Explanatory note

The Ontario Government is releasing past SIU Director Reports (submitted to the Attorney General prior to May 2017) that include fatalities involving a firearm, physical altercation, and/or use of conducted energy weapon, or other extensive police interaction that did not result in a criminal charge.

Justice Michael H. Tulloch made recommendations about the release of past SIU Director Reports in the Report of the Independent Police Oversight Review, released on April 6, 2017.

Justice Tulloch explained that since past reports were not originally drafted for public release they may have to be edited substantially to protect sensitive information. He took into account that confidentiality assurances were given to various witnesses during the course of SIU investigations, and recommended that some information be redacted in the interests of privacy, safety, and security.

As recommended by Justice Tulloch, this explanatory note is being provided to assist the reader’s understanding of why certain information is redacted in these reports. Notes have also been inserted throughout the reports to help describe the nature of the information that was redacted and why it was redacted.

Law enforcement and personal privacy information considerations

Consistent with Justice Tulloch’s recommendations and guided by section 14 of the Freedom of Information and Protection to Privacy Act (FIPPA) (relating to law enforcement information), portions of these reports have been removed to protect:

  • confidential investigative techniques and procedures used by the SIU
  • 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
  • witness statements and evidence gathered in the course of the investigation, provided to the SIU in confidence

Consistent with Justice Tulloch’s recommendations and guided by section 21 of FIPPA (relating to personal privacy information), personal information, including sensitive personal information, has also been redacted, except that which is necessary to explain the rationale for the Director’s decision. This information may include, but is not limited to, the following:

  • subject officer name(s)
  • witness officer name(s)
  • civilian witness name(s)
  • location information
  • other identifiers which are likely to reveal personal information about individuals involved in the investigation, including in relation to children
  • witness statements and evidence gathered in the course of the investigation, provided to the SIU in confidence

Personal health information

Information related to the personal health of individuals that is unrelated to the Director’s decision (taking into consideration the Personal Health Information Protection Act, 2004) has been redacted.

Other proceedings, processes, and investigations

Information may have also been excluded from these reports 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.

Director’s report

Notification of the SIU

On Tuesday, April 12, 2005 at 1957 hrs, Notifying Officer of the Waterloo Regional Police Service (WRPS) notified the SIU of the death of Mr. Adam Steele. It was Notifying Officer ’s understanding that officers went to Fairview Park Mall in Kitchener about a man causing a disturbance. Officers found the man frothing at the mouth, crawling on all fours and being very aggressive. He was arrested after a struggle and placed in a cruiser, where he “went vital signs absent” (VSA). The man was taken to hospital and pronounced dead.

The investigation

On April 12, 2005 at 2045 hrs, three SIU Investigators and two Forensic Identification Technicians (FIT) were dispatched to Fairview Park Mall. The first investigator arrived at the mall at 2141 hrs. The SIU FIT carried out forensic examinations inside and outside the mall, which included videotaping, photographing, and seizing physical and biological evidence. They also mapped the scene using a Sokkia Total Station to produce a scale diagram. The SIU FIT and an SIU Investigator attended the post mortem examination of Mr. Steele. The SIU Investigators carried out a canvass in Fairview Mall and appealed through the media for witnesses. Over the next several days investigators interviewed many witnesses.

The following WRPS officers were designated as subject officers, were interviewed and provided copies of their notes:

  • Subject Officer #1 (April 18, 2005)
  • Subject Officer #2 (April 18, 2005)
  • Subject Officer #3 (April 20, 2005)
  • Subject Officer #4 (April 20, 2005)

Subject Officer #3 also provided investigators with a typed statement.

The following officers were designated as witness officers, were interviewed and provided copies of their notes:

  • Witness Officer #1 (April 13, 2005)
  • Witness Officer #2 (April 13, 2005)

The WRPS provided the following materials to the SIU:

  • Occurrence Reports for the incident
  • Copy of civilian witness statements take by members of the WRPS and names of witnesses
  • Copy of Computer Aid Dispatch (CAD) Incident History
  • Copy of telephone and radio communications for the incident
  • Copy of Mobile Data Terminal transmissions (MDT) for the subject and witness officers
  • Copy of Police Regional Information Data Entry (PRIDE) event details
  • Copy of training records for Subject Officer #2, Subject Officer #1, Subject Officer #3
  • Copy of Use of Force policy, training questions, Prisoner Care and Control policy, Prisoner Transportation policy, Auxiliary Police policy and training materials, and
  • Copy of photographs taken by WRPS FIT

The following civilian witnesses were interviewed:

