SIU Director’s Report - Case # 20-OCD-268
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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 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 29-year-old woman (the “Complainant’).
Notification of the SIUOn October 13, 2020, a lawyer contacted the SIU and reported the following:
On April 18, 2020, at about 4:40 p.m., the family of the Complainant called 911 because she had expressed suicidal ideations. When Peel Regional Police (PRP) police officers and Emergency Medical Services (EMS) arrived, they spoke to both the family and the Complainant. According to the lawyer, there were multiple signs that showed the Complainant was in distress, such as cuts on her arms and wrists. During their interactions, police officers and EMS personnel called the Crisis Outreach Assessment Support Team (C.O.A.S.T.) to assist with speaking to the Complainant.
At some point, the police and EMS personnel took no further action with the Complainant because of COVID-19.
The Complainant left her family’s home and attended a Walmart on her own where she purchased a knife and a bottle of Windex cleaner. There was video surveillance footage that captured some of the Complainant’s movements both in the store and after she left.
At approximately 7:45 p.m., the Complainant was found deceased in a field.
A coroner attended the scene. An autopsy was subsequently performed by a pathologist, and the cause of death was deemed to have been a stab wound to the chest.
The TeamNumber of SIU Investigators assigned: 3
Complainant:29-year-old female, deceased
Civilian WitnessesCW #1 Interviewed
CW #2 Interviewed
CW #3 Interviewed
CW #4 Interviewed
Witness OfficersWO #1 Interviewed
WO #2 Interviewed
WO #3 Interviewed
The SceneThe Complainant’s body was found on a grassy scrub area on the southeast edge of the property of the Walmart at 9455 Mississauga Road, Brampton. The area consisted of concrete pillars which supported a railing type fence which separated the property from residences on Royal West Drive. There was a pedestrian walkway with seating benches on the grassy area.
911 Calls to PRP4:32:40 p.m.
The 911 call-taker transferred the call to EMS dispatch. The EMS dispatcher asked CW #2 to confirm his address. He confirmed his address and provided the closest major intersection as Mississauga Road and Williams Parkway off Royal West Drive. CW #2 provided the phone number he was calling from.
The EMS dispatcher asked CW #2 if the person he was calling about [now known to have been the Complainant] was awake. CW #2 replied, “She had cut…(inaudible)…because she was so depressed …. (inaudible)…. we had brought her there…because she was feeling so…(inaudible)…like.” The EMS dispatcher asked CW #2 if the person who needed the ambulance was awake. CW #2 replied, “Yes.” The dispatcher asked if the Complainant was breathing and he replied that his daughter was breathing normally and that she had been in the washroom. The dispatcher asked how old the Complainant was and CW #2 told her his daughter was 30/29-years-old.
The EMS dispatcher asked CW #2 what was happening. He told the dispatcher that his daughter had been quiet, working from home, and was alone in her apartment. So, with the current situation, she was getting depressed. CW #2 and his wife felt she could come home to their house and they went downtown and brought her to their house. She appeared to be normal but this morning or afternoon she went to the washroom and she was in the bathtub… (call dropped).
EMS called the PRP and asked them to respond for a 29-year-old female who was depressed and self-harming. She had cut her arms and might have taken some Benadryl. The PRP said they would respond.
The call was answered, and the male caller asked for police and ambulance. The caller responded that there was someone who was bloody and unresponsive near Royal West Drive and Walmart. He was asked whether it was a male party and he replied he could not tell. When asked, he said the body [now known to have been that of the Complainant] was in the Walmart yard. The Complainant was not responding and faced away from him. She was in a garden section of the Walmart lot and she had blood on her hands. The caller initially thought it was a male body but as the body had tight jeans on, he believed it was a female.
The call was put through to the EMS. The caller reported there was a person [the Complainant] in a garden between the Walmart and Royal West Drive and he or she was unresponsive. The caller was asked whether he could wake the person; he replied she was not responsive, had blood on her, and was not breathing. He was asked if he was prepared to do CPR. He replied he was not prepared to do that. The caller was asked if he knew what happened and he said he did not. He said there was blood on the Complainant’s hands which were closed.
The PRP Duty Inspector called the Communications Centre. He inquired as to what was happening at the Walmart. The call-taker told him it looked like they had a female [the Complainant] at the Walmart bleeding, not breathing, and with a knife beside her. It was unknown if it was a suicide or somebody stabbed her. The communications operator had checked and there was no record of any missing females in PRP 22 Division. He did not know if the Complainant was alive. The only witness was the 911 caller, who had called it in. The Duty Inspector indicated he would make his way to the scene.
