Sunday 20 June 2010

Well it's Father's Day and everybody's wounded.

Up, Down, Appendices.

"Ten thousand men on a hill, some of ’m goin’ down, some of ’m gonna get killed."

Alton Lee WilsonAlton Lee WilsonAlton Lee WilsonAlton Lee WilsonAlton Lee WilsonAlton Lee WilsonAlton Lee WilsonAlton Lee WilsonAlton Lee Wilson
I'm going looking for his grave today, I helped carry him to it back ... 1981 sometime ... died just about on his birthday, I couldn't reach him by phone ... they found him a week later bloated and rotten, summertime ... I think that last picture is some kind of bullshit corporate honour - 50 years on the job maybe it was, yeah, we had a piano in our house though I never learned to play,

if I had to say one thing it would be that he loved his wife and his wife loved him, with all their hearts, and if I had to say two I would add that he loved me and I loved him, the same way - with all out hearts, and three - he loved gardening, God bless him.

Floribert Chebeya BahizireFloribert Chebeya BahizireFloribert Chebeya BahizireFloribert Chebeya BahizireFloribert Chebeya BahizireFloribert Chebeya Bahizire was one of those who got killed, obviously courageous, probably stubborn as fuck, a husband and father ... this is about memory and honour and dignity today ...

Robert DziekanskiRobert Dziekanski wasn't a father as far as I know, and I haven't seen anything about his father, but he might have been a father if the RCMP hadn't murdered him, it's been almost three years now and last week Thomas Braidwood released his final report - and the RCMP carries on 'praised by faint damning'

Thomas BraidwoodThomas BraidwoodBraidwood is reported saying (here and here), "I think I was blunt enough, full enough, and hopefully accurate enough that those reading it can draw their own conclusions," all good I guess except I thought we had just kept him busy for two years and filled his jeans with cash exactly in order that he draw conclusions? wasn't that it?

Richard PeckRichard Peckthe muffle-mouth shit-head leader of the RCMP, William Elliott, goes on spinning and trying to spin, and now we await the results of yet another inquiry, this time by Richard Peck who has been assigned as 'special prosecutor' by Mike de Jong, the BC Attorney General, God knows when they will finally put these murderers behind bars, if ever? GOD DAMN THEM ALL!

not nice things to be saying on Sunday morning and all ...

all this delay might be construed as somehow reasonable if there had not been a video taken by Paul Pritchard which shows as clear as day exactly what the Mountie thugs did to him, we can only hope that Paul Pritchard eventually becomes a father.

and finally, Khattiya Sawasdipol / Seh Daeng, from Thailand, killed by government forces, and his grieving daughter:
Khattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya SawasdipolKhattiya Sawasdipol

1. Remembering Floribert Chebeya, Dave Peterson, Jun 11 2010.
2. Is depression a disease?, Leah McLaren, June 18 2010.
3. Talking therapies are more effective than Prozac-type drugs, says scientist, Hannah Devlin, June 14 2010.
4. Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration, Irving Kirsch1, February 26 2008.
5. RCMP officers to face second look at charges, Neal Hall, June 19 2010.
6. Piling up the negatives, Brian Hutchinson, June 19 2010.

Remembering Floribert Chebeya, Dave Peterson, Jun 11 2010.

Floribert’s murder is an enormous outrage. He was undoubtedly Congo’s most prominent, committed, courageous human rights activist. From his early years when he won the Reebok Human Rights awards in 1992 for fighting the Mobutu dictatorship, through the national conference process, the civil war, the Laurent Kabila regime, the Congolese elections, and the current dispensation, which continues to deteriorate – Floribert persevered, finally paying the ultimate price for his vision of a free and democratic Congo. He should be remembered as one of Congo’s greatest freedom fighters, a leader of Africa’s democratic movement, and an international human rights giant. This is a terrible loss. His death must not be in vain. His life’s work must continue.

