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News Release

SIU Concludes Death Investigation in Thunder Bay

Case Number: 14-OCD-178

Mississauga (4 June, 2015) --- The Director of the Special Investigations Unit (SIU), Tony Loparco, has concluded that there are no reasonable grounds to charge any officer with the Thunder Bay Police Service (TBPS) with a criminal offence in relation to the death of a 44-year-old man in August of 2014.

The SIU assigned three investigators and two forensic investigators to probe the circumstances of this incident. As part of the investigation, four witness officers and six civilian witnesses were interviewed. The subject officer did not participate in an SIU interview and declined to provide a copy of her duty notes, as is her legal right.

The SIU investigation found that the following events took place on Saturday, August 2 and Sunday, August 3, 2014:

  • At approximately 4:15 p.m. on August 2, two officers were dispatched to attend a church in regards to an unconscious man. Upon locating the man, officers realized he was seriously intoxicated. They managed to walk him over to their cruiser. Paramedics soon arrived and dealt with the man. The paramedics then left the scene and the officers took the man to the police station. 
  • The officers arrived at the station shortly before 5 p.m. and lodged the man in a cell. The jailer and watch commander were relieved after 6 p.m. by the subject officer and another officer.
  • On August 3, at approximately 3 a.m., the subject officer found the man on the cell floor unresponsive. EMS arrived and pronounced the man dead.

Director Loparco said, “There is little doubt that the man’s arrest for public intoxication was lawful. He was highly intoxicated and in no condition to care for himself. The officers were right to arrest him for his own safety. However, the investigation has revealed problems with the manner in which the man was cared for while in police custody. Beginning with the conduct of the arresting officers, there is no indication in their notes and statements that they informed the paramedics that they had observed the man with breathing difficulties. One is left to imagine that the paramedics might have taken the state of the man’s health more seriously were his complaints more than simply words. Once at the station, it seems the same officers failed to mention the man’s complaint of breathing difficulties to any of the officers who would have primary care of the man while in cells. Had they done so, it might well have been the case that someone would have intervened to secure medical attention for the man or, at least, to ensure that he was carefully monitored while in custody. When the man asked to be taken to the hospital again because of his shortness of breath, one of the arresting officers refused, saying that the paramedics had cleared the man. The officers, it seems to me, ought to have erred on the side of caution and taken him to hospital.

“The man’s custodians at the station fared little better. The jailer took a hands-off approach in his attitude regarding the extent of his responsibilities over prisoner care. A prudent officer in his circumstances, I am satisfied, would have made some minimal inquiries of the man’s condition.  Had he done so, a closer watch could have been arranged for the man and medical service secured at an earlier point. The watch commander’s appreciation of the extent of her duties also leaves much to be desired. While she was not the primary eyes and ears on the prisoners at the time in question, she failed to grasp the true nature of her responsibilities as being the officer with overall and ultimate responsibility for the care of prisoners. With respect to the subject officer, the investigation is simply at a loss to explain why she failed to conduct personal checks on the man as she was required to do pursuant to police policy. TBPS policy requires that the jailer make physical checks of the prisoners every half hour and no less than once every hour in the case of a pressing circumstance requiring the jailer’s attention elsewhere. The man was left unattended and personally unchecked for upwards of five hours.”

Director Loparco continued, “The man’s cause of death was determined at autopsy to be ketoacidosis complicating diabetes mellitus, chronic alcoholism and septicemia. It is unclear on the evidence whether the officers getting the man to  hospital at some point preceding his death would have saved his life. That said, I am satisfied on the evidence that the absence of medical treatment, in the words of the offence provision, endangered his life.”

Director Loparco added, “The offence that arises for consideration, in my view, is failure to provide the necessaries of life under section 215 of the Criminal Code. In the case of failure to provide the necessaries of life, what is required is a finding that the impugned conduct constitutes a marked departure from the standard of care expected of a reasonably prudent person in the circumstances. While close to the line, I am unable to reasonably conclude that the conduct in question meets that test. The critical evidence that mitigates much of the officers’ conduct was that paramedics had dealt with the man at the scene and determined that he was fine and did not need to go to the hospital. While it is true that their assessment might have been different had the officers conveyed information regarding what they had seen of the man’s breathing, the fact remains that they were in a position to satisfy themselves of his health. This evidence further tempers the officers’ failure to convey information about the man’s breathing to other officers at the station or to take more seriously his laboured breathing at the station and his requests to be taken to the hospital. I wish to stress that this is not to absolve the officers from taking what in my view would have been reasonable steps in the man’s care; it is only to suggest that their failure to do so was not without context or explanation. 

“The same goes for the other officers, including the subject officer. To be sure, they knew enough about the man’s intoxicated state to put them on notice that he required careful watch. That said, the simple fact remains that they did not appreciate, nor were they told of, the man’s complaints of breathing difficulties. And what they did know and see, at least for a significant portion of the man’s time in custody, did not suggest he was in medical distress or in need of immediate medical attention. For example, the booking and cellblock video recordings show that the man answered questions at the time of his booking, appeared to be breathing normally for portions of time and was active at various times until his last movement just after midnight. Also important are the automated records produced by the TBPS prisoner management system, which record the subject officer checking the man 26 times between 6:58 p.m. and 2:49 a.m. While this latter series of purported checks was clearly not the result of personal inspections, I cannot dismiss the possibility these checks were made via the monitors to which the subject officer had access.” 

Director Loparco concluded, “A tragic series of missteps by all of the officers involved in the man’s custody conspired against him that day. In some ways, it is because the responsibility in this case is spread wide across the officers that there is insufficient evidence that any one officer is sufficiently blameworthy to attract criminal sanction. Be that as it may, while I am satisfied on the evidence that the care the man received from the police was substandard, I am not satisfied on balance that the care of any one officer was markedly so in the circumstances. For the foregoing reasons, the grounds in this case fall short of proceeding with criminal charges.”                              

The SIU is an arm’s length agency that investigates reports involving police where there has been death, serious injury or allegations of sexual assault. Under the Police Services Act, the Director of the SIU must

  • consider whether an officer has committed a criminal offence  in connection with the incident under investigation
  • depending on the evidence, lay a criminal charge against the officer if appropriate or close the file without any charges being laid
  • report the results of any investigations to the Attorney General. 

Monica Hudon, monica.hudon@ontario.ca
SIU Communications/Service des communications, UES
Telephone/No de téléphone: 416-622-2342 or/ou 1-800-787-8529 extension 2342