SIU Director’s Report - Case # 17-OCD-317


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Mandate of the SIU

The Special Investigations Unit is a civilian law enforcement agency that investigates incidents involving police officers where there has been death, serious injury or allegations of sexual assault. The Unit’s jurisdiction covers more than 50 municipal, regional and provincial police services across Ontario.

Under the Police Services Act, the Director of the SIU must determine based on the evidence gathered in an investigation whether an officer has committed a criminal offence in connection with the incident under investigation. If, after an investigation, there are reasonable grounds to believe that an offence was committed, the Director has the authority to lay a criminal charge against the officer. Alternatively, in all cases where no reasonable grounds exist, the Director does not lay criminal charges but files a report with the Attorney General communicating the results of an investigation.

Information restrictions

Freedom of Information and Protection of Privacy Act (“FIPPA”)

Pursuant to section 14 of FIPPA (i.e., law enforcement), certain information may not be included in this report. This information may include, but is not limited to, the following:
  • Confidential investigative techniques and procedures used by law enforcement agencies; and
  • Information whose release could reasonably be expected to interfere with a law enforcement matter or an investigation undertaken with a view to a law enforcement proceeding. 
Pursuant to section 21 of FIPPA (i.e., personal privacy), protected personal information is not included in this document. This information may include, but is not limited to, the following:
  • Subject Officer name(s);
  • Witness Officer name(s);
  • Civilian Witness name(s);
  • Location information; 
  • Witness statements and evidence gathered in the course of the investigation provided to the SIU in confidence; and 
  • Other identifiers which are likely to reveal personal information about individuals involved in the investigation.

Personal Health Information Protection Act, 2004 (“PHIPA”)

Pursuant to PHIPA, any information related to the personal health of identifiable individuals is not included.

Other proceedings, processes, and investigations

Information may have also been excluded from this report because its release could undermine the integrity of other proceedings involving the same incident, such as criminal proceedings, coroner’s inquests, other public proceedings and/or other law enforcement investigations.

Mandate engaged

The Unit’s investigative jurisdiction is limited to those incidents where there is a serious injury (including sexual assault allegations) or death in cases involving the police.

“Serious injuries” shall include those that are likely to interfere with the health or comfort of the victim and are more than merely transient or trifling in nature and will include serious injury resulting from sexual assault. “Serious Injury” shall initially be presumed when the victim is admitted to hospital, suffers a fracture to a limb, rib or vertebrae or to the skull, suffers burns to a major portion of the body or loses any portion of the body or suffers loss of vision or hearing, or alleges sexual assault. Where a prolonged delay is likely before the seriousness of the injury can be assessed, the Unit should be notified so that it can monitor the situation and decide on the extent of its involvement.

This report relates to the SIU’s investigation into the death of a 44-year-old man (the Complainant) following an interaction with police on October 31, 2017.

The Investigation

Notification of the SIU

At approximately 11:10 a.m. on October 31, 2017, the Peel Regional Police (PRP) notified the SIU of the Complainant’s custody death.

The PRP reported that on October 31, 2017, at 8:44 a.m., the PRP communications received a call from the Complainant requesting assistance and that police attend his residence. When questioned why he needed police, the Complainant informed the call taker that he was wanted on outstanding warrants, that he had been drinking and doing cocaine, and that his girlfriend was with him.

At 9:19 a.m., the police attended, confirmed the outstanding warrants, and subsequently arrested the Complainant. During the arrest, the Complainant was taken to the ground. When the Complainant was helped back to his feet, police officers noticed that he did not appear well. Emergency Medical Services (EMS) attended and decided to transport the Complainant to hospital. While en route, the Complainant went vital signs absent (VSA). At 10:16 a.m., the Complainant was pronounced dead.

