SIU Director’s Report - Case # 18-OCD-050
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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.
Freedom of Information and Protection of Personal 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.
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 44-year-old man (the Complainant) on February 21, 2018 following an interaction with police.
Notification of the SIUAt approximately 3:08 p.m. on February 21, 2018, the Halton Regional Police Service (HRPS) reported a custody injury sustained by the Complainant. At 6:00 p.m. on that same date, the HRPS reported that the Complainant had passed away from his injuries.
The TeamNumber of SIU Investigators assigned: 3
Number of SIU Forensic Investigators assigned: 1
The SIU Forensic Investigator responded to the scene and identified and preserved evidence. He documented the relevant scenes associated with the incident by way of notes and photography and later attended and recorded the post-mortem examination.
Complainant:44-year-old male deceased, medical records obtained and reviewed
Civilian WitnessesCW #1 Interviewed
CW #2 Interviewed
CW #3 Interviewed
Witness OfficersWO #1 Interviewed, notes received and reviewed
WO #2 Notes reviewed, interview deemed not necessary
WO #3 Interviewed, notes received and reviewed
WO #4 Interviewed, notes received and reviewed
WO #5 Interviewed, notes received and reviewed
WO #6 Notes reviewed, interview deemed not necessary
WO #7 Interviewed, notes received and reviewed
WO #8 Interviewed, notes received and reviewed
WO #9 Interviewed, notes received and reviewed
WO #10 Notes reviewed, interview deemed not necessary
Subject OfficersThe SO Interviewed, but declined to submit notes, as is the subject officer’s legal right.
On February 20, 2018, the Complainant worked the afternoon shift as a custodian at a public school in the City of Oakville. He started work at 7:00 p.m. but, by 9:30 p.m., Civilian Witness (CW) #1, another custodian at the school, could not locate him. CW #1 checked the school and the Complainant’s motor vehicle in the parking lot, but could not find him. CW #1 first contacted her supervisor and then, sometime before midnight, the security company responsible for the school. CW #3, who worked for the security company, attended at the school and located a trail of blood in and around the Complainant’s motor vehicle and contacted the HRPS.
At 12:36 a.m. on February 21, 2018, Witness Officer (WO) #1 arrived at the school. WO #9 and WO #4 also attended and followed a trail of blood which led from the Complainant’s pick-up truck, on the north parking lot, to a walkway on the south side of the school lot. The blood trail ended at a portable located on school property. WO #2 found a box cutter type knife inside the Complainant’s motor vehicle, along with several pools of blood. Additional police officers were called and WO #3 made call outs to the Complainant at the portable.
The HRPS confirmed that the Complainant had a registered firearms licence. WO #8 attended the Complainant’s residence to check on the well-being of his family and to ascertain whether the Complainant was present. WO #8 reported that the Complainant was not present, but had contacted his wife by way of telephone calls and text messages in a distressed and anxious state. The Complainant reportedly told his wife that he loved her and that he was sorry for any grief he had caused her. At 11:00 p.m., the telephone call had been dropped.
Police call outs were again made to the Complainant, without any response. The Tactical Response Unit (TRU), along with a canine (K-9) unit, and a negotiator, were requested and responded. The Subject Officer (SO), who was the Critical Incident Commander (CIC), arrived on scene at 1:04 a.m. The Complainant was seen, at times, through a window in the portable with a cut on his neck. Noises coming from inside the portable led police officers to believe that the Complainant had barricaded himself inside. Attempts to contact the Complainant by cellular telephone were unsuccessful. At 2:15 a.m., the TRU was able to gain entry to the portable, where they found the Complainant lying on the floor, unconscious but breathing. The Complainant was observed to have a cut to his neck and his right wrist. He was transported to the hospital by ambulance, where he was pronounced dead at 6:00 p.m. on February 21, 2018.
Cause of DeathA post mortem was conducted on February 23, 2018. During the post-mortem, the Complainant’s body was found to have a number of cuts to his veins which were determined to have been sufficient to have caused him to bleed to death. The preliminary cause of death was determined to be hypoxia due to lack of blood.
The SceneThe scene was located at a public school in the City of Oakville, both in the Complainant’s motor vehicle in the parking lot and in one of the portables on the school property. The presence of blood and the blades from a box cutter type knife in the Complainant’s motor vehicle appeared to indicate that the injuries had been inflicted inside the motor vehicle, prior to the Complainant barricading himself inside the portable, where he was later located by police and transported to the hospital.