A call from the Complainant’s mother was transferred from EMS to the PRP Communications Centre. CW #1 stated she did not want the cops in her house as they had been at her home earlier regarding a problem they were having with their daughter. CW #1 had called 911 again to tell the police something or complain about the incident with her daughter and said that she did not need them in her house. The call-taker gave CW #1 the non-emergency number to call.
PRP Communications called the Toronto Police Service (TPS) Communications and asked if they had any report of the Complainant having been reported missing. It was noted that she had been found with multiple stab wounds in a garden area and PRP did not know whether it was self-inflicted or not. The TPS undertook to do a check and call PRP back.
CW #1 called the non-emergency line. She told the call-taker the call was related to an incident they had had in their house earlier that day. She noted that the police and ambulance had been at her house already that day and they came to the conclusion that her daughter, the Complainant, would remain at her house for the day because she was in a very bad state of mind. The Complainant then went for a walk when the police left. She said she was just going for a walk and as she was a 29-year-old, they had to let her go but she had not returned home. She reported that her daughter had been gone for two hours and they did not know where she was, and she was not answering their calls. CW #1 provided her address. She provided her daughter’s name, her own name, and the Complainant’s date of birth. CW #1 said the police had been at her house a couple of hours earlier and when her daughter had left the house the police spoke to her for a while. They, the police, were outside. The call-taker said she would send police officers back to CW #1’s house.
Additional 911 RecordingsThe original call was made to the PRP and transferred to EMS. During the process some of the recording was not captured. The following refers to a portion of the conversation that was not contained in the original recordings received from PRP.
The 911 call-taker transferred the call to EMS dispatch. Another operator interjected and said she was transferring a call for an ambulance to an address in Brampton. The EMS call-taker asked CW #2 what was happening. He told the call-taker that his daughter had been quiet, working from home, and was alone in her apartment. So, with this current situation, she was getting depressed.
CW #2 and his wife felt she could come home to their house and they went downtown and brought her to their house. She did not appear to be normal but this morning or afternoon she went to the washroom and she was in the bathtub and her mother saw her and that she had cut a vein…(phone passed over to CW #1). CW #1 explained that they were calling about their daughter [now known to have been the Complainant] and noted that she had taken some Benadryl and had made some cuts to her hands which were bleeding all over. The call-taker asked if the Complainant was drowsy or confused and CW #1 replied she was confused. [Female in background could be heard calling out, “Mom, mom.”]
CW #1 told the call-taker that her daughter had not taken ten Benadryl as she had just showed her the tablets but that she had made a lot of cuts to her hands (cross talk; male shouting in background). CW #1 advised it was her son who was shouting, and he was heard to tell her not to talk to them (EMS). CW #1 apologized for her son’s behaviour. The call-taker asked CW #1 if she needed an ambulance as her daughter had cut her arms. CW #1 said she thought so but asked the call-taker to advise her. The call-taker replied that she could not give medical advice. The call-taker said she could send an ambulance and CW #1 asked whether they should take her by car saying they could do that. The call-taker told her she could not make that decision for her and CW #1 said she would go with the ambulance. When asked by the call-taker if her daughter was a danger to herself or others CW #1 replied, “Not at all, not at all.” The call-taker said, “Except for cutting her arms.” CW #1 replied, yes, that she was a danger to herself. When asked if her daughter had taken the Benadryl, CW #1 replied she had taken a few but not all ten. CW #1 said her daughter had taken the Benadryl a couple of hours earlier. She was asked a couple of COVID-19 standard questions.
PRP Radio CommunicationsMedical assist call
The radio dispatcher dispatched WO #2 and an undesignated officer to a priority call to CW #1 and CW #2’s address for a medical assist. [NB. The undesignated officer was diverted to another call and did not attend the address.] It was noted that they were responding with ambulance for a 29-year-old female, who was suicidal and self-harming, and had taken a quantity of medication. The dispatcher then sent WO #1 and WO #3 to the call.
WO #1 reported at the scene with the ambulance.
PRP units were dispatched to a medical assist call to an address on Royal West Drive in relation to a body in the parking lot of the Walmart that was not moving, unresponsive, and possibly a male party. The 911 caller would not be on the Walmart property. The ambulance was also responding.
The dispatcher advised that the party [now known to have been the Complainant] was not conscious and had blood on her. She did not appear to be breathing and was in her 30s.
The first PRP unit arrived on scene.