I first met Floribert about 20 years ago when he was visiting the U.S. and the Endowment made its first grant to the organization he led, Le Voix des Sans Voix, in 1991 for $31,289, “to support the VSV’s efforts to increase the understanding of and commitment to human rights and democracy in Zaire through a civic education program that includes a monthly bulletin, audiovisual materials, and public meetings.” It was the first grant NED made in Zaire, along with one to the Ligue Zairois des Droits de l’Homme, which folded a few years later. But VSV carried on and has continued to receive NED support ever since, one of a small elite. NED’s program in Congo is now our largest in Africa, and there can be no question that Floribert paved the way and set the standard for all that followed.

Floribert was both gentle and fierce. His small stature, soft voice, thick glasses and warm smile belied the toughness and determination that landed him in and out of detention on multiple occasions, and that elevated him to be the widely acknowledged leader of Congo’s human rights movement in networks such as Droits de l’Homme Maintentant, and mentor to scores of human rights NGOs across the country. When the pressure and threats became too great, Floribert would send his wife and children across the river to Brazzaville, but he stayed behind in Kinshasa to continue his work. He lived modestly, and if he had political ambitions, he never pursued them. His family had to move from time to time for security reasons, but the occasions when I was honored to have dinner at his home were filled with the love and warmth of his devoted wife and children. When he spoke before mass audiences his eloquence and passion were captivating, but unlike so many other tribunes of the people, his integrity was incorruptible, he never lost his connection with the Congolese people whose voice he had become. I sat with him once as he interviewed an alleged recent victim of human rights abuse. He was gentle, yet probing, and rather than rushing to use her as a convenient weapon against the authorities, determined that her case was doubtful, but he promised to follow up with her later. He and the staff of VSV investigated and sought redress for hundreds of such cases.

Floribert was a realist. He understood politics. But he never sacrificed principles. He was as unafraid to denounce American policies he saw as wrong as he was those of his own government. When most other Congolese, including some human rights advocates, were denouncing the Tutsis and Banyamulenge after the Rwandan invasion, Floribert defended the rights of innocent civilians who were targets of human rights abuse no matter what their ethnicity. He had enormous energy. Leading a committed team, Voix de Sans Voix has issued hundreds of press statements over the years, meticulously documenting human rights abuses and denouncing them. VSV has likewise held hundreds of workshops, training conferences, civic education events, and campaigns. Floribert undoubtedly inspired hundreds of activists throughout the country who still cite VSV for getting them off the ground, showing them how to do human rights work, and counseling them on strategy. He distributed his Reebok Human Rights Award among other civil society organizations rather than keeping it for himself or even his own organization. His impact on the human rights movement and the understanding and appreciation for democracy in Congo was profound.

Whether or not the gunman or the person who gave the orders is ever identified, we know who killed Floribert Chebeya. The Congolese political system has become increasingly repressive, human rights organizations are continually threatened, journalists have been murdered, the political opposition emasculated, and the rule of law flouted. In the east the vicious killings, looting, and mass rapes committed by the Congolese army continue unabated. The UN peacekeepers are being pressed to leave, and the prospects for any democratic elections in the future are fading. The Congolese people have lost one of their most ardent defenders. Floribert will be remembered among the pantheon of African martyrs and freedom fighters such as Patrice Lumumba, Steve Biko, and Tom Mboya. But those who committed this crime must not go unpunished. Floribert’s vision of a free and democratic Congo must be preserved. Floribert would have demanded no less.

Is depression a disease?, Leah McLaren, June 18 2010.

Big Pharma says yes, but others aren't so sure

‘It's all in your head” isn't something a chronically depressed person likes to hear. In the age of Prozac, when adjusting your serotonin level is as normal as checking the oil in your car, it seems unhelpful to suggest that someone might think their way into – or out of – a disease of the mind.

And yet depression is all in our heads. Where else would it be? The real question, still hotly debated in the scientific community, is whether its cause is chemical and ultimately curable (good news for Big Pharma) or something far more complex (good news for poets and pot-smoking students of existential philosophy).

