A report from the Commission for Public Complaints Against the RCMP has reiterated the findings of the coroner's inquest into the 2008 death of Raymond Silverfox.

The document, released today, says police policies were not followed; officers and guards treated Silverfox with callousness and disrespect; and the Carmacks man was left in "deplorable” conditions during his 13-hour stay in the RCMP cells in Whitehorse.

But, as with the inquest, the report stops short of recommending any disciplinary action against the officers and guards who failed in their duty of care to Silverfox.

It finds no fault with a criminal investigation and an administrative review which did not take into account the audio recording taken during Silverfox's last 13 hours of life.

That recording revealed officers and guards mocking and swearing at Silverfox as he lay in an increasingly filthy cell, covered in his own vomit and unable to move away from the mess on the floor around him.

The report recommends time and time again that the RCMP follow their own policies of regularly checking on prisoners, of moving prisoners from "uninhabitable” cells, and of treating people with respect and decency.

Although the first officers who arrested Silverfox at the Salvation Army building and transported him to cells were doing the right thing by ensuring he did not spend the night on the streets, they failed to test his blood-alcohol level, the report states.

It was the first misstep in a tragic sequence of events that would ultimately end in the 43-year-old man's death from a blood and lung infection likely brought on by inhaling his own vomit.

The second guard who was in charge of watching over Silverfox disregarded policies and basic care, the report says.

Heather Balfour told Silverfox he would have to clean his own cell if he continued to throw up, something he could clearly not stop doing, and she did not do physical checks of his cell.

The report pointed out that in the last three hours of Silverfox's time in the cells, the checks done by guard Hector McLellan were "entirely inadequate.”

The report says watch commander Cpl. Calista McLeod failed to personally check on Silverfox and instead relied on the guards to inform her of what was happening on her watch.

"Watch commanders should not find themselves surprised by a condition that has been developing over the course of some eight hours,” the report states.

It notes McLeod did not notice Silverfox's plight until he had already stopped breathing, although she had been on duty for almost his entire stay.

"Mr. Silverfox was in the Whitehorse RCMP detachment cells for almost 13 hours at the time of his death,” the report states.

"He had been ill for virtually the entire length of his stay. However, as was demonstrated in the cell block video, he was left virtually alone as a number of individuals – members, guards and civilians – entered and exited the guardroom of the Whitehorse RCMP detachment.”

The fact they all thought Silverfox was "simply sobering up,” or that he continued to be intoxicated, is no excuse, the report states.

Silverfox was violently ill for the entire time he was in police custody, and "the frequency and severity of his sickness did not diminish during his time in cells,” the report states.

"Despite all of this, no medical assistance was sought for Mr. Silverfox prior to the determination that he was no longer breathing.”

The public complaints commission is an independent agency mandated to investigate the RCMP and report to Parliament.

However, as communications director Jamie Robertson explained at a news conference this morning in Whitehorse, it has no power to discipline officers, or even recommend disciplinary actions.

According to the RCMP, four of five officers have been disciplined for their actions, or inactions, on the day Silverfox died, but they have not provided any details about how they were disciplined.

The fifth officer is on medical leave, and any disciplinary action will be addressed if and when that officer returns.

See Friday's Star for additional coverage.