnston, Staff Sergeant, British Columbia Use of Force Coordinator

Ontario Police College - Chris Lawrence, Instructor

Wednesday, January 30, 2008

Canadian Police Research Centre - Steve Palmer, Executive Director

Taser International Inc. - Tom Smith, Chairman

Robert Dziekanski had no drugs or alcohol in his system

October 27, 2007
PATRICK BRETHOUR, The Globe and Mail

VANCOUVER -- Robert Dziekanski had no alcohol or drugs in his system when he died after being tasered by police at Vancouver International Airport, his family's lawyer says.

Mr. Dziekanski was acting erratically after being delayed more than 10 hours at the Vancouver airport - it still is not clear why - with police saying he was yelling, sweating profusely, behaving irrationally, throwing chairs, tipping his luggage cart over, and pounding on windows.

But toxicology tests on samples taken from Mr. Dziekanski's remains were negative, said lawyer Walter Kosteckyj. British Columbia's Coroner Service provided those results to the family, but is not making them public. The RCMP is not releasing the information either, saying it does not want to impede its investigation.

A preliminary autopsy did not uncover any anatomical cause of death, either trauma or disease, meaning there is no clear medical picture of why Mr. Dziekanski stopped breathing and died within a few minutes of being repeatedly tasered in the early morning hours of Oct. 14.

The RCMP say he was tasered twice, but a witness has said she saw police use tasers four times.

Police have said that three officers attempted to speak to Mr. Dziekanski, but that he ignored them and attempted to grab an item off a desk. However, Mr. Kosteckyj said on Thursday that police waited just 24 seconds before tasering the 40-year-old man, and that he did not appear to pose a danger to anybody.

The police have said that Mr. Dziekanski continued to struggle after being tasered, but Mr. Kosteckyj questioned that assertion yesterday, saying his muscles may have been contracting as a result of the taser blasts.

Resolving that discrepancy, along with the number of taser blasts, could prove to be pivotal. According to Dr. John Butt, a pathologist and former chief coroner for Nova Scotia, repeated taser shocks could exhaust a person's chest muscles and cause him or her to stop breathing.

That exhaustion, formally termed tetany, is not detectible at autopsy, he said. But if Mr. Dziekanski continued to struggle after being tasered, it is not likely that the shocks triggered tetany, Dr. Butt said.

But Mr. Kosteckyj said the notion that Mr. Dziekanski died from muscle exhaustion brought on by repeated taser strikes "makes perfect sense."

RCMP guidelines for the use of tasers allow multiple strikes. Only about one in five taser strikes connect properly with a target subject, RCMP Corporal Greg Gillis said. Multiple strikes increase the chances of subduing a person, he said.

Jeff Dolan, B.C.'s assistant deputy chief coroner, said a full coroner's report will not be ready for a considerable time, likely weeks.

CTV News reported on Thursday that, based on emergency radio logs, police arrived at the scene at 1:28 a.m. and two minutes later, it was reported that a "male has been tasered."

The radio log does not say when police approached Mr. Dziekanski. But it does indicate that he was down two minutes after they arrived, and that he lost consciousness two minutes after that.

CTV reported there was a 12-minute delay before medical help arrived.

Mr. Kosteckyj said it appears likely that Mr. Dziekanski's family will sue, although it is not clear who will be the target of any lawsuit. "I'm sure there's going to be more than one defendant."

Timeline of events the night Robert Dziekanski died

CTV British Columbia has obtained an airport log that shows a four-minute lag between when Dziekanski lost consciousness and when B.C. ambulance crew members were called, and an almost 15-minute gap between the time he passed out after being tasered, and when the ambulance crew arrived on the scene.

Here is the timeline of events of Oct. 14:

1:21 a.m. -- Vancouver International Airport calls the RCMP, reporting a 50-year-old male is throwing suitcases and appears to be intoxicated.

1:26 -- The passenger has now thrown a chair through a window.

1:27 -- Two security guards show up. One minute later, the RCMP arrives.

1:30 - A male has been tasered and is unconscious but breathing. Ambulance is called.

1:31 -- Security guards help restrain the man, who is now described as a suspect.

1:32 -- The log reports that Dziekanski has lost consciousness.

