Director's Report Details

The Special Investigations Unit is a civilian law enforcement agency that investigates incidents involving an official where there has been death, serious injury, the discharge of a firearm at a person or an allegation of sexual assault. Under the Special Investigations Unit Act, 2019 (SIU Act), officials are defined as police officers, special constables of the Niagara Parks Commission and peace officers under the Legislative Assembly Act. The SIU’s jurisdiction covers more than 50 municipal, regional and provincial police services across Ontario.

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, 2019

Pursuant 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 Personal Privacy Act

Pursuant to section 14 (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.

Pursuant to section 21 (i.e., personal privacy), protected personal information is not included in this report. This information may include, but is not limited to, the following:

• 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, 2004

Pursuant to this legislation, any information related to the personal health of identifiable individuals is not included.

Other proceedings, processes, and investigations

Information 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.

Pursuant to section 15 of the SIU Act, the SIU may investigate the conduct of officials, be they police officers, special constables of the Niagara Parks Commission or peace officers under the Legislative Assembly Act, that may have resulted in death, serious injury, sexual assault or the discharge of a firearm at a person.

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

Notification of the SIU[1]

On February 11, 2025, at 4:15 a.m., the Hamilton Police Service (HPS) contacted the SIU with the following information.

On February 10, 2025, at 5:43 p.m., the Complainant was arrested for seven outstanding ‘fail to comply’ warrants. She was transported to HPS Central Station and lodged without incident. At an unknown time, the Complainant began to bang her head on the cell wall and was transferred to a padded cell. During the overnight hours, the Complainant was checked every 30 minutes, per HPS policy. At about 2:30 a.m., the Complainant was observed not breathing and, at 2:39 a.m., Emergency Medical Services (EMS) were called. At 3:10 a.m., the Complainant arrived at St. Joseph’s Hospital (SJH). At 3:22 a.m., the Complainant was pronounced deceased.

The Team

Date and time team dispatched: 2025/02/11 at 4:25 a.m.

Date and time SIU arrived on scene: 2025/02/11 at 4:52 a.m.

Number of SIU Investigators assigned: 3

Number of SIU Forensic Investigators assigned: 1

Affected Person (aka “Complainant”):

31-year-old female; deceased

Civilian Witness (CW)

CW Interviewed; next-of-kin

The civilian witness was interviewed on February 11, 2025.

Subject Official (SO)

SO Interviewed; notes received and reviewed

The subject official was interviewed on February 24, 2025.

Witness Officials (WO)

WO #1 Interviewed; notes received and reviewed

WO #2 Interviewed; notes received and reviewed

The witness officials were interviewed between February 14, 2025, and March 14, 2025.

Service Employee Witnesses (SEW)

SEW #1 Interviewed; notes received and reviewed

SEW #2 Interviewed; notes received and reviewed

SEW #3 Interviewed; notes received and reviewed

SEW #4 Interviewed; notes received and reviewed

SEW #5 Interviewed; notes received and reviewed

SEW #6 Interviewed

SEW #7 Interviewed

SEW #8 Interviewed; notes received and reviewed

The service employee witnesses were interviewed between February 14, 2025, and March 27, 2025.

Investigative Delay

The Report of Postmortem Examination was obtained by the SIU from the Coroners Office on July 25, 2025.

Delay was also incurred because of resource pressures in the Director’s Office.

The Scene

The events in question transpired in the cells area of HPS Central Station, 155 King Willian Street, Hamilton.

Physical Evidence

On February 11, 2025, SIU forensic services attended the cells area of the HPS Central Station, 155 King Willian Street, Hamilton. Arriving at 6:35 a.m., they were escorted to the cells area, viewed the two involved cells, and took digital images.

SIU forensic services left the cell area to attend SJH and take photographs of the Complainant, returning to the HPS cells area at 8:27 a.m.