The Team

Number of SIU Investigators assigned: 4
Number of SIU Forensic Investigators assigned: 2


44-year-old male, deceased

Civilian Witnesses

CW #1 Interviewed
CW #2 Interviewed
CW #3 Interviewed
CW #4 Interviewed
CW #5 Interviewed
CW #6 Interviewed

Witness Officers

WO #1 Interviewed, notes received and reviewed
WO #2 Notes reviewed, interview deemed not necessary
WO #3 Notes reviewed, interview deemed not necessary
WO #4 Notes reviewed, interview deemed not necessary
WO #5 Notes reviewed, interview deemed not necessary

Subject Officers

SO #1 Declined interview, as is the subject officer’s legal right. Notes received and reviewed.
SO #2 Declined interview and to provide notes, as is the subject officer’s legal right

Incident Narrative

On July 26, 2017, a bench warrant was issued by the court for the arrest of the Complainant for failing to appear on a number of criminal charges.

On October 31, 2017, at approximately 3:00 a.m., a 911 call was received by the PRP 911 call centre from a male indicating that he was scared; the caller sounded very confused. The 911 call taker attempted several times to call back to the number from which the 911 call had been received, and was eventually able to make contact with the Complainant and to ascertain his location; four police officers were then dispatched to respond to the call.

The Complainant, after having been located by the officers, asked them to let him work the remainder of that day, or he would lose his job. The Complainant promised that he would voluntarily turn himself in later that day. Despite the outstanding warrant for the Complainant’s arrest, WO #2, using his discretion, decided not to arrest the Complainant at that time, and the police officers left.

Approximately five hours later, another 911 call was received by the 911 call centre from the Complainant, wherein he advised that he had now consumed cocaine and that there was a warrant issued for his arrest for failing to appear in court; the two subject officers were dispatched to the Complainant’s location.

Upon arriving at the Complainant’s location, and prior to taking him into custody on the outstanding warrant, the two subject officers requested that the EMS attend and assess the Complainant, as a result of his admission that he had consumed narcotics.

After the paramedics assessed the Complainant, he became belligerent and non-compliant, and was taken to the ground. He was then handcuffed and the police officers, in concert with the paramedics, placed him into the ambulance and he was transported to hospital and taken into the triage area. Almost immediately upon his arrival at the hospital, the Complainant went into medical distress and a resuscitation protocol was initiated. The medical staff was unable to revive the Complainant, and, at 10:16 a.m., he was pronounced dead.

Cause of Death

On November 2, 2017, a post-mortem examination was performed on the body of the Complainant by a forensic pathologist; no immediate cause of death could be determined at that time, pending results of the toxicological examination of the blood and urine samples obtained from the Complainant.

On October 17, 2018, the SIU received both the Final Post-Mortem Report and the Toxicology Report related to the examination of the Complainant’s body. The reports concluded that the cause of the Complainant’s death was cocaine toxicity in a man with cardiomegaly and atherosclerotic heart disease.


The Scene

The scene was located outside of a townhouse which was positioned in the middle of a line of townhouses, with a driveway and an attached garage. A sidewalk led from the driveway to the front door. The PRP police cruiser was parked on the south side of the roadway in front of the townhouse.

Scene Diagram

Scene diagram

Forensic Evidence

Samples of the Complainant’s blood and urine were collected during the post-mortem examination on November 2, 2017, and subsequently submitted to the Centre of the Forensic Sciences (CFS) on November 6, 2017, for toxicological analyses.

On October 17, 2018, the SIU received the Final Post-Mortem Report, with the Toxicology Report appended. The Toxicology Report indicated that the samples taken from the Complainant indicated that he had the following drugs in his system, in the amounts indicated, at the time of his death:

The Toxicology Report indicated that the samples taken from the Complainant indicated that he had the following drugs in his system, in the amounts indicated, at the time of his death.

The report also interpreted the results as follows:

1. Blood concentrations following recreational cocaine use overlap those associated with fatalities. In a study of deaths in which cocaine was determined to be incidental, blood concentrations of cocaine and benzoylecgonine ranged from 0.04 - 0.5 mg/L and 0.24 - 2.4 mg/L respectively. In the same report, however, deaths attributed to cocaine intoxication detected blood cocaine and benzoylecgonine concentrations ranging from 0.05 to 3.4 mg/L and 0.8 to 9.1 mg/L, respectively. Benzoylecgonine is the breakdown product of cocaine both in vivo and in vitro and it is devoid of pharmacological activity in the central system.