A police officer reported having located the Complainant and described her as a young female, bleeding, and not breathing. The police officer reported having located a knife.
A police officer radioed-in and gave the Complainant’s identification, including her date of birth.
A police officer radioed-in and advised that the Complainant had multiple stab wounds to her chest.
A police officer radioed-in and advised that the Complainant had been declared deceased at 8:06 p.m. by a doctor.
The dispatcher advised the road sergeant that dispatch had received a call from a person in relation to the Complainant and that it appeared she lived in the area.
A Criminal Investigation Bureau police officer reported that he was at CW #1 and CW #2’s residence.
Closed-circuit Television (CCTV) from WalmartStarting at 00 seconds into the recording
A person [now known to have been the Complainant] wearing white runners, light blue jeans and dark-coloured coat was seen hunched down next to a pillar. The pillar formed part of the fencing around a grassy area on the Walmart property. There was a pedestrian walkway and seating benches in view. The view of the Complainant and the pillar was partially blocked by a tree. There was a red brick house behind the pillar.
Starting at 04 seconds into the recording
The Complainant stood up and appeared to be holding a light-coloured object in her right hand (believed to have been a grey-coloured plastic shopping bag). She was facing the pillar.
Starting at 13 seconds into the recording
The Complainant bent down and appeared to either place or pick something up off the ground.
Starting at 19 seconds into the recording
The Complainant’s head tilted backwards, and she appeared to be drinking something using her right hand.
Starting at 21 seconds into the recording
The Complainant dropped what was in her right hand to the ground and walked up to the pillar pressing her chest against it. Her right arm was roughly at chest level and bent at her elbow in towards her body. She then took one step back from the pillar.
Starting at 27 seconds into the recording
The Complainant crouched down on her haunches and with her right hand picked something up from the ground. She then stood back up facing the pillar.
Starting at 37 seconds into the recording
With her right hand again at chest level and bent in towards her chest, the Complainant pushed her body into the pillar. She then stepped back.
Starting at 40 seconds into the recording
The Complainant again pushed her body into the pillar and fell down on her left side and onto her back on the ground. There was some movement of her body on the ground.
At 54 seconds into the recording
The video ended.
Materials obtained from Police ServiceThe SIU obtained and reviewed the following records from the PRP:
• Computer-assisted Dispatch;
• Mental Health Policy;
• 911 communications recordings;
• Radio communications;
• CCTV footage from Walmart Store;
• Notes of WOs; and
• Occurrence Details.
Materials obtained from Other SourcesInvestigators also obtained and reviewed the following:
• Report of Post-mortem Examination from Coroner’s Office.
At about 4:30 p.m. of April 18, 2020, the Complainant’s father, CW #2, called 911 for an ambulance from his home in Brampton. He and his wife were extremely concerned with their daughter’s welfare. The COVID-19 pandemic and the attendant social isolation caused by pandemic control measures were having a negative impact on the Complainant’s mental health. CW #2 and his wife, CW #1, had brought her home from Toronto. On this date, CW #2 reported, the Complainant had cut her arms and taken some Benadryl.
Paramedics were dispatched to the address, as were, at the ambulance service’s request, police officers. The officers were of WO #1, WO #2 and WO #3. WO #3 was a member of COAST at the time. COAST, or the Crisis Outreach Assessment Support Team, brings together police officers with specific training in mental health with non-police officer mental health professionals. Where available, COAST units are tasked with responding to calls for service involving mental health crisis. Because of the pandemic, WO #3 was on-duty by himself and not with his COAST partner. The officers were advised via dispatch that the Complainant, 29-years-old, was suicidal and self-harming, and had taken a quantity of medication.
The paramedics, CW #3 and CW #4, and WO #1 and WO #2, were the first to the scene, joined later by WO #3. WO #1 was the first officer to speak with the Complainant. The Complainant acknowledged she was depressed and having trouble sleeping, which was why she had taken two Benadryl, but denied wishing to harm herself. As she explained, if she had wanted to, she could have taken more of the Benadryl. Asked about the cuts to her arms, the Complainant said she was a “cutter”. On inspection by the officer, the cuts appeared fresh but superficial and without any blood.
The Complainant, then seated at the kitchen table, was next assessed by the paramedics, who concluded the Complainant was fine from a medical perspective. The paramedics took their leave shortly after 5:00 p.m.
