SIU Director’s Report - Case # 20-PCD-217


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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 55-year-old man (the “Complainant”).

The Investigation

Notification of the SIU

On September 1, 2020, at 11:51 a.m., the Ontario Provincial Police (OPP) notified the SIU of the death of the Complainant.

According to the OPP, OPP officers were dispatched to the Complainant’s residence on August 28, 2020, for a well-being check. When police officers arrived, they forced entry into the Complainant’s home and subsequently apprehended him. The Complainant was taken to hospital, where he was admitted under the authority of the Mental Health Act. Sometime between August 29 and 30, 2020, the Complainant was released from hospital.

On August 31, 2020, the Complainant’s family called the OPP and requested another well-being check on him. When police officers arrived at the Complainant’s residence, they knocked on the front door and heard music playing from inside the house. The volume of the music was increased. The police officers left the residence.

On September 1, 2020, the OPP were again called and asked that a well-being check be done for the Complainant because he had not shown up for work that morning. When police officers arrived at the Complainant’s house, they forced entry into the house and found him hanging.

The Team

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

The SIU attended the scene and recorded measurements and photographs. 


55-year-old male, deceased

Civilian Witnesses (CW)

CW #1 Not interviewed
CW #2 Interviewed

Witness Officers (WO)

WO #1 Interviewed, notes received and reviewed
WO #2 Interviewed, notes received and reviewed
WO #3 Interviewed, notes received and reviewed
WO #4 Notes reviewed, interview deemed not necessary
WO #5 Notes reviewed, interview deemed not necessary
WO #6 Notes reviewed, interview deemed not necessary

Subject Officer (SO)

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


The Scene

The Complainant’s residence was located in Elgin County. There were two entrances into the house, one into the kitchen and one into the garage. The kitchen door showed evidence of having been forced open.

Police found the Complainant hanging by a ligature from the ceiling of the garage. On the door leading from the living room into the garage, the Complainant had written, “Don’t come in, call 911.”

Physical Evidence

Computer-Assisted Dispatch (CAD) Reports

On August 28, 2020, at 7:31 p.m., CW #2 called police and reported she was parked outside of the Complainant’s residence. She further reported the Complainant was standing at a window holding a gun and saying he intended to kill himself. CW #2 reported she could not confirm whether the firearm was real. She reported that the Complainant had been drinking and using prescribed oxycodone. She further reported the Complainant was apologizing to her and telling her it was his time to go.

The first officer was reported on scene at 7:36 p.m. Responding police officers were asked to put on their hard-ballistic vests and were instructed to avoid passing by the front of the residence. At 7:43 p.m., it was reported the Complainant had sent a text message to CW #1, stating he was waiting for the police to arrive to end things.

At 8:08 p.m., it was reported surveillance cameras inside the residence showed the Complainant sitting on the couch with his head in his hands.

At 8:42 p.m., someone reported the Complainant had sent a text message stating, “Can’t do this anymore.” The Complainant texted that he would be found in the garage.

At 9:24 p.m., it was reported the Complainant had been drinking excessively. It was also reported there was loud music playing inside the residence. At 9:28 p.m., the Complainant was reported to be asleep on the couch, with the lights out.

At 10:41 p.m., it was reported that the OPP Tactical and Rescue Unit (TRU) team had taken over positions manned by the OPP Emergency Response Team (ERT) team.

At 1:01 a.m., on August 29, 2020, it was reported the Complainant was sleeping on his couch, with a shotgun on the table in front of him. The OPP TRU team moved their armoured vehicle into a position from which they could attempt to hail the Complainant on the loudspeaker. The Complainant was seen to be shaking his head in response to those efforts.

At 2:27 a.m., the OPP TRU team entered the Complainant’s residence and the Complainant was apprehended. He was transported to hospital.

On August 31, 2020, at 12:40 p.m., CW #2 telephoned the OPP, again to ask that the OPP confirm the well-being of the Complainant. She reported the Complainant had been involved in a suicide threat on August 28, 2020, and had been admitted to the hospital, but had been released. CW #2, by way of accessing surveillance cameras inside the Complainant’s residence, was aware he had arrived home on August 29, 2020. CW #2 reported the Complainant had later deactivated the surveillance cameras. She reported the Complainant’s vehicle was parked in front of the residence rather than inside the garage, which was unusual.

