Alberta has rejected excited delirium as a cause of death, but it’s all over this police-related autopsy report

Mazin Zaim was 46 years old when he died following an arrest by Edmonton police officers. (Steve Zaim)

A controversial diagnosis that Alberta officials say they don’t recognize as a cause of death is cited numerous times in the autopsy report for a man who died after being forcibly restrained by Edmonton police, the IJF has learned.

Mazin Zaim died in hospital on Oct. 2, 2023, nearly two weeks after he was handcuffed, hogtied and pinned down by Edmonton Police Service (EPS) officers responding to reports of an erratic man waving an ice scraper.

The IJF has obtained an official autopsy report confirming something called excited delirium was cited as a factor in Zaim’s death. The term has been rejected as a diagnosis or cause of death by a growing number of organizations across North America — including Alberta’s Office of the Chief Medical Examiner (OCME).

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Yet a medical examiner’s certificate in Zaim’s autopsy report says he “died in hospital with signs of anoxic brain injury 12 days after he suffered a cardiorespiratory arrest when he was restrained prone by police while experiencing drug-induced excited delirium.” Elsewhere, the report says excited delirium would have “significantly increased” the risk of death.

In all, the phrase “excited delirium” is mentioned five times in the body of the autopsy report and twice more in the footnotes. In the same document, the OCME declined to make a finding on whether his death was a homicide, citing “controversies related to this type of death.”

Steve Zaim, Mazin’s father, told the IJF he strongly objects to any use of excited delirium in reference to his son’s death.

“The people who’ve been using this term, excited delirium — this is something that’s always going to be used when the police kill somebody,” he said.

Video taken at the scene shows Mazin Zaim lying face down on the street before officers approach and press him to the ground with their knees for several minutes while they restrain him and he protests vocally. When they eventually turn him over, he is limp and unresponsive.

“I saw the video this morning. I saw it last night. I have it in my cellphone. I have it in every computer at my house and I cannot get tired of seeing it. I cry because I hear him saying, begging them, ‘Please, I cannot breathe,’” Steve Zaim said.

Excited delirium is said to describe a state of severe agitation, aggression, superhuman strength and pain resistance, often linked to illicit drugs or mental illness. For decades, police have invoked it as an explanation when people die in interactions with officers, in cases ranging from Robert Dziekanski at Vancouver International Airport to the murder of George Floyd in Minneapolis.

But excited delirium has been rejected as a diagnosis by both the American Medical Association and the American Psychiatric Association, and as a cause of death by the U.S. National Association of Medical Examiners and a number of provincial coroners’ offices in Canada.

“There is a very increasing proliferation of medical associations acknowledging that it is junk science — pseudoscience,” Zaim family lawyer Heather Steinke-Attia said. “It’s never been validly a medical diagnosis and it needs to be removed because it appears that the only time that it’s ever used, according to the researchers, is when it’s police-involved deaths.”

Steinke-Attia said she asked for all mentions of excited delirium to be removed from the autopsy report, but the OCME declined.

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Zaim’s family believes he was having a mental health crisis, and they allege the officers used excessive force.

“This was not somebody who was in the process of engaging in a criminal activity when the police were called in,” Steinke-Attia said. “This appears to be more of a mental health scenario where Mazin was happy to see the police arrive, and he didn’t deserve the way he was treated that day.”

Alberta Ministry of Justice spokesperson Katherine Thompson confirmed in an email to the IJF that the OCME no longer recognizes excited delirium as a cause of death. She said she couldn’t comment on individual cases for privacy reasons, but any mention of excited delirium in an autopsy report would come from hospital staff, not the medical examiner.

“Hospitals may sometimes still use the terms ‘excited delirium’ or ‘excited delirium syndrome’ in their reports, and a hospital’s independent use of these terms may be quoted in an OCME death investigation report,” Thompson wrote.

None of the references to excited delirium in the autopsy report are written as quotes or otherwise indicate the term came from hospital reports.

The Alberta Serious Incident Response Team, an independent agency that investigates police misconduct and incidents leading to serious injury or death, is still investigating the encounter that killed Zaim. Spokespeople did not respond to requests for comment about when that process might be complete.

The EPS declined to comment on the investigation while it’s underway.