There is no doubt that depression exists. Inexplicable sadness – or “melancholia,” as it was historically known – has been with us since Hippocrates conceived his famous oath. But a groundbreaking new study has found that not only is depression affected by the way we think about it, so too is its cure.

Last week Irving Kirsch, a professor at the University of Hull in the U.K., presented a study that found Prozac and its ilk are no more effective than placebos in treating depression. In his view, there is no substantial link between serotonin – the brain chemical that antidepressants are supposed to regulate – and chronic depression.

It's a controversial study – one that many members of the psychiatric community reject out of hand – but it also raises a nagging question about depression: How did it come to be recognized as a disease in the first place?

Like Hirsch, psychologist and writer Gary Greenberg is part of a growing number of psychiatric professionals who have begun to publicly question the underpinnings of popular thinking on depression.

His recent book, Manufacturing Depression, debunks the prevailing notion that depression is a disease and anti-depressants the long-awaited cure.

In his view, the game is rigged. As he told me in a phone interview, “the disease was invented to justify the cure.”

Greenberg sums up the history of modern depression like this: In the 1950s, doctors researching drugs for unrelated illnesses discovered that certain substances made people feel high. They didn't know why or how, just that they'd struck oil. These psychoactive drugs were marketed as mood enhancers and by the 1960s minor tranquilizers like Valium and Librium were routinely prescribed to people who these days would likely be classified as clinically depressed. Once the market was established, the race was on to develop the perfect mood-elevating pill. At the same time, pharmaceutical companies began to search for a way to increase the market share. An executive at the U.S. drug company Merck had a brilliant idea – why not broaden the diagnostic criteria for depression in order to sell more people the drugs? They recruited a doctor to write a book entitled Recognizing the Depressed Patient, which was then distributed to some 50,000 doctors around the country. The strategy was a resounding success and stands as an early triumph of viral marketing. And the script in that book is the same criteria doctors today use to determine whether a patient qualifies for anti-depressants and is, by extension, “chemically imbalanced.”

In his own book, Greenberg participates in a clinical trial himself, signing up first as a minor depressive (for which he believes himself qualified) and later getting upgraded to major depressive simply by answering the questions honestly.

As a clinician he takes issue with the methodology used to determine depression. He points out that answering “yes” to questions like “Have you been feeling depressed lately?” and “Do you ever wonder if life is worth living?” may be evidence that you are a Prozac candidate or simply a natural response to watching the latest news on the BP oil spill.

“With clinical depression, the symptoms justify the disease,” he says. “There's an infinite regress and no bottom. Don't forget they used to be able to scientifically ‘diagnose' homosexuality the same way.”

As a practising psychologist, Greenberg knows the dirty truth about anti-depressants – that the theory on which their effectiveness is based is just that: a theory. The notion of chemical imbalance has never been proven and remains highly controversial. It is, according to Greenberg, “a myth, which, like all great myths, gathers together the central beliefs and ethos of a society.” In this case, it's the belief in magic-bullet medicine combined with the prevalence of materialism (i.e. the belief that psychological truths can be located in the physical brain).

And of course, it's all very convenient for Big Pharma, which makes billions curing people of a disease that may not exist. Last year in Canada alone, almost 35-million prescriptions were filled for anti-depressants, at a total cost of over $1.5-billion.

This is not to say that Greenberg agrees with Kirsch. “His interpretation of the effects of consciousness-altering drugs doesn't really add up. Frankly I don't think he's taken many of them.”

While Greenberg believes depression is over-diagnosed and anti-depressants are over-prescribed, he sees nothing wrong with experimenting with pharmaceuticals in order to alleviate sadness or mental suffering, which are of course as old as human consciousness itself. He just wishes we would understand that that's what we're doing, rather than convincing ourselves we're suffering from a mental illness and in need of a cure. Such behaviour brings to mind my temperance worker grandmother who used to allow herself a thimble of whisky every night on the grounds that her doctor had prescribed it as “medicine.”

