An 18-year old died in police custody in Medicine Hat five years ago, and following an extensive investigation provincial court Judge Gordon Krinke has issued a report that calls for better examinations of prisoners and a higher standard of care when it comes to ensuring prisoner well-being.

In February of 2010, Morbe Buluk arrived at his parents’ home and was acting strangely. Concerned that he was drunk or on drugs, they called the police and Buluk was arrested after spitting at one of the officers.

Though it wasn’t known at the time, earlier that day Buluk had been punched and had hit his head on the sidewalk. This head injury was almost certainly the cause of his strange and aggressive behavior, as these are common outcomes after a brain injury.

After his arrest, Buluk underwent an examination by paramedics that left out certain key medical tests, including checking his pupils for their dilation reflex—a common test used to identify concussions following head injuries, and a standard examination even if a head injury is not initially suspected.

Several hours later he was found unresponsive on the floor of his cell, and he died in the hospital shortly thereafter.

After considering all of the facts in this incident and examining the general guidelines and procedures in place for the medical assessment of prisoners, Judge Krinke produced a report that lists eight separate recommendations for improving care, including more thorough initial examinations.

Brain injuries can lead to immediate and sometimes frightening behavioral changes, and law enforcement as well as average Alberta citizens should be aware of this possible explanation for any strange behavior.