SIU Director’s Report - Case # 18-OCD-051
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Mandate of the SIU
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.
Freedom of Information and Protection of Personal 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.
- 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.
Pursuant to PHIPA, any information related to the personal health of identifiable individuals is not included.
Personal Health Information Protection Act, 2004 (“PHIPA”)
Other proceedings, processes, and investigationsInformation 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.
“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 28-year-old woman (the Complainant) during a contact with the police on February 21, 2018.
Notification of the SIUAt approximately 5:43 p.m. on February 21, 2018, the Peel Regional Police (PRP) reported the custody death of the Complainant.
The PRP reported that at approximately 4:00 p.m. on that same date, PRP officers and paramedics had responded to a 911 call in regards to a woman (later identified as the Complainant) standing on the roof of her townhouse complex. The police officers tried to negotiate with the Complainant to come down, but she subsequently jumped and fell to the pavement below.
The Complainant was treated by the paramedics at the scene and subsequently transported to hospital where she was pronounced dead.
The TeamNumber of SIU Investigators assigned: 4
Number of SIU Forensic Investigators assigned: 3
SIU Forensic Investigators responded to the scene and identified and preserved evidence; they documented the scene associated with the incident by way of notes and photography. The Forensic Investigators also attended and recorded the post-mortem examination.
Complainant:28-year-old female, deceased
Civilian WitnessesCW #1 Not Interviewed (Next-of-kin)
CW #2 Interviewed
CW #3 Interviewed
CW #4 Interviewed
CW #5 Interviewed
CW #6 Interviewed
CW #7 Interviewed
CW #8 Interviewed
CW #9 Interviewed
Witness OfficersWO #1 Interviewed, notes received and reviewed
WO #2 Interviewed, notes received and reviewed
Subject OfficersSO #1 Interviewed, notes received and reviewed
On February 21, 2018, at approximately 4:00 p.m., a 911 call was received from CW #2, who reported that the Complainant was standing on the roof of a four-level townhouse located in the City of Mississauga.
PRP officers and paramedics were dispatched to the residence. The SO, WO #1, and WO #2, arrived at the residence and tried to engage the Complainant in conversation in order to convince her to abandon her thoughts of suicide. They repeatedly asked the Complainant to come down from the roof, but she did not do so, instead telling the officers to look away. The Complainant then jumped from the roof, falling to the pavement below.
Immediately following the Complainant’s fall, paramedics moved in and provided medical assistance and the Complainant was transported to hospital, where she was pronounced dead.
Cause of DeathOn February 22, 2018, a post-mortem examination was conducted. The forensic pathologist determined that the cause of death was due to blunt force impact to the head and torso resulting in an almost completely ruptured aorta, following a descent from a height.
The post-mortem report, which the SIU received on November 1, 2018, noted a history of mental health issues, depression and suicidal ideation on the part of the Complainant, who had previously taken antidepressant medication but stopped in July of 2017. The toxicology report attached to the post-mortem report established that the Complainant had no drugs or alcohol in her system at the time of her death. She had been to the emergency department of the hospital on February 5-6 and February 20 for suicidal ideations, but had been released on both occasions and discharged as not being a danger to herself, with follow-up scheduled for the outpatient mental health clinics (on February 14, 2018 which she did not attend due to lack of money for transportation, and on February 27, 2018 which she obviously did not attend due to her death).
The SceneThe scene was located in front of a townhouse in a townhouse complex in the City of Mississauga. The townhouse had four-levels, with a balcony on the top level, from which one could access the rooftop. The area of this rooftop overlooked the paved driveway below.
The scene was secured by the SIU, examined, and photographed. SIU investigators also canvassed the area for witnesses and closed-circuit television (CCTV).
Physical EvidenceFive suicide notes authored by the Complainant were seized from the residence and reviewed. Each of the notes was addressed to a friend or family member and contained apologies from the Complainant for what she had done and gave directions with respect to disposal of her remains after death.
A similar timed text message from the Complainant sent to five recipients was also viewed by the SIU investigators.
Forensic Evidence Biological specimens from the post-mortem examination were submitted to the Centre of Forensic Sciences for analysis; the results of that analysis had not yet been released to the SIU at the time of writing this report.