2. Tetrahydrocannabinol (THC) is the principal psychoactive constituent found in cannabis products such as marijuana and hashish. Carboxy - THC is an inactive metabolite of THC. The detected blood THC concentration is indicative of past administration. To date, there are no reliable reports of fatalities attributed solely to THC.

Expert Evidence

Post-Mortem Examination

On November 2, 2017, a Forensic Pathologist performed the post-mortem (PM) examination on the Complainant’s body; no anatomical cause of death could be determined at that time.

The final Post-Mortem Report, with Toxicology Report appended, was received by the SIU on October 17, 2018. The reports concluded that the cause of the Complainant’s death was cocaine toxicity in a man with cardiomegaly and atherosclerotic heart disease.

Video/Audio/Photographic Evidence

The SIU obtained a video taken by CW #2, from a nearby townhouse, which revealed the Complainant lying on the ground beside a police cruiser, with both officers standing over him, while two paramedics are seen placing a sheet onto a stretcher. The police cruiser’s passenger rear door is open and there is a stretcher on the sidewalk, south of the police cruiser. A police officer is seen hunched over between the stretcher and the police cruiser. The second police officer is on his feet, bent over to the left of the first police officer. A paramedic is standing to the left of the stretcher, spreading a white sheet on the stretcher.

The police officers can be seen lifting the Complainant, who is handcuffed with his hands behind his back, up from the ground. The officers appear to be having difficulty, as the Complainant is a large man and appears unable to get his feet under him. The Complainant’s upper body is placed face down in the middle of the stretcher and he is then lifted up by one of the police officers, using the sheet he is lying on, and moved up further to the middle of the stretcher.

The police officers are then seen grabbing underneath both of the Complainant’s legs, lifting and swinging the Complainant’s legs to the right and out, and then onto the right side of the stretcher. The Complainant’s head moves to the left side of the stretcher and he ends up on his right side with his face towards the camera. The female paramedic then lifts the sheet and obscures the Complainant’s face and body.

Both paramedics and one of the police officers lift the sheet and pull the Complainant further to the left on the stretcher. The paramedics strap the Complainant onto the stretcher and then push the stretcher to the right, on the sidewalk, accompanied by the two police officers. The stretcher is then pushed into the back of the ambulance.

Other than assisting the Complainant to his feet, and then lifting and positioning him onto the stretcher, no force is seen to be used by either police officer or the paramedics.

Communications Recordings

The 911 calls from the Complainant on October 31, 2017, the attempted callbacks from the 911 Operator, and the police transmissions recordings, were obtained and reviewed, and revealed the following:

Initial 911 Call on October 31, 2017 at 2:51:42 a.m.:

The caller said, “I feel like I am in danger.” The 911 call taker asked if the caller needed the police or the ambulance and the caller’s response was unintelligible. The phone disconnected and, after several call back attempts by the 911 operator, which went directly to a voicemail message, a man answered and identified himself as the Complainant.

The call taker repeated the Complainant’s name and asked, “Hi, what are you doing?” The Complainant said, “Ya, hold on, I got to call my daughter.” The 911 call taker said, “No, tell me where you are (referring to the Complainant by name).” The Complainant said, “Where I am usually at.” The call taker said, “Well, I don’t know. Are you in a house?” The Complainant said, “Ah, yes.” The call taker said that the Complainant had said that his life was in danger. The Complainant said, “Yeah,” and disconnected.

Subsequent 911 Call on October 31, 2017 at 8:43:09 a.m.:

The Complainant asked for a unit at his address and that he wanted to turn himself in, and he had a warrant. The call taker asked if anyone had been doing drugs and the Complainant said he had taken cocaine. CW #1 can be heard talking in the background and the Complainant said, “What? OK, I’m gonna go with the cops. That’s what I wanna do. I’m gonna get help.” The call taker asked if he was going to get aggressive when the police came and the Complainant said no.

The call taker asked the Complainant how much cocaine he had today and the Complainant responded, “Quite a bit.” The call taker asked the Complainant to go outside because the police officers were there.

Police Transmissions from October 31, 2017:

A police transmission indicated that SO #1 and SO #2 had arrived at the Complainant’s address. SO #2 reported that the Complainant was being checked by the ambulance and that the Complainant was in custody.