Examination of a padded cell showed it was metal, with an interior padded coating. Two Plexiglas windows were in the upper and lower portions of the door with a sliding access port in-between. The interior of the cell was rectangular, measuring 2.6 metres in length by 1.58 metres wide and 2.1 metres in height. The doorway was on the west side at the northwest corner, measuring 0.67 metres wide and 2.0 metres in height. The interior of the room walls was smooth and padded. Within the cell were a quantity of packaging and pieces of medical therapy used in the initial response by paramedics. The packaging and loose items were photographed and collected. A small area of dried red-brown staining was observed on the floor near the southwest corner.

The initial cell in which the Complainant had been lodged was viewed by SIU forensic services. It measured 2.05 metres long by 1.53 metres wide and 2.15 metres high. The door, which slid open to the right (facing in), measured 0.67 metres wide and 2.14 metres in height. A built-in bench was along the east side. On the north wall was a single unit stainless steel sink/ toilet. On the floor, just inside the door, were two pieces of damp white cloth. These were documented and collected. They were later determined to be from a single garment - a pair of underpants - that had been ripped in two.

Video/Audio/Photographic Evidence[2]

HPS Custody Footage

On February 10, 2025, starting at about 6:06 p.m., WO #1 was captured asking standard intake questions of the Complainant in the sally port. The Complainant responded that she had no injuries and her health was poor. When asked if she had consumed drugs or alcohol prior to arrest, the response was indecipherable. She was escorted to a bench where she was searched by SEW #8, including with the use of a metal detecting wand. She remained cooperative throughout.

Starting at about 6:14 p.m., she was escorted to a cell. While in the cell, the Complainant was restless. She fiddled with her clothing and hair. She began to rap on the Plexiglas shield with her knuckles.

Starting at about 6:25 p.m., SEW #2 and SEW #8 brought the Complainant a cup. They spoke and she seemed to settle. Four minutes later, SEW #2, SEW #4 and SEW #8 visited the Complainant and they spoke for about two minutes. About six minutes later, the Complainant hit the Plexiglas with more frequency until SEW #4 arrived. About nine minutes later, WO #1 visited the Complainant, who was animated. After WO #1 departed, the Complainant’s behaviour and agitation continued to escalate. She rocked back and forth, made frantic gestures, yelled, and hit the Plexiglas.

Starting at about 7:08 p.m., the Complainant gently knocked the left side of her head against the Plexiglas barrier several times, gradually increasing this behaviour in frequency and intensity. SEW #4 attended twice but the Complainant did not calm.

Starting at about 7:49 p.m., the Complainant stood on the bench in the cell and attempted to shift the Plexiglas window above the bars. She kicked the cell door, pounded it with her fist, and exhibited an increased level of agitation.

Starting at about 8:22 p.m., the Complainant was escorted from the cell to the secure phone booth [call with counsel]. She walked unassisted. Shortly thereafter, she was photographed and fingerprinted. She appeared upset and wiped her eyes several times. She had no visible head or facial injuries. She was escorted back to the cell. Shortly thereafter, she fumbled under the blanket and inside her sweater while she sat on the cell bench.

Starting at about 8:49 p.m., the Complainant examined something in her right palm and inserted it into her mouth.

Starting at about 9:16 p.m., SEW #8 and SEW #1 attended the cell and the Complainant slid a plastic card under the cell door. SEW #1 unlocked the cell and searched her against the far wall, which included the inside of her sweater, the waistband of her leggings, and her legs, ankles and feet (without removing her socks). Some items were collected, and the Complainant returned to the cell.

Starting at about 9:22 p.m., the Complainant removed her sports bra. She chewed and ripped it before she tossed it into the toilet. She became highly agitated, chewed her fingernails, and frequently drank water. She stuffed blankets at the bottom of her cell door. Eight minutes later, SEW #1 conversed with the Complainant, who was highly agitated and upset.

Starting at about 9:38 p.m., the Complainant jammed pieces of her sports bra in the upper corner of the cell door, which were removed by SEW #2 and SEW #8. About 20 minutes later, the Complainant’s behaviour became violent as she kicked and punched on the cell door.

