SIU Director’s Report - Case # 21-OCD-104
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Mandate of the SIU
Under the SIU Act, the Director of the SIU must determine based on the evidence gathered in an investigation whether there are reasonable grounds to believe that a criminal offence was committed. If such grounds exist, the Director has the authority to lay a criminal charge against the official. Alternatively, in cases where no reasonable grounds exist, the Director cannot lay charges. Where no charges are laid, a report of the investigation is prepared and released publicly, except in the case of reports dealing with allegations of sexual assault, in which case the SIU Director may consult with the affected person and exercise a discretion to not publicly release the report having regard to the affected person’s privacy interests.
Special Investigations Unit Act, 2019Pursuant to section 34, certain information may not be included in this report. This information may include, but is not limited to, the following:
- The name of, and any information identifying, a subject official, witness official, civilian witness or affected person.
- Information that may result in the identity of a person who reported that they were sexually assaulted being revealed in connection with the sexual assault.
- Information that, in the opinion of the SIU Director, could lead to a risk of serious harm to a person.
- Information that discloses investigative techniques or procedures.
- Information, the release of which is prohibited or restricted by law.
- Information in which a person’s privacy interest in not having the information published clearly outweighs the public interest in having the information published.
Freedom of Information and Protection of Privacy ActPursuant to section14 (i.e., law enforcement), certain information may not be included in this report. This information may include, but is not limited to, the following:
- Confidential investigative techniques and procedures used by law enforcement agencies; and
- Information that could reasonably be expected to interfere with a law enforcement matter or an investigation undertaken with a view to a law enforcement proceeding.
- The names of persons, including civilian witnesses, and subject and witness officials;
- Location information;
- Witness statements and evidence gathered in the course of the investigation provided to the SIU in confidence; and
- Other identifiers which are likely to reveal personal information about individuals involved in the investigation.
Personal Health Information Protection Act, 2004Pursuant to this legislation, any information related to the personal health of identifiable individuals is not included.
Other proceedings, processes, and investigationsInformation may also have been excluded from this report because its release could undermine the integrity of other proceedings involving the same incident, such as criminal proceedings, coroner’s inquests, other public proceedings and/or other law enforcement investigations.
A person sustains a “serious injury” for purposes of the SIU’s jurisdiction if they: sustain an injury as a result of which they are admitted to hospital; suffer a fracture to the skull, or to a limb, rib or vertebra; suffer burns to a significant proportion of their body; lose any portion of their body; or, as a result of an injury, experience a loss of vision or hearing.
In addition, a “serious injury” means any other injury sustained by a person that is likely to interfere with the person’s health or comfort and is not transient or trifling in nature.
This report relates to the SIU’s investigation into the death of a 16-year-old male (the “Complainant”).
Notification of the SIUOn April 4, 2021, at 1:40 p.m., the Timmins Police Service (TPS) notified the SIU of the following.
Earlier that day, at 12:42 a.m., the Subject Official (SO) and Witness Official (WO) #1 were dispatched to a residence for a medical assist call. The Complainant was alone in his bedroom, yelling and throwing items. The SO and WO #1 encountered Primary Care Paramedics - Civilian Witness (CW) #2 and CW #3 - at the residence, and saw the Complainant being held down on the ground by his father, CW #1. The Complainant continued to yell and was unable to calm down when CW #1 asked what happened.
The Complainant was restrained by the officers in an attempt to allow the paramedics to medically assess him. The paramedics brought the stair chair upstairs to transport him to the ambulance. The Complainant said he consumed, “Blue juice.”  Due to the Complainant’s condition and level of agitation, the paramedics were unable to transport him to hospital. The Complainant was lifted, placed in the rear of the SO’s police vehicle, and transported to the Timmins and District Hospital (TDH).
While in the area of Ross Avenue and Pine Street, the Complainant began to breathe slowly. Upon arrival at TDH, the SO saw the Complainant was not breathing in the back of his police vehicle.
