SIU Director’s Report - Case # 21-OCD-018


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Mandate of the SIU

The Special Investigations Unit is a civilian law enforcement agency that investigates incidents involving an official where there has been death, serious injury, the discharge of a firearm at a person or an allegation of sexual assault. Under the Special Investigations Unit Act, 2019 (SIU Act), officials are defined as police officers, special constables of the Niagara Parks Commission and peace officers under the Legislative Assembly Act. The SIU’s jurisdiction covers more than 50 municipal, regional and provincial police services across Ontario.

Under the SIU Act, the Director of the SIU must determine based on the evidence gathered in an investigation whether there are reasonable grounds to believe that a criminal offence was committed. If such grounds exist, the Director has the authority to lay a criminal charge against the official. Alternatively, in cases where no reasonable grounds exist, the Director cannot lay charges. Where no charges are laid, a report of the investigation is prepared and released publicly, except in the case of reports dealing with allegations of sexual assault, in which case the SIU Director may consult with the affected person and exercise a discretion to not publicly release the report having regard to the affected person’s privacy interests.

Information Restrictions

Special Investigations Unit Act, 2019

Pursuant to section 34, certain information may not be included in this report. This information may include, but is not limited to, the following: 
  • The name of, and any information identifying, a subject official, witness official, civilian witness or affected person. 
  • Information that may result in the identity of a person who reported that they were sexually assaulted being revealed in connection with the sexual assault. 
  • Information that, in the opinion of the SIU Director, could lead to a risk of serious harm to a person. 
  • Information that discloses investigative techniques or procedures.  
  • Information, the release of which is prohibited or restricted by law.  
  • Information in which a person’s privacy interest in not having the information published clearly outweighs the public interest in having the information published. 

Freedom of Information and Protection of Privacy Act

Pursuant to section14 (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 that 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 (i.e., personal privacy), protected personal information is not included in this report. This information may include, but is not limited to, the following: 
  •  The names of persons, including civilian witnesses, and subject and witness officials; 
  • 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

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

Other proceedings, processes, and investigations

Information may also have 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

Pursuant to section 15 of the SIU Act, the SIU may investigate the conduct of officials, be they police officers, special constables of the Niagara Parks Commission or peace officers under the Legislative Assembly Act, that may have resulted in death, serious injury, sexual assault or the discharge of a firearm at a person.

A person sustains a “serious injury” for purposes of the SIU’s jurisdiction if they: sustain an injury as a result of which they are admitted to hospital; suffer a fracture to the skull, or to a limb, rib or vertebra; suffer burns to a significant proportion of their body; lose any portion of their body; or, as a result of an injury, experience a loss of vision or hearing.

In addition, a “serious injury” means any other injury sustained by a person that is likely to interfere with the person’s health or comfort and is not transient or trifling in nature.

This report relates to the SIU’s investigation into the death of a 61-year-old man (the “Complainant”).

The Investigation

Notification of the SIU

On January 13, 2021, the Niagara Regional Police Service (NRPS) reported the following:

On January 13, 2021, at 2:10 p.m., NRPS police officers responded to a call to assist Emergency Medical Services (EMS) with a violent patient in an ambulance in Fort Erie. The patient, identified as the Complainant, was being transported to hospital from his residence and became violent. The Complainant underwent heart surgery on January 12, 2021 and experienced a medical episode which necessitated his return to hospital. When police officers arrived, they assisted EMS personnel in subduing the Complainant, and applied handcuffs in the ambulance. The Complainant was transported to Welland County General Hospital (WCGH) where his condition deteriorated.

The NRPS subsequently advised that the Complainant passed away in WCGH and was pronounced deceased on January 13, 2021, at 11:59 p.m. 

The Team

Date and time team dispatched: 01/14/2021 at 9:36 a.m.

Date and time of SIU response: 01/14/2021 at 9:40 a.m.

