The investigation, ordered by provincial Justice Minister Ross Landry last August, found that Truro police did not properly monitor Victoria Rose Paul's health while she was in custody three years ago.
The 44-year-old resident of Indian Brook, N.S., was arrested Aug. 28, 2009, outside a Truro bar for public drunkenness and was taken the following day to a Halifax hospital, where she died on Sept. 5, 2009.
After she was brought to jail, she settled down and fell asleep. But three hours later, she fell off her bunk onto the floor "and continued to move around as if in distress," the report said.
When the officer in charge of the lockup visited her cell nearly five hours after she was jailed, Paul's underpants had partly fallen off, she had lost control of her bladder and was incoherent.
"It was not normal practice to place and leave a person in custody on the floor for over four hours, not normal practice to leave a person in custody in contaminated clothing," the report said.
"It was not normal practice to allow a person in custody to lie in his or her urine for an extended time."
The review was led by Nadine Cooper Mont, the Nova Scotia Police Complaints Commissioner, who said Paul wasn't medically assessed or taken to hospital until 10 hours after she was incarcerated.
"Truro police service did not appropriately monitor Victoria Rose Paul's health; nor did it provide access to medical assessment in a timely fashion," the 136-page report said.
The province's medical examiner determined that the stroke likely occurred while Paul was in custody and was so severe that she wouldn't have survived even if she'd been immediately treated.
"This does not excuse the delay," Cooper Mont said in the report.
Cheryl Maloney, president of the Nova Scotia Native Women's Association, said the report is disturbing to the aboriginal community where Paul grew up.
She cited a section of the report where a jailhouse commissionaire watching Paul is quoted as saying he argued with two police sergeants, urging them to "call the health people."
Maloney said she can't understand why Truro police didn't act more quickly.
"This is the first time the Mi'kmaq community, the family have been able to see what happened that day," she told a news conference in Indian Brook.
"But we'll never be able to understand why it happened that day."
Cooper Mont said Truro police did not comply with all appropriate training, policies and procedures while Paul was in custody.
She also said Sgt. Lee Henderson, the on-duty officer overseeing the lock-up, "exercised poor judgment and neglected his duties," adding that he had a responsibility to ensure that medical attention for Paul was sought earlier.
In her report, Cooper Mont said the Halifax police led a separate review of Henderson's conduct but their interview with the officer "was not thorough enough to reasonably conclude anything with respect to any potential wrongdoing on his part or if an investigation would be warranted under the Police Act."
She said by the time the Halifax police review was finished, the six-month statutory requirement to file a complaint under the province's Police Act had expired.
Family members said the case shows that the statute of limitation provision in the Police Act should be repealed.
George Paul, Victoria's brother, said the justice system failed his sister.
"The statute of limitation into her death should never run out ... until all the answers are answered," he said.
"This should not happen. It bothers me because my people have to deal with it everyday."
A spokeswoman for the Truro police said the chief was handling all inquiries about the report but he was unavailable for comment Thursday.
The report recommends better policies be implemented to assess the condition of intoxicated people when they're brought to jail and better sharing of information during shift changes.
It also urges the provincial government to update and clarify the rules on jail cell inspections, a measure the justice minister said will be implemented.
"We can look at better ways to communicate to ensure that the personnel that work within our ... agencies have the most current and up-to-date information," Landry said.
Note to readers: This is a corrected story. A previous version did not specify that the province's medical examiner determined Paul's stroke "likely" occurred while she was in custody.