The Complainant was transferred into the care of medical staff, where resuscitation efforts were commenced and he regained a pulse. The Complainant was transferred to the Intensive Care Unit (ICU).
The SIU was subsequently advised by CW #1 that the Complainant was brain dead. The Complainant was pronounced deceased on April 5, 2021.
The TeamDate and time team dispatched: 04/06/2021 at 8:00 a.m.
Date and time SIU arrived on scene: 04/06/2021 at 12:00 p.m.
Number of SIU Investigators assigned: 4
Number of SIU Forensic Investigators assigned: 1
Affected Person (aka “Complainant”):16-year-old male, deceased
Civilian Witnesses (CW) CW #1 Interviewed
CW #2 Interviewed
CW #3 Interviewed
CW #4 Interviewed
CW #5 Interviewed
CW #6 Interviewed
CW #7 Interviewed
The civilian witnesses were interviewed between April 6, 2021, and May 4, 2021.
Subject Official (SO) SO Interviewed, and notes received and reviewed
The subject official was interviewed on July 13, 2021.
Witness Officials (WO) WO #1 Interviewed
WO #2 Interviewed
WO #3 Interviewed
The witness officials were interviewed between April 21, 2021, and May 14, 2021.
The investigation was delayed to an extent by the need to await the arrival of the Report of Postmortem Examination, which was provided to the SIU on April 29, 2022.
The HomeOn April 28, 2021, SIU investigators were dispatched to examine and photograph a single-family residential house in Timmins. The interior of the residence was an open concept living room and kitchen area. The stairs leading to the second floor were situated in the corner of the open space.
The Complainant’s bedroom was located on the left, at the top of the stairs. His room consisted of a double-bed, chairs, desk, and small shelf with a large flat screen television at the end of the bed.
Photographs of the residence were taken.
The SO’s CruiserThe SO was operating a fully marked Dodge Charger. The front bucket seats were adjustable. There was a stationary partition separating the front and rear compartments. The rear two seats consisted of a solid molded bench. The front seat to the rear footwell partition was found to be 23 cm. From the centre of the rear area to each door was found to be 58.5 cm.
Postmortem and Toxicology EvidenceOn April 7, 2021, the post-mortem examination of the Complainant was performed in Sudbury. The pathologist found multiple abrasions, contusions, and superficial lacerations all over his body, and handcuff imprints on both wrists, with hemorrhage of underlying soft tissues. These injuries were not fatal, nor did they contribute to the death.
Biological samples from the Complainant were submitted to the Toxicology Section for analysis. The results of that analysis are reported below.
On April 29, 2022, the SIU received a copy of the Toxicology Report, with the following results:
The report’s author noted that LSD is a physiologically safe drug with no reports of fatal poisonings at recreational doses and that deaths associated with LSD are typically due to injuries acquired while intoxicated by LSD. It was further noted that the Centre of Forensic Sciences laboratory did not have a method for the quantitation of LSD.
Toxicology Letter of Opinion
The toxicologist’s letter of opinion is reproduced below.
Global Positioning System (GPS) Data from TPS cruiserThe SIU reviewed the GPS data from the SO’s police vehicle and determined that the SO stopped and waited for two red lights to cycle through and change to green. The total distance from the Complainant’s residence to TDH was about 3.7 km. The average speed of the cruiser was about 44 km/h and the maximum speed was 80 km/h.
Video/Audio/Photographic Evidence 
Communications RecordingsOn April 19, 2021, the SIU received relevant communications recordings from the TPS. A summary of the material information therein follows.
On April 4, 2021, at 12:41:10 a.m., CW #4 called 911 and was connected to the ambulance stream. She reported that her brother was freaking out and acting erratically. She speculated he might be suffering a seizure. CW #4 told the dispatcher that her father was holding the Complainant down on the floor and that his behaviour was uncharacteristic of him. The Complainant could be heard screaming in the background.
CW #4 told the dispatcher that the Complainant was known to smoke marijuana. She learned from CW #5 that the Complainant may be overdosing on “acid”. The 911 call-taker advised CW #4 that TPS officers were also responding.