Expert EvidenceOn February 22, 2018, a post-mortem examination was conducted at the CFS. The attending forensic pathologist determined that the cause of death was due to blunt force impact to the head and torso causing an aortic rupture, following a descent from a height.
The post-mortem report authored by the pathologist was received by the SIU on November 1, 2018.
Video Recording obtained from CW #6’s Cellular phone:The SIU received a cellular video recording from CW #6’s cellular phone. The recordings did not have any time stamp and depicted the Complainant sitting on the edge of the roof of a townhouse located in the City of Mississauga. The Complainant did not move during the course of the video, but had her right leg extended over the roof’s ledge.
The SIU also obtained and reviewed photos taken by CW #8 and CW #2 depicting the Complainant on the roof of the four-level townhouse.
Communication Recordings from PRP for February 20, 2018:The SIU investigators obtained and reviewed the audio communication recordings and the event chronology report from the PRP for February 20, 2018. The audio communication recordings and the event chronology depicted the following:
1524:00 hrs A woman called 911 and reported that she had received a text message from her roommate (later identified as the Complainant) indicating that she was having suicidal thoughts. The caller told the 911 operator that the Complainant was worried that she was going to be arrested;
1529:09 hrs The dispatcher requested that police officers and paramedics attend at the address provided by the 911 caller;
1542:43 hrs PRP officers attended the Complainant’s residence and arrested her under the Mental Health Act (MHA) and transported her to hospital.
The communication recordings supported the event chronology report and occurrence report obtained from the PRP relating to the February 20, 2018 incident.
Communication Recordings from PRP for February 21, 2018:The SIU investigators obtained and reviewed the audio communication recordings and the event chronology report from the PRP for February 21, 2018. The audio communication recordings and the event chronology depicted the following:
1556:29 hrs A woman (CW #2) called 911 and reported that a woman (the Complainant) had been standing on the roof of a townhouse for the past thirty minutes;
1606:00 hrs The 911 operator told CW #2 that a police officer (WO #2) was at the scene;
1559:19 hrs The dispatcher requested PRP officers to attend the townhouse complex for a woman wanting to jump off the roof. WO #1 requested that the dispatcher put him on the call as he was closer to the scene;
1601:08 hrs The dispatcher requested that paramedics attend the scene;
1604:58 hrs WO #2 arrived at the scene and told the dispatcher that she saw the Complainant on the roof of a townhouse;
1607:03 hrs The SO requested that the dispatcher tell the paramedics and fire services personnel to stay out of the Complainant’s view;
1607:31 hrs The dispatcher told the SO, WO #2, and WO #1, that the Complainant had been apprehended the day before under the MHA;
1615:08 hrs The dispatcher requested that a tactical vehicle with a ladder attend the scene;
1617:35 hrs The SO requested that more police officers attend;
1620:27 hrs The SO told the dispatcher that the Complainant had jumped.
The communication recordings supported the event chronology report and occurrence report obtained from the PRP relating to the February 21, 2018 incident.
Materials obtained from Police ServiceUpon request, the SIU obtained and reviewed the following materials and documents from the PRP:
- Recordings of 911 Calls from February 20, 2018 and February 21, 2018;
- Recordings of Police Transmissions Communications;
- Procedure: Emotionally Disturbed Persons;
- Event Chronologies (x2);
- Notes of the SO and WO #s 1 and 2; and
- Occurrence Details Report.
The SIU obtained and reviewed the following materials and documents from other sources:
- Photo taken by CW #8 of Complainant on roof of building;
- Photo taken by CW #2 of Complainant on roof of building;
- Video taken by CW #6 of the Complainant seated on the roof of the townhouse;
- A timed text message sent by the Complainant to five recipients, received by them after her death; and
- Five suicide notes left by the Complainant for family and friends.
Section 219 and 220, Criminal Code -- Criminal negligence causing death
(a) in doing anything, or(b) in omitting to do anything that it is his duty to do,
(a) where a firearm is used in the commission of the offence, to imprisonment for life and to a minimum punishment of imprisonment for a term of four years; and(b) in any other case, to imprisonment for life.
Analysis and Director's Decision
The following day, February 21, 2018, a 911 call was again received by the 911 communications centre, this time from CW #2. CW #2 reported that she had observed the Complainant on the roof of her townhouse and that she had been there for the past 30 minutes. Police and paramedics were again dispatched to the residence.
