SIU Director’s Report - Case # 20-OOD-318


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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 43-year-old woman (the “Complainant”).

The Investigation

Notification of the SIU

On November 22, 2020, at 11:05 a.m., the Waterloo Regional Police Service (WRPS) reported the following.

On November 21, 2020, at about 11:10 p.m., the Complainant called 911 and stated that her boyfriend was a drug dealer, she was a “rat”, and that the Jamaican mafia was after her.

Subject officer (SO) #1 and SO #2 attended the Complainant’s apartment unit at 11:24 p.m., for a well-being check. While speaking to her, SO #1 and SO #2 believed the Complainant appeared fine and calm. She did not express any suicidal tendencies. She thanked the police officers before they left her apartment. A few minutes later, the Complainant called 911 again and SO #2 spoke with her. She sounded calm and said, “I love you guys. You guys are doing great.”

On November 22, 2020, at about 12:35 a.m., the Complainant called 911 several times. At about 12:59 a.m., the dispatcher heard a bottle of pills rattling in the background, and the Complainant advised that she had taken pills. She had also consumed three beers.

The dispatcher transferred the call to EMS, who then asked for a crisis worker from “Here 24/7” to assist. At this point, the police had not been advised of this call.

At 1:21 a.m., EMS advised the WRPS communications that they could not get into the Complainant’s apartment unit. At 1:27 a.m., a crisis worker called for police assistance. At 1:29 a.m., EMS could hear the Complainant breathing heavily and snoring. At 1:49 a.m., police arrived on scene and advised that they could not get the door open to the apartment unit, requesting further assistance from the Fire Services.
At 2:04 a.m., the door was breached, and CPR was initiated on the Complainant. She was subsequently pronounced dead.

The Complainant’s body was taken to the hospital and the coroner had requested that WRPS forensic services attend the hospital.

The Team

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


43-year-old female, deceased

Civilian Witnesses

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

Police Employee Witnesses

PEW #1 Interviewed
PEW #2 Interviewed
PEW #3 Not interviewed
PEW #4 Interviewed
PEW #5 Not interviewed
PEW #6 Not interviewed
PEW #7 Not interviewed
PEW #8 Not interviewed
PEW #9 Not interviewed

The SIU determined that three of the nine police employee witnesses had communication with the Complainant. As a result, only three police employee witnesses were interviewed.

Subject Officers

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


The Scene

The incident took place in the area of Joseph Street in Kitchener, within the dwelling of the Complainant; specifically, the bedroom of the Complainant, where multiple pills and pill bottles were observed scattered across the bed.

Communications Recordings

911 Communications

The 911 recordings started on November 21, 2020 at 11:09:55 p.m. and concluded on November 22, 2020 at 3:09:10 a.m. The recordings involved the Complainant, two 911 call-takers, volunteer crisis workers from the crisis organization known as “24/7”, an ambulance call-taker, and a Fire Services call-taker.

21 November 2020

11:10:39 p.m. An intoxicated female identified herself as the Complainant. The Complainant had slurred speech and asked for help. She stated she was in danger and she had fucked up. Her ex-boyfriend was a drug dealer and he said that she only had five to six months to live. The Complainant was asked for her address and she refused to give it.

The call-taker asked how 911 could help and she said that he was going to murder her. She refused to give his name. The Complainant was kept on the line. She rambled and continued to say she feared for her life.

It appeared from the manner in which she spoke with the 911 call-taker that the Complainant was intoxicated.

At 18 minutes into the call, the Complainant stated someone was at the door, and asked whether she should answer it. The 911 call-taker told her she could. [It is believed this was the WRPS.]

22 November 2020

12:02:11 a.m. The Complainant called 911 again. She still sounded intoxicated. She cried and slurred her speech. The Complainant was asked her address again (presumably by a different operator). She refused to provide it. The Complainant later gave her address.