  • Civilian Witness #1 (April 12, 2005)
  • Civilian Witness #2 (April 19, 2005)
  • Civilian Witness #3 (April 20, 2005)
  • Civilian Witness #4 (April 21, 2005)
  • Civilian Witness #5 (April 12, 2005)
  • Civilian Witness #6 (April 21, 2005)
  • Civilian Witness #7 (April 19, 2005)
  • Civilian Witness #8 (April 19, 2005)
  • Civilian Witness #9 (April 12, 2005)
  • Civilian Witness #10 (April 15, 2005)
  • Civilian Witness #11 (April 20, 2005)
  • Civilian Witness #12 (April 12, 2005)
  • Civilian Witness #13 (April 15, 2005)
  • Civilian Witness #14 (April 18, 2005)
  • Civilian Witness #15 (April 15, 2005)
  • Civilian Witness #16 (April 20, 2005)
  • Civilian Witness #17 (April 19, 2005)
  • Civilian Witness #18 (April 20, 2005)
  • Civilian Witness #19 (April 20, 2005)
  • Civilian Witness #20 (April 15, 2005)
  • Civilian Witness #21 (April 19, 2005)
  • Civilian Witness #22 (April 20, 2005)
  • Civilian Witness #23 (April 19, 2005)
  • Civilian Witness #24 (April 19, 2005)
  • Civilian Witness #25 (April 19, 2005)
  • Civilian Witness #26 (April 12, 2005)
  • Civilian Witness #27 (April 19, 2005)
  • Civilian Witness #28 (April 20, 2005)
  • Civilian Witness #29 (April 15, 2005)
  • Civilian Witness #30 (April 12, 2005)
  • Civilian Witness #31 (April 19, 2005)
  • Civilian Witness #32 (April 14, 2005)
  • Civilian Witness #33 (April 21, 2005)
  • Civilian Witness #34 (April 15, 2005)
  • Civilian Witness #35 (April 21, 2005)
  • Civilian Witness #36 (April 15, 2005)

A lengthy wait for the results of toxicology examinations delayed the completion of the SIU investigation.

Confidential witness statements and evidence gathered in the course of the investigation provided to the SIU in confidence (Law Enforcement and Privacy Considerations)

Director’s decision under s. 113(7) of the Police Services Act

It is clear on the evidence that none of the subject officers committed a criminal offence in connection with Mr. Steele’s death.

The evidence establishes that this young man was in the throes of a manic episode on the evening of April 12, 2005, probably brought on by an overdose of cocaine. Shortly after 6:00 p.m., police began receiving calls about a male individual behaving strangely, first darting in and out of traffic in the area of Highway 8 and Fairway Road, and then inside Fairview Mall, where Mr. Steele variously screamed, leaped counters and displays, collapsed and mumbled incoherently.

Mall security were the first to respond, followed quickly by an off-duty officer, who happened to be in the food court at the time, and three firefighters from the Kitchener Fire Department. Soon after, two officers and an auxiliary member of the Waterloo Regional Police Service arrived. They all attempted to calm Mr. Steele, who by this time was on the ground near a New York Fries outlet. It seems Mr. Steele did settle down for a time, however, his agitation resurfaced and the decision was made to arrest him in the interests of public safety under the Mental Health Act. In all the circumstances, I am satisfied the officers acted lawfully in so arresting Mr. Steele.

Mr. Steele was handcuffed and helped outside to a waiting cruiser by the two officers. The officers searched him and then placed him in the rear seat. Their intention was to take Mr. Steele to hospital for treatment. Neither officer, however, was satisfied with Mr. Steele’s position inside the cruiser – lying on his stomach across the backseat. Their training told them that a prone position heightened the risk of positional asphyxia in manic individuals, and should be avoided. Accordingly, they removed Mr. Steele from the cruiser and re-inserted him, careful this time to ensure he came to rest in a semi- seated position. Throughout this process, Mr. Steele gave no indication of being in any immediate medical distress. In fact, evidence from a number of witnesses indicates that Mr. Steele was at times able to communicate with the officers, stand on his own power while being searched and even offer some physical resistance while being placed in the cruiser.

The paramedics who had been called to the scene arrived at the cruiser several minutes later. They were speaking with the officers about how best to take Mr. Steele to hospital when one of them peered into the cruiser’s back seat and noticed Mr. Steele was quiet and motionless. Mr. Steele was taken from the cruiser, his handcuffs removed and placed on a stretcher. He continued to be unresponsive and fell into cardiac arrest. Assisted by an off-duty paramedic and the auxiliary officer, the attending paramedics began a course of resuscitation. The other two officers left to retrieve the ambulance, which had been parked at another of the mall’s entrances. They returned quickly and Mr. Steele was placed in the ambulance and taken to St. Mary’s Hospital, arriving there just after 7:00 p.m. Unfortunately, Mr. Steele could not be saved and he was pronounced dead at hospital shortly thereafter.

As of the date of this report, the cause of Mr. Steele’s death remains undetermined. Toxicological testing did reveal that Mr. Steele had a potentially lethal level of cocaine in his system at the time of his death.

Whatever the cause of Mr. Steele’s death, however, I am satisfied that none of the subject officers bear any criminal liability in relation to it. In their short time with Mr. Steele they managed to arrest him without incident notwithstanding his emotional state, were cognizant of the dangers associated with positional asphyxia and took steps to mitigate them, and then acted quickly to assist in whatever way they could with medical intervention at the first sign of distress. In these circumstances, I am of the view that the officers’ conduct fell well within the requisite level of care prescribed by the criminal law. Indeed, I believe that these officers did all that they could to ensure that Mr. Steele was treated properly.

Date: August 24, 2005

Original signed by

James L. Cornish
Director
Special Investigations Unit