1:36 - A Code 3 is issued to paramedics, indicating someone is unconscious.

1:44 - Paramedics arrive, 12 minutes after Dziekanski, 40, first slipped into unconsciousness.

Sources told CTV B.C. that a Code 3 call should have been issued to paramedics immediately after the individual became unconscious. However, it wasn't until four minutes later that the Code 3 went out. It also reports that an on-site emergency responder had told the team at the airport to hold off on immediately upgrading the status of the call.

John Butt, a former coroner who is an expert on Taser deaths, told CTV News in Vancouver on Friday that he is concerned about how quickly the RCMP used the Taser stun gun. According to CTV News in Vancouver, police used a Taser on Dziekanski 24 seconds after they arrived. "I don't know the situation directly, but it obviously requires a degree of assessment," Butt said. "If police had confined the man (in a secure area away from the public), the 24 seconds seems a very, very small period of time." Butt said he was also concerned about the 12-minute lag between when Dziekanski slipped into unconsciousness and when the first ambulance arrived. "I don't know the protocols for the Vancouver airport and I don't think I'm misspeaking myself by saying that's quite a long time," he said.

EDITORIAL: Time to recognize the risks of tasers

October 23, 2007
Globe and Mail

If Canadian police officers had fired a revolver at Robert Dziekanski at the Vancouver airport and at Quilem Registre on the streets of Montreal, and killed them, people would have been outraged. After all, while each man may have been out of control, neither one posed a serious danger to anybody. But when police used a taser, not a regular gun, and both men died, the outrage was muted because of a belief, repeated again yesterday by Robert Lafrenière, Quebec's deputy public security minister, that tasers do not kill.

But they do. Here is one way: The person shot develops tetany, a physiological condition of muscular exhaustion. It can lead to death by respiratory paralysis, John Butt, a forensic pathologist in British Columbia who does private consulting in Canada and the United States, explained in an interview yesterday.

Dr. Butt is not opposed to taser use, within limits. When he served on a committee of the B.C. Police Complaints Commission that examined taser use two years ago, the committee urged that jolts from the stun gun not be given too quickly in succession because rapid use might contribute to tetany. Mr. Dziekanski was shot twice, say the RCMP (four times, says an independent witness). In Montreal, officers jolted Mr. Registre an unknown number of times (his sister says six times). Of the six Canadians who died in 2005 and 2006 after being shot by police tasers, all were shot more than once, according to Amnesty International Canada.

The death of the Polish-speaking Mr. Dziekanski was horrifying and seemingly avoidable. He had reportedly travelled five hours on a bus in Poland and 13 hours on a plane, and then been held at Canadian customs and immigration for some hours. He couldn't find his mother, who had waited 10 hours for him in vain. He was lost and no one understood him. He began shouting and throwing computers. The mind boggles that humanity is smart enough to invent the taser but unable to think up a way to intervene in this fraught situation without killing the man.

There's a bit of semantics at play, too. Police in Canada say tasers do not directly cause death. The question should be, however, whether a taser used (often more than once) on a person in a state of delirium, and followed up by severe restraint, may cause death. The answer is that, in just 4½ years, 17 people who were tasered in Canada have died. Death might not have come directly, but it came - far too often.

There is also a crucial flaw in the police logic (and the logic of some medical experts) around taser use. The police say when someone is in a wild, irrational state of delirium, he might die even when not tasered. What they mean is that (apart from the occasional death from the delirium itself) the death occurs after a neck restraint, hog-tying or asphyxia caused when police officers put their knees on the person's chest. The police defend tasers by arguing that they are no more dangerous than other restraints. But does that mean tasers are safe? Of course not.

Would Mr. Dziekanski have died if he had not been tasered? (An autopsy did not reveal why he died; further tests are scheduled.) How about the other 16 over the past 4½ years? Any doubt should weigh heavily against taser use in all but those situations where it is an alternative to lethal force, such as firearms. Until we know the answer, police need much stricter limits on taser use. It should be a last-resort alternative to deadly force.

Taser technology review - final report

June 14, 2005
Office of the Police Complaint Commissioner

One of the authors of this review was Sgt. Darren Laur, a former Taser Shareholder