SIU Director’s Report - Case # 20-OCI-361


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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 serious injuries a 17-year-old woman (the “Complainant”) suffered during an interaction with police.

The Investigation

Notification of the SIU

On December 30, 2020, at 12:05 a.m., the Hamilton Police Service (HPS) notified the SIU of an injury to the Complainant.

HPS advised that on December 29, 2020, at 9:31 p.m., the Complainant contacted the HPS and advised she was going to harm herself. A subsequent cellular phone ping located her in the area of Ferguson Avenue North and Barton Street East, Hamilton.

The HPS officers attended the area and located the Complainant standing on a bridge over railroad tracks on Ferguson Avenue North, north of Barton Street East. The Complainant had climbed over the bridge handrail and was threatening to jump. The police officers attempted to communicate with the Complainant and convince her to climb back to safety.

At 10:07 p.m., the Complainant slipped and began screaming for help. The police officers attempted to pull the Complainant to safety; however, she slipped and fell to the track area below.

The Complainant was taken by the Emergency Medical Services to the Hamilton General Hospital (HGH) where she was diagnosed as having suffered a fractured pelvis and vertebrae. The Complainant was admitted for treatment.

The Team

Date and time team dispatched: 12/30/2020 at 1:28 a.m.

Date and time SIU arrived on scene: 12/30/2020 at 2:11 a.m.

Number of SIU Investigators assigned: 3
Number of SIU Forensic Investigators assigned: 1 

Affected Person (aka “Complainant”):

17-year-old female interviewed on December 30, 2020, medical records obtained and reviewed

Civilian Witnesses (CW)

CW Interviewed on December 31, 2020

Subject Officials (SO)

SO #1 Declined interview and to provide notes, as is the subject official’s legal right
SO #2 Declined interview and to provide notes, as is the subject official’s legal right

Witness Officials (WO)

WO #1 Interviewed on January 11, 2021, notes received and reviewed
WO #2 Interviewed on January 5, 2021, notes received and reviewed
WO #3 I nterviewed on January 5, 2021, notes received and reviewed


The Scene

On December 30, 2020 at 2:11 a.m., an SIU Forensic Investigator attended at the scene, which was being secured by HPS.

The scene was on the east side of Ferguson Avenue North, about 275 metres north of Barton Street in Hamilton, at the top centre of an overpass of two sets of railroad tracks at ground level. The area was dark when this interaction occurred. There were overhead streetlights on both sides of the overpass.

Ferguson Avenue North ran north/south the entire distance between downtown Hamilton and Burlington Street East. On the southeast side of Ferguson Avenue North at the overpass was the parking lot of a medical building. On the southwest side of the overpass was the rear yard of the Hamilton Wentworth Detention Centre. On the northwest side of the overpass there were houses, and on the northeast side there was a park.

The Ferguson Avenue North overpass consisted of one lane for each direction of travel with a sidewalk on the east side of the bridge.

The sidewalk was 2.75 to 3 metres in width in between two railings, one to separate the sidewalk from the vehicle travel portion of the roadway, and the other separating the sidewalk from the outside edge of the bridge. The railing separating the sidewalk from the edge of the bridge was made entirely of metal, was 1.4 metres in height, and consisted of five evenly spaced horizontal rails and a wider top rail.

The railing was mounted in the centre of a concrete ledge which appeared to be about 25 to 30 centimetres in height and in width. The horizontal rails were attached to the sidewalk side of the evenly spaced support posts, leaving a ledge of concrete about 15 centimetres in width at the base of the railing for the Complainant to sit upon.

There was an HPS uniform jacket on the sidewalk on top of the overpass in the area where the police officers interacted with the Complainant. The jacket was determined to belong to one of the responding sergeants, having been removed when the police officers were attempting to hold onto the Complainant, and left there when the police officers ran down to the Complainant after she had fallen. The jacket was photographed in the position it was found and returned to a member of the HPS.

The scene on the overpass was photographed. The area of the railroad tracks below the east side of the overpass was also photographed. There was a rock that was wrapped with yellow police caution tape which indicated where the Complainant’s feet were located after she landed on the railroad tracks.

The height from the top of the railing to the railroad tracks below was measured as 10.7 metres, therefore the height from the ledge upon which the Complainant was sitting, and then hanging from, was about 9.3 metres.

Figure 1 - Scene (Ferguson Avenue North Overpass)

Figure 1 - Scene (Ferguson Avenue North Overpass)

Video/Audio/Photographic Evidence

Police Communications Recordings

The communications recordings provided by HPS on January 11, 2021 included telephone calls to and from HPS Communications, which were the basis of the information relayed to the responding police officers on the police radio, including the telephone calls from the COAST [1] crisis worker who was talking to the Complainant initially, and when she (the Complainant) was on the overpass prior to and at the time of the arrival of SO #1.

At 9:30 p.m., the COAST crisis worker initially called HPS communications regarding the Complainant. The crisis worker explained the situation, including that the Complainant had called COAST three days previously. The COAST worker said the Complainant would be at Victoria Avenue North and Shaw Street to meet the police officers and paramedics.