Complainant’s motor vehicleAt 11:45 am on February 23, 2018, an SIU Forensic Investigator attended the yard where the Complainant’s motor vehicle had been towed after the incident and photographed the interior and exterior of the Complainant’s pick-up truck. A snap blade from a box cutter knife was located on the passenger floor area. The blade had a small blood stain on the sharp of the blade. It was photographed and collected. The interior of the truck was blood stained throughout. A blood swab from the staining was collected from the driver’s side rocker panel.
The blood-stained interior of the Complainant’s motor vehicle.
The box cutter blade located inside the motor vehicle with blood visible on the blade.
Forensic Evidence No submissions were made to the Centre of Forensic Sciences.
Post-Mortem Examination:At 11:15 am on February 23, 2018, the post-mortem of the body of the Complainant was performed by a Forensic Pathologist. As the Complainant’s organs had been harvested, the Pathologist concentrated on the areas of the self-inflicted wounds, which were on the Complainant’s neck and right wrist. The Pathologist was shown the blade that the deceased had allegedly used to inflict the wounds to his body. Under the direction of the Pathologist, the post-mortem was photographed. At the completion of the post-mortem examination, the Pathologist advised that the deceased had cut veins, and not arteries, as a result of which he would have bled to death.
Video/Audio/Photographic Evidence No video/audio recordings were located. The photos taken by the HRPS of the scene were received and reviewed.
Communications RecordingsFebruary 21, 2018
0031 hrs: A member of the security company responsible for the school called the HRPS and advised that he had found a pool of blood at a truck parked on the school property in the City of Oakville. The owner of the truck, the Complainant, was a custodian at the school and was missing;
0036 hrs: WO #1 was on scene and spoke to the member from the security company;
0040 hrs: Police officers were advised that the Complainant was CFRO positive (meaning he had a firearms licence);
0059 hrs: Police officers got a visual on the Complainant, through the window on the door of the portable located on school property. The sound of banging from inside the portable could be heard but there was no verbal response to the call outs made by police;
0059 hrs: A request was made to call out the TRU;
0130 hrs: The last sound of banging from inside the portable was heard;
0156 hrs: The TRU was on scene;
0213 hrs: WO #10 (the police negotiator) made 2 calls to the Complainant’s cellular telephone and in both cases the calls went to voice mail;
0217 hrs: The TRU entered the portable and facilitated getting the Complainant into an ambulance.
Materials obtained from Police ServiceUpon request, the SIU obtained and reviewed the following materials and documents from the HRPS:
- Police Radio Transmissions Recordings;
- Telephone Call Recording from Security Company to the HRPS;
- Event Details;
- Scene Photos;
- General Occurrence Report authored by WO #1;
- Computer Aided Dispatch (CAD) Event Details;
- List of Dispatched Officers;
- Notes of WO #s 1-10;
- Witness Statement from CW #3;
- Policy: Tactical Rescue Unit;
- Policy Directive: Hostage Taking/Barricaded Persons;
- Policy Directive: Use Of Force;
- Shift Activity Report;
- Supplementary Occurrence Reports (x6); and,
- Notes of WO #3.
The SIU obtained and reviewed the following materials and documents from other sources:
- Critical Incident Report from the Security Company;
- Ambulance Call Report; and,
- Medical Records of the Complainant related to this incident.
Section 219 and 220, Criminal Code -- Criminal negligence causing death
(a) in doing anything, or(b) in omitting to do anything that it is his duty to do,
(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
The Complainant was a recovering alcoholic who was apparently dealing with some issues causing him anxiety and guilt. On February 20, 2018, the Complainant started a new job as a custodian at a public school in the City of Oakville. The Complainant began his shift at 7:00 p.m. Civilian Witness (CW) #1, another custodian at the school, last saw the Complainant at 9:00 p.m., when she told him that she had cleaned and locked one of the school portables and that he would be responsible for cleaning the other three.
At 9:30 p.m., CW #1 could not locate the Complainant and, when she still had not seen him by 11:15 p.m., she began to look for him. CW #1 solicited the help of some contractors, who were at the school, to attempt to locate the Complainant, and they searched the three portables that he had been assigned to clean, but could not find him. CW #1 noted, however, that the Complainant’s pick-up truck was still in the parking lot, as a result of which she contacted her supervisor and reported that the Complainant was missing. CW #1 then called the security company responsible for the school, who dispatched CW #3 to the school to assist in looking for the Complainant.