SO #1 reported that the Complainant was being transported to the hospital by the EMS.

WO #1 then reported that the Complainant went VSA and the doctors had worked on him, but he had been pronounced dead at 10:16 a.m.

Materials obtained from Police Service

Upon request, the SIU obtained and reviewed the following materials and documents from the PRP:
  • Audio Copy Report of 911 Call and attempted callbacks from PRP 911 Call Centre;
  • Audio Copy Report of Police Radio Transmissions;
  • Duty Roster;
  • Event Chronology Reports (x2);
  • Person Details for Complainant;
  • Notes of WO #s 1-5 and SO #1;
  • Occurrence Details Reports (x2);
  • Procedure: Use of Force;
  • Procedure: Criminal Warrants;
  • Procedure: Criminal Investigations; and,
  • Training Records for SO #s 1 and 2.

The SIU obtained and reviewed the following materials and documents from other sources:
  • CFS Toxicology Report received by the SIU on October 17, 2018;
  • Final Post-Mortem Report received by the SIU on October 17, 2018;
  • EMS Ambulance Call Report;
  • Photos of Complainant at hospital following his death, taken by a family member; and,
  • Video of arrest of the Complainant outside of the police cruiser, following which he was picked up and placed onto a stretcher and removed from the scene.

Relevant Legislation

Section 25(1), Criminal Code -- Protection of persons acting under authority

25 (1) Every one who is required or authorized by law to do anything in the administration or enforcement of the law
(a) as a private person,
(b) as a peace officer or public officer,
(c) in aid of a peace officer or public officer, or
(d) by virtue of his office,
is, if he acts on reasonable grounds, justified in doing what he is required or authorized to do and in using as much force as is necessary for that purpose.

Analysis and Director's Decision

On October 31, 2017 at 8:43:09 a.m., a call was received by the PRP 911 call centre from the Complainant indicating that he required police assistance as he wished to turn himself in on an outstanding arrest warrant. Upon being asked, the Complainant confirmed that he had been drinking and had ingested cocaine on that date. As a result, at 8:45:17 a.m., SO #1 and SO #2 were dispatched in two separate police vehicles to the Complainant’s location at an address in the City of Brampton; an ambulance was also requested to attend, as a precaution.

Shortly after 8:57:02 a.m., both police officers had arrived at the residence and were speaking with the Complainant. The summary of the police transmissions, also referred to as the Event Chronology Report, indicates that it was reported that at 9:07:32 a.m., the Complainant was being seen by paramedics, at 9:19:49 he was taken into police custody, and at 9:24:09, the Complainant was in the ambulance and en route to hospital accompanied by SO #1, with SO #2 following in his police vehicle. At 9:56:03 a.m., it was reported that the Complainant was at hospital but was Vital Signs Absent (VSA) and the doctors were working on him. At 10:16 a.m., the Complainant was pronounced dead and the SIU was notified and an investigation launched.

On November 2, 2017, a post-mortem examination was conducted by a forensic pathologist, but no cause of death could be determined at that time pending the results of toxicological analyses of the Complainant’s blood and urine. On October 17, 2018, the SIU received the Final Post-Mortem Report relating to the examination of the Complainant’s body, with the Toxicology Report attached.

The Toxicology Report indicated that the Complainant had both cocaine and benzoylecgonine, the breakdown product of cocaine, in his system at the time of his death and that the cause of his death was determined to have been cocaine toxicity in a man with cardiomegaly (abnormal enlargement of the heart) and atherosclerotic heart disease (clogged arteries). In other words, the Complainant’s death was attributable to his ingestion of cocaine which led to a cardiac incident followed by death. While the Complainant was found to have some superficial abrasions to his face and body, those were determined to be unrelated to his death and did not contribute to his death in any way.

During the course of this investigation, four civilian witnesses who were present during the police interaction with the Complainant, as well as a family member, and the doctor who worked on the Complainant, were interviewed. While both subject officers, who were with the Complainant prior to his death, declined to make themselves available for an interview with SIU investigators, as is their legal right, SO #1 provided his notes of the incident for review. One police witness was also interviewed, and five police officers provided their notes to SIU investigators. In addition, the SIU investigators had access to a video prepared by an independent civilian witness of the interaction with police, as well as the Final Post-Mortem and Toxicology Reports prepared following the Complainant’s death.

