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

Notification date and time: 06/11/2015 at 0204 hours
Notified by: Police

At 0210 hrs on Thursday, June 11, 2015, Notifying Officer of the Peterborough Police Service (PPS) notified the SIU of Deceased’s custody death. Notifying Officer reported that Deceased was in custody of the Central East Correctional Centre (CECC) and had been admitted to the Peterborough Regional Health Centre (PRHC) for unknown medical reasons. While at PRHC, Deceased was under the guard of a PPS police officer, Subject Officer #1, as well as an Ontario Provincial Police (OPP) police officer, Subject Officer #2. On occasion, CECC would utilize local police officers to guard hospitalized inmates.

At about 0100 hrs on June 11, 2015, Deceased became agitated and was restrained by the police officers. Deceased went Vital Signs Absent (VSA) and was subsequently pronounced dead.

Overview

Deceased was in the custody of the Canadian Border Services Agency (CBSA) as a refugee claimant and was incarcerated in CECC while awaiting deportation. Deceased had a history of schizophrenia/bipolar Sensitive Personal Information. On June 3, 2015, Deceased was brought to Ross Memorial Hospital in Lindsay after he was thought to have had a seizure. He was then transferred to PRHC for treatment. While at PRHC Deceased was under the guard of correctional officers.

On June 11, 2015, Subject Officer #2 and Subject Officer #1 were assigned a paid duty of guarding Deceased starting at 1900 hrs. After the police officers arrived, Subject Officer #2 noticed Deceased was agitated and screaming, as well as eating and throwing feces. It was determined by the medical staff that Deceased would be sedated. The police officers and hospital staff restrained Deceased and he was sedated. Sometime later, the hospital staff needed to clean Deceased so the police officers were asked to assist in restraining Deceased.

While the police officers were restraining Deceased and the nurses were cleaning him, Deceased went VSA. Attempts to resuscitate Deceased were not successful.

The investigation

Response type: Attend Immediately
Date and time team dispatched: 06/11/2015 at 0247 hours
Date and time SIU arrived on scene: 06/11/2015 at 0355 hours
Number of SIU Investigator(s) assigned: 5
Number of SIU Forensic Investigator(s) assigned: 2

Complainant

Deceased Deceased

Civilian witnesses

Civilian Witness #1 Initial interview: June 11, 2015

Civilian Witness #2 Initial interview: June 11, 2015

Civilian Witness #3 Initial interview: June 11, 2015

Civilian Witness #4 Initial interview: June 11, 2015

Subject officers

Subject Officer #1 Declined interview

Subject Officer #2 Initial interview: September 2, 2015

Copies of notebook entries were not provided by Subject Officer #1 and Subject Officer #2.

Witness officer

Witness Officer #1 Initial interview: June 23, 2015

Upon request the SIU obtained and reviewed the following materials and documents from the OPP and the PPS

  • Sensitive Personal Information
  • OPP-Policy-Paid Duty
  • PPS-General Order-Paid Duties
  • PPS-General Order-Prisoner Care and Control, and
  • PPS-Occurrence Report

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

For the following reasons, in my view, there are no reasonable grounds to believe that either Subject Officer #2 or Subject Officer #1 committed a criminal offence in the course of their interaction with Deceased. Consequently, no charges will issue.

On June 10, 2015, both Subject Officer #2 of the Ontario Provincial Police and Subject Officer #1 of the Peterborough Police Service accepted a paid duty detail at the Peterborough Regional Health Centre. The duty entailed guarding Deceased who was a refugee claimant in the custody of the Canadian Border Services Agency awaiting deportation. He also suffered from significant mental health issues, including schizophrenia and bipolar disorder, Sensitive Personal Information. During the course of the paid duty, Deceased died and this Unit invoked its mandate.

The paid duty commenced at 7:00 p.m., when Subject Officer #2 and Subject Officer #1 relieved two correctional officers. Deceased was in one of the hospital’s isolation rooms. Subject Officer #2 became immediately concerned upon observing Deceased, who was mumbling and screaming incoherently. He had shackles on his feet, but they were not affixed to the bed. He also had loose restraints on his wrist, which allowed him to sit upright. During the ensuing hours, Deceased presented substantial difficulties for both the police officers and hospital staff alike.