Over the course of the evening, the Complainant had been texting and speaking to his wife, CW #2, on his cell phone. Initially, in speaking to the Complainant, everything seemed to be fine. At approximately 10:20 p.m., however, the Complainant texted his wife and told her that he was sorry and that he loved them all. When CW #2 asked her husband what was going on and why he was sorry, he began to cry and told her that he had ruined everything and that he was scared. CW #2, who was aware that her husband suffered from anxiety arising out of some incidents in his past, told him that if he was afraid, he should come home.
Shortly after 11:00 p.m., when CW #2 was speaking with her husband, and she asked him what he was doing, he told her that he was walking. She continued to hear his footsteps, but he stopped speaking with her and finally terminated the call. When she then texted him and again told him to finish work and come home, he did not respond.
At approximately 12:15 a.m. on February 21, 2018, CW #3 arrived at the school and spoke to CW #1, who advised him that the Complainant had arrived at the school in a pick-up truck that was parked in the parking lot. CW #3 then attended at the truck, where, with the assistance of his flashlight, he discovered a thin stream of blood leading away from the truck, and a pool of blood on the rocker panel side step. Upon looking inside the truck, CW #3 also observed blood on the driver seat and the steering wheel of the vehicle. CW #3 then followed a blood trail from the truck, which appeared to be leading toward the rear of the school where the portables were located, for about 75 feet. CW #3 first contacted his dispatcher to ask them to contact police, and then he placed a call to the Halton Regional Police Service (HRPS) himself, which was received at 12:31 a.m., in which he requested police assistance and told them what he had seen.
Within five minutes of CW #3’s call, Witness Officer (WO) #1 arrived at the school and spoke to CW #3. Shortly after his arrival, WO #2 arrived and both officers viewed the Complainant’s pick-up truck, taped off the area around the truck, and requested that a K-9 unit attend to assist in locating the Complainant. Moments later, WO #9 and WO #4 also arrived at the school and the Complainant’s motor vehicle was queried on the police computer and revealed that the Complainant was licenced to possess firearms. WO #9 then drove around the school, and he and WO #4 walked an asphalt walkway in the area of the portables, where they observed a trail of blood leading to portable #4. Upon arrival at the portable, the officers observed blood splattered on the walls and the steps to the portable, with one set of boot prints visible at the doorway.
At approximately 12:50 a.m., WO #3 arrived at the portable, followed by two undesignated police officers, who attempted to communicate with the Complainant using both verbal commands and a public announcement system. Loud banging could be heard from inside the portable, causing the officers to surmise that they were dealing with a barricaded person. The officers called out to the Complainant, from outside of the portable, advising him that they were the police and were there to help and that he should come out. The Complainant was seen at the door with blood on his face and neck, but did not exit or respond. As a result of observing the Complainant’s injuries, officers were aware that there was a real possibility that the Complainant was armed with a knife and that they had to proceed with caution.
At approximately 1:10 a.m., the TRU supervisor, WO #7, was notified to attend the school for a barricaded person inside a school portable. The decision was made to deploy the unit’s Armored Rescue Vehicle (ARV), along with a group of TRU members who would act as an Immediate Action (IA) team. The IA team consisted of five TRU members.
At approximately 1:15 a.m., the on-call duty officer, who was also the on-call Critical Incident Commander (CIC), the Subject Officer (SO), was notified at his home of an ongoing barricaded person call at the school and he was provided the details gathered to that point, including that the Complainant was in a school portable and refused to come out, that he was injured and hostile, that blood had been located outside of the portable, and that negotiators and the TRU team had already been dispatched to the school.
The SO then directed that uniformed officers attend at the Complainant’s residence in the City of Burlington, and an undesignated sergeant and WO #8 were dispatched at 1:22 a.m. Upon their arrival, WO #8 took photographs of the text messages received by CW #2 and determined that the Complainant had a firearm licence, which she communicated to the dispatcher, who in turn forwarded that information to the officers at the school. WO #8 later returned to the residence and viewed the location of the Complainant’s gun locker. After again speaking with CW #2, who was of the view that the Complainant had not accessed the locker and that no firearms had been disturbed, that information was also forwarded to the officers at the school.
The SO made the decision that the ARV would move the IA team towards the portable and take over containment. Because the ARV weighed 17,000 pounds, it was decided that it would remain on the concrete walkway, so as not to get stuck in the wet ground around the portable, and the IA team would proceed on foot. A tactical paramedic was requested to attend.