Prior to the arrival of the police, CW #3 went to his balcony and saw the Complainant sitting on the roof of her townhouse looking depressed, and asked her what was wrong, to which she responded that she wanted to jump off the roof.
The first police officer to arrive at the residence in response to the 911 call was WO #2, who approached the Complainant’s townhouse and stood on the ground below where the Complainant was sitting on the edge of the roof and attempted to communicate with her. WO #2 urged the Complainant not to jump and asked the Complainant for her name and why she wanted to jump. WO #2 could not make out any response from the Complainant, but CW #3, who was up on his balcony, heard WO #2 ask the Complainant why she was on the roof and heard the Complainant respond that she didn’t want to be alive anymore. WO #2 was also heard to tell the Complainant that she cared about her and wanted her to come down. WO #2 observed the Complainant to walk around on the roof and sometimes sit on the edge.
Shortly after the arrival of WO #2, WO #1 arrived. Several civilian witnesses in the area heard WO #2 and WO #1 telling the Complainant not to jump, with WO #2 specifically being heard to tell the Complainant that she cared about her and wanted to help her. While the officers were attempting to speak with the Complainant, she was observed to lean on her backside and move closer to the edge; she was also heard talking to herself and taking deep breaths, which both civilian and police witnesses surmised was an indication that she was about to jump. While the Complainant was speaking to herself, she was heard to say that life was not worth living and that no one could help her.
The SO arrived at the townhouse at approximately 4:13 p.m. and he too approached and stood below the location where the Complainant was perched on the roof. The SO introduced himself to the Complainant and told her that he was there to help and asked her not to jump, that he would provide her with whatever she needed. The SO was unable to clearly hear what the Complainant was saying, so he asked her to go to her balcony, but she refused. WO #2 then asked if she could come up to the balcony to speak to the Complainant, but again the Complainant refused. The SO then asked the Complainant to move away from the roof’s edge, but she would not.
The SO requested the attendance of a tactical unit with a ladder and elevating platform, in order to rescue the Complainant from the rooftop. Fire personnel present asked if they should break into the Complainant’s unit, but the SO advised them not to do so, as that might spook the Complainant and force her to jump. The SO requested that fire and paramedics remain out of the Complainant’s sightline, for that same reason.
Prior to the arrival of any further assistance, the Complainant told the officers to stop looking at her. Both WO #2 and WO #1 told her that they would not do so, as they believed that the Complainant was asking them to look away in order that she could jump without their observing her do so. Despite that, the Complainant then leaned forward and jumped, landing on the paved driveway below. The police officers and paramedics then immediately moved in to perform life saving measures, following which the Complainant was transported to hospital, where she was pronounced dead.
According to the communications log, the 911 call from CW #2 was received at 3:56:30 p.m., and four uniformed police officers were immediately dispatched to the area, with the first being WO #2, dispatched at 3:59:10 p.m. The responding sergeant, the SO, was dispatched at 4:01:33 p.m. While still en route to the residence, the SO requested the assistance of paramedics and fire, and requested that they stage around the corner from the unit and out of sight. The SO further requested that dispatch attempt to get a cell phone number and the unit number for the Complainant, and that the tactical unit also attend.
At 4:05:04 p.m., the first officer, WO #2, arrived at the location, followed by WO #1 at 4:07:07 p.m. and the SO at 4:13:05 p.m. Twelve additional police officers were dispatched to the scene and were en route, along with the tactical unit, when at approximately 4:20 p.m., the Complainant jumped from the rooftop. At 4:22:19 p.m., the SO is recorded as reporting to the dispatcher that the Complainant was Vital Signs Absent (VSA).
There is no dispute that the Complainant, of her own accord, spread out her arms and jumped from the roof of her townhouse to the pavement below, which is confirmed by the evidence of the eight civilian and two police witnesses, as well as the evidence from the SO.