At 9:33 p.m., SO #1 and WO #1 were dispatched.

At 9:42 p.m., SO #1 and WO #1 arrived at the arranged location along with an ambulance. SO #1 reported the Complainant was not there. SO #1 told the dispatcher he called the Complainant’s cellular phone but she did not answer. SO #1 said the ambulance was going to leave until the police located the Complainant. He requested her cellular phone be “pinged”.

At 9:43 p.m., an HPS communicator called an external phone number and asked for the cellular phone provider for the Complainant’s cellular phone number. The communicator then called TELUS, requested a ping and, at about 9:46 p.m., received the most recent GPS (Global Positioning System) coordinates of the cellular phone.

At 9:47 p.m., a different COAST crisis worker called HPS communications and said his co-worker was again talking to the Complainant who said she was “wandering around” and wanted to be talking to someone while she died.

At 9:48 p.m., the dispatcher provided the results of the “ping” to SO #1 and WO #1 which indicated the Complainant was within a 296 metre radius of Ferguson Avenue North, north of Cannon Street East, which was south of Barton Street East. The location of the ping was in excess of 500 metres south of where the Complainant was later located by SO #1.

At 9:51 p.m., the dispatcher told SO #1 and WO #1 that the crisis worker was again speaking with the Complainant and the Complainant had said she wanted someone to speak to as she died.

At 9:53 p.m., the crisis worker called with an update that the Complainant was known to be on a bridge near railroad tracks. The dispatcher updated SO #1 and WO #1.

At 9:55 p.m., SO #1 said he had located the Complainant on the Ferguson Avenue North overpass. He said she was sitting on the outside side of the railing. About a minute later, SO #1 said he was trying to communicate with the Complainant, and she was not cooperative.

At 9:57 p.m., SO #2 was dispatched with his escort, the CW.

At 10:00 p.m., SO #1 reported the Complainant had climbed “a little bit more over”, and was entirely on the outside of the railing. WO #1 arrived. SO #2 and the CW arrived.

At 10:01 p.m., the Complainant was reported to be leaning, facing out, with her arms behind her.

At 10:02 p.m., the Complainant was reported to be sitting on the narrow ledge with her arms around the railing.

At 10:05 p.m., a trained negotiator was requested and a female detective said she would attend shortly.

At 10:07 p.m., the Complainant was reported to be hanging off the bridge by her fingertips.

At 10:08 p.m., the Complainant was reported to have called out for help. Voices and an apparent commotion were heard in the background.

At 10:09 p.m., the Complainant fell to the ground and the police officers reported that they “lost her”. As the police officers were making their way down to the railroad tracks, the Complainant could be heard screaming in the background.

Materials Obtained from Police Service

Upon request, the SIU was provided with the following materials and documents from the HPS between December 30, 2020 and January 13, 2021:
  • HPS General Occurrence Report;
  • HPS Occurrence Details Report;
  • List of Involved Persons from Occurrence Report;
  • HPS Mental Illness Policy;
  • HPS Supplementary to Occurrence Report;
  • Notes-WO #2;
  • Notes-WO #1;
  • Notes-WO #3;
  • HPS Supplementary to Occurrence Report (x2);
  • Will State-WO #2;
  • Will State-WO #1; and
  • Will State-WO #3.

Materials Obtained from Other Sources

The SIU received the following record from non-police sources on January 22, 2021:
  • Medical record from HGH.

Incident Narrative

The material events in question are clear thanks to interviews with the Complainant, and several police witnesses and a civilian eyewitness present at the time of the incident. As was their legal right, neither subject official interviewed with the SIU or consented to the release of his notes. In the evening on December 29, 2020, a despondent Complainant contacted the HPS COAST and spoke to a crisis worker, indicating that she planned to do herself harm. After some time on the phone with the worker, the Complainant agreed to meet with police officers and paramedics in the area of Victoria Avenue North and Shaw Street.

SO #1 and WO #1 were dispatched to the intersection to meet with the Complainant, but she failed to attend. Instead, the Complainant decided to make her way to the Ferguson Avenue North bridge over railway tracks, about 275 metres north of Barton Street East. It was her intention to end her life by jumping from the bridge.

SO #1 searched the area for the Complainant and eventually located her on the bridge after her cell phone company informed police of her phone’s last GPS coordinates. The Complainant was on the east sidewalk of the Ferguson Avenue North overpass. The officer stopped his cruiser south of the overpass, exited and attempted to speak with the Complainant from a distance of several metres. The Complainant was not interested in conversation; she largely ignored SO #1 as he asked how she was feeling and attempted to build a rapport with her.

WO #1 was next to arrive at the bridge. The officer parked his cruiser on the northside of the overpass, exited and approached the Complainant. By this time, the Complainant had scaled the overpass railing and was standing on a ledge facing eastward, her hands holding onto the railing behind her. SO #1 continued to try and speak with the Complainant without success; at one point, the Complainant screamed out at the officer, “Go away, this is not easy.”