CW #4 told the dispatcher that the Complainant was no longer controlled by CW #1 and had begun to froth at the mouth. The dispatcher advised the ambulance would soon be arriving.
At 12:48:01 a.m., CW #4 concluded the call when the ambulance arrived on scene.
TPS Radio Communications
The following is a summary of the material information from the communications dispatcher. The transmissions were not time stamped and the dispatcher did not provide times.
The SO to Dispatch: I’m [police code], on my way.
Dispatch: The address is [redacted]. A 16 year old male, possibly [the Complainant], is having an episode, apparently on acid.
Dispatch: EMS (Emergency Medical Services) also attending.
WO #1 to Dispatch: What is the status of [the Complainant]?
Dispatch: He is [police code].
SO to Dispatch: Mark us both at the scene. EMS is also here.
WO #1 to Dispatch: We have to take him to TDH.
Dispatch: Do you need another unit there?
WO #1 to Dispatch: Should be good for now.
Dispatch: Everything okay there?
WO #1 to Dispatch: Standby. [Commotion could be heard in the background.]
SO to Dispatch: [The Complainant] is having a bad trip right now. He’s on board going to TDH. Mileage is 125086. Call TDH and let them know we will need four points. The ambulance will follow in case they are needed. [Moaning could be heard in the background.]
Dispatch: Dispatch called TDH advising 16-year-old male en route experiencing a bad “acid” trip. He was too agitated to go by ambulance. An ambulance was following and a request for four point restraints was made.
TDH to Dispatch: What is your ETA?
Dispatch to TDH: Probably about four minutes or so. They are coming from [name of street].
WO #1: Add [CW #1], the father as a witness.
SO: At TDH. Mileage is 125090.
EMS Phone and Radio Communications12:42:06 a.m.: A ambulance unit was dispatched - “Code 4” - to the Complainant’s residence.
12:43:19 a.m.: Unit acknowledged the call for service.
12:43:25 a.m.: Unit was mobile.
12:43:30 a.m.: The dispatcher advised unit that the call involved a 16-year-old male who might be overdosing on “acid”. Police were also responding.
12:48:01 a.m.: Unit arrived on scene.
1:01:35 a.m.: Unit left the residence. CW #3 advised that the Complainant was in police custody and that they did not provide any patient care.
1:01:51 a.m.: CW #3 advised they would follow police to TDH in case they were needed.
1:02:02 a.m.: The dispatcher acknowledged and cancelled the call at [the residence].
1:02:16 a.m.: CW #3 requested that TDH be notified of a combative and uncooperative patient en route.
1:06:17 a.m.: CW #3 advised he had arrived at TDH.
1:16:01 a.m.: CW #3 called dispatch to advise the Complainant arrived at TDH VSA [vital signs absent].
1:19:04 a.m.: CW #2 called dispatch requesting times for the call. During the call, she said, “We really didn’t do anything.”
In-car Camera System (ICCS) Footage—The SO’s Police Vehicle On April 13, 2021, the SIU received a copy of the ICCS footage from the SO’s police vehicle. There were four camera views available for review, one within each folder labelled Stream 0 (front view 1), Stream 1 (front view 2), Stream 2 (wide angle front view), and Stream 3 (rear seat view). All the camera views provided the date, time, and GPS coordinates at the top centre of the screen and the speed, information text, and fleet number at the bottom of the screen. A Ministry of Finance Technical Officer determined there was no recoverable or recorded audio before minute 15 or after the present audio within the video. A summary of Cameras 1 and 3, which captured the most salient information, follows.
Camera 1, Video 1
This camera was mounted on the dash of the police vehicle, and captured a view of the front of the police vehicle. The available footage went from 12:46:56 a.m. until 1:17:35 a.m. on April 4, 2021. There was no sound recorded for the first two minutes of the five-minute and 30-second journey from the Complainant’s residence to TDH. The emergency lights and siren were not activated.
