Director's Report Details

The Special Investigations Unit is a civilian law enforcement agency that investigates incidents involving police officers where there has been death, serious injury or allegations of sexual assault. The Unit’s jurisdiction covers more than 50 municipal, regional and provincial police services across Ontario.

Under the Police Services Act, the Director of the SIU must determine based on the evidence gathered in an investigation whether an officer has committed a criminal offence in connection with the incident under investigation. If, after an investigation, there are reasonable grounds to believe that an offence was committed, the Director has the authority to lay a criminal charge against the officer. Alternatively, in all cases where no reasonable grounds exist, the Director does not lay criminal charges but files a report with the Attorney General communicating the results of an investigation.

Freedom of Information and Protection of Privacy Act (“FIPPA”)

Pursuant to section 14 of FIPPA (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 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. 

Pursuant to section 21 of FIPPA (i.e., personal privacy), protected personal information is not included in this document. 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; 
• 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 (“PHIPA”)

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

Other proceedings, processes, and investigations

Information may have also 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.

The Unit’s investigative jurisdiction is limited to those incidents where there is a serious injury (including sexual assault allegations) or death in cases involving the police.

“Serious injuries” shall include those that are likely to interfere with the health or comfort of the victim and are more than merely transient or trifling in nature and will include serious injury resulting from sexual assault. “Serious Injury” shall initially be presumed when the victim is admitted to hospital, suffers a fracture to a limb, rib or vertebrae or to the skull, suffers burns to a major portion of the body or loses any portion of the body or suffers loss of vision or hearing, or alleges sexual assault. Where a prolonged delay is likely before the seriousness of the injury can be assessed, the Unit should be notified so that it can monitor the situation and decide on the extent of its involvement.

This report relates to the SIU’s investigation into the death of a 35-year-old man (the “Complainant”).

Notification of the SIU

On August 6, 2019, at 8:25 p.m., the Chatham-Kent Police Service (CKPS) reported the following. At 7:00 p.m., CKPS officers went to a residence on Grant Street in Chatham to assist Emergency Medical Services (EMS) with an overdose. When the police officers arrived, the Complainant was on the stretcher and being loaded into the ambulance. A CKPS officer went in the ambulance and travelled with the Complainant to the hospital. The Complainant was combative but restrained at the time. Once they arrived at the hospital, two CKPS officers also arrived. The Complainant continued to be combative and was spitting at the police and hospital staff. The police officers physically controlled him. NARCAN was administered and the Complainant went vital signs absent (VSA). He was revived but went VSA again. The Complainant was pronounced deceased at 7:46 p.m.

The Team

Number of SIU Investigators assigned: 4
Number of SIU Forensic Investigators assigned: 2

Complainant:

35-year-old male, deceased

Civilian Witnesses (CW)

CW #1 Interviewed
CW #2 Interviewed
CW #3 Not interviewed (Next-of-kin)
CW #4 Interviewed
CW #5 Interviewed
CW #6 Interviewed
CW #7 Interviewed
CW #8 Interviewed

Witness Officers (WO)

WO #1 Interviewed, notes received and reviewed
WO #2 Interviewed, notes received and reviewed

Subject Officer (SO)

SO Declined interview and to provide notes, as is the subject officer’s legal right

The Scene

The Complainant was carried by the paramedics from his residence into the ambulance. Once in the ambulance, the SO entered the back of the ambulance for transport to the Chatham Kent Health Alliance (CKHA). Once at CKHA, within two minutes of entering the trauma room, the Complainant went VSA and CPR was administered.

Video/Audio/Photographic Evidence

Closed-circuit Television (CCTV) Recordings from a Residence on Grant Street

An SIU investigator secured a copy of CCTV recordings from a residence on Grant Street.

At 6:50:05 p.m., an ambulance with emergency lights activated arrived and parked in front of the Complainant’s residence.

At 6:50:27 p.m., a paramedic got out of the driver’s side door of the ambulance and, at 6:51:12 p.m., paramedics carried a stretcher towards the residence.

At 6:59:58 p.m., a CKPS police vehicle parked behind the ambulance and another CKPS police vehicle parked behind the first police vehicle.

At 6:59:59 p.m., a paramedic ran from the rear of the ambulance to the driver’s side door.