At no time was the Complainant alone with either of SO #1 or SO #2, with at least one independent civilian witness being present from the first contact, until the Complainant was pronounced dead at hospital. On that basis, despite neither subject officer providing a verbal statement to SIU investigators, the entirety of the interaction between SO #1 and SO #2 is accounted for and there is no dispute as to the facts.

According to an independent civilian witness, CW #1, she kicked the Complainant out of her home at approximately 8:00 a.m. that morning and, when he returned a half hour later, she could immediately tell that he was high on cocaine; she was able to make this determination based on her prior experience dealing with the Complainant when he was high on cocaine. As a result, CW #1 would not allow the Complainant back into her home and she observed him call 911, while he was outside of her house, and request police assistance.

When the two police officers arrived at approximately 8:45 a.m., CW #1 heard them ask the Complainant to identify himself and he did so; CW #1 then went inside her home and closed the door. Shortly thereafter, CW #1 heard the Complainant calling out, “Help me!” and she looked out and saw him lying on his stomach, with the two police officers over top of him attempting to handcuff him. CW #1 then opened her door and asked what was going on and one of the officers indicated that the Complainant was “trippin.” CW #1 observed the Complainant to be resisting the attempts to handcuff him by squirming and writhing on the ground.

CW #2 looked out from his residence and observed the two police officers attempting to arrest the Complainant, who he described as struggling and resisting. CW #2 observed the struggle move across the street and onto the ground, at which point CW #2 began to video record the interaction on his cell phone. CW #2 described the police officers as trying to hold the Complainant down on the ground, while he continued to resist and was yelling, “Help me!” The Complainant was described as lying face down with one police officer kneeling beside the Complainant with one knee on the Complainant’s leg, while he used his left arm to try to keep the Complainant down, while a second officer, using his right arm, was trying to pull the Complainant’s arm out from under him for handcuffing, while the Complainant continued to try to pull his arm away. CW #2 indicated that neither police officer was punching or kicking the Complainant, but that they were simply trying to overpower him and to calm him down and handcuff him; no use of force options were used. CW #2 observed the Complainant eventually have his hands handcuffed behind his back, while he continued to pull away from the officers. The Complainant was then placed onto a stretcher and moved to a waiting ambulance. The video recording made by CW #2 fully confirms this version of events.

CW #4, one of two paramedics who attended to assess the Complainant, indicated that upon his arrival, the Complainant was standing on the sidewalk facing the two police officers. CW #4 described the Complainant as holding his cell phone in one hand and being very fidgety and picking at his skin, while the two officers stood an arm’s length or two away from the Complainant asking him what was going on. The Complainant responded that he didn’t know what was going on, while he constantly moved from left to right and moved his arms around. The police officers then told the paramedics that the Complainant had ingested cocaine and needed to be assessed. The Complainant then entered the ambulance with the two paramedics while the police officers remained outside.

Once inside the ambulance, both paramedics, CW #4 and his partner, CW #3, heard the Complainant indicate that he had consumed cocaine on that date but that he had purchased it from someone other than his usual supplier; he would not disclose how much cocaine he had ingested. While the paramedics found the Complainant’s heart rate to be elevated, they cleared him medically and asked him to exit the ambulance.

When the Complainant exited the ambulance, one of the police officers tapped him on the shoulder and told him that he was under arrest, at which point the Complainant became combative and screamed, “Help me!”, while trying to throw the police officer, who was attempting to take him by the arm, off of him. One of the police officers was heard to tell the Complainant to stop resisting, but he continued to struggle for approximately 20 seconds. CW #4 described the two police officers as holding the Complainant’s right arm behind his back and then moving him onto his knees on the driveway, following which they lowered him to the ground and onto his stomach, where the Complainant rubbed his face on the pavement while screaming and fighting. CW #4 then observed the Complainant to punch, with enormous strength, at the police officer trying to control and handcuff his right arm, causing the officer to move back and towards the Complainant’s lower back, at which point the Complainant tried to kick his heels at the officer, and both paramedics moved in to assist in holding the Complainant down.