Starting at about 10:01 p.m., SEW #2 and SEW #1 spoke with the Complainant along with SEW #8. Twenty-two minutes later, the SO spoke with the Complainant for about two minutes. He gestured to the ceiling and floor grate during the conversation.

Starting at about 10:31 p.m., SEW #1 spoke with the Complainant for over five minutes. Six minutes later, the Complainant stood on the cell bench and kicked the Plexiglas. A few minutes later, the Complainant struck the left side of her head against the Plexiglas a half-dozen times or so. Shortly thereafter, she struck the top centre of her forehead against the Plexiglas four times, the intensity of her thumping increasing. Three minutes later, she hit her head five more times. SEW #2 and SEW #8 spoke with her. She banged the crown of her head four times in their presence. They departed one minute and 42 seconds later. The Complainant then banged her head five more times.

Starting at about 11:05 p.m., the Complainant was escorted to the padded cell by SEW #2 and SEW #3. SEW #1 and SEW #8 met them in the corridor. The Complainant was unsteady on her feet and had to be supported. She had red marks and mild swelling in the centre of her forehead. The Complainant was escorted past the custody counter and was heard asking, “Why did you do that to me? Why? Why? She left me screaming…,” and her voice trailed off down the corridor where she was escorted to a padded cell. Shortly after, SEW #2 delivered a blanket through the cell door slide. He spoke with the Complainant through the open slide as she continued to cry and scream.

Starting at about 11:13 p.m., SEW #2 attended the padded cell and spoke to the Complainant through the closed cell door. The Complainant was in constant agitation and in emotional distress. She pounded the cell door window with a combination of open palms and closed fists, screamed, and kicked the door. Shortly after, she struck the cell door upper window with the centre of her forehead multiple times and continued to cry and scream. Minutes later, she struck her head again multiple times against the cell door window. No blood was visible on her face.

Starting at about 11:30 p.m., the Complainant bent over fully at the waist and adjusted her hair. She appeared to lose balance and fell onto her face near the upper right corner of the cell. She remained still with her face on the floor. Her legs and feet twitched, and her lower body shifted marginally to the left. The Complainant’s right leg bent at the knee and kicked a few times. Periodically, the Complainant’s legs would suddenly kick. The exposed portion of her stomach indicated sharp breaths and her body subtly spasmed. Her face never rose off the floor. Three minutes later, she shifted to a completely prone position and remained facedown. There was no further apparent movement from the Complainant.

On February 11, 2025, starting at about midnight, SEW #2 looked inside the padded cell but did not open the door. Thirty minutes later, SEW #1 checked the padded cell through the upper cell door window, then the bottom. She departed 82 seconds later. Twelve minutes later, SEW #1 again checked the padded cell through the open slide and departed 29 seconds later.

Starting at about 1:00 a.m., SEW #2 checked the padded cell through the upper and lower windows. He departed 22 seconds later. Thirty minutes later, SEW #2 checked the padded cell through the open slide and departed 51 seconds later. Thirty minutes later, SEW #2 checked the padded cell through the open slide and departed 34 seconds later. At no time did SEW #2 enter the padded cell.

Starting at about 2:31 a.m., SEW #8 checked the padded cell through the upper and lower window and departed 29 seconds later. She returned with SEW #1 and opened the cell door. SEW #1 prodded the Complainant’s right thigh with her left foot, which failed to rouse her. SEW #1 stepped over the Complainant and shook the small of her back with no reaction. SEW #8 remained in the hallway. SEW #1 and SEW #8 rolled the Complainant onto her back where she remained motionless. They departed the padded cell and, about two minutes later, SEW #8 returned to the cell and patted the Complainant’s right arm, still with no response.

Starting at about 2:41 a.m., a female HPS officer and a male special constable entered the padded cell. They checked the Complainant’s breathing and attempted to revive her by shaking her wrist and jostling her chest. An unknown female sergeant entered.