12:32:04 a.m. The Complainant called back. She was asked again and finally gave her address in the area of Joseph Street, Kitchener. The Complainant was still seemingly intoxicated. She cried and slurred her speech. She rambled and said her ex-boyfriend would kill her because she was a “rat”. She stated that he said she would have only had five months to live.

12:54:49 a.m. The Complainant called 911 again. She sounded intoxicated and slurred her speech. She stated that the police had told her she was harassing the 911 call-taker and, if she continued to do so, she would be arrested.

The Complainant then stated she had taken pills and one drink. She wanted to kill herself. She gave her address. She further stated she did not want any help, and that she just wanted to die on her own. The Complainant cried and stated she had taken various prescription medication. The 911 operator put the Complainant through to a counselor at 24/7.

12:54:49 a.m. A male counselor attempted to speak with the Complainant. The Complainant’s address was confirmed by the 911 operator. This was a three-way conversation between the female 911 operator, the Complainant and the counselor.

12:58:23 a.m. The ambulance dispatcher called and confirmed with the 911 operator that they were responding to the address in the area of Joseph Street, Kitchener.

1:12:42 a.m. EMS asked if WRPS were en route. Their crew were on scene and could not get into the building.

1:24:13 a.m. The EMS supervisor asked to speak to the 911 supervisor.

1:25:17 a.m. A female counselor from “24/7” called from her personal cell. Her work colleague (the male counselor) was speaking with the Complainant on their office line. The Complainant said she had taken prescription medication. Her colleague felt the Complainant’s breathing was laboured and she was not answering any questions. The Complainant told him she could hear someone at her door.

The 911 operator stated EMS and a police officer were outside the door, attempting to get in.
1:26:32 a.m. EMS spoke with the 911 call-taker and confirmed this was a police issue. EMS asked for the ETA of police. Fire Services could not get into the building.

1:30:10 a.m. Ambulance wanted the ETA of police. The 911 operator stated that it was probably five to ten minutes.

1:47:11 a.m. “24/7” called 911. The male staff member of 24/7 stated they still had the Complainant on an open line; however, he could no longer hear her breathing. Her breathing had changed dramatically.

1:49:24 a.m. The staff member from 24/7 was still on the open line with the Complainant. He could not hear her breathing. The 911 call-taker advised there were lots of units on scene; however, they still could not get access to the building. A female staff member from 24/7 stated it was now approximately ten minutes with no breathing sounds from the Complainant.

2:33:51 a.m. An unknown male (possibly a police communications supervisor) called into 911 and asked what time the Complainant called-in when she spoke about taking pills. He was advised it was at 12:56 a.m. He stated the incident did not meet the mandate of the SIU; however, he would speak with the duty officer.

2:46:52 a.m. A police officer called-in to 911 and spoke with the operator. He stated he believed the Complainant took the pills because a police officer told her that if she called 911 again, she would be arrested.

3:09:10 a.m. A supervisor called into 911. He told the female operator he spoke with [a police officer]. The officer stated when he last saw the Complainant, she was in good spirits with police officers. She must have gone manic after they left her. The supervisor stated not to worry about this as it was not going to be an SIU investigation. The 911 operator stated [a woman] was on the line with the Complainant when she stated she had taken the pills.

Radio Communications

The recording had a start time of 11:00 p.m., on November 21, 2020, and concluded at 6:51:34 a.m., on November 22, 2020.

The audio recording was not date or time stamped. The only clock attached to the audio was the running chronometer which started at 00:00 and concluded at 0651:34. This audio incorporated the involved units attached to this investigation, along with all patrol units working that nightshift. The audio was difficult to understand at times, as multiple calls were dispatched during the recording. At times, the dispatcher would talk about a female in need of assistance. At times, it was unknown whom she was calling, or the address she was sending units to.

16:10 Dispatch requested [Unit 1] and [Unit 2] to attend to the scene. The female (now known to be the Complainant) was crying into the line. She said the police ignored her, and her boyfriend, a drug dealer, was out to get her.