“When we call a form of suffering an illness, we are saying it deserves recognition and resources. In this case, unfortunately, the kind of resources it commands are money for drugs. What if we could use those resources for other things – say, to figure out ways to make our society less isolating, less individualistic?”

There's no question where Greenberg lands on the scale between Big Pharma and the poets.

As for me, I'd rather get on with life. And by that I mean staring at the wall and contemplating whether it's actually worth living.

Talking therapies are more effective than Prozac-type drugs, says scientist, Hannah Devlin, June 14 2010.

Antidepressants of the Prozac type are no better than a placebo, a leading psychologist has claimed. According to Irving Kirsch, the evidence is overwhelming that there is no link between depression and serotonin, the brain chemical that such drugs are supposed to affect.

Practising psychiatrists, however, say that it would be disastrous to use stricter criteria for the prescription of antidepressants on the basis of Professor Kirsch’s research findings. “Be very careful what you advise, because we in the surgeries will be left to pick up the pieces,” said Amjad Uppal, a consultant psychiatrist for the Gloucestershire NHS Trust.

Last year in England the NHS issued 39 million prescriptions to treat depression, more than half being for “selective serotonin reuptake inhibitor” (SSRI) drugs. Three million people took antidepressants daily. Antidepressants including Prozac and the newer generation of SSRIs, such as Seroxat, are taken to increase the level of serotonin in the brain.

Professor Kirsch argued that they worked through the placebo effect — patients expect to be made to feel better — and said that “talking treatments” such as cognitive behavioural therapy were more effective in the long term.

“Although the chemical-imbalance theory is often presented as if it were fact, it is actually a controversial hypothesis,” he said. “This is about as close as a theory gets in science to being disproven by the evidence.”

Others maintain that antidepressants do have an active biochemical influence. “We do not fully understand how these drugs work, but there is evidence that they influence the number of neurons and the connections between neurons. You can’t draw conclusions about this because of the nature of the study,” said Hamish McAllister- Williams, a consultant psychiatrist and psychopharmacologist at Newcastle University.

He said that depression was a dangerous illness, noting that sufferers were at as high a risk of a heart attack as those who smoked 20 cigarettes a day.

Dr McAllister-Williams believed that “at least a proportion” of the effect of the drugs was “due to active ingredients, but either way they work and we really need an effective treatment”. Dr Uppal said: “I have a very high threshold for prescribing antidepressants, but there’s no doubt in my mind they work. Research studies are artificial and do not capture the difference between effectiveness and efficacy.”

Professor Kirsch’s research, presented at The Times Cheltenham Science Festival, shows that a new drug, tianeptine, is just as effective as SSRIs in treating depression. Tianeptine, which is a serotonin reuptake enhancer, actually decreases the level of the chemical.

In comparisons of tianeptine with SSRIs and the earlier tricyclic antidepressants, the three produced virtually identical response rates: 63 per cent of patients responded to tianeptine, 62 per cent to SSRIs and 65 per cent to tricyclics. If drugs having three different effects on serotonin brought similar benefits, these could not be due to their specific chemical activity, Professor Kirsch said. “The idea that the neurotransmitter serotonin is a causal factor in depression is wrong.”

Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration, Irving Kirsch1, Brett J. Deacon, Tania B. Huedo-Medina, Alan Scoboria, Thomas J. Moore, Blair T. Johnson, February 26 2008.

Kirsch and colleagues show that, in antidepressant trials, there is a greater difference in efficacy between drug and placebo amongst more severely depressed patients. However, this difference seems to result from a poorer response to placebo amongst more depressed patients.


Meta-analyses of antidepressant medications have reported only modest benefits over placebo treatment, and when unpublished trial data are included, the benefit falls below accepted criteria for clinical significance. Yet, the efficacy of the antidepressants may also depend on the severity of initial depression scores. The purpose of this analysis is to establish the relation of baseline severity and antidepressant efficacy using a relevant dataset of published and unpublished clinical trials.