At 7:00:00 p.m., the second police vehicle reversed, followed by the ambulance and the first police vehicle.

At 7:00:13 p.m., the ambulance, followed by both CKPS police vehicles, drove away with emergency lights activated.

Police Communications Recordings

CKPS provided a copy of their communication recordings for August 6, 2019.

At 6:43 p.m., a man called 911 requesting an ambulance to a residence on Grant Street. At 6:52 p.m., the Wallaceburg Central Ambulance Communications Centre called CKPS requesting police attend the residence on Grant Street to assist with a 35-year-old male [now known to be the Complainant]. The Complainant had a reaction to a drink that an unknown person gave him. The paramedics were requesting the police to attend.

At 6:54 p.m., the EMS made an urgent request for assistance. The paramedics needed assistance with a patient at the same address on Grant Street. At 6:58 p.m., a police officer advised that units [now known to be the SO, WO #1 and WO #2] were on scene. At 6:59 p.m., a police officer advised that the Complainant was combative and the SO would be in the ambulance with EMS; WO #1 and WO #2 would follow. At 7:09 p.m., a police officer said the Complainant had gone VSA on the hospital bed and CPR was being administered.

At 7:14 p.m., the SO called a sergeant (parts of the conversation were inaudible). The SO said the Complainant was VSA and still being worked on. The Complainant was in the ambulance when police arrived at the scene and the SO went in the ambulance because the Complainant was combative. The SO and a male paramedic [now known to be CW #5] restrained the Complainant while they travelled to the hospital. The Complainant was handcuffed to the EMS stretcher. In the trauma room, the Complainant sat up, took a couple swings and kicked at the nurses. The SO, WO #1 and WO #2 secured the Complainant and the Complainant had a spit hood on. The SO secured his head and arms while WO #1 and WO #2 secured his feet. The SO, WO #1 and WO #2 held the Complainant for a couple of minutes as he kept trying to fight. The hospital staff were doing their assessment and then someone said, “He’s out.” The SO, WO #1 and WO #2 released their hold of the Complainant. The medical staff had been working on him since but he remained VSA. The SO said he and WO #2 would remain at the hospital and WO #1 would return to the scene. The family was at the hospital and they might have issues. The accusation was that someone had put something in the Complainant’s drink and he spoke gibberish.

At 7:22 p.m., the SO called the sergeant to advise that medical staff had obtained a faint pulse. The SO spoke to the female paramedic [now known to be CW #6] and confirmed that the Complainant had an allergic reaction to a drink. He had taken a shower and his behaviour changed after that.

At 7:32 p.m., the SO called the sergeant and advised the Complainant was VSA again. The medical staff continued CPR on the Complainant. The paramedics told the SO that they were told the Complainant was acting odd for 30 minutes before the EMS were called. The sergeant said it sounded like possible excited delirium and the SO said the doctors gave him a few doses of NARCAN, a brief pulse was obtained, then he arrested again. The doctor said he had possibly used methamphetamine and fentanyl.

At 7:44 p.m., the SO called the sergeant. The doctor [now known to be CW #8] had told the SO that the Complainant was going to die. The medical staff were performing CPR for a while and keeping him alive. The Complainant had taken something that prevented his heart from beating and CW #8 thought a cutting agent was responsible for his condition.

At 7:49 p.m., WO #2 called to confirm the Complainant was pronounced dead at 7:43 p.m.

Materials obtained from Police Service

Upon request, the SIU obtained and reviewed the following materials and documents from CKPS:

• Background Event Chronology;
• Communication Recording 911;
• General Occurrence;
• Notes-WO #2;
• Notes-WO #1;
• Will say-WO #2; and
• Will say-WO #1.

Materials obtained from Other Sources

The SIU obtained and reviewed the following records from non-police sources:

• CCTV footage from a Residence on Grant Street;
• Ambulance Call Report;
• EMS Occurrence Report – CW #5;
• EMS Occurrence Report – CW #6;
• Medical Records – CKHA; and
• Post-mortem Examination and Toxicology Reports (provided to the SIU on August 25, 2020).