Shortly after WO #1’s arrival, a COAST team consisting of SO #2 and the CW attended at the scene, parking their vehicle behind SO #1’s cruiser. The CW, a mental health professional of 30 years’ experience, exited the cruiser and also tried to engage the Complainant in conversation. Again, the Complainant was not receptive, indicating that no one could help her.

As these efforts at communication were ongoing, the Complainant lowered herself into a seated position on the outer ledge, her arms out to the side and hands clasping a horizontal metal bar behind her. The Complainant turned briefly to face Ferguson Avenue North, then suddenly dropped her legs from the ledge while hanging on with her hands to one of the railing’s horizontal bars. With her hands now bearing her entire weight, the Complainant yelled out for help as her hold on the bar started to slip.

SO #1 and SO #1 rushed to the Complainant and each grabbed a hold of one of her arms through the metal bars of the railing. Because the bars were horizontal, they were effectively precluded from lifting the Complainant up. Instead, they tried to hang on while a rescue plan could be formulated. It was suggested that handcuffs be used to secure the Complainant’s hands to the metal bar. WO #3, who was now also on scene, removed his handcuffs and attempted to affix one of the cuffs onto the Complainant’s arms, but was unable to because of the sweater the Complainant was wearing. Given their awkward position and tenuous grasp, the Complainant began to slip from the officers’ grip even as WO #1 attempted to reach over the top rail and grab hold of the Complainant; she was just beyond his reach.

SO #1 and SO #2 eventually lost their grips and the Complainant fell onto the southernmost railway track below, a distance of about nine metres.

The officers on scene rushed to the tracks below to render aid as the Complainant screamed in pain. With the arrival of paramedics and firefighters, the Complainant was removed from the railway tracks and taken to hospital. She had suffered multiple fractures .

Relevant Legislation

Sections 219 and 221, Criminal Code -- Criminal negligence causing bodily harm

219 (1) Every one is criminally negligent who
(a) in doing anything, or
(b) in omitting to do anything that it is his duty to do,
shows wanton or reckless disregard for the lives or safety of other persons.

(2) For the purposes of this section, duty means a duty imposed by law.

221 Every one who by criminal negligence causes bodily harm to another person is guilty of an indictable offence and liable to imprisonment for a term not exceeding ten years

Analysis and Director's Decision

On December 29, 2020, the Complainant suffered serious injuries when she fell from a bridge. Because police officers were present on the bridge and had interacted with her in the moments prior to the Complainant’s fall, the SIU was notified and opened a file. SO #1 and SO #2 were identified as subject officials for purposes of the SIU investigation. On my assessment of the evidence, there are no reasonable grounds to believe that either officer committed a criminal offence in connection with the Complainant’s fall and injuries.

The offence that arises for consideration is criminal negligence causing bodily harm contrary to section 221 of the Criminal Code. The offence is premised, in part, on conduct that amounts to a marked and substantial departure from the level of care that a reasonable person would have exercised in the circumstances. In the instant case, the issue is whether there was any want of care in the manner in which the officers dealt with the Complainant which contributed to her fall and was sufficiently egregious as to attract criminal sanction. In my view, there was not.

SO #1 and SO #2, and the other officers that attended at the Ferguson Avenue North overpass, were lawfully at the scene in pursuit of their foremost duty; namely, the duty to preserve and protect life. Given what they had been told of the call the Complainant had made to COAST, they had good reason to believe that the Complainant had designs on committing suicide.

The officers were obliged to do what they could to locate the Complainant and attempt to prevent her from harming or killing herself, and I am satisfied that they did just that. For starters, SO #1, with help from a “ping” of the Complainant’s phone that had been done to narrow the area of her whereabouts, was able to locate the Complainant in short order after she had failed to turn up for the prearranged meeting at Victoria Avenue North and Shaw Street. Thereafter, he spoke to the Complainant in calm and reassuring tones, attempting to convince her to return to safety while maintaining a distance so as not to provoke her. Very quickly after SO #1’s arrival, a COAST team was dispatched to the scene. The COAST a mental health professional with expertise in techniques of mental health crisis intervention and de-escalation, took over communications and appeared to be making some inroads with the Complainant. Indeed, the Complainant appeared to reconsider, when something inside her triggered and she decided to embark on her planned descent from the overpass. As the Complainant did so, and began to scream seeking help, SO #1 and SO #2 reacted quickly running to her side and grabbing hold of her arms. Though they were unable to maintain their grip on the Complainant, it was not for want of trying. As soon as the Complainant fell, officers rushed to the railway tracks below and rendered assistance.

On the aforementioned-record, there is no suggestion of a want of care on the part of the subject officers throughout their engagement with the Complainant. On the contrary, the evidence indicates that they comported themselves at all times with full care and regard for the Complainant’s health and safety. Accordingly, there is no basis for proceeding with criminal charges in this case, and the file is closed.

Date: March 8, 2021

Joseph Martino
Special Investigations Unit


  • 1) COAST is the Crisis Outreach and Support Team, an HPS program that pairs specially trained police officers with mental health professionals to more effectively respond to calls involving persons in mental health crisis in certain circumstances. [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.