THUNDER BAY — The coroner's office has called an inquest into the death of Donald Mamakwa in Thunder Bay five years ago.
The 44-year-old man was found in medical distress on Aug. 3, 2014 while in the custody of Thunder Bay Police.
Paramedics who were called to police headquarters on Balmoral Street found him deceased.
In June 2015, Ontario's Special Investigations Unit concluded an investigation into Mamakwa's death and determined that there were no reasonable grounds to charge any police officer with a criminal offence.
However, the SIU did find problems with the manner in which he had been cared for while in custody.
"Beginning with the conduct of the arresting officers, there is no indication in their notes and statements that they informed the paramedics that they had observed the man with breathing difficulties. One is left to imagine that the paramedics might have taken the state of the man's health more seriously were his complaints more than simply words," SIU Director Tony Loparco's report stated.
The report also stated that "When the man asked to be taken to the hospital again because of his shortness of breath, one of the arresting officers refused, saying that the paramedics had cleared the man. The officers, it seems to me, ought to have erred on the side of caution and taken him to hospital."
According to the SIU, an autopsy determined the cause of death to be ketoacidosis complicating diabetes mellitus, chronic alcoholism and septicemia.
"I am satisfied on the evidence that the absence of medical treatment...endangered his life," Loparco said.
Although he found that "a tragic series of missteps by all the officers involved in the man's custody conspired against him that day," he added that "there is insufficient evidence that any one officer is sufficiently blameworthy to attract criminal sanction."
Inquests into the deaths of individuals in police custody are mandatory under Ontario law.
Regional Supervising Coroner Dr. Michael B. Wilson says the inquest into Mamakwa's death will begin on June 3.
Ten days have been set aside for the inquest, and approximately 20 witnesses are expected to testify.
Dr. David Eden will preside as the inquest coroner.