ASIRT finds no reasonable grounds to charge in Lethbridge holding cell death
ASIRT finds no grounds to charge after a woman’s 2023 fentanyl death in a Lethbridge holding cell; report cites missed checks and recommends 24/7 paramedics.
Alberta’s Serious Incident Response Team has concluded there are no reasonable grounds to charge a Lethbridge police supervising officer or a civilian commissionaire in the Lethbridge holding cell death of a woman on Sept. 2, 2023. The ASIRT report, signed by acting executive director Matthew Block, determined the death was caused by a fentanyl overdose and that neither individual’s actions met the threshold for criminal charges. The finding follows an investigation into custody practices, medical observations and missed welfare checks at the short-term holding facility.
ASIRT’s decision and legal threshold
ASIRT determined the supervising officer and the civilian under investigation were not medical practitioners and that their conduct did not satisfy the standard for criminal prosecution. The agency noted it must assess whether there are reasonable grounds to believe a criminal offence occurred; in this case it concluded that threshold was not met. The report emphasizes the different responsibilities of health-care providers and custodial staff when dealing with intoxicated or medically unstable detainees.
Chronology of the incident
Police arrested the woman on Sept. 1, 2023, after an alleged stabbing and charged her with assault causing bodily harm. Officers found a small quantity of suspected drugs in a baggie during a search before placing her in the Lethbridge short-term holding facility. Early on Sept. 2, emergency medical services attended and transported her to Chinook Regional Hospital after officers observed signs consistent with a possible overdose.
Medical treatment and hospital release
At the emergency department, hospital staff observed the woman ingesting yellow fentanyl pills and administered multiple doses of naloxone, reportedly seven times, to restore respiratory function. By midafternoon on Sept. 2 a doctor documented the woman walking independently to a bathroom and recommended her discharge from hospital care. She returned to the police holding facility just under an hour after that medical assessment.
Observations and missed checks in custody
Upon return to custody the woman displayed reduced responsiveness, needed help standing, and vomited while in her cell, according to the ASIRT report. A commissionaire who began a shift at 7 p.m. was assigned to complete 15-minute physical checks but did not complete all required checks because of other tasks. At 7:45 p.m. a supervising officer attempted to rouse the woman by nudging her elbow and side and later recorded she “refused to awake,” while a community peace officer described her as appearing to snore.
Critical moments and response when she stopped breathing
At 8:58 p.m. a later attempt to wake the woman found no detectable pulse and CPR was initiated by officers until EMS arrived and confirmed her death. ASIRT identified the officer’s 7:45 p.m. check as a key moment when a higher level of medical assessment—specifically a paramedic check—would likely have been warranted. The report also notes that no paramedic was on duty in the short-term holding facility at the time of the incident.
Recommendations on custody and medical care for intoxicated persons
ASIRT’s report highlights the complex challenge of where to hold intoxicated people who no longer require hospital supervision but remain medically vulnerable. The agency said individuals in such states “would be safer in facilities specifically designed for intoxicated persons” and recommended increased medical attention where dedicated facilities do not exist. Lethbridge Police Service has since placed paramedics in the holding facility on a 24-hour basis, a change ASIRT described as valuable in the absence of alternative dedicated care sites.
Lethbridge Police Service response and implementation
Lethbridge police confirmed the introduction of continuous paramedic coverage in the short-term holding facility following the investigation. The service framed that adjustment as a practical step to improve detainee care and reduce the risk of future medical deterioration in custody. ASIRT acknowledged the move as consistent with its recommendations and stressed that closer medical oversight is an important mitigation where intoxicated persons are kept in police custody by default.
The ASIRT report makes clear that custodial staff are often the last-line caretakers for intoxicated or medically unstable people who cycle between hospitals and police facilities. It calls for clearer protocols, adequate staffing and medical presence to ensure that the welfare checks and escalations required for vulnerable detainees are consistently carried out.