The SO arrived at the school at 1:43 a.m. and was advised of the information gathered at the Complainant’s residence by WO #8, including the content of the text messages and that the Complainant was not likely in possession of a firearm. Present at the school at that time were the Operational Tactical Sergeant, WO #7, the Tactical Liaison Sergeant, (not designated), an officer acting in a logistics role (not designated), and an officer who was running the containment aspect of the incident, WO #3, in addition to approximately 25 uniformed officers. Information available at that time was that uniformed officers had made call outs to the Complainant, without response, and that an injury had been observed to the Complainant’s neck.
After 1:44 a.m., there were no further sightings of the Complainant and no further sounds came from the portable.
Based on the information in his possession at that time, the SO determined that this was a situation of a person in crisis and that the Complainant was alone in the portable and no criminal offence was being committed.
At 1:57 a.m., the TRU team and the tactical paramedic arrived on scene, and shortly thereafter, the IA team, along with the tactical paramedic, proceeded toward the portable. At 2:13 a.m., the police negotiator, WO #10, advised that calls made to the Complainant’s cell phone were going directly to voice mail and no further sounds were being heard from inside the portable.
At that point, the SO determined that the need to assess the injuries to the Complainant, and to provide him with medical attention, outweighed the risk to officers of a possible use of force encounter with the Complainant, and at approximately 2:15 a.m., the SO directed the sergeant to have the TRU conduct a breach and hold of the portable, which was the least intrusive of the tactical techniques available. WO #7 and his team were given authority by the SO, via the sergeant, to enter the portable. A key was provided to the portable and the officers entered, with the first officer in, WO #5, observing the Complainant lying on the ground with nothing in his hands. WO #5 then advised the rest of the team, all of whom then entered and observed the Complainant lying on the floor with a large amount of blood around him.
Upon entry, WO #7 described the Complainant as breathing, but his breathing was labored and appeared agonal , with his eyes open but unresponsive. The Complainant’s clothing was cut off by the tactical team in order to assist the tactical paramedic to assess his injuries. At that time, a three to four inch laceration on the right forearm and a laceration to the neck of the Complainant was located and the Complainant was removed and transported to hospital by ambulance.
The Complainant’s medical records reveal that he arrived at a Hamilton hospital at 3:10 a.m. with penetrating stab wounds to his right neck and right wrist with a 1.5 cm laceration to his right neck and an approximate five cm vertical laceration at the site of the radial artery of his right wrist. As a result of the extreme blood loss from his injuries, it was determined that he had suffered an ischemic stroke , leading to loss of oxygen to the brain and an Anoxic Brain Injury  and then brain death. From a review of the extensive medical records, it appears that at no time did the Complainant regain consciousness and, following a family meeting, it was agreed that his organs would be donated to assist others in need.
This version of events is not in dispute, having been verified and confirmed by the three civilian and seven police witnesses interviewed, as well as the evidence of the SO, the police transmissions communications recordings, the text messages authored by the Complainant, and the Complainant’s medical records.
It is clear, on a review of all of the evidence, that on February 20, 2018, the Complainant found himself in a personal crisis and decided to take his own life. It is apparent from the text messages that the Complainant sent to his wife, as well as the final telephone call, that the Complainant was anxious and upset and was using the opportunity to say his good byes and express his remorse and love to his wife and family. It is further clear, based on the amount of blood in and around the Complainant’s motor vehicle, the presence of the box cutter blades, which had apparently been used to slash his neck and throat, in the truck, and the absence of any weapon or sharp edged object in the portable, that the Complainant had already caused the fatal injuries to himself prior to the police ever even having been made aware that he was missing and possibly in crisis.
Since the Complainant had not been seen by CW #1 since 9:30 p.m. that evening; CW #2 had not spoken to her husband since 11:00 p.m., at which time it appeared that he was already walking toward the portable where he eventually barricaded himself; and that CW #3 observed the blood in the pick-up truck at 12:15 a.m., it is difficult to determine exactly when the Complainant inflicted the fatal injuries, but there is no question that it was some time, and possibly a significant amount of time, before the police were notified. Furthermore, from the fact that the Complainant did not openly tell his wife that it was his intention to end his life; that he locked himself into portable #4, the one portable that CW #1 had advised him she had already cleaned and locked for the night; and, that upon police arrival at the portable, loud banging sounds were heard coming from inside the portable, which police surmised was the Complainant barricading himself inside, it appears clear that the Complainant, after inflicting his injuries, did not wish to be found prior to such time as his injuries progressed to the point of maximum damage and ultimately death.
