Vancouver Inquest Reveals Missed CPR Response in Woman’s Cardiac Emergency
A recent inquest revealed troubling details about the response to a medical emergency at the Vancouver jail, where 58-year-old Cheryl Ann Cowan was found unresponsive but was not receiving CPR — despite multiple trained staff standing nearby.
Paramedics Shocked to Find No CPR Being Performed
When paramedics arrived, they found Cowan lying on her back on the pavement, surrounded by jail and medical staff who were not providing treatment.
Rodrick MacKenzie, lawyer for the B.C. Coroner’s Service, asked paramedic Mike Burgwin whether he was surprised that CPR hadn’t been started.
“Yes,” Burgwin replied, noting that staff appeared confused about whether CPR should be initiated.
What Happened Before Paramedics Arrived
Cowan had been arrested on Dec. 15, 2014, after a drunken break-and-enter/trespassing incident at her estranged husband’s home. She was kept inside a police transport van for 48 minutes before anyone checked on her.
By that time, she showed clear signs of cardiac arrest:
No pulse
Blue lips
Fixed stare
Low body temperature
Video presented at the inquest showed Cowan being moved from a wheelchair to the ground just before paramedics arrived.
Present were the on-duty jail doctor, two nurses, the jail sergeant, a Vancouver police constable, and several other staff — yet no lifesaving measures had begun.
CPR Should Have Started Immediately
Paramedic Katelyn McRae told the inquest:
“CPR should have been initiated before we arrived because they’re all trained professionals. It’s a standard intervention for cardiac arrest.”
However, jail physician Dr. Brendan Russell testified that he had told others, “She’s gone.”
A nurse recalled asking whether she should start CPR but was instructed not to, despite her instinct to act.
Resuscitated — But Too Late
Paramedics were able to resuscitate Cowan, but the delay in CPR caused irreversible damage. She remained on life support for eight days before dying from lack of oxygen to the brain.
Inquest Calls for Better Emergency Protocols
Witnesses highlighted major gaps in emergency response, including:
No clear chain of command
Uncertainty about who should initiate CPR
Recommendations from testimony included:
Mandatory CPR training for all jail staff
A “code blue” alert system similar to hospitals
Regular mock emergency drills
Video cameras in transport vans, monitored remotely
The inquest jury will reconvene to finalize recommendations to prevent similar tragedies.
Learn CPR — It Truly Saves Lives
This case underscores how delayed CPR can mean the difference between life and death.
If you want to be prepared to act in an emergency, consider taking a certified CPR and AED course.
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