SIU Director’s Report - Case # 18-POD-180


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Mandate of the SIU

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.

Information Restrictions

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.

Mandate Engaged

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 28-year-old man.

The Investigation

Notification of the SIU

On June 15, 2018, at 12:50 p.m., the Ontario Provincial Police (OPP) reported the following information:

On June 9, 2018, at 12:33 p.m., Elgin County OPP Detachment received a call from a woman identified as Civilian Witness (CW) #2, [now known to be her sibling, CW #1] stating that she found her brother, the Complainant, hanging in his residence in Port Stanley.

Elgin County Emergency Medical Service (EMS) and Fire Department personnel were dispatched in response to the 911 call that was tiered to include the OPP communications centre.

The OPP reported that the Subject Officer (SO), who was not at the scene but en route to it, told the OPP dispatcher that if the Complainant had been hanging for some time, he was not to be cut down and that this information was to be relayed to EMS and fire service dispatchers. The EMS dispatcher responded by refusing this direction and the SO’s direction was repeated by the OPP dispatcher.

At 12:41 p.m., firefighters were first to arrive at the scene. At 12:43 p.m., they reported that the Complainant was obviously Vital Signs Absent (VSA) and they would not cut him down.

EMS personnel arrived shortly thereafter and reported that signs of life were evident and that lifesaving attempts were viable. They cut the Complainant down and administered cardiopulmonary respiration (CPR), then transported him to the St. Thomas Elgin County Hospital where he was placed on life support. He was pronounced dead on June 13, 2018.

WO #1 was the first OPP officer to arrive at the scene in Port Stanley, but arrived after fire service and EMS personnel, as did WO #2.

The Team

Number of SIU Investigators assigned: 4
Number of SIU Forensic Investigators assigned: 1


28-year-old male, deceased

Civilian Witnesses

CW #1 Interviewed
CW #2 Interviewed
CW #3 Interviewed
CW #4 Interviewed
CW #5 Interviewed
CW #6 Interviewed
CW #7 Interviewed
CW #8 Interviewed
CW #9 Interviewed
CW #10 Interviewed
CW #11 Not interviewed (Next-of-kin)

Witness Officers

WO #1 Interviewed
WO #2 Interviewed
WO #3 Interviewed
WO #4 Interviewed
WO #5 Notes reviewed, interview deemed not necessary

Subject Officers

SO Interviewed, and notes received and reviewed


The Scene

The scene was confined to the interior of the residential property in Port Stanley. The stairway, from which the Complainant was reported to have been hanging, was directly across from the front door with two steps up to a first landing. The next elevation was 90 degrees to the left where one step led up to a second landing. To the left of the second landing were six additional steps that led up to the second floor. There were decorative handrails along both sides of the stairway. The handrails consisted of two parallel cross-members with central decorative details that also had two cross-members.

At the time of the SIU Forensic Investigators’ (FIs) attendance on June 26, 2018, the SIU had no direct information as to where and how the Complainant hanged himself in the residence other than from the stairway with a belt. Marks were found on support beams over the first landing that supported the upper stairs leading to the upper third floor area. Photographs were made of the area and measurements were made of the vertical aspects of the stairway. Measurements had been made at the scene and it was determined that the distance from the lower cross-member to the landing was 1.5 metres.

Physical Evidence

On June 26, 2018, at 4:35 p.m., the SIU FIs met with CW #2 in Port Stanley and received a black leather belt that had been cut into two pieces. At that time, CW #2 advised that her brother had been hanging from the lower cross-member of the decorative railing above the second landing on the stairway near the wall. This area had already been photographed prior to the SIU receiving of the belt.

On June 27, 2018, the belt was photographed and measured. The belt was a Kirkland brand belt size 34/85. One piece of the leather belt with the buckle was measured and found to be 28 inches long, with 26 inches of belt and two inches of belt for the buckle. The other piece of the belt was measured and found to be 13 inches long.

Communications Recordings

EMS Communications Audio Recordings Summary

At 12:32 p.m., on June 9, 2018, a distraught female [now known to be CW #1] called 911 for an ambulance and reported her 28-year-old brother [now known to be the Complainant] had hanged himself in Port Stanley. CW #1 was asked if she could cut the Complainant down and she replied, "I don’t know," and said she could not talk anymore. A woman who identified herself as the neighbour spoke and said they were the only two there. The neighbour did not want to go into the house. CW #1 could not go in as she had her two children with her. The neighbour reported she last saw the Complainant at 7:00 p.m. the night before and that he had a friend at the house. The neighbour was encouraged to cut the Complainant down, in order that CPR could be done when help arrived.

At 12:32 p.m., the Central Elgin Fire Services (CEFS) was called by the ambulance call taker and told that a ‘medical fire response’ was needed in Port Stanley for a 28-year-old man that had hanged himself and was VSA. The OPP were called and the same information was relayed, but the OPP were also told that the ambulance call taker was trying to get the man cut down.

At 12:33 p.m., CW #3 and CW #4 of the EMS were dispatched to the hanging of a 28-year-old man and were told that it was unknown how long the Complainant had been there, and it was a neighbour that had called. They were further advised that the OPP were on the way.

At 12:37 p.m., the OPP called [believed to be a dispatcher in the OPP communications centre] and enquired how long the Complainant had been there. The reply was that it was unknown. The caller said, “The SO is just requesting if he’s been there for some time, we’re requesting he not be cut down.” The request was acknowledged and then the caller said the OPP were 20 minutes away.

At 12:39 p.m., there was an internal EMS telephone call and when the caller repeated what the SO had requested, she was cut off and told by the recipient of the call, “That’s ridiculous, no.” When asked if she should call fire, the caller was told, “Absolutely not.”

At 12:40 p.m., London EMS called the OPP. The caller stated that they got a call from the OPP requesting EMS to tell fire not to cut down the patient if it looks like he’s been there awhile. The caller stated, “We are not going to call fire and say that. You can.” The caller also advised that this was not their protocol, that their protocol was to try to get the person down. The caller again stated they would not tell the CEFS to not cut the patient down.

At 12:41 p.m., CW #3 of the EMS asked if the CEFS was on the scene and he was told no update had been received. At 12:45 p.m., EMS paramedics, CW #3 and CW #4, arrived at the house.

At 12:46 p.m., the CEFS called the EMS and said that she had spoken to the OPP, who had not arrived at the scene yet. The CEFS caller realized that EMS was on the scene, but reported that the OPP had requested that nobody do anything with the man “right now;” to leave him as is and not to cut him down. The EMS were told that the caller did not know how many family members were on the scene and she was trying to keep it quiet by using the telephone rather than radio communications.

At 12:49 p.m., EMS CW #5 arrived at the scene.

At 12:51 p.m., CW #3 advised that the Complainant was VSA, but that they were working on him. He further requested that the hospital in St. Thomas be alerted that the Complainant would be coming to the emergency department. At 12:52 p.m., the emergency department was notified of the 28-year-old that had hanged himself and that paramedics were bringing him to the hospital.

At 12:59 p.m., CW #3 communicated with the emergency department and reported the condition of the Complainant. He also stated that the Complainant was still alive and that he was warm to the touch when cut down.

At 1:05 p.m., CW #5 requested that the hospital be told the Complainant was last known to be alive at 10:59 a.m., when he text-messaged a family member.

CEFS Communications Audio Recordings Summary

At 12:32 p.m., on June 9, 2018, the EMS communications centre called the OPP communications centre and advised that the EMS were going to Port Stanley for a 28-year-old man that was VSA from a hanging.

At 12:40 p.m., the EMS call-taker acknowledged that CEFS personnel were at the scene and she advised that the OPP would be contacted for their estimated time of arrival. Dialing could be heard and the call made by the CEFS dispatcher was answered by the OPP communications centre call taker. The CEFS dispatcher identified herself and asked if the OPP were going to the hanging in Port Stanley. The OPP communications centre call taker said they were and he identified the address. The CEFS dispatcher advised that they had just arrived on scene. The OPP communications centre call taker replied that OPP officers were south of St Thomas.

The following audio-recorded conversation ensued.

OPP: If you guys are on scene can you make sure he is not cut down.
CEFS: (To OPP) Okay yeah.
CEFS: Can you standby, I have OPP on the line before you proceed. Time is 1241. I’ll talk to them directly.
CEFS: (To OPP) So OPP, so you’re south of St. Thomas:
OPP: Yep and our request is if the male has not been cut down already, if he can stay that way.
CEFS: (To OPP) Yeah, like…
OPP: We’ve already advised ambulance of this.
CEFS: (I/A) standby, I’ll call you right now while I have OPP on the line.
CEFS: (To OPP) I’m going to call them right now actually while you are on the phone with me.
OPP: Okay.
CEFS: (dialing heard) I’m trying to keep some of this off the radio waves and…
Car 1: Reported he was on location.
CEFS: At 1241 hrs, Rescue, can you stand by I have OPP on the line before you proceed.
RESCUE: Acknowledged.
CEFS: Rescue standby, I’m going to call you right now while I have OPP on the line.
CEFS: Hi its [CEFS] calling. I have OPP on the line right now. Apparently they are en route. They are south of St. Thomas.
CEFS: (To OPP) What did you think your ETA was approximately?
OPP: I’m not sure.
CEFS: Okay, but they’re asking, if obv… if VSA. Yea okay definitely VSA sir and they’re requesting if he’s not been cut down…
OPP: Just to make sure he’s not cut down…
CEFS: Okay if he’s still…
OPP: Only if he’s…
CEFS: Okay no he has not been…
OPP: …been there for some time.
CEFS: Okay, he’s not been cut down at all. Okay I’m just going to relay that okay.
CEFS: (To OPP) OPP I’m letting you know that fire says he has not been cut down.
OPP: Okay.
CEFS: Okay.
OPP: Has not yet been cut down.
CEFS: No has not yet been cut down.
OPP: Okay.
CEFS: Okay, there’s been no ment... No move to do anything with him right now.
CEFS: (To OPP) I’m asking that of Rescue, sorry. Okay.
OPP: Yea, so the request is…
CEFS: (To OPP) Rescue is on scene and they just confirmed he is VSA and he’s not been cut down, okay.
OPP: Okay, yeah, only if he has been there for some time is what our request is.
CEFS: Okay.
OPP: So he’s obviously VSA.
CEFS: Okay, OPP is requesting then…Yes he is obviously VSA.
OPP: and I would think if …
CEFS: The OPP requesting if he has been there for a long time….
OPP: No, for some time,
CEFS: I’m sorry for some time…
OPP: If he’s obviously VSA than I would think that leaving him there would be the best course of action.
CEFS: Okay, they are saying that…they are just requesting if he is VSA then just leave him as is until OPP arrive on scene.
OPP: Yep and if that changes within the…
CEFS: Okay.
OPP; the next minute or so
CEFS: And yeah…
OPP: …of course we will give you a call.
CEFS: …and if that has to change at all just call me back on or let me know to contact over the radio. I’ll call you immediately on this line again so can update the OPP. Okay fair enough. Okay thanks. Okay bye.
CEFS: (To OPP) Hi, okay, I’ve given them all the messages. So no they are not going to do anything. They’ll stand back and wait.
OPP: I appreciate that yeah…
CEFS: No problem.
OPP: So we’re on the way and as quick as that changes we’ll let you know exactly.

OPP Communications Audio Recordings Summary

Audio Recording #1
At 12:33 p.m., on June 9, 2018, the EMS notified the OPP that they were responding from St. Thomas to a reported hanging of a 28-year-old man [now known to be the Complainant] who was VSA in Port Stanley. The EMS was trying to have a party that was on scene cut the Complainant down for CPR. The EMS was told that the OPP were on the way. The OPP communications centre supervisor, WO #5, was immediately notified of the situation by the OPP communications centre call taker. At 12:41 p.m., the CEFS dispatcher called and spoke to the OPP call taker. It was confirmed that the OPP was going to the reported hanging. The CEFS had just arrived at the scene and they asked if the OPP was coming. The OPP call taker confirmed that the OPP was responding from south of St. Thomas.

Audio Recording #2

At 12:46 p.m., an OPP dispatcher called WO #5 and advised him that the SO was requesting WO #3 be contacted.

At 12:52 p.m., WO #5 called WO #3 and notified him of the suicide in Port Stanley. He further advised that the man was found hanging and that EMS was trying to convince the people at the residence to cut him down.

WO #3 was told the SO was at the scene and requested a call. WO #5 went on to say that the OPP just got there. The fire department cut the man down and they were doing chest compressions. There was no ambulance on scene.

At 12:57 p.m., the OPP dispatcher called WO #5 and updated him that the Complainant was being taken to the hospital, but he was still VSA. It was further stated that a belt was used around his neck. The OPP dispatcher called and told WO #5 that the SO was requesting the name of WO #3. She was told WO #3’s name.

At 1:59 p.m., the SO called WO #5 and advised that the Complainant was still alive, but they did not know how long he was there. The SO stated that the CEFS would not cut the Complainant down, on his direction. The SO explained that was not what he said, but that he said if it was obvious he’d been there a while, then not to cut the rope. The SO said apparently the CEFS did not even go in the house, but ambulance showed up and got him down. They got a signal and shocked him. He said they were waiting to see what type of brain function he was going to have.

Audio Recording #3
At 12:34 p.m., the SO advised the OPP dispatcher that he had just read the Computer Aided Dispatch (CAD) screen and requested, “If the male’s been there for a while if we can have the ambulance not, instruct them not to cut the male down that would be fantastic.” The OPP dispatcher acknowledged that she would advise EMS. The SO then stated, “Obviously that depends how long he’s been there,” and again the OPP dispatcher acknowledged the request.

At 12:38 p.m., the OPP dispatcher told the SO that she just got off the telephone with EMS and they’re not sure how long the male has been there, but have been advised of his request. The SO replied, “Unless they are trying to save his life, but if he’s been there awhile we will take care of everything.” The OPP dispatcher acknowledged hearing his communication.

At 12:43 p.m., the OPP dispatcher advised the SO that the fire crew was on the scene and that the male party was still as found at that point. The SO acknowledged hearing the information.

At 12:44 p.m., the SO was informed that the fire crew was in the beach house and advised that the man was obviously VSA, and they would not be cutting him down. The SO acknowledged this information and advised that he was a couple minutes from the scene, then asked which Detective Sergeant was on duty.

At 12:48 p.m., WO #1 said she was on scene and it looked like they, meaning CEFS and EMS personnel, were trying to do compressions on the man.

At 12:50 p.m., the SO was at the scene, and at 12:59 p.m., the SO was told that WO #3 had been notified and he would be calling the SO.

Audio Recording #4
At 12:37 p.m., there was a call made to the EMS. The caller confirmed that EMS was going to Port Stanley. The caller asked if EMS knew how long the man had been there. She was told that the EMS did not know. The caller relayed the message that the SO requested, “If he’s been there for some time we’re requesting he not be cut down.” When asked, the caller stated the closest OPP officer was 20 minutes away. The ambulance dispatcher replied, “I’ll let them know that.”

At about 12:45 p.m., the telephone was heard to ring and the OPP dispatcher spoke to WO #5 advising him that the SO was requesting WO #3 be contacted.

At 12:55 p.m., the SO called the OPP dispatcher and advised that the Complainant was being transported to the hospital, but he was still VSA. The OPP dispatcher asked if the Complainant was there for some time and she