12:46:56 to 12:47:50 a.m.: The police vehicle caught up to and followed an ambulance through residential streets in Timmins to the Complainant’s residence, where both police vehicles and the ambulance parked on the street.
12:47:55 a.m.: Two male uniformed police officers [now known to be the SO and WO #1] appeared in front of the police vehicle. Two females [now known to be CW #2 and CW #6] and one male [now known to be CW #3], uniformed paramedics, emerged from the ambulance, which was parked in front of the police vehicle.
12:48:36 a.m.: The SO, WO #1, CW #3, CW #2 and CW #6 went out of camera view. [It is believed they entered the residence.]
12:53:59 a.m.: CW #3 and CW #6 returned to the ambulance. CW #6 returned equipment to the rear of the ambulance and CW #3 retrieved a stair chair from the passenger side door. They both returned to the residence.
12:56:09 a.m.: The SO and WO #1, as well as CW #3, CW #2 and CW #6, emerged from the residence. The SO and WO #1 were each holding onto the Complainant’s arms as he was dragged headfirst with his feet behind him towards the police vehicle. The Complainant was placed face down on the sidewalk, near the side of the street. The SO and WO #1 were holding him down.
12:56:48 a.m.: CW #2 entered the police vehicle via the driver’s door.
12:57:05 a.m.: CW #3 walked in front of the police vehicle and out of camera view. CW #1 emerged from the residence and kneeled beside the Complainant who was still face down on the sidewalk and in the custody of the SO and WO #1. The Complainant was handcuffed with his hands behind his back.
12:57:17 a.m.: CW #5 exited the residence and appeared to be watching the Complainant.
12:57:23 a.m.: The SO left the Complainant and went to the driver’s door of his police vehicle. His police vehicle was moved forward, closer to the rear of the parked ambulance, and closer to the Complainant’s position on the sidewalk.
12:58:08 a.m.: The parked ambulance moved forward, away from the front of the police vehicle.
12:58:20 a.m.: The police vehicle was driven forward to the space vacated by the ambulance and stopped at the location of the Complainant and WO #1.
12:58:50 to 1:00:48 a.m.: CW #3 entered the rear driver side door of the police vehicle and assisted the SO and WO #1 in loading the Complainant into the rear compartment via the rear passenger side door. The SO and WO #1 pushed the Complainant’s legs while CW #3 pulled the Complainant by his shoulders. The Complainant was handcuffed with his hands behind his back and placed on the rear seat. The paramedics returned to the ambulance.
1:01:05 a.m.: Both the police vehicle and the ambulance left the front of the residence. The SO was in the driver’s seat with the Complainant in the rear seat, unaccompanied by either WO #1 or any paramedics.
1:01:05 to 1:02:58 a.m.: The police vehicle passed the ambulance. No emergency lights or siren was activated, and the audio component was not activated. The SO travelled through streets of Timmins.
1:02:59 a.m.: The audio component of the ICCS was activated. The audio captured moaning sounds emanating from the rear seat. The SO said, “It’s okay, [name of Complainant]. You’re okay, okay?”
1:03:03 a.m.: The SO said, “It’s okay my man, you’re good.” Faint moaning was heard emanating from the rear compartment. At this point, there was no apparent sound emanating from the rear compartment.
1:03:35 a.m.: The SO said, “You okay, [name of Complainant]?” There was no response.
1:03:40 a.m.: There was no kicking or moaning sounds heard from the rear compartment.
1:03:49 a.m.: The SO said, “[name of Complainant], you good?” There was no response. The police vehicle was traveling at speed.
1:03:50 a.m.: There was no apparent sound from the rear compartment.
1:04:11 a.m.: The SO said, “Hey, [name of Complainant]!” There was no response. The police vehicle stopped at a red traffic light, then made a left turn.
1:04:48 a.m.: The police vehicle came to a complete stop.
1:05:07 a.m.: The police vehicle was mobile again. Speeds were up above the posted speed limit.