At approximately 7:30 p.m., Subject Officer #2 entered Deceased’s room after hearing a loud bang. When the officer entered the room, he/she was confronted with an overpowering smell of feces. He/She also noted that Deceased was wearing a diaper, and that there was fecal matter all over the room. He/She provided a cup of water to Deceased who was mumbling incoherently. Deceased sipped some of the water, but then spat at the officer as he/she walked past the bed. As Subject Officer #2 left the room, Deceased threw the cup of water at the door.

Both officers entered Deceased’s room between 10:30 p.m. and 10:45 p.m. Prior to that, Deceased’s behaviour had degenerated further. He had been smearing his feces on the bed, his face, his forehead and his arms. He was also ingesting feces and clumps of his own hair. As such, the decision was made to sedate Deceased. The officers, along with five nurses and three hospital security guards, donned gowns, gloves and masks prior to entering the room. Subject Officer #2 states that he/she was provided a towel by a nurse, and told to hold it against Deceased’s mouth to prevent him from biting and spitting. While the security guards held down Deceased’s legs, Subject Officer #1 held his left arm and Subject Officer #2 used to the towel to block Deceased’s mouth and force his head down. Deceased was breathing, snorting and biting the towel during the exchange. The sedative was successfully administered and Deceased went to sleep within five minutes.

At approximately 1:00 a.m. on July 11, 2015, the decision was made to again enter Deceased’s room so that he could be cleaned up. The two officers and four nurses again donned protective clothing and went inside, which prompted Deceased to wake up. He sat up and began yelling at the police officers and hospital staff. He pulled feces from his rectum and put it in his mouth. He then spit it out and threw it about the room. Subject Officer #1 was directed by the lead nurse to hold down Deceased’s left arm to prevent him from procuring anything else to throw. Subject Officer #2 took a towel to both cover Deceased’s mouth and hold his head against the bed as he/she had done earlier. While Deceased was being restrained, he kicked, hit and grabbed at the nurses who were attempting to clean him and his bedding. Suddenly, he stopped moving. It was determined that he was absent vital signs and a “code blue” was called. Resuscitation efforts were performed for approximately 25 minutes, but were ultimately unsuccessful. Deceased was pronounced dead at 1:30 a.m.

The issue that I need to determine is whether or not the actions of either of the subject officers were a significant contributing cause of Deceased’s death. My conclusion is that neither officer did anything that could reasonably satisfy the essential offence element of causation. First, although Subject Officer #1 did not provide an interview or his/her notes to this Unit (as is his/her legal right), the accounts of everyone else present are consistent about his/her actions. Subject Officer #1’s role was limited to restraining Deceased’s left arm while the nurses attempted to clean him and the room. There is absolutely no basis to conclude that his/her holding onto Deceased’s arm had any adverse effect whatsoever on his well- being. As such, no charges will issue with respect to Subject Officer #1.

The actions of Subject Officer #2 require a more detailed analysis of the facts and medical evidence. He/She held Deceased’s head down by placing a towel over his mouth. This raises the concern that Deceased may have been unable to breathe, which in turn led to his demise. Subject Officer #2, as well as all four of the nurses in the room at the time, all indicated that Deceased had no difficulty breathing while he was being restrained. The towel was placed over his mouth, but his nose was unobstructed and no force was applied to his throat. Moreover, all witnesses recalled that Deceased was audibly snorting through his nose and yelling through the towel during the exchange. On the observable facts alone, it would not appear that Subject Officer #2’s actions prevented Deceased from breathing.

Further, a post-mortem examination was finalized on April 7, 2016 and received by the SIU on April 18, 2016. The forensic pathologist, Dr. Doctor, was unable to determine the cause of death. However, mechanical asphyxiation was explicitly excluded as a cause of death. There was no medical evidence of any obstruction of Deceased’s airway, nor was there any evidence of pressure having been exerted on his neck or chest.

Deceased appeared to be breathing while he was restrained. Asphyxiation has been definitively ruled out as a cause of death. As such, I cannot reasonably conclude that Subject Officer #2’s actions contributed in a significant way to Deceased’s death. As such, no charges will issue with respect to Subject Officer #2.

Deceased’s death is tragic. However, it does not attract any criminal liability on the part of either of the subject officers.

Date: June 9, 2016

Original signed by

Tony Loparco
Director
Special Investigations Unit