At about 2:45 a.m., EMS entered the cell and shifted the Complainant; a smear of blood was on the floor where her face had been. A minute later, firefighters entered the padded cell and began chest compressions; a respirator was applied.

At about 2:52 a.m., EMS and Hamilton Fire Department carried an unresponsive Complainant from the padded cell and EMS took her away.

Materials Obtained from Police Service

Upon request, the SIU obtained the following records from the HPS between February 11, 2025, and April 3, 2025:

• Cell Activity Report
• Cell Floor Plan
• Custody footage
• Arrest Booking Reports
• General Occurrence Report
• Training sheets
• Notes and will-state - SEW #2
• Will-state - WO #1
• Notes and will-state - WO #2
• Notes - SEW #3
• Notes - the SO
• Notes and will-state - SEW #1
• Notes and will-state - SEW #8
• Notes - SEW #4
• Notes - SEW #5

Materials Obtained from Other Sources

The SIU obtained the following records from other sources between February 12, 2025, and July 25, 2025:

• Preliminary Autopsy Findings Report from the Ontario Forensic Pathology Service
• Toxicology Report from the Centre of Forensic Sciences
• Report of Postmortem Examination from the Coroner’s Office

The evidence collected by the SIU, including interviews with the SO and additional police witnesses, and video footage that captured the incident in part, gives rise to the following scenario.

The Complainant was arrested by WO #2 in the evening of February 10, 2025, for violations of multiple probation orders. She was taken into custody without incident and transported to HPS Central Station.

WO #1 was the sergeant in charge of the custody area when the Complainant was brought in. She asked the Complainant a series of questions related to her health and well-being. The Complainant denied alcohol or drug consumption, and gave no indication of wanting to hurt herself. She was searched and lodged in a cell shortly after 6:00 p.m.

Soon after her placement in cells, the Complainant began to complain of breathing problems and asked to be taken to hospital. WO #1 spoke to the Complainant and satisfied herself that the Complainant was breathing well, and she did not need medical attention. The Complainant’s behaviour in cells became more and more erratic. She continuously banged on the cell door and walls, including with her head, and repeatedly asked to be taken to hospital. WO #1 concluded the Complainant’s behaviour, not unlike the behaviour she had witnessed from other prisoners, was a ploy to avoid having to spend the night in jail.

At about 8:50 p.m., after her return to the cell from having spoken to her lawyer in another room, the Complainant appeared to retrieve a substance from her person and ingest it. Her agitation continued unabated. At one point, seemingly convinced that there were mice in her cell, the Complainant used a blanket and pieces of her bra that she chewed off to plug spaces in the cell to prevent their entry. The special constables monitoring the Complainant attempted to assure her there were no rodents. When the Complainant continued to bang her head off the cell, the SO, who was now in charge of the cells, approved her transfer into a padded cell.

The Complainant entered the padded cell at about 11:00 p.m. Once inside, she continued to strike the cell with her feet, hands and head. At about 11:30 p.m., the Complainant bent down, lost her balance and fell front forward. Her body made minor movements while in this position for the next few minutes, after which she appeared still. Special constables continued to check on the Complainant from outside the cell and via video monitors.

At approximately 2:30 a.m., following a check performed by SEW #8 in which it appeared the Complainant was unwell, she and SEW #1 entered the cell to find her not breathing. SEW #1 called 911 and requested that a sergeant attend the cell. Additional officers arrived at the cell and efforts were made to rouse the Complainant.

Paramedics and firefighters arrived at about 2:45 a.m. and took charge of the Complainant’s care. Chest compressions were begun, and a respirator was applied.

The Complainant was transported to hospital where she was pronounced deceased at about 3:22 a.m.

Cause of Death

The pathologist at autopsy was of the view that the Complainant’s death was attributable to “acute ketoacidosis in a woman with fentanyl and methamphetamine toxicity”. The pathologist was unable to identify a definitive cause of the ketoacidosis.