WO #2 spoke with the Complainant after the paramedics left and expressed sympathy with her when told that COVID-19 had recently brought about feelings of depression and anxiety. The officer acknowledged that she also felt anxious from time to time and that everybody’s “normal” had been upended by the pandemic. The Complainant noted that she had no previous mental health diagnosis, was not on any medication, and was not suicidal. WO #2 noted cuts on the Complainant’s wrists, which were not deep or bleeding.
As these conversations were occurring, WO #1 spoke with CW #1 and CW #2. CW #1 indicated that life under the pandemic had taken a toll on the Complainant, especially the self-isolation, as the Complainant was a very social person. CW #1 wanted her daughter taken to the hospital.
Upon his arrival, WO #3 spoke briefly with WO #1 and then joined the Complainant alone at the kitchen table. The Complainant was calm and lucid. She again explained how she had been feeling down and experiencing pandemic-related anxiety. The two Benadryl she had taken were to help her relax and sleep. The Complainant indicated that she was a self-cutter, but assured the officer that her cutting was always superficial and meant to relieve tension. She had no thoughts of hurting herself. WO #3 asked the Complainant whether she was agreeable to speaking with a mental health crisis worker on the phone. The Complainant responded in the affirmative. A registered social worker and member of COAST via the Canadian Mental Health Association was reached on WO #3’s phone and put in touch with the Complainant over a video chat. The officer left the kitchen.
The Complainant and the social worker spoke for several minutes. Though she conveyed passive suicide ideation, the Complainant denied any intention of ending her life. The Complainant acknowledged general feelings of anxiety and mood swings, and noted that her self-cutting had become for her a coping mechanism unrelated to any desire on her part to end her life. It was agreed with the Complainant that a full mental health assessment would be completed with her the following day via video conference and that the results of that assessment would be used to assist in referring her to supports and provided to her family doctor. The Complainant also agreed to contact the Canadian Suicide Prevention Service 24-hour crisis line if she started having suicidal thoughts.
At CW #1’s request, the social worker spoke with her following her conversation with the Complainant. CW #1 communicated her concerns regarding the Complainant’s self-cutting, consumption of Benadryl for anxiety, and recent unusual behaviour.
The social worker then spoke with WO #3 and indicated that she was not of the view that there were grounds to apprehend the Complainant under the Mental Health Act. The Complainant had denied wishing to hurt herself, had expressed no plans to do so, and was amenable to meeting with the social worker and her team the following day.
WO #3 conveyed the substance of his conversation with the social worker to WO #1 and WO #2; they all agreed that there was no basis to take the Complainant into custody to transport her to hospital for psychiatric examination. The officers spoke with CW #1 and CW #2 about the plan that had been put in place, namely, that the Complainant would spend the night with her parents and speak with the crisis team again in the morning. The Complainant wanted to return home to her place in Toronto but was persuaded to stay for the night. The officers then left the house. The time was about 5:50 p.m.
Some ten to 15 minutes later, the Complainant left the house telling her parents she was going for a walk. WO #3, who was still in his cruiser on the roadway writing his notes, noticed the Complainant and asked what she was up to. They went over the plan for the night again, after which the Complainant continued on her way.
At the Walmart nearby, the Complainant purchased a bottle of Windex and a knife. She walked through the parking lot and stopped at the end of the fence that bordered the shopping premises east of the Walmart building. Thereafter, with the knife held against her chest, she pushed her upper body into a fence pillar, collapsing thereafter.
The Complainant’s body was discovered by a man, who called 911 at about 7:45 p.m. Paramedics arrived on scene, followed shortly by PRP officers. The Complainant was declared deceased at 8:06 p.m.
Cause of DeathThe pathologist at autopsy attributed the Complainant’s death to a “[s]tab wound of chest”.
Section 219, Criminal Code -- Criminal negligence causing death
(a) in doing anything, or(b) in omitting to do anything that it is his duty to do,
Section 17, Mental Health Act -- Action by police officer
(a) has threatened or attempted or is threatening or attempting to cause bodily harm to himself or herself;(b) has behaved or is behaving violently towards another person or has caused or is causing another person to fear bodily harm from him or her; or(c) has shown or is showing a lack of competence to care for himself or herself,
(d) serious bodily harm to the person;(e) serious bodily harm to another person; or(f) serious physical impairment of the person,
Section 220, Criminal Code -- Criminal negligence causing death or bodily harm220 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
(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.
