To observers of the inquest looking into the 2018 death of 43-year-old North Bay man Gordon "Dale" Couvrette, the resolution may have seemed somewhat anti-climactic following the previous day's testimony and the evidence presented ruling out the use of a Taser or conducted energy weapon (CEW) by a North Bay Police Service officer as a contributing factor in Couvrette's death.
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To the family of the deceased, despite the inquest's subdued conclusion, they say the finding of accidental death and the recommendations of the jury go a long way toward satisfying their goals at the outset. Lillian and Glen Couvrette, Dale's mother and older brother, say they were searching for clarity on some of the details of the case and desired answers to their questions about what ultimately killed their loved one.
See also: Questions remain for family of Dale Couvrette as inquest opens
Additionally, if the jury's recommendations lead to meaningful changes to the protocols of first responders in cases involving the deployment of a CEW or Taser — despite the unexpected irrelevance as a contributing factor to Couvrette's death — the family is hopeful others can receive the care they need in similar scenarios involving police intervention with subjects experiencing mental health and addictions crises.
And: Day 2 of Couvrette inquest features first responders' testimony
After three days of testimony from witnesses present during various stages of the incident — including several police officers, the girlfriend Couvrette was staying with at the Harris Drive townhouse, a primary care paramedic, and family members, experts testified on police use of force protocols and training, as well as CEW training. The forensic pathologist who performed the post-mortem on the deceased and a forensic psychiatrist also contributed expert background and topical testimony to the proceedings.
Following the charge instructions from Dr. Steven Bodley, the presiding officer of the inquest, the five-person jury began deliberating late Thursday morning and delivered the verdict Thursday afternoon. Since the "who, what, where and when," had been established and agreed upon by all parties with standing in the inquest," Bodley instructed the jury to come back with its determination of the manner of death — the "how" — and any relevant recommendations.
The verdict was delivered swiftly and without further comment. Following an early morning episode at the Harris residence involving hallucinations and extreme paranoia, and a combative encounter with three police officers, Gordon "Dale" Couvrette died at 6:21 a.m. on Feb. 22, 2018, at the North Bay Regional Health Centre due to "sudden death with no anatomical cause associated with acute-on-chronic cocaine and amphetamine abuse/intoxication, forcible struggle and possible autonomic hyperactivity syndrome."
This cause of death is in line with the findings of Dr. Martin Queen, who performed the autopsy. The jury saw fit to omit the finding of "possible excited delirium syndrome," as designated in the report by Queen, and update it with a more current classification of "possible autonomic hyperactivity syndrome." The forensic pathologist himself said the original designation of the term was controversial in medical circles, a sentiment shared by forensic psychiatrist Dr. Gillian Munro in her testimony on Wednesday.
The manner of death was deemed by the jury to be an "accident," from the list of five possible designations which also includes "natural, suicide, homicide, and undetermined."
The recommendations of the inquest are that the North Bay Police Service and its police board consider policy and training amendments that require officers to notify EMS personnel that a conductive energy weapon was deployed in cases of a medical emergency where EMS is called to the scene. The NBPS should also take steps to ensure that EMS policies regarding response protocols are followed when a CEW is involved.
The NBPS and its police board and police oversight body, the SIU, should review the process of data extraction from CEWs to ensure that a pulse log draft is used in combination with the enhanced data log to validate the effect of the CEW.
The role of the inquest was to examine the circumstances surrounding Couvrette’s death. The jury may (and did) make recommendations aimed at preventing future deaths in similar circumstances. In their recommendations to prevent future deaths, the jury’s role is not to assign blame, free someone from blame, nor state or imply any judgment. Inquest juries are prohibited from making any finding of legal responsibility and expressing any conclusion of law.