29:07 [Unit 1] stated they were doing door knocks in attempts to locate the Complainant. He asked the dispatcher to have her come to the door if she called back.

30:08 The dispatcher advised [Unit 1] that they had asked her to come to the door. [Unit 1] stated she was at the door now.

44:05 The dispatcher asked for an update. An unknown patrol unit advised there was no answer at the door.

44:32 Unknown patrol unit advised to disregard and that he had someone now.

1:02:40 The dispatcher asked about the status of the investigation. She advised she had received multiple hang-ups from the Complainant’s phone. [Unit 1] advised the Complainant was locking up her residence and was getting ready for bed.

1:09:15 The dispatcher contacted [Unit 1] and asked that he read the updates in the call. He advised he would try and give her a call back. It was the same things they talked to her about upstairs.

2:29:05 The dispatcher asked [Unit 2] to clear and assist ambulance. They had a couple of callers. The Complainant had taken an unknown quantity of pills and they were unable to get her to answer the door. They could hear snoring and heavy breathing.

2:30:20 The dispatcher advised they had an open line. There was no contact with the Complainant. An ambulance supervisor was at the door to her unit.

2:32:15 Dispatcher asked if [Unit 2] wanted Fire Services to access the apartment. [Unit 2] said not right now. He asked the Communications Branch if they had a “Super” to the building on file.

2:34:55 Dispatch called [Unit 2] and provided the superintendent’s name and address.

2:40:43 [Unit 2] stated that she should let EMS know he had propped the door open for them. If someone had taken the “prop” down, EMS should call. She would answer.

2:41:37 Dispatch called [Unit 2]. She wanted to confirm that he was propping the door, as EMS was asking. [Unit 2] stated to disregard and that he was heading up to the Complainant’s residence now.

2:43:10 [Unit 2] asked whether they were still on the line with her, and whether they could hear her breathing.
2:48:35 [Unit 2] to [Unit 3]. [Unit 2] stated he had spoken with a neighbour, who confirmed no superintendent lived in the building.

2:49:00 [Unit 3] asked for Fire Services to attend.

2:50:16 Dispatcher advised Fire was en route.

2:50:35 Dispatcher advised they had contacted 24/7. They advised there was no sound on the line.

2:51:20 [Unit 2] to [Unit 3]. [Unit 2] asked if the sergeant wanted him to give it a try (force the door). The sergeant replied go ahead.

3:04:15 Unknown unit advised that CPR had started.

3:20:00 A supervisor or commander asked the dispatcher when 24/7 last heard the Complainant breathing. The dispatcher responded that, at 1:48 a.m., 24/7 advised there were long pauses and shallow breaths, and that, at 1:50 a.m., 24/7 advised there were no more sounds.

Materials obtained from Police Service

The SIU obtained and reviewed the following records from the WRPS:
• Letter to SIU regarding Disclosure Request;
• List of WRPS Civilian Employees Involved in Occurrence;
• Computer-assisted Dispatch Incident;
• Occurrence Report;
WRPS 911 and Communication Recordings;
WRPS Letter to SIU regarding Disclosure Request; and
WRPS Photographs.

Incident Narrative

The following scenario emerges from the evidence collected by the SIU, which included interviews with WRPS call-takers and a review of relevant police communication recordings. Shortly before 1:00 a.m. of November 22, 2020, an intoxicated Complainant called 911 indicating that she had consumed a quantity of prescription medications and wanted to die. Paramedics were dispatched to her address in the area of Joseph Street, while the Complainant was kept on the line and put through to “Here 24/7” – a crisis support centre.

As paramedics arriving at the scene could not access the Complainant’s unit, police officers were dispatched to assist with entry. In the meantime, the counselor with “Here 24/7” who had been speaking with the Complainant reported that her breathing had become laboured and she had stopped answering questions. At about 1:47 a.m., some 20 minutes later, the counselor indicated that he could no longer hear the Complainant breathing. The fire department was subsequently summoned to breach the Complainant’s door.
First responders gained access into the Complainant’s unit at about 2:00 a.m., whereupon CPR was started. The Complainant could not be resuscitated.