(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 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 predicated, 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 a more serious offence intended to capture behaviour that reveals a wanton or reckless disregard for the lives or safety of others. It requires conduct that is a substantial, as well as a marked, departure from a reasonable level of care, which causes the death in question. In the instant case, the issue boils down to whether the officers who attended at CW #1 and CW #2’s residence exercised a reasonable level of care in dealing with the situation before them. If not, were any failings associated with the Complainant’s death and/or sufficiently egregious as to attract criminal sanction. In my view, there are no reasonable grounds to believe the officers transgressed the limits of care prescribed by the criminal law.
WO #1, WO #2 and WO #3 were at all times lawfully placed inside CW #1 and CW #2’s home in furtherance of their duty to protect and preserve life. Though the CW #1 and CW #2 had asked for an ambulance, the police were asked to attend by the ambulance service as the call involved a person in mental health distress who was potentially suicidal and self-harming. There is no evidence that the officers were not wanted in the home by anyone.
Once in the home, I am satisfied that the officers comported themselves with due regard for the Complainant’s health and safety. In addition to WO #1 and WO #2, a COAST officer with specific experience and training in dealing with mental health calls – WO #3 – was dispatched. Though pandemic control measures prevented the personal attendance of the mental health professional who would otherwise have accompanied WO #3, arrangements were made to have the Complainant and a social worker speak over a video conference. On every occasion when probed by the officers and the social worker, the Complainant denied wanting to harm herself. The Complainant openly acknowledged her recent mental health struggles living under the pandemic, including her feelings of depression and anxiety. She explained her recent Benadryl consumption and cut marks, both of which had caused her parents much distress. The former was intended to help her sleep; had she wanted to harm herself, she would have taken more than she had. The latter, which were superficial in nature, was a coping mechanism she had adopted.  By the end of the social worker’s interventions, and having consulted with the Complainant and her parents, a course of action was agreed whereby the Complainant would remain at her parents’ home through the night and meet with a team of mental health professionals in the morning to revisit her condition and discuss next steps. Considered in context, I am unable to characterize any of this as manifestly imprudent.
With the benefit of hindsight, it is clear that the Complainant might well have benefitted from a visit to the hospital and further examination. It is, in fact, one of the chief complaints that she was not taken to hospital despite the family’s repeated requests.  However, police officers are not simply free to apprehend persons for involuntary admission to hospital in these cases short of lawful grounds for doing so under section 17 of the Mental Health Act. That provision provides that a police officer may only do so where, inter alia, there is reason to believe that the person is suffering from mental disorder that is likely to result in serious bodily harm to themselves or others. A mental health professional working with the police service’s COAST had assessed the Complainant and concluded there were no grounds to proceed with a Mental Health Act apprehension. Though the Complainant had expressed passive thoughts of suicide, it was noted that she had no specific plan, method or intention. The other officers, including WO #3, agreed with that assessment. On this record, I am unable to reasonably conclude that the officers were remiss in failing to take the Complainant into custody.
Nor are there reasonable grounds to believe that WO #3 committed a criminal offence when he briefly spoke with the Complainant as she left her parents’ home, shortly after the officers’ departure, and failed to intercede in any way. The officer was concerned about what the Complainant was up to as the plan was that she would remain in the house. However, she assured him that she was just going for a walk to clear her head and that her parents were okay with her doing so. Though it might be that WO #3 should have adopted a more proactive posture, perhaps by returning to the home to re-assess the situation with CW #1 and CW #2, I am not satisfied that any shortcomings along these lines, considered in context, amounted to a marked deviation from a reasonable level of care, much less a marked and substantial departure.
In the final analysis, while the Complainant’s death was doubtless a terrible tragedy, there is insufficient evidence to reasonably conclude that her self-inflicted chest wound and resulting death were attributable in any way to criminal conduct on the part of the police officers who had dealt with her on that day. Accordingly, there is no basis for proceeding with criminal charges.
Date: August 16, 2021
Electronically approved by
Special Investigations Unit
- 1) With respect to the cuts, it should be noted that the paramedics had examined the Complainant’s arms and were satisfied that they did not warrant medical attention. [Back to text]
- 2) There was some evidence that the family was told the police would not be bringing the Complainant to the hospital because of the “COVID-19 situation”. However, none of the officers indicated that the Complainant was kept from the hospital because of COVID-19; rather, it was their evidence that there were no grounds to compel her attendance at hospital. In the circumstances, I was unable to place much weight on the evidence in this regard, and certainly not to any extent that would tip the balance in the liability analysis. [Back to text]
- 3) In this regard, it should also be noted that PRP policy prevents officers from voluntarily transporting persons to hospital where there are no grounds for apprehension under the Mental Health Act. [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.