Methods and Findings:
We obtained data on all clinical trials submitted to the US Food and Drug Administration (FDA) for the licensing of the four new-generation antidepressants for which full datasets were available. We then used meta-analytic techniques to assess linear and quadratic effects of initial severity on improvement scores for drug and placebo groups and on drug–placebo difference scores. Drug–placebo differences increased as a function of initial severity, rising from virtually no difference at moderate levels of initial depression to a relatively small difference for patients with very severe depression, reaching conventional criteria for clinical significance only for patients at the upper end of the very severely depressed category. Meta-regression analyses indicated that the relation of baseline severity and improvement was curvilinear in drug groups and showed a strong, negative linear component in placebo groups.

Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication.

RCMP officers to face second look at charges, Neal Hall, June 19 2010.

Attorney-General makes announcement after release of final report into Robert Dziekanski's death

A special prosecutor will take a second look at charges against four RCMP officers after the Braidwood inquiry found the Taser used on Robert Dziekanski in 2007 was an unnecessary use of force, B.C.'s attorney-general announced Friday.

In addition, the province will establish, within a year, an independent civilian agency to investigate police-related deaths and serious injuries. The agency, to be led by a civilian who has never worked for police, will be called the Independent Investigations Office (IIO) and will have the authority to investigate the RCMP and municipal police.

Attorney-General Mike de Jong made the announcement Friday, minutes after the release of inquiry commissioner Thomas Braidwood's bluntly worded final report.

"Moving to an IIO model will help prevent in future what played out during the inquiry and is highlighted in the commission's report -- a number of discrepancies between what RCMP officers told investigators in 2008 and what came out at the inquiry," de Jong said.

In his report, Braidwood concluded the "shameful conduct" of the officers was not justified.

The retired appeal-court judge condemned the actions of the four RCMP officers, who responded to a 911 call reporting the presence of a violent drunk at Vancouver International Airport after 1:30 a.m. on Oct. 14, 2007. (An autopsy later determined he had no alcohol or drugs in his system.)

Braidwood found the officers mishandled the situation by approaching Dziekanski as though they were dealing with a pub brawl instead of a distraught and exhausted visitor, who had spent more than 10 hours after arriving from Poland unsuccessfully trying to find his mother at the airport.

One of the officers repeatedly shocked Dziekanski with a Taser, even after he fell to the floor writhing in pain.

Dziekanski, 40, died minutes after police handcuffed his hands behind his back.

His mother, Zofia Cisowski, waited at the airport for more than seven hours, but finally returned to her Kamloops home when told by customs officials that her son could not be found.

Dziekanski was hoping to start a new life in Canada. He spoke no English and had never been on a plane before.

Braidwood found the four officers should have used their skills and training to de-escalate the situation rather than deploying the stun gun five times. Police contact with Dziekanski lasted only 75 seconds, he pointed out.

Braidwood quoted Dziekanski's final words, spoken in Polish: "Leave me alone. Did you become stupid? Have you gone insane? Why?"

The 459-page report is titled Why? The Robert Dziekanski Tragedy.

"In my view, Const. [Kwesi] Millington was not justified in deploying the weapon against Mr. Dziekanski, given the totality of the circumstances he was facing at the time," Braidwood concluded in his report.

"Similarly, Cpl. [Benjamin] Robinson was not justified in instructing him to deploy the weapon."

Braidwood dismissed as false the officers' claims that they were forced to wrestle Dziekanski to the ground, noting that he'd fallen after the first shock.

"The initial claims by all four officers that they wrestled Mr. Dziekanski to the ground were untrue," said the report. "In my view they were deliberate misrepresentations, made for the purpose of justifying their actions."

The incident was captured on an amateur video that was posted on YouTube, prompting an international public outcry because the video showed a markedly different scenario than the police version of events. The officers testified at the inquiry that they believed Dziekanski intended to attack because he had a stapler in his hand.

But Braidwood dismissed their testimony, saying, "I do not believe that either of these officers honestly perceived that Mr. Dziekanski was intending to attack them or the other officers."