The Complainant had made a number of 911 calls prior to the one indicating she was suicidal. At about 11:10 p.m. of November 21, 2020, she contacted police expressing fear of her ex-boyfriend, a drug dealer, who had told her she only had months to live. Officers were dispatched to check on her well-being.

SO #1 and SO #2 had attended at the Complainant’s residence at about 11:30 p.m. and spoken with the Complainant. It appears they then left at about midnight having assured themselves that the Complainant was okay and that her unit was secured.

At about 12:02 and 12:32 a.m. of November 22, 2020, the Complainant called 911 again, crying and slurring her speech on each occasion. She reiterated her fear of her ex-boyfriend, believing he was out to kill her. Sometime after one or the other of these calls, either SO #1 or SO #2 spoke with the Complainant again, this time cautioning her against repeated 911 calls.

Cause of Death

The pathologist at autopsy attributed the Complainant’s death to “[a]cute intoxication with [prescription medication] and ethanol”.

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.

Section 219, 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.

Section 220, Criminal Code -- Criminal negligence causing death or bodily harm

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.

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.

Analysis and Director's Decision

The Complainant passed away of a drug overdose on November 22, 2020 in Kitchener. As WRPS police officers had attended at her apartment with other first responders when she was in medical crisis, and had earlier interacted with her in the hours before her death, the SIU was notified and opened a file. SO #1 and SO #2 were identified as subject officers for purposes of the SIU’s investigation. On my assessment of the evidence, there are no reasonable grounds to believe that either subject officer committed a criminal offence in connection with the Complainant’s death.

The offences that arise for consideration are failure 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, a more serious offence, is reserved for conduct that demonstrates a wanton or reckless disregard for the lives or safety of other persons. It is not made out unless the impugned behaviour constitutes a marked and substantial departure from a reasonable level of care. In the instant case, the issue is whether the subject officers fell short in their duty of care toward the Complainant and, if so, whether their dereliction contributed to the Complainant’s death and/or was so egregious as to attract criminal sanction. In my view, these questions must be answered in the negative.

There is little evidence of the nature and extent of the officers’ interaction with the Complainant when they first attended at her residence. What evidence there is, derived from the officers’ radio transmissions, indicates they spoke with the Complainant about her concerns, took steps to address her fears about her ex-boyfriend by ensuring her apartment was secure (including locking her balcony door) and departed believing she was off to bed. While it appears the Complainant was intoxicated at the time, and would likely have appeared as such to the officers, there is no evidence to suggest she was suicidal. On this record, there is insufficient evidence to reasonably conclude that the officers did not conduct themselves with due care and regard for the Complainant’s well-being.

The same is true of the officers’ subsequent touchpoints in this matter, namely, the call made to the Complainant following one of her other 911 calls after their initial departure, and their efforts to assist other first responders gain access to the Complainant’s apartment. While it appears that the officer who called the Complainant upset her when he warned her against repeated 911 calls for the same matter, I am unable to fault the officer - whether SO #1 or SO #2 - to any significant degree. To reiterate, there is no suggestion in the evidence that suicidal ideation had entered the picture at this time, in which event greater discretion would have been in order. And the officer had a legitimate interest in wanting to deter any additional 911 calls unless there had been some material change in the Complainant’s situation. As is clear from the information she conveyed in the two calls, there had not. Thereafter, there is nothing in the record to suggest that either officer failed to act with dispatch in doing what they could to assist with entry into the apartment.

In the result, as there are no reasonable grounds to believe that either subject officer transgressed the limits of care prescribed by the criminal law in connection with the Complainant’s unfortunate passing, there is no basis for proceeding with charges in this case. The file is closed.

Date: July 12, 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.