At 1:09 p.m., police officers (WO #2 and WO #1) reported they had attended the residence. They reported nobody would answer the door, but music playing inside the residence was turned up while police were on scene. The officers reported they would check back later.

On September 1, 2020, at 7:30 a.m., a man contacted the OPP to ask that they check on the well-being of one of his employees, the Complainant. At 7:55 a.m., responding police officers reported there was no answer at the door and music was still playing from inside the residence. At 8:06 a.m., the police officers were instructed to enter the residence. The Complainant was located hanging in the garage.

Police Communications Recordings

On August 31, 2020 at 12:43 p.m., WO #3, the shift senior officer, called the dispatcher and asked that WO #1 and WO #2 be asked to conduct a check well-being call. WO #2 stated he was having some computer issues, so he was going to the detachment to rectify that. The dispatcher advised him of the well-being check in the call for service queue. WO #2 asked if it was an emergent situation. The dispatcher reported it was a well-being check for a man who had been suicidal and taken to the hospital on Friday.

WO #3 advised WO #2 it was the person who had barricaded himself on Friday, and he had not been heard or seen from since Saturday. WO #2 asked who it was that made the request for the well-being check, and WO #3 responded the woman had access to cameras inside the residence but the subject had since turned them off, so she was concerned. WO #2 said he would respond with somebody given the previous barricaded person call. WO #1 agreed to attend the call. The dispatcher provided the name of the resident, the Complainant.

WO #3 said he too would head over to the address.

Later, WO #1 reported they were both “10-8”, but he asked that the call be left open. He reported they did not contact the Complainant, but the music was turned up when they attended so it appeared someone was alive and well inside. WO #1 was going to give the Complainant a call.

Materials obtained from Police Service

Upon request, the SIU obtained and reviewed the following materials and documents from the OPP:
  • Scene photographs;
  • CAD Event Details Report (x3);
  • Communications recordings;
  • Interview Statement – CW #2;
  • Interview Statement – CW #1;
  • Notes – WO #3;
  • Notes – WO #2;
  • Notes – WO #4;
  • Notes – WO #6;
  • Notes – WO #1;
  • Notes – WO #5;
  • Police Orders – Individuals Experiencing Mental Health Crisis; and
  • Shift Briefing Report (Day) – August 31, 2020.

Materials obtained from Other Sources

The SIU obtained and reviewed the following records from non-police sources:
  • Report of Postmortem Examination and Toxicology Report received from the Coroner’s Office on January 14, 2021.

Incident Narrative

The following scenario emerges on the evidence collected by the SIU, which included statements from three witness officers and members of the Complainant’s inner circle. As was his legal right, the SO declined to interview with the SIU or authorize the release of his notes.

In the morning of September 1, 2020, OPP officers were dispatched to the Complainant’s address when his employer contacted police to indicate that he had failed to report for work the last two days. Officers entered the home and located the Complainant hanging in the garage.

The day before, OPP officers had also been to the Complainant’s home to check on his well-being. Their attendance was prompted by a call to police by CW #2. She had expressed concern that the Complainant, who had been released from hospital early Saturday morning following a suicide scare, had not been heard from over the weekend. WO #1 and WO #2 arrived at the residence at about 1:00 p.m. They knocked on the door and walked around the residence attempting to spot the Complainant, without any success. They did, however, hear music playing inside the home, which was turned up while the officers were there. Satisfied that someone was inside the house alive and well, WO #1 and WO #2 departed.

Back at the station, the officers reported what they had done and a note was prepared for the following shift to follow-up with the Complainant. The SO was the officer in charge of the evening shift. There is no evidence to suggest that any further inquiries were made that day.

Four days before the Complainant was discovered, in the evening of August 28, 2020, OPP officers had apprehended the Complainant inside his home on the authority of the Mental Health Act and taken him to hospital for psychiatric examination. On that occasion, officers were dispatched based on a call to police by CW #2. CW #2 had had a falling out with the Complainant earlier in the week when she refused to provide him prescription pain medication. The Complainant was experiencing severe pain from gastric problems that had developed in the past year and had run out of his oxycodone. CW #2 had just left the Complainant’s residence with her belongings and called police to report that he was threatening suicide and had a firearm in his possession.