The inquiry commissioner found Dziekanski was compliant with police commands and did not brandish the stapler as a weapon.

"Mr. Dziekanski did not bring this on himself," Braidwood told reporters Friday.

Braidwood was asked by a reporter why he stopped short of calling the RCMP officers' actions misconduct.

"I think I was blunt enough, full enough, and hopefully accurate enough that those reading it can draw their own conclusions," he explained.

"This tragic case is, at its heart, the story of shameful conduct of a few officers. It ought not to reflect unfairly on the many thousands of RCMP and other police officers who have, through years of public service, protected our communities and earned a well-deserved reputation in doing so."

The attorney-general, however, said minutes later: "There was misconduct here and it reflects badly. The response here was way out of proportion to what was warranted."

De Jong credited Braidwood for doing "a tremendous job of unravelling and probing all the circumstances surrounding the tragic death.... B.C. agrees with the intent, principle and purpose of each of the report's recommendations."

De Jong also praised Dziekanski's mother for attending Friday's news conference. "You are a brave lady and I think British Columbians and Canadians have seen that firsthand. I thank you for being here," he said.

Cisowski said she was pleased by the attorney-general's appointment of a special prosecutor to review whether charges should be laid.

The Criminal Justice Branch announced Friday that senior Vancouver criminal lawyer Richard Peck has been appointed as special prosecutor.

RCMP Commissioner William Elliot admitted Friday to reporters in Vancouver that the force's handling of the fatal incident "failed at many levels" and the events should have unfolded differently.

"It is clear our policies and training in place at the time were deficient," he told reporters. "We acknowledge that the actions of our members who dealt with Mr. Dziekanski also fell short."

He went on to outline all the changes the RCMP has made since the incident, in training, policy and procedures involving the use of force and Taser use.

Elliot began his news conference by offering Dziekanski's mother "our sincere condolences on the death of her son Robert and to apologize unconditionally for the role the RCMP, including individual members of the RCMP, played in his tragic death."

A Vancouver Sun reporter asked why the RCMP didn't apologize when the citizen's video was released, but instead waited more than two years.

"That's a very good question," Elliot said.

"I wish we would have offered an apology to Mrs. Cisowski a lot sooner than we did."

He said the force will be revisiting some of the decisions made at the time.

Elliot admitted that the RCMP "messed up," making mistakes and errors in judgment that undermined public confidence in the force: "Canadians will not support us when they don't trust us."

He said the RCMP welcomed the B.C. government's plan to establish a civilian agency and will cooperate with a special prosecutor appointed to review the original Crown decision not to charge the four Mounties.

Elliot said one of the officers has been suspended for an unrelated incident and the other three have been assigned to administrative duties. Vancouver RCMP Insp. Tim Shields, asked if it was true that three of the officers were on medical leave, said he could not comment.

Robinson has been charged with obstruction of justice for his involvement in an accident in Delta in 2008 that killed motorcyclist Orion Hutchinson, 21.

Delta police recommended Robinson be charged with impaired driving, but the Crown said there was insufficient evidence. The officer left the accident scene with his two children and went to his nearby home, where he claimed he had a couple of shots of vodka.

Piling up the negatives, Brian Hutchinson, June 19 2010.

It was the first question put to Thomas Braidwood at his news conference yesterday, and the most significant. The nut of it lay in the preamble, rather than in the query itself. Judge Braidwood had just released his meticulously constructed and damning 460-page analysis of events leading to the death of Polish immigrant Robert Dziekanski.

"You found misconduct," declared Global television reporter John Daly, before getting to the gist of his question, which I'll confess I didn't quite catch. I had stopped listening and was looking for Judge Braidwood's reaction instead.

Seconds earlier, Judge Braidwood stopped half-an-inch short of calling the four RCMP members involved in the 2007 Vancouver airport tragedy incompetents, liars and thugs. But he hadn't alleged "misconduct" on their part. And nowhere does the word "misconduct" appear in his report.