On all of the evidence, it appears that the Complainant was struggling due to some incidents from his past which he was apparently unable to come to terms with, resulting in his decision to end his life. While it is unclear what exactly pushed the Complainant to the point where he resorted to the fatal actions which he did, it is clear that the senior officers tasked with attempting to save the life of the Complainant, once they became aware of his intention, and the officers under them, did all that they could to try to save his life.
On all of the evidence, it is evident that the Complainant took his own life without any intervention by police. It is also clear that while the Complainant inflicted the injuries which would eventually end his life long before police were notified that there was even a problem, as soon as the HRPS received the call from CW #3 at 12:31 am, they immediately sprang into action, with officers attending at the school within five minutes of the call. Thereafter, while it was unclear as to what had occurred and why there was the amount of blood found in and around the truck, police had to move cautiously until they could determine if this was a criminal act or an act of self-harm. However, as soon as WO #8 observed the text messages from the Complainant to his wife, and was able to confirm that he was not in possession of a firearm, she relayed that information to officers at the scene, and the SO almost immediately made the decision that the need to assess and assist the Complainant outweighed any possible risk to the responding officers which could result from a possible interaction with the Complainant.
I note that the SO, who arrived at the school at 1:43 a.m., had already made the decision to deploy the TRU team to breach and hold the portable by 2:13 a.m., only 30 minutes after his arrival, whereupon both police officers and the tactical paramedic entered the portable. While the response by the HRPS was quick and efficient, the Complainant had unfortunately thwarted their efforts and eventually succumbed to his injuries. Although police could have possibly entered the portable some minutes earlier, it is clear that until it could be determined that the Complainant was not armed and not a danger to the officers, it would have been foolish to do so at the risk of loss of life to all involved.
The only criminal charge open for consideration on these facts would be one of criminal negligence causing death contrary to sections 219 and 220 of the Criminal Code. There are numerous decisions of the higher courts defining the requirements to prove an offence of criminal negligence; while most relate to offences involving driving, the courts have made it clear that the same principles apply to other behaviour as well.
In order to find reasonable grounds to believe that the SO, or any officer who responded to the school in the early morning hours of February 21, 2018, committed the offence of criminal negligence causing death, one must first have reasonable grounds to believe that they omitted to carry out their legal duty to the Complainant, and that omission, pursuant to the decision of the Supreme Court of Canada in R. v J.F. (2008), 3 S.C.R. 215, represented ‘a marked and substantial departure from the conduct of a reasonably prudent person in circumstances’ where the officers ‘either recognized and ran an obvious and serious risk to the life’ of the Complainant ‘or, alternatively, gave no thought to that risk’.
Having considered all of the evidence, there is no doubt that the officers tasked with attempting to prevent the loss of the Complainant’s life followed all necessary procedures to prevent that loss of life, while proceeding with caution in order to preserve their own. Even had they acted less prudently and more quickly, it appears unlikely on the evidence that they would have been able to save the life of the Complainant, as he had already inflicted the fatal injuries prior to the police ever being notified. As such, the police officers, who responded to this crisis as quickly as they were able, cannot be held responsible for the Complainant’s actions in fulfilling his intention to end his own life. I am satisfied on all of the evidence that the SO, and the officers under him, exercised a level of care in their dealings with the Complainant that fell well within the limits prescribed by the criminal law. On these facts, I find that there are no reasonable grounds for the laying of criminal charges and none will issue.
Date: December 20, 2018
Special Investigations Unit
- 1) Agonal breathing refers to a shallow breathing pattern that is often related to cardiac arrest and death (https://medical-dictionary.thefreedictionary.com/Agonal+breathing.) [Back to text]
- 2) An ischemic stroke occurs as a result of insufficient blood to the brain (www.strokeassociation.org/STROKEORG/AboutStroke/typesofStroke). [Back to text]
- 3) Anoxic brain injury occurs when the brain is deprived of oxygen, causing brain cells to die. When a large number of brain cells simultaneously die, patients can be left with diminished brain function. If the oxygen deprivation continues, anoxic brain injuries may be fatal. (www.spinalcord.com/anoxic-brain-injury). [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.