Number of SIU Investigators assigned: 3
Number of SIU Forensic Investigators assigned: 2

Affected Person (aka “Complainant”):

61-year-old male, deceased

Civilian Witnesses

CW #1 Interviewed
CW #2 Interviewed
CW #3 Not interviewed (Next-of-kin)

Subject Officials

SO Declined interview and to provide notes, as is the subject official’s legal right

Witness Officials

WO Interviewed

The witness officer was interviewed on January 19, 2021.


The Scene

The incident occurred inside an ambulance of the Niagara Region Emergency Medical Services.

Materials Obtained from Police Service

The SIU obtained and reviewed the following records from the NRPS:
  • Deceased's information;
  • NRPS General Order - Powers of Arrest;
  • NRPS General Order - Mentally Ill Persons;
  • Notes of the WO; and
  • General Occurrence.

Materials Obtained from Other Sources

The SIU obtained and reviewed the following records from non-police sources:
  • Ambulance Call Report;
  • EMS Dispatch Report;
  • EMS Incident Report (x2);
  • Preliminary Autopsy Findings.

Incident Narrative

The following scenario emerges on the evidence collected by the SIU, which included interviews with a witness officer and two paramedics who were present with the SO when the Complainant lapsed into dire medical distress. In the afternoon of January 13, 2021, paramedics with the Niagara Emergency Medical Services were dispatched to a residence in Fort Erie. The Complainant resided at the address. The day before, he had undergone a vascular procedure at hospital following which he was sent home and began experiencing pain and lightheadedness.

Upon the arrival of the paramedics, the Complainant informed them that he was having trouble breathing and had taken too much methadone. The paramedics attempted to assess the Complainant, but the task was made difficult given the Complainant’s agitation. Eventually, the paramedics managed to get the Complainant onto a stretcher and place him in the ambulance. They had travelled a short distance when the paramedic driving the ambulance pulled over to request the assistance of police. The Complainant’s extreme agitation had resulted in her partner being struck in the head by one of the Complainant’s elbows.

The SO was the first to arrive at the scene, followed shortly by the WO. The SO spoke with the paramedics, observed their patient and decided to apprehend the Complainant under the Mental Health Act. He and the WO affixed handcuffs to both of the Complainant’s arms, securing them to the stretcher, whereupon the SO rode in the ambulance to hospital with the WO following in his cruiser.

The Complainant’s condition deteriorated en route to the hospital. Once there, the Complainant was quickly placed in the care of the hospital’s emergency department. The Complainant passed away in hospital later that day.

Cause of Death

At autopsy, the pathologist was of the preliminary view that the Complainant’s death was attributable to surgical / medical complications. According to the pathologist, the autopsy turned up “no incidence of arrest-related trauma”.

Analysis and Director's Decision

On January 13, 2021, the Complainant died after he had been taken into custody by the NRPS earlier in the day. The SO was among the officers who had apprehended the Complainant and was identified as the subject official for purposes of the SIU investigation. On my assessment of the evidence, there are no reasonable grounds to believe that the SO committed a criminal offence in connection with the Complainant’s death.

There is no indication, in my view, of any want of care or undue force having been brought to bear by either of the SO or the WO in this incident. Given what they could see of the Complainant’s behaviour and had been told by the paramedics, there were grounds to conclude that the Complainant was of unsound mind at the time and a danger to himself. On this record, I am satisfied that the Complainant’s apprehension under section 17 of the MHA was lawful. Thereafter, aside from securing the Complainant’s hands to the stretcher in handcuffs, which was done without incident, the extent of the officers’ involvement in the matter consisted of their mere presence with the Complainant as he was escorted to, and then examined at, hospital. The use of restraints was clearly necessary if the paramedics were going to be able to do their job.

In the result, as there are no reasonable grounds to believe that either of the SO or the WO committed a criminal offence in connection with the Complainant’s death, there is no basis to proceed with criminal charges in this matter and the file is closed.

Date: February 25, 2021

Electronically approved by

Joseph Martino
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.