Yet the retired judge didn't correct Mr. Daly. Why not?

Last year, his commission of inquiry counsel fought the four RCMP officers all the way to the B.C. Appeal Court to protect his authority to determine misconduct. A finding of misconduct would surely influence any future prosecution, should one ever come. But Judge Braidwood didn't go that far.

Why is that, another reporter pressed.

"I think I was blunt enough, full enough, and hopefully accurate enough that those reading it can draw their own conclusions," Judge Braidwood replied.

This is an eminent jurist who doesn't make mistakes. Judge Braidwood chooses his words carefully, deliberately. In those exchanges yesterday, he seemed to be playing a bit coy. He allowed to pass suggestions that there was misconduct, without making them himself. I think he had realized at some point, preparing his report, that he didn't need to. The report would be strong enough. After his press conference yesterday, B.C. Attorney-General Mike de Jong announced the appointment of a special prosecutor, Richard Peck, to consider charges against the four officers. The special prosecutor will start with the full Braidwood report, and go from there.

The special prosecutor will read how the RCMP constable who zapped Mr. Dziekanski five times with his Taser "deliberately misrepresented" the incident in his police report. To the same passage--indeed, the same sentence -- Judge Braidwood added the words "overstated," "prejudicial" and "self-serving." That's some pretty strong stuff.

There's his description of the senior officer's "refusal" to remove handcuffs from Mr. Dziekanski as the 40-year-old lay dying on the airport floor, post-Tasering, post-police dog pile. This refusal was "unjustified," wrote Judge Braidwood.

There's much more. The negatives pile up. "Unprofessional," wrote Judge Braidwood. "Factually inaccurate." "Shameful conduct by a few officers."

The judge also made it clear yesterday that the public should not focus only on missteps made by the four officers. While he did not have the authority to ascribe blame or recommend charges, he was certainly able to make findings of fact and point fingers wherever warranted.

He came down hard on the Canada Border Services Agency, in particular on one of its Vancouver airport officers. Robert Dziekanski's death could have been avoided had the CBSA worked differently than it did on that night in October 2007.

Mr. Dziekanski arrived at YVR from Poland "fatigued, confused and stressed," writes Judge Braidwood. "He was dishevelled and sweating profusely around the face. I do not find any of this remarkable, given his fear of flying, the long trip and his inability to speak English."

After clearing customs and immigration, Mr. Dziekanski wandered inside the airport's international arrivals area for hours.

"One would think that the Canada Border Services Agency would want, for its own security purposes, to maintain tighter control than this on the movements of arriving passengers," Judge Braidwood writes in his report. "The fact that Mr. Dziekanski went unnoticed for more than five hours points to inadequate services to ensure that passengers move through the customs and immigration processes in an orderly and prompt manner."

Mr. Dziekanski's mother, Zofia Cisowski, waited with a friend in the airport's public meet and greet area. Her son had arrived from Poland and was still inside the customs zone, she was sure. They managed to speak via telephone to a CBSA officer inside, Tina Zadravec; she told them she could not find a man matching Mr. Dziekanski's description. She'd looked. She refused their offer to take down Mr. Dziekanski's name and run it through a flight manifest. But this would have confirmed that Mr. Dziekanski had indeed landed.

As Judge Braidwood concluded, "it was ill-considered and cavalier for her, not having taken those steps, to advise [Ms. Cisowski's friend] that in all certainty Mr. Dziekanski was not there and that they might as well go home."

They went home. "Had they been told to wait outside, [Mr. Dziekanski] would be alive today," Judge Braidwood said yesterday.

Ms. Zadravec, the CBSA officer, would later spot Mr. Dziekanski seated in a chair. She told police weeks later that she thought he might have been drunk. Other witnesses said the same. But Mr. Dziekanski wasn't drunk. He did become agitated. He would soon be dead.

Judge Braidwood made eight recommendations in all. Most, if not all, likely will be implemented. And while his work is over, this RCMP business isn't. Judge Braidwood could have gone further, but the door's been left open a crack.

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