Section 215, Criminal Code - Failure to Provide Necessaries

215 (1) Every one is under a legal duty

(c) to provide necessaries of life to a person under his charge if that person

(i) is unable, by reason of detention, age, illness, mental disorder or other cause, to withdraw himself from that charge, and

(ii) is unable to provide himself with necessaries of life.

(2) Every person commits an offence who, being under a legal duty within the meaning of subsection (1), fails without lawful excuse to perform that duty, if

(b) with respect to a duty imposed by paragraph (1)(c), the failure to perform the duty endangers the life of the person to whom the duty is owed or causes or is likely to cause the health of that person to be injured permanently.

Sections 219 and 220, Criminal Code - Criminal Negligence Causing Death

219 (1) Every one is criminally negligent who

(a) in doing anything, or

(b) in omitting to do anything that it is his duty to do,

shows wanton or reckless disregard for the lives or safety of other persons.

(2) For the purposes of this section, duty means a duty imposed by law.

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

(a) where a firearm is used in the commission of the offence, to imprisonment for life and to a minimum punishment of imprisonment for a term of four years; and

(b) in any other case, to imprisonment for life.

The Complainant lapsed into medical crisis while in a HPS cell on February 11, 2025, and was subsequently pronounced deceased. The SIU was notified of the incident and initiated an investigation. The SO – the officer with overall responsibility for the care of prisoners at the time of the events in question – was identified as the subject official. The investigation is now concluded. On my assessment of the evidence, there are no reasonable grounds to believe that the SO committed a criminal offence in connection with the Complainant’s death.

The offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing death contrary to sections 215 and 220 of the Criminal Code, respectively. Both require something more than a simple want of care to give rise to liability. 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 premised on even more egregious conduct that demonstrates 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 question is whether there was any want of care on the part of the SO, sufficiently serious to attract criminal sanction, that endangered the Complainant’s life or caused her death. In my view, there was not.

There are no questions raised in the investigation regarding the lawfulness of the Complainant’s arrest and her period in custody for violations of probation orders.

With respect to the care the Complainant received while in custody, the evidence does not reasonably establish that it fell below the requisite standard prescribed by the criminal law. The Complainant was regularly checked by special constables while in cells. It is true that her repeated requests to be taken to hospital were denied, but that judgment call made by her custodians was not without justification. Though she presented as highly agitated, the Complainant did not give the appearance while in the initial cell of someone in need of immediate medical attention. That said, her custodians did take steps to ensure her safety; to prevent the Complainant doing harm to herself by repeatedly banging the hard surfaces of the cell, they moved her to a padded cell. Once in that cell, there is evidence that the Complainant was checked periodically. It might have been preferable for the monitoring special constables to enter the cell to examine the Complainant more carefully from a closer distance, but it was their evidence that they were satisfied the Complainant was simply sleeping (and breathing) when they looked at her through the cell door’s window or the slide opening.[3] Once SEW #8 expressed concerns about the Complainant’s well-being at about 2:30 a.m., steps were taken to secure medical attention.

There remains the issue of how the Complainant was allowed to retrieve a substance from her person, presumably, a drug of some type, and ingest it while in custody. Short of a strip search or continuous monitoring, it is unlikely that the Complainant’s conduct could have been prevented. Neither of those options, however, was necessarily justified in the circumstances: see R. v. Golden, [2001] 3 SCR 679. The Complainant had not been arrested for a drug offence, had denied drug use and did not appear impaired by drugs at her booking, and, despite having a suicide caution in her police record, denied wanting to self-harm.

As I am unable to reasonably conclude that the care the Complainant received while in custody departed markedly from a reasonable standard, there is no basis for proceeding with criminal charges against the SO, who was responsible for the special constables tasked most immediately with the Complainant’s supervision. The file is closed.

Date: October 6, 2025

Electronically approved by

Joseph Martino

Director

Special Investigations Unit