Inquest Makes Recommendations After Coffey's Death

The inquest into the death of a Port Elgin man while in police custody has reached a conclusion.

Christopher Coffey died on June 21, 2013 after a scuffle with police officers inside his neighbour's home.

While no one was charged with his death (and the jury was not asked to lay blame), the week-long jury released eight recommendations late Friday night, aimed at preventing another death like Coffey’s.

Those recommendations include the following:

• Defibrillators and oropharyngeal airways should be installed in all Saugeen Shores Police Service cruisers and all SSPS officers should be trained in how to use them.
• Local emergency services should liaise with area mental health resources to increase awareness of said resources.
• Saugeen police and the County of Bruce should look into reviewing dispatch training (with the dispatch centre in Owen Sound) when it comes to mental health calls.
• That the Ministry of Community Safety and Correctional Services review police training protocol when it comes to conducted energy weapons (CEW).
• Saugeen Police and Bruce County EMS consider automatic dispatch of EMS officials during a 10-78 call (when a police officer asks for assistance).
• Saugeen Police review the 911 calls from this incident for quality assurance.
• Saugeen Shores police consider training all officers to use CEW's (tasers).
• Saugeen Shores Police Service should consider reviewing this incident with staff, to stress the importance of proper use of personal protective equipment.

The court ruled that Christopher Coffey died a "sudden death associated with excited delrium," which is a violent condition that's associated with paranoia and hyper-aggression.

Coffey had struggled with mental illness for most of his life, according to lawyers at the proceedings. He was wearing only underwear when he broke down his neighbour's door that summer night.

The jury heard from witnesses who claimed it took four police officers to hold Coffey down, only for the 46-year-old to suddenly become limp as he was being handcuffed.

Officers noticed he was blue in the face and called for medical assistance soon after.

Both police and EMS officials say their response time was adequate, with EMS members arriving "well-ahead" of their expected response time.

For the entire report, check out the embedded document below.