A Quebec coroner  is recommending the Sûreté du Québec review its policy for the surveillance of people under its care following an incident in which a woman who collapsed in an interrogation room at the police station in Campbell’s Bay in 2024 later died in hospital. 

The recommendations were first reported by Le Droit.

In her Jan. 9 report, coroner Francine Danais lays out the details of the case. A woman from Clarendon was arrested by police and brought to the Campbell’s Bay police station on Mar. 1, 2024. Her name is redacted in the report. She suffered a medical emergency while in the station’s interrogation room, and collapsed in convulsions. An ambulance was called and she was taken initially to Pontiac Hospital, and then transferred to Hull the following day. The woman died there on Mar. 4, 2024. An autopsy was performed on Mar. 11 in Montreal.

Analysis

Danais’ report states that the woman had several conditions – chronic obstructive pulmonary disease, chronic anemia, depression, and substance use disorder (alcohol and cocaine) – and was prescribed medications for them. It notes that based on the last time the prescriptions had been filled, and the quantities remaining, she may have been in “non-compliance” with her treatment schedule. 

According to the provided timeline, determined with the surveillance footage as well as testimonies from witnesses, she was taken to the interrogation room at around 9 a.m. and at around 9:30 a.m. she requested her medication, which police said they were retrieving. Her condition appeared to deteriorate as she was left alone in the room, and she loses her balance, while continuing to knock on the door and ask for her medication. She fell to the floor at one point around 10:15 a.m., but returned to her chair with difficulty and was breathing heavily. 

Though she received some medication containers from an officer around 10:30 a.m., she did not mention feeling unwell or the fall, Danais notes.  

At around 10:50 a.m. she became more agitated and asked to see a doctor, and at 11:08 a.m. she collapsed again and began to convulse. The convulsions end three minutes later, but she laid on the ground breathing heavily. An officer entered the room at 11:15 a.m. and found her, helping her into a chair. Emergency services were called, and she convulsed again at 11:29 a.m. A civilian employee who was also a first responder attended to her. The paramedics arrived at 11:39 a.m., began CPR and she was subsequently transported to hospital. 

The report concluded that the death was accidental, caused by a “prolonged cardiorespiratory arrest, likely induced by recent use of illicit drugs (cocaine and methamphetamine).”

“It should also be noted that the medications requested by Ms. [redacted] did not counteract the cardiotoxic effects of methamphetamine and cocaine, and their administration, or the delay in taking them, did not contribute to her death,” she said. “In summary, based on my investigation, it appears that Ms. [redacted] had consumed methamphetamine and cocaine prior to her arrest and that she suffered from the harmful effects of these substances, which would have occurred regardless of where she was,” she wrote.

Danais notes that coroners do not have the authority to rule on civil or criminal liability, or determine whether officers operated according to best practices, as there are other authorities for these determinations. 

“Thus, one can question what appears to be the lack of supervision of Ms. [redacted] while she was experiencing discomfort in the interrogation room,” Danais wrote. “In light of my investigation, there appears to be a lack of precision in the ‘Sûreté du Québec’s Management Policy’ as well as in the ‘Guide to Police Practices of the Ministry of Public Security’ regarding the definition of a detained person and their supervision.”

Coroner’s recommendations

Danais made two recommendations each to the Department of Public Security and the Sûreté du Québec.

She recommended the DPS revise their guide on people detained in a police station to include detention and custody in an interview room, as well as revise their policies to clarify what constitutes a detained person and to add a section on people “detained at the police station in all premises other than a cell, including an interview room, interrogation room, or even a police vehicle.”

For the SQ, she recommended they update their guidelines on the use of an interrogation room, specifying in particular the definition of a person in custody. She also recommended that a designated supervisor “exercises close, regular, and constant supervision, which must be adapted to the condition of the person in custody, in order to guarantee their well-being, as soon as they are in custody, regardless of where they are located.”

Prosecutor found no grounds to lay charges following BEI investigation

Back in July 2025, Quebec’s police watchdog, the Bureau des enquêtes indépendantes (BEI), announced that they had closed their investigation into the case, after the director of criminal and penal prosecutions (DPCP) had reviewed the file and found no grounds to lay any charges. 

“The surveillance camera footage shows that it was difficult to assess the woman’s condition. Her condition deteriorated when she was alone. It was only upon returning to the interrogation room that the officer became aware of her precarious state of health,” the DPCP’s report notes. “At that point, he provided her with assistance and contacted emergency services. The available evidence does not support a finding of marked departure from the conduct of a reasonable police officer in the same circumstances, nor does it support a finding that they failed to provide the necessities of life to a dependent.”

“In criminal law, the burden of proof that the prosecution must meet is very demanding. Due to the principle of the presumption of innocence, the prosecution must demonstrate the guilt of the accused beyond a reasonable doubt before the court,” the DPCP report adds. “The decision to prosecute or not is a discretionary decision made by the prosecutor in the performance of their professional duties, without fear of judicial or political interference and without yielding to media pressure. Furthermore, it is not the prosecutor’s responsibility to rule on possible civil or ethical misconduct. They only seek evidence that allows them to conclude that a criminal act has been committed and to determine whether they can reasonably prove it. Nor is it their role to make comments or recommendations regarding police intervention methods.”