Cause of Death

The pathologist at autopsy attributed the Complainant’s death to hanging.

Relevant Legislation

Section 215, Criminal Code - Failure to Provide Necessaries

215 (1) Every one is under a legal duty

(c) to provide necessaries of life to a person under his charge if that person
(i) is unable, by reason of detention, age, illness, mental disorder or other cause, to withdraw himself from that charge, and
(ii) is unable to provide himself with necessaries of life.

(2) Every person commits an offence who, being under a legal duty within the meaning of subsection (1), fails without lawful excuse to perform that duty, if
(b) with respect to a duty imposed by paragraph (1)(c), the failure to perform the duty endangers the life of the person to whom the duty is owed or causes or is likely to cause the health of that person to be injured permanently.

Sections 219 and 220, Criminal Code -- Criminal negligence causing death

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.

220 Every person who by criminal negligence causes death to another person is guilty of an indictable offence and liable
(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

On September 1, 2020, the Complainant was found hanging in the garage of his home in Elgin County. As OPP officers had attended at his residence in the days prior to his death, and were the ones to have located him in the garage, the SIU was notified of the matter and opened a file. The SO was identified as the subject officer 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.

The offences that arise for consideration are failing to provide the necessaries of life and criminal negligence causing death contrary to sections 215 and 220 of the Criminal Code, respectively. The former is premised, in part, on conduct that amounts to a marked departure from the level of care that a reasonable person would have exercised in the circumstances. The latter is intended to capture more egregious conduct and is not made out unless there is negligence that amounts to a marked and substantial departure from a reasonable level of care. In the instant case, the issue is whether there is evidence to reasonably conclude that the SO caused or contributed to the Complainant’s death, or otherwise endangered his life, by way of conduct that was sufficiently derelict to attract criminal sanction. In my view, there is not.

It is instructive to begin with a broad lens at the police dealings with the Complainant in the days preceding September 1, 2020. On August 28, 2020, ERT and TRU officers deployed to his residence based on credible information from CW #2 that he was in possession of a firearm and threatening to harm himself. There were clear grounds in these circumstances to force entry into the Complainant’s residence based on exigent circumstances and to take him into custody under section 17 of the Mental Health Act.

I am not satisfied that those same grounds necessarily existed when WO #1 and WO #2 arrived at the Complainant’s home on August 31, 2020 to check on his well-being. Though their attendance was again prompted by CW #2, the circumstances had materially changed. There was no articulable and immediate concern for his health and safety, and no mention of a firearm in his possession. Moreover, the Complainant had recently been released from hospital following psychiatric examination. On this record, I am unable to fault the officers for believing they did not have the lawful authority to enter into the Complainant’s residence, particularly as they had heard the volume of music being played in the home turned up while they were outside.

The issue turns to the conduct of the SO. It would have been his responsibility to review the Shift Briefing Report. Had he done so, the officer would have seen a notation of WO #1 and WO #2’s earlier attendance at the Complainant’s residence and a request that the evening shift officers follow-up to ensure his well-being. As the SO exercised his right to remain silent, it is unknown whether he read the report and what, if anything, he did about it. It does not appear that any officers returned to the Complainant’s address that date.

Notwithstanding this lacuna in the evidence, the evidence is such that I am unable to reasonably conclude that any lapses on the part of the SO transgressed the limits of care prescribed by the criminal law. Assuming that the SO did nothing with the notation, the fact remains that two officers had mere hours before checked on the Complainant and, within the limits of their lawful authority, did what they could to check on him. Had officers been dispatched again by the SO, it is doubtful they could have done anything more to ensure the Complainant’s safety. For starters, it might well be that the Complainant had already committed suicide by that time. But even if he had not, there is no reason to believe that the Complainant would have been any more receptive to their efforts, nor would there have been any more grounds than were available to WO #1 and WO #2 to force the issue under the Mental Health Act.

In the result, as the evidentiary record does not give rise to a reasonable belief that any indiscretions on the part of the SO would have amounted to a marked deviation from a reasonable level of care in the circumstances, there is no basis for proceeding with criminal charges in this case. The file is closed.

Date: March 15, 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.