A woman died in Lethbridge Police Service custody on September 2, 2023. ASIRT investigated for nearly three years. The report came out July 3, 2026. No one will be charged.
ASIRT acting executive director Matthew Block found no reasonable grounds to believe the supervising officer, a civilian commissionaire, or any other LPS staff committed a criminal offence. What the report documents is a series of failures in her care that, while not meeting the threshold for criminal liability, raise serious questions about what happened inside LPS's short-term holding facility on the last night of her life.
How she ended up back in police custody
LPS officers arrested the woman for assault causing bodily harm on the evening of September 1, 2023, following a stabbing. A small amount of suspected drugs was found in her hand during a search. She was taken to LPS's short-term holding facility and immediately showed signs of overdose she was extremely drowsy. EMS was called and arrived at 12:38 a.m., transporting her to Chinook Regional Hospital.
At the hospital, a community peace officer watching her saw her put yellow pills into her mouth and chew them. Staff identified them as fentanyl. She received seven doses of Narcan, overdosed again, and had to be revived a second time.
By mid-afternoon she had stabilized. The emergency room physician noted she walked to the bathroom on her own about 30 to 40 steps down the hallway and spoke coherently with staff. He discharged her at approximately 5:00 p.m., noting on the prisoner form she had been treated for a fentanyl overdose and had received large amounts of Narcan.
She arrived back at LPS's short-term holding facility at 5:31 p.m. She was slouched in a wheelchair, vomiting, and not responding to questions. A paramedic took her vital signs in the wheelchair and cleared her to be placed in a cell. She was vomiting into the toilet when placed in the cell, then lay on her side on the cell bench.
What the video showed
A commissionaire was assigned to complete physical wellness checks on the woman every 15 minutes. ASIRT obtained her check sheet and compared it against video footage from the facility.
The comparison found the commissionaire recorded checks she did not complete. At 7:13 p.m. and 7:15 p.m., the check sheet showed entries but video showed her sitting at the commissionaire desk. At 8:00 p.m. and 8:15 p.m., she was occupied booking in another prisoner.
At 7:45 p.m., the supervising officer entered the woman's cell. He used his foot to nudge her and pushed her with a clipboard. She did not respond. He wrote "refused to awake" in the log and left. A community peace officer with him noted she appeared to be snoring.
At 8:58 p.m. the same peace officer entered the cell, could not find a pulse, and called for assistance. He administered Narcan and began CPR. The supervising officer arrived at 9:03 p.m. and took over compressions. EMS arrived at 9:08 p.m. She was pronounced deceased.
The cause of death, established by autopsy, was acute p-fluorofentanyl intoxication — an analogue of fentanyl. Her post-mortem drug level was higher than the blood sample taken at hospital that morning, consistent with repeated drug use after her discharge.
What ASIRT concluded and why no charges were laid
Block found the failures missed checks, the decision to leave after she did not respond were deficiencies but not marked departures from the standard of care required for criminal liability under Alberta law.
"The SO's check at 7:45 p.m., where he nudged her with his foot and clipboard and she did not wake, likely should have resulted in a check by a paramedic," the report states. "There was no paramedic in LPS STHF at that time."
Neither the supervising officer nor the commissionaire agreed to be interviewed by ASIRT. Both had the right to refuse as subjects of a criminal investigation.
The emergency room physician who treated her told investigators that people committed to using drugs can be very resourceful and that it is very difficult to prevent this type of death. He did not believe police would have been able to prevent it unless someone was watching her constantly.
What this case reflects about a broader problem
The woman's death did not happen in a vacuum. It happened at the intersection of two systems policing and health care that both had contact with her that day and neither fully resolved her situation.
She overdosed in LPS custody overnight. Hospital staff treated her, revived her twice, and discharged her as stable. LPS took her back. She overdosed again and died.
The emergency room physician's comment is the most honest line in the entire report: he did not believe police could have prevented this death unless someone was watching her constantly. That is not an exoneration. It is an acknowledgment that a short-term holding cell is not a medical facility, that the people staffing it are not medical professionals, and that returning someone who has just survived two fentanyl overdoses to police custody the same afternoon creates a situation nobody in that facility is equipped to manage alone.
Block said it plainly in his conclusion: "The problem of where to hold intoxicated persons is a complex one. Often, police facilities end up holding such people by default after they are no longer suitable for a hospital. They would be safer in facilities specifically designed for intoxicated persons."
What changed after her death
During ASIRT's investigation, LPS advised that paramedics are now stationed in its short-term holding facility 24 hours a day. That change was not in place when the woman died. Block specifically noted: "In the absence of dedicated facilities, efforts to have more medical attention such as this are valuable."
ASIRT did not publicly release the woman's name. The report refers to her only as "the affected person" throughout.
Sources:
ASIRT, Decision in the Matter of an In-Custody Death in Lethbridge on September 2, 2023, Acting Executive Director Matthew Block, July 3, 2026 (albertaprc.ca/media/ukqjbuw3/act-ed-in-custody-death-lethbridge-20230902.pdf)
Government of Alberta, ASIRT concludes investigation into in-custody death in Lethbridge, July 3, 2026 (alberta.ca)