‘Unresponsive and not breathing’

Zaim was 46 years old and ran his own upholstery shop in Edmonton. His father said he loved children and could be generous to a fault.

“He was very sweet. In fact, I didn’t like the fact he’s too sweet, too naive, he’s too kind, he’s too generous,” Steve Zaim said. “Our neighbours — all our neighbours — they loved him so much, how kind, how helpful he was.”

The events that led to his death began on Sept. 20, 2023, when Mazin Zaim was staying at a friend’s house to care for his elderly father while the friend was out of town, according to his family.

Neighbours called 911 to report a man holding a large ice scraper in the middle of the street, the Jan. 11, 2024 autopsy report says.

“When police arrived, he followed commands to kneel and lay down, but became agitated while being detained and having handcuffs placed by several police officers while prone on the ground, which took about three and a half minutes,” the report reads.

“He was hogtied at the completion of the restraint using reportedly a total of three handcuffs due to the obese body habitus [physique], and when he was turned supine about four minutes after initiating the restraint, he was observed to be unresponsive and not breathing.”

Despite CPR from police and paramedics at the scene, Zaim never regained consciousness and was taken off life support in hospital 12 days later.

The autopsy identifies a lack of oxygen to the brain as the immediate cause of death, saying it was the result of “restraint asphyxia” caused by the “effects of cocaine use.”

The pathologist who performed the autopsy wrote that excited delirium made Zaim more vulnerable to death by asphyxiation. “The risk of death due to restraint in individuals with excited delirium is significantly increased,” he said.

He declined to find that police caused Zaim’s death, although he noted “pressure on his chest during the restraint would have impaired his ability to breathe.” The report says, “The manner is classified as undetermined due to the controversies relating to this type of death, which some would consider as accidental, and others would classify as homicide.”

‘A bad and discredited habit’

American forensic medical expert Dr. Michael Freeman, who has spent years reviewing the research on excited delirium, was disappointed to see it apparently being used to classify Zaim’s manner of death as “undetermined.”

Freeman described the continued use of the term in police-involved deaths as “a bad and discredited habit” that draws attention away from the actions of officers.

“When they put [someone] face down, they’ve got him prone and they restrain him, and they cuff him and they put weight on his back, that’s a known cause of asphyxia and acidosis and other factors that can lead to sudden, cardiopulmonary arrest,” Freeman said.

“If you take away the restraint, there’s nothing to say that the condition of being either delirious or excited or agitated or hallucinating — or anything else — is physically killing him.”

When the American Medical Association announced its 2021 decision to reject excited delirium as a diagnosis, the organization acknowledged it is “disproportionately cited in cases where Black men die in law enforcement custody.”

Those inequities were also highlighted in a 2023 study from researchers at McGill University, who analyzed the use of the term in police-related deaths from an ethical standpoint.

“We see that it’s, more often than not, people of colour, Indigenous people in Canada. It’s the same groups of people that are subjected to police violence much more than others,” said co-author Phoebe Friesen, an assistant professor in the university’s Department of Equity, Ethics and Policy.

The label can also influence how police respond, she added.

“You so often see a characterization of someone as having excited delirium met with extreme force, and that force is explained, why? ‘Well, the person can’t even feel pain. There’s no way we could restrain them without six officers on top of them,’” she said.

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Today, recognizing and responding to excited delirium continues to be part of police training and policies for many Canadian departments, including the RCMP.

EPS spokesperson Carolin Maran said the force’s understanding is that excited delirium isn’t a diagnosis, but rather a set of behaviours.

“The EPS does not ask officers to make medical diagnoses, but officers are trained to recognize symptoms of the associated collection of behaviours, commonly known as excited delirium and to call for medical support at the earliest signs of distress,” she wrote in an email.

RCMP spokesperson Robin Percival said the national police force shares a similar understanding of the term, but acknowledged it’s contentious.

She told the IJF the Mounties’ response to the controversy is to find a new name.

“We are currently working with medical experts, various first responders, and other partners to come to a national consensus on a new naming convention that removes any real or perceived diagnostic language or bias and focuses on the prevention of arrest-related deaths,” Percival wrote in an email.

By Bethany Lindsay, Investigative Journalism Foundation, and Angela Amato