CW #3, the second paramedic, described the physical interaction between the two police officers and the Complainant as the Complainant becoming aggressive and combative, while thrashing his arms and elbows from side to side as he tried to get away from the officers while they were trying to arrest him. CW #3 heard the Complainant scream, “Get off me!” while the two police officers, who she described as being both calm and respectful, with neither cursing or yelling at the Complainant, were telling the Complainant, “Sir, try to calm down, we have to put you in handcuffs, you’ll be going with us in the police car.”

CW #3 observed the two police officers take the Complainant down to his knees and then onto his stomach on the asphalt driveway, which she described as the Complainant’s body buckling as the officers “lowered” him onto his stomach, with the Complainant yelling at the top of his voice throughout. CW #3 stated that the Complainant’s contact with the asphalt did not cause her any concern. After the Complainant was down on his stomach, one police officer straddled the Complainant across the small of his back, while the second tried to control the Complainant’s left hand and arm. The Complainant continued to resist and clenched his fist around his own hair, while dragging his face left and right and back and forth across the asphalt, badly scuffing his face and causing abrasions.

The Complainant was observed, by both paramedics, to be eventually handcuffed with both hands behind his back using two sets of handcuffs. When the Complainant then kicked the back of his heels at the back of one of the police officers, CW #3 placed her left foot on one of his legs, while CW #4 did the same with the other, in order to hold his legs to the ground. Both paramedics advised that at no time did any police officer or paramedic ever strike or kick the Complainant, nor did either police officer produce any use of force equipment. When the officers asked the Complainant politely to please get up, he refused to do so and the officers had to lift him up, at which point it was observed that the Complainant had abraded his face and his nose was bleeding. As a result of both his self-inflicted injuries, and his odd behaviour, which the paramedics surmised may have been indicative of his suffering from excited delirium, the Complainant was no longer considered to be eligible to be medically cleared and the decision was made that he was to be taken to the hospital in the ambulance, and the Complainant was placed onto a stretcher while the officers controlled his arms and the paramedics his legs, with the Complainant continuing to fight and kick the entire time.

The Complainant was then transported to the hospital in the back of the ambulance, escorted by SO #1. Upon arrival, the Complainant was taken into the hospital on the stretcher where he went into medical distress and was found to be without vital signs. Chest compressions were then started and the Complainant was taken to the resuscitation room and the handcuffs were removed. Unfortunately, the Complainant could not be revived and was pronounced dead at 10:16 a.m.

The attending physician who worked on the Complainant indicated that his observations leading up to the Complainant’s death were consistent with the Complainant’s death being as a result of a cocaine overdose inducing arrhythmia, or a heart attack. The doctor had no concerns whatsoever with respect to the abrasions on the Complainant’s face and body and opined that they did not contribute to his death; the medical opinion of the attending physician was later confirmed by the Final Post-Mortem and Toxicology reports.

The notes provided by SO #1 of his involvement in the Complainant’s arrest and transport were fully consistent with, and confirmed by, all of the other evidence.

Having reviewed all of the evidence with respect to this matter, it is clear that there is no causal connection between the death of the Complainant and the actions of SO #1 and SO #2. Furthermore, based on the observations of all of the civilian witnesses present, it is clear that the response of SO #1 and SO #2 to the Complainant’s resistance and combativeness was to resort to no more than the minimal amount of force required in order to handcuff the Complainant and place him onto the stretcher in order that he get the medical attention that he required. Furthermore, the evidence of all of the civilian witnesses present confirmed that the officers were at all times calm, courteous, and professional towards the Complainant.

On the record before me, I find that there is absolutely no evidence that either of the arresting officers resorted to an excessive use of force in dealing with the Complainant, or that their actions in any way caused or contributed to his unfortunate death. As such, since I lack the necessary grounds for the laying of criminal charges, none shall issue.

Date: November 30, 2018

Original signed by

Tony Loparco
Special Investigations Unit


The signed English original report is authoritative, and any discrepancy between that report and the French and English online versions should be resolved in favour of the original English report.