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Recommendations Of The Coroner's Inquest Into The Death Of Robert Gentles

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7. It is recommended that as soon as an inmate is securely restrained that he be placed in a sitting position provided that it can be done without risk or injury to inmate or staff.


CSC issued a Security Bulletin (99-05) in March 1999 dealing with the subject of "Positional Asphyxia and Excited Delirium." This bulletin provides instructions to staff for the care of restrained inmates and is designed to minimize the potential for in-custody injury or death. This bulletin was emphasized and reinforced at the National Use of Force Trainer's Conference held in Kingston, Ontario on September 14-16, 1999.

Included in this document is the requirement for officers to "get the inmate off his/her stomach and on to his/her side or seated upright", as soon as restraints are applied.

The procedures also provide additional instructions for staff to follow in cases where breathing difficulties or loss of consciousness occurs. These instructions include the requirement to transport the inmate to a medical facility equipped to cope with the potential complications of excited delirium or positional asphyxia.

In addition, the Correctional Training Program (CTP 2000), does include a module on Sudden In-Custody Death Syndrome (SICDS) whereby recruits who are already pre-qualified in First Aid and CPR learn more about the situations that may contribute to "excited delirium" and "positional asphyxia" which both form part of SICDS.