The death of Ida Paul in June 2009 has been ruled accidental, caused by multi-organ failure.
That was the determination Thursday of the jury in the coroner's inquest held at Don Ross Centre to look into the case. Paul died in hospital shortly after spending approximately 12 hours in the custody of the RCMP in North Battleford.
The six-member jury - four men and two women - came back with a unanimous verdict on the fourth day of the inquest. The jury determined that Ida Paul, 34, died on June 10 2009 between the hours of 5 and 5:19 p.m. at Battlefords Union Hospital. The cause of death was multi-organ failure and the jury found the manner of death to be an accident.
There were two recommendations made by the jury. The first was that consideration be made to Paul's family and the videos from the RCMP detachment, showing Ida Paul in the cells, are not released to the public. The second recommendation was for the RCMP to be more active in physically checking their prisoners in custody every two hours beyond the monitoring they already do.
The call for RCMP to do physical checks of those in custody was in line with the wishes of Paul's family members including Percy Paul, who had expressed their concerns during the inquest the RCMP may not have reacted quickly enough to deal with Ida Paul's health situation while in custody.
Paul had been taken into custody around midnight on the morning of June 10 following a complaint from her former boyfriend about apparent intoxication and disorderly conduct at her home on 107th Street in North Battleford.
She was held in the "drunk tank" cell of the RCMP detachment in the Battlefords and monitored by staff through the night and morning. An ambulance was called around noon that day when it was clear Paul was unresponsive and not showing signs of sobering up.
One of the main points of contention during the inquest proved to be the issue of whether the video from the cells in which Paul spent the last hours of her life should be released to the public.
The Paul family had wanted presiding coroner Keith Kilback to make an order that the videos not be disclosed outside of the coroner's inquest, but Kilback declined, finding the reasons presented did not justify making a non-publication order. However, the jury ruled otherwise, recommending the videos not be disclosed by the coroner's office.
The jury's finding that the manner of death was by "accident" was in line with testimony, which indicated an overdose of acetaminophen, found in over-the-counter medications such as Tylenol, could have played a role in Paul's death.
During his testimony Tuesday, chief pathologist for the province Dr. Shaun Ladham testified it was possible Paul could have been overusing Tylenol over a period of several days prior to her death. Ladham conducted the autopsy on Paul on June 12, 2009.
Ladham concluded her multi-organ failure was the cause of death and it had been triggered by acute liver failure. Ladham also testified he didn't see any infection or pneumonia that could have triggered it or any trauma. While there was evidence of a clinical history of alcohol abuse, Ladham didn't think chronic alcohol abuse was the cause of death either.
Blood samples showed the levels of Tylenol were actually in the normal "therapeutic" range, but Ladham testified this was not inconsistent with the possibility Paul could have been taking excess levels of Tylenol for days in advance.
The testimony of doctors from Battlefords Union Hospital on Wednesday more or less confirmed Ladham's findings and seemed to point the finger at overuse of Tylenol as the cause of Paul's liver failure.
Dr. William Viviers testified Wednesday that Tylenol is typically one of the main toxic causes of sudden rapid-onset liver failure, such as what happened to Paul.
Viviers testified Paul went into cardiac arrest shortly after she was admitted to hospital. A defibrillator had to be used to bring Paul back to life, he said.
Another doctor at the hospital that day, Dr. Matthew Ntambazi, also noted Paul had to be revived following an initial cardiac arrest.
In his testimony by phone Wednesday afternoon, Ntambazi described Paul's condition that afternoon as 小蓝视频 "very very grave" and noted Paul was dehydrated and jaundiced - a sign of liver failure.
Ntambazi pointed to liver failure as a cause of death, along with renal failure and profuse internal bleeding - in line with the testimony of Dr. Ladham.
There had been plans to transfer Paul to Saskatoon, but she died before that came to fruition, Ntambazi testified. Ntambazi also testified Paul would have needed a liver transplant to survive.
The doctors also noted during their testimony Paul had previously been admitted to hospital in the week prior and was known by some of the staff.
Following the verdict, Percy Paul told reporters that he was not surprised by the jury's decision.
"I wasn't expecting anything else, I guess," Percy said, who added the jury's recommendations were in line with what he was expecting.
"That's basically what I saw that went wrong," said Paul. "They could have made the outcome a little bit different."
The finding on the RCMP's role was in line with what he wanted, said Paul, who had voiced his concerns throughout the inquest that the RCMP had failed to respond quickly enough to Ida's situation while in the cells.
"They could have done their job better," he said of the RCMP, noting the family felt for a long time that, had the RCMP acted differently. the outcome would have been different.
Percy described the emotions felt by the family during the entire inquest, particularly the video of Ida's time in custody in the police cells at the Battlefords detachment.
"The whole week was very tough. It started with the videos, which were hard to see for anybody, I guess - even for me," Paul said. "It was tough to get through."
Coroner's counsel Dennis Cann was happy with how the inquest went.
"I was very pleased with how the evidence went in over several days," said Cann.
He also indicated he was happy with the jury's conduct.
"I think the recommendations were very proper, appropriate in the circumstances, so I hope they're followed through on."