An examination of the Complainant’s residence by SIU forensic investigators located five handwritten notes authored by the Complainant, which were clearly suicide notes, along with directions with respect to the disposal of her body after her death. Additionally, a text from the Complainant, which had been timed to be delivered to five recipients after the Complainant’s death, was also provided to the SIU by one of those five recipients. The text read that if it had been received, the Complainant was dead, as she would have rescinded the text otherwise. In her suicide notes, the Complainant profusely apologized for what she had done, and clearly indicated that “this was my best option. Life has been so hard and I am making my peace with it. This was no one’s fault but my own,” and, “I always knew things would end this way. I couldn’t visualize my life past 30.”
A post-mortem examination carried out on the body of the Complainant determined that the cause of death was as a result of blunt force trauma to the head and torso, resulting in an aortic rupture, following a descent from a height.
It is clear, on a review of all of the evidence, that the Complainant had decided to take her own life and had planned and taken all the steps needed to carry out her intention, from writing out a number of suicide notes, including her wishes as to how her body should be dealt with after her death, to sending out a timed text message to family and friends, and to placing a stool and a chair on the balcony of her townhouse, in order that she could easily climb over and access the roof. On all of the evidence, it is clear that the Complainant was struggling with some issues which she found were insurmountable and she felt that her only recourse was to end her life. While it is unclear what exactly pushed the Complainant to the brink and caused her to resort to the drastic decision to end her own life, it is clear that she had made that decision on her own, and had been contemplating it for some time. The police officers who attended and tried to save the Complainant’s life, despite her wishes to the contrary, did all they could to try to save that life in the very short time available to them, before the Complainant took that last fatal leap.
While the SO, as the senior officer on scene, was designated as the subject officer, it is clear that all of the officers present acted together in order to attempt to save the life of the Complainant.
On these facts, the only charge even remotely relevant for consideration would be that of criminal negligence causing death, contrary to sections 219 and 220 of the Criminal Code. In order to find reasonable grounds to believe that the SO, or either of WO #2 or WO #1, committed the offence of criminal negligence causing death, one must first have reasonable grounds to believe that they had a duty toward the Complainant which they omitted to carry out, and that omission, pursuant to the decision of the Supreme Court of Canada in R. v. J.F. (2008), 3 S.C.R. 215, represented ‘a marked and substantial departure from the conduct of a reasonably prudent person in circumstances’ where they ‘either recognized and ran an obvious and serious risk to the life’ of the Complainant or, ‘alternatively, gave no thought to that risk’.
It is clear on all of the evidence that all of the police officers present fully appreciated the risk to the life of the Complainant, should she be allowed to carry out her intention of jumping from the rooftop. Each of the three officers made every effort, as was witnessed by numerous civilian witnesses interviewed, to attempt to build a rapport with the Complainant and to convince her to abandon her intentions. Additionally, even prior to arriving on scene, the SO acted quickly and efficiently to ensure that all necessary services were notified and present on scene to either rescue the Complainant, or to provide assistance should she succeed in jumping. Rather than a marked and substantial departure from the conduct of a reasonably prudent person in the circumstances, each of these officers acted more than reasonably and prudently to save the Complainant’s life, despite the tragic outcome. It is clear from the coordinated response of the PRP, that they were taking the threat to the Complainant’s life extremely seriously and that they responded both quickly and efficiently to prevent this tragic death.
On all of the evidence, it is clear that the Complainant took her own life without any intervention by police. It is further clear that the Complainant, while constantly perched on the edge of the rooftop of her townhouse, left police with no options to which they could resort to attempt to safely bring her down, other than to try and convince her to abandon her plan. The SO followed all procedures as set out in the policy guidelines, and reached out to all resources at his disposal to try and assist the Complainant, and cannot be held responsible for the Complainant’s actions in fulfilling her intention to end her own life. On all of the evidence, it is clear that all three officers present attempted to engage the Complainant with both calm and compassion, and that they never abandoned their attempts to save her life, even after she had jumped from the rooftop which ultimately led to her death, when they immediately moved in to perform life-saving procedures.
On these facts, I find that the evidence fails to satisfy me either that the conduct of any responding police officer represented ‘a marked and substantial departure’ from that of a reasonably prudent person in these circumstances, or that there is any causal connection between the actions of the officers present and the tragic death of the Complainant. As such, there are no grounds here, reasonable or otherwise, for the consideration of criminal charges and even less so for the laying of same.
Date: November 2, 2018
Original signed by
Special Investigations Unit
- 1) See Cause of Death at page 6 of this Report. [Back to text]
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.