The following scenario emerges from the evidence collected by the SIU, which included interviews with two police officers who had dealings with the Complainant in the moments prior to his death, paramedics and hospital staff, as well as a review of the post-mortem examination report. As was his legal right, the SO chose not to interview with the SIU or authorize the release of his notes.

In the evening of August 6, 2019, the SO, with his partner, WO #1, and WO #2, were dispatched to an address on Grant Street. Paramedics had earlier been called to the scene for a male – the Complainant – who had reportedly had a reaction to something he had imbibed. The paramedics – CW #6 and CW #5 – had encountered a frantic situation on their arrival at the residence. The Complainant was in a seated position at the top of a flight of stairs from the main floor doorway, foaming at the mouth, speaking gibberish and flailing his limbs. His brother was belligerent with the paramedics and yelled at them to remove the Complainant from the home, at one point grabbing his brother’s legs and attempting to pull him down the flight of stairs to the main floor. Wishing to prevent physical injury to the Complainant, CW #5 lifted him by his upper body and helped carry the Complainant downstairs. It was right around this time that CW #6, concerned for her and her partner’s personal safety, asked that police be dispatched to the scene.

The Complainant had already been placed on the paramedics’ stretcher and was outside the residence by the time of the officers’ arrival. As the Complainant was spitting uncontrollably, the SO asked WO #1 to retrieve their spit mask, which was then placed on the Complainant. The SO accompanied the paramedics in their ambulance to hospital. WO #1 and WO #2 followed behind in their cruisers.

Once at the hospital, a trip of no more than a couple of minutes, the Complainant was quickly assessed and directed immediately into trauma room “B”. His arms had been handcuffed to the stretcher’s siderail by the SO. It was clear that the Complainant’s condition was dire and life-threatening. The Complainant’s agitation continued in the trauma room. The attending doctor – CW #8 – ordered that the Complainant be placed in soft-restraints.

The SO, WO #1 and WO #2 assisted in keeping the Complainant restrained on the stretcher as one of the nurses, CW #7, attempted to place soft-retrains on his ankles. WO #1 was on the Complainant’s left side pressing his lower left leg down on the stretcher while WO #2 was on the other side doing the same with the Complainant’s right left. The SO was to WO #2’s left using his hands at times to press down on the Complainant’s upper chest.

At some point, the Complainant lifted his upper body off the stretcher a distance and was forced back down by WO #1. [1] More specifically, the officer reached up with a hand and pushed him back down flat on the stretcher. Shortly thereafter, the SO used one or both hands to keep the left side of the Complainant’s head pressed down on the stretcher.

Within several of minutes of being in the trauma room, the Complainant lost vital signs. The medical staff transferred him onto the hospital stretcher and CPR and other life-saving measures were attempted. The Complainant could not be resuscitated and was declared deceased at 7:46 p.m.

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,

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 passed away in hospital in Chatham on August 6, 2019. As CKPS officers had assisted paramedics in his transport to hospital and, thereafter, with his restraint while in hospital, the SIU was notified and commenced an investigation. One of the CKPS officers – the SO – was identified as the subject officer for purposes of the SIU investigation. 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 offence that arises for consideration is criminal negligence causing death contrary to section 220 of the Criminal Code. The offence is reserved for conduct that constitutes a wanton or reckless disregard for the lives or safety of others, which conduct causes or contributes to death. Simple negligence is insufficient to ground liability. What is required, among other things, is conduct that amounts to a marked and substantial departure from a reasonable level of care in the circumstances. In the instant case, the issue is whether there was any want of care in the manner with which the involved officers interacted with the Complainant that was causally connected to his death and was sufficiently egregious to attract criminal sanction. In my view, there was not.

At the outset, it should be noted that the officers were at all times lawfully placed in their dealings with the Complainant. They were acting in the discharge of their foremost duty to protect and preserve life when they answered the call to assist paramedics at the Grant Street address. And they remained within the four corners of that duty as they accompanied the Complainant to hospital and attempted to keep him under control. The Complainant was in a state of extreme agitation, described by some witnesses as excited delirium, and in need of immediate medical attention. That was not likely to happen unless he could be sufficiently subdued to make medical assessment and treatment possible.

The issue turns to the reasonableness of the officers’ interventions. And this, in turn, boils down to the conduct of WO #1 and the SO in the trauma room, namely, their use of force to keep the Complainant’s upper body and head pinned to the stretcher. I take no issue with the force used by WO #1 and WO #2 to keep the Complainant’s legs under control. At the direction of CW #8, CW #7 was attempting to affix soft-restraints on the Complainant’s ankles and clearly needed the officers to help keep the Complainant from flailing his legs.

There is evidence that WO #1, in pushing the Complainant back onto the stretcher, had his hand around the Complainant’s neck for a short period. According to this body of evidence, it is said that as the Complainant “reared” up a distance of about eight centimetres, WO #1 grabbed him by the neck for three to four seconds and slammed him back onto the stretcher. The Complainant’s face turned beet red at this time. In describing a similar incident, it is also said the Complainant lunged at CW #5, the police officers and the nurses in a threatening way, and that WO #1 reacted by pushing down on the Complainant’s chin with his hand. As the Complainant was pushed back, WO #1’s hand slipped from the chin onto his throat, after which the officer withdrew his hand.

There is also evidence that the SO put pressure on the Complainant’s neck as he pressed the Complainant down on the stretcher. It was reported that the SO’s fingers and/or thumb were seen over the Complainant’s neck pinching off his carotid artery. The officer maintained his hold for between two to five seconds, at which time it appeared the Complainant had lost vital signs and the SO removed his hand. It was said in a different version of events that the SO used his left hand to press down on the Complainant’s right cheek so that his head faced left, telling WO #1 to “let go” as he had control. With his thumb on the Complainant’s jawline and his fingers near his eyes, he maintained that hold from anywhere between five to 15 seconds, at the most. Shortly thereafter, the Complainant lost vital signs and CPR was initiated.

While there was conflict in the evidence regarding the officers’ use of manual power to keep the Complainant’s upper body/head area down, I am satisfied there are reasonable grounds to believe it occurred to one extent or another. It should be noted that WO #1 denies having used force of this nature. As far as the officer was concerned, his contact with the Complainant in the trauma room was limited to holding his left leg down. In addition, none of the other persons in the room interviewed by the SIU – CW #8, WO #2 and the nurses – say they saw any force of this nature, albeit it is very possible that they were not in a position to have seen it or simply missed it as it was occurring given the chaotic nature of the circumstances around them. Finally, there were inconsistencies in the body evidence suggesting the SO had contact with the Complainant’s neck with respect to how exactly the contact occurred. Notwithstanding these difficulties, I am unable to dismiss the evidence of some form of neck compression, particularly in light of bruising that was identified at autopsy to the left and right sides of the Complainant’s neck. What, then, is to be made of this evidence?

On the one hand, it would certainly appear from a layperson’s perspective that compressing the neck of a person in obvious and acute medical distress is a bad idea. It does not take any great expertise to appreciate that a disruption of the respiratory and/or circulatory systems of a patient in such condition could contribute to negative health outcomes.

On the other hand, the evidence is ambiguous as to whether the officers intentionally wrapped their hands or fingers over the Complainant’s neck or whether any such contact was inadvertent – the result, for example, of WO #1’s hand slipping from the Complainant’s chin onto the upper chest/neck area. One must also allow for the dynamic situation in which the parties found themselves. If WO #1 and the SO acted improvidently, they did so in a pressure-filled atmosphere in which those gathered around the Complainant believed it was imperative to keep him restrained if he was to receive the medical care he urgently required. Finally, aside from its impact as a restraint-related “stressor”, in like manner to the other physical restraints applied to the Complainant around the time of his death (handcuffs, etc.), there was no affirmative pathological evidence that neck compression or impact induced a reflex cardiac arrest via “carotid bifurcation stimulation”. [2]

On the aforementioned-record, I am unable to reasonably conclude on balance that the officers’ indiscretions, if they be such, were so wanting as to amount to a marked and substantial deviation from a reasonable level of care in the circumstances.

In conclusion, as there are no reasonable grounds to believe that WO #1 and the SO committed the criminal offence of criminal negligence causing death, there is no basis for proceeding with criminal charges in this case. Accordingly, the file is closed.


Date: April 12, 2021

Electronically approved by

Joseph Martino
Director
Special Investigations Unit