1:06:01 a.m.: The SO arrived at TDH.
1:06:34 a.m.: The SO parked in the ambulance bay at TDH.
1:06:44 a.m.: The SO remotely unlocked the rear doors of the police vehicle. The SO said, “[Name of Complainant], how you doing back there?” There was no response.
1:06:47 a.m.: CW #2 said, “Did he calm down a little bit?” The SO responded, “Yeah.” The remaining communications were unintelligible.
1:07:01 to 1:08:45 a.m.: CW #2 and the SO engaged in conversation. WO #1 and CW #3 might also have been involved. Parts of the conversation were unintelligible:
CW #2 said, “Guys, guys! He’s VSA!”
“Yes, bring the stretcher in here. He’s VSA.”
“We’ve got to get him out of here, get him out.”
“Watch his head. Watch his head.”
“He’s VSA. Get a bag.”
1:08:45 a.m.: The voices faded and those involved appeared to move away from the police vehicle.
1:08:47 a.m.: The police vehicle was locked remotely.
1:09:45 a.m.: The SO and WO #1 returned to an area where the audio component in the vehicle captured their conversation, which was difficult to discern.
1:13:10 a.m.: There was conversation between a male and female. The content of that conversation could not be discerned.
1:16:20 a.m.: A female voice was heard but it was unclear what was said.
1:17:35 a.m.: The audio component captured a discussion between two males, which was difficult to discern. At this time, the audio component of the ICCS was deactivated.
Camera 3, Video 1
This camera had a view of the rear seat of the police vehicle. The available footage went from 12:46:59 a.m. until 1:19:15 a.m. on April 4, 2021. There was no sound captured for the first two minutes of the five-minute and 30-second journey from the Complainant’s residence to TDH. The emergency lights and siren were not activated.
12:46:59 to 12:49:45 a.m.: There were no images or sounds captured by this camera during this period. It appeared the police vehicle was mobile, likely traveling from TPS to the Complainant’s residence.
12:49:45 a.m.: There were no images or sounds captured by this camera. The police vehicle appeared to stop, likely in front of the Complainant’s residence.
12:49:45 to 12:57:40 a.m.: There were no images or sounds captured by this camera. The police vehicle appeared to be parked and unoccupied during this period.
12:57:40 a.m.: The rear passenger door of the police vehicle was opened by a uniformed police officer, believed to be WO #1.
12:58:15 a.m.: The rear passenger side door was closed.
12:58:32 a.m.: The rear passenger side door was re-opened.
12:58:43 a.m.: There were three males struggling at the entrance of the rear passenger side door. The head of the Complainant was visible. It appeared that the Complainant was being held by males who were out of camera view. [These males are believed to be the SO and WO #1].
12:58:54 a.m.: The rear driver side door was opened, and CW #3 entered the rear seat of the police vehicle. He appeared to be positioned to assist in the loading of the Complainant into the rear seat from the rear passenger side door.
12:59:30 a.m.: The Complainant was pushed through the rear passenger side door partially onto the rear seat of the police vehicle.
1:00:11 a.m.: CW #3 completed the loading of the Complainant into the rear seat of the police vehicle by grabbing him under the armpits and pulling him onto the seat.
1:00:41 a.m.: The Complainant appeared to be too tall to fit comfortably in the rear seat. With his legs bent at 90 degrees against the rear passenger side door, after some effort, the door was finally closed. The Complainant was wearing long pants and a long-sleeved top. He was not wearing any socks or shoes.
1:00:57 a.m.: The Complainant was moving around on the rear seat. He appeared to slide off the seat with his upper body between the seat and the partition that separated the front and rear compartments. He was kicking his feet frantically and his pants had slid down to his knees. The patrol vehicle was stationary in front of the residence.
1:01:07 a.m.: The police vehicle appeared to be mobile.
1:01:18 a.m.: The upper body of the Complainant remained off the rear seat between the seat and partition. Both of his legs were kicking violently and frantically. The police vehicle was traveling at the posted speed limit with no emergency lights or siren activated. There was no audio on the recording.
1:01:19 to 1:02:46 a.m.: The Complainant continued to kick his legs frantically. The patrol vehicle continued to travel at the posted speed with no emergency lights or siren activated. There was no audio on the recording.
1:02:46 a.m.: The Complainant’s kicking had slowed noticeably and did not appear to be as frantic or violent.
1:02:59 a.m.: The audio recording portion of the ICCS was activated. The Complainant was not as active and was moaning. The SO said, “It’s okay [name of Complainant]. You’re okay, okay?”
1:03:03 a.m.: The Complainant’s moaning was faint, and the kicking motion of his feet was sporadic and not nearly as violent. The SO said, “It’s okay my man. You’re good.”
1:03:35 a.m.: The Complainant was silent and barely moving. The SO said, “You okay, [name of Complainant]?”
1:03:40 a.m.: The Complainant was motionless and there was no apparent sound.
1:03:49 a.m.: The SO said, “[Name of Complainant], you good?”
1:04:11 a.m.: The SO said, “Hey [name of Complainant].”
1:04:48 a.m.: The police vehicle slowed and came to a stop.
1:06:01 a.m.: The SO advised the dispatcher that he had arrived at TDH.
1:06:34 a.m.: The police vehicle was parked in the ambulance bay at TDH.
1:06:41 a.m.: The SO exited the police vehicle.
1:06:44 a.m.: The SO said, “[Name of Complainant], how are you doing back there?”
1:06:47 a.m.: CW #2 said, “Did he calm down a little bit for you?” The SO responded, “Yeah,” but the rest of his response was unintelligible.
1:06:52 a.m.: The rear driver side door of the police vehicle was opened.
1:07:01 a.m.: CW #2 was visible at the rear driver side door. She said, “Guys, guys! He’s VSA!”
1:07:04 a.m.: CW #2 said, “Bring a stretcher here! He’s VSA.” She was still visible at the rear driver side door.
1:07:08 a.m.: The rear passenger side door was opened. CW #2 said, “Hey guys! We got to get him out of here!”
1:07:09 a.m.: The Complainant was being pulled from the rear seat headfirst through the rear driver side door. It appeared that a few people were involved. CW #2 said, “Get him out! Get him out!”
1:07:13 a.m.: The Complainant was pulled from the rear seat and placed on the floor beside the police vehicle. He was placed on his back with his head facing the rear of the police vehicle. CW #2 said, “Watch his head.”
1:07:16 a.m.: CW #2 said, “Watch his head.”
1:07:23 a.m.: The Complainant was on his back and it appeared that one of the paramedics was performing chest compressions. CW #2 said, “This is fresh. Get a bag! Get a bag!” There was hollering that was unintelligible.
1:07:44 a.m.: The rear driver side door was closed. Someone said, “Fuck!” There were voices in the background; however, the conversation was unintelligible.
1:08:00 a.m.: CW #2 said, “Get him on the stretcher!” The voices appeared to fade.
1:08:07 a.m.: CW #2 said, “Get him on the stretcher, guys!”
1:08:48 a.m.: Sounds of a stretcher being moved away could be heard.
1:09:43 a.m.: A uniformed police officer, believed to be WO #1, returned to the ambulance bay. He was engaged in a telephone conversation. The conversation was unintelligible at times but he said, “He went VSA in the car. We had to transport (inaudible).”
1:11:15 a.m. to 1:13:00 a.m. There was no audio in the ambulance bay.
1:13:00 to 1:17:00 a.m.: The SO and WO #1 were visible through the rear window of the police vehicle and appeared to be having a conversation with a female. The conversation was unintelligible.
1:17:41 a.m.: The front passenger side door was opened. The audio portion of the ICCS was turned off. The SO and WO #1, and the paramedics, were still visible through the rear window of the police vehicle.
1:19:15 a.m.: The SO and WO #1, and the paramedics, were no longer visible.
Materials Obtained from Police Service Upon request, the SIU obtained the following materials from TPS between April 7, 2021, and December 15, 2021:
- Communications recordings;
- ICCS footage;
- Computer-assisted Dispatch Details;
- Pictures of the SO’s police vehicle;
- General Occurrence Reports;
- Incidents linked to Complainant’s residence;
- Policy on Prisoner Care and Control;
- Policy on Prisoner Transportation;
- Notes-the SO;
- Notes-WO #2;
- Notes-WO #3;
- Notes-WO #1;
- Occurrence Summary;
- Persons Involvement List;
- Prior Involvement with the Complainant;
- Sudden Death Report; and
- Supplementary Reports.
Materials Obtained from Other SourcesThe SIU obtained the following records from the following other sources:
- Ambulance Call Report-Cochrane District EMS;
- Incident Report-CW #2;
- Incident Report-CW #3;
- Ministry of Finance Report and Audio Enhancement of ICCS footage; and
- Report of Postmortem Examination, dated April 1, 2022, and received by SIU on April 29, 2022, from the Coroner’s Office.
In the early morning of April 4, 2021, the Complainant’s family found the Complainant in a highly agitated state, initially believing he was suffering a seizure. The family soon learned that the Complainant had apparently taken eight “hits” of acid. The Complainant’s sister called 911 as his parents attempted to control the Complainant until the arrival of first responders.
Paramedics and police officers – the SO and WO #1 – were dispatched to the scene, arriving within minutes of the 911 call. They entered the home of the Complainant and climbed a set of stairs to the second floor. The Complainant’s father was restraining his son on the floor. Unable to calm the Complainant, the officers handcuffed him behind his back so that the paramedics could safely assess the situation. The Complainant’s continued aggression, even while handcuffed, prevented that from happening. It was decided that the Complainant should be taken to hospital.
The Complainant was pulled down the stairs feet first at the insistence of his father. The stair chair retrieved by the paramedics was not an option given the Complainant’s excited state, and his father wanted to get him down the stairs as soon as possible despite the risk of injury. With the officers protecting the Complainant’s head, he was brought down without injury and then dragged outside by the officers – his feet lagging behind him as each officer had a hold of the Complainant’s upper body – towards the sidewalk.
The SO moved his cruiser a short distance up towards the Complainant. As one or another of the paramedics on scene had decided they would not take the Complainant in ambulance because of his volatile behaviour, the officers decided to load him into the police vehicle for transportation to hospital. The SO and WO #1, with the assistance of one of the paramedics, CW #3, placed the Complainant in the rear compartment of the cruiser. He was positioned on his right side – his head in the direction of the rear driver side door, his legs bent at the knees to allow for the closure of the rear passenger side door.
The trip to hospital took about five-and-a-half minutes. The Complainant had slipped off the seat so that his upper body, faced towards the rear, was between the rear seats and the back of the front seats. His legs remained above his torso. In that position, the Complainant moved his legs and moaned for upwards of the first two minutes of travel. That stopped in the last three minutes of transport to the hospital.
The operator of the cruiser – the SO – observed all stop signs and stopped for the duration of two red lights. The officer increased his velocity for the second half of the trip. From time to time, he asked how the Complainant was doing and encouraged him to hang on, but never received a response.
The SO’s cruiser entered into the ambulance bay of the hospital and came to a stop. The officer exited the vehicle and opened the rear driver side door. Within seconds, one of the paramedics, who had followed the cruiser in the ambulance, observed the Complainant through the open door and alerted the others that he was ‘VSA’.
The Complainant was removed from the cruiser, laid flat on the floor and provided emergency care by the paramedics. Hospital staff arrived and the Complainant was taken into the hospital on a stretcher. The Complainant was eventually transferred to the ICU and placed on life support. In the morning of April 5, 2021, he was pronounced deceased.
Cause of DeathThe pathologist at autopsy described the cause of the Complainant’s death in the following terms:
Hypoxic-ischemic encephalopathy due to cardiopulmonary arrest in an agitated, obese, handcuffed teenaged boy in a confined space, with LSD toxicity.
In arriving at her findings, the pathologist made the following comment in her Report of Postmortem Examination:
This boy was clinically obese (BMI 33.6); his placement in right lateral position in a confined space in the back of a police vehicle, along with being handcuffed and agitated, may have contributed to his sudden death. The precise mechanism is unclear.
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.
Sections 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 offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing death contrary to sections 215(2)(b) and 220 of the Criminal Code, respectively. As offences of penal negligence, a simple want of care will not suffice to give rise to liability. The former, for example, is predicated 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 reserved for more serious cases of neglect that demonstrate a wanton or reckless disregard for the lives or safety of other persons. It is not made out unless the neglect constitutes a marked and substantial departure from a reasonable standard of care. In the instant case, the issue is whether there was any negligence on the part of the SO, sufficiently egregious to attract criminal sanction, that endangered the life of the Complainant or caused his death. In my view, there was not.
At the outset, I am satisfied that the SO was at all times lawfully placed and in the execution of his duties. An officer’s foremost obligation is the protection and preservation of life. Having been called to the scene of a person in apparent medical distress, it was incumbent on the SO to attend at the Complainant’s residence to do what he could to render aid. This included the decision to handcuff the Complainant in order that first responders, including paramedics, be given an opportunity to deal with him safely.
It also included the decision to transport the Complainant to hospital in the SO’s cruiser. Though an ambulance was on scene, and would have been better equipped to deal with the Complainant en route to the hospital, the evidence indicates that a paramedic made the decision not to take the Complainant for safety reasons given his state of aggression and agitation. As time was of the essence, I am satisfied the officers made a reasonable decision to take the Complainant to hospital rather than engage in any sort of debate with the paramedics or pursue some alternative course.
The real question, in my view, is with the SO’s conduct during the trip to the hospital. Though it was clear that the Complainant was in medical distress, the officer appears not to have exercised the urgency the moment called for. He travelled at moderate speeds for much of the trip without the use of his emergency equipment and while waiting for two red lights to turn green before proceeding through traffic signal controlled intersections. It would also seem that the officer did not act with vigilance when, no longer hearing the sound of the Complainant kicking or moaning in the back of the cruiser, he failed to bring his cruiser to a stop so that the paramedics following behind in their ambulance could assess the situation and provide emergency life-saving care if necessary.
On the other side of the ledger, the SO’s indiscretions were mitigated by a number of extenuating considerations. For starters, it is apparent that he and WO #1 took care to place the Complainant in the recovery position when loading him into the cruiser. That is to say, they were seemingly cognizant of the dangers of restraint in a prone position and sought to avoid those risks from materializing. Though true their efforts may have been for not as the Complainant, soon after he was placed in the rear, slipped because of his agitation into the space between the rear and front seats, it is not clear that the SO was aware of what had happened. Nor is it likely that the SO, from his vantage point in the driver’s seat of the cruiser, was in a position to recognize what had occurred behind him. Regarding the officer’s speed, if the SO’s pace was not what it should have been in the early stages of the trip to the hospital, the evidence indicates he began moving at speed in the final stages not long after the Complainant had stopped moving. As for why the SO did not stop his cruiser for emergency intervention by the paramedics prior to his arrival at hospital, the officer says that he could still hear the Complainant breathing. The ICCS footage was inconclusive on this point; it could well be that the Complainant was breathing up to, or shortly before, his arrival at hospital. Lastly, it bears noting that the trip to the hospital was a relatively short one – about 3.7 kilometres. If the SO failed in his duty of care towards the Complainant, the officer’s dereliction is tempered to an extent by the brevity of time and distance over which events unfolded.
On the aforementioned-record, I am not satisfied on reasonable grounds that the officer’s conduct transgressed the limits of care prescribed by the criminal law. Accordingly, there is no basis for proceeding with criminal charges in this case. The file is closed.
Date: August 31, 2022
Electronically approved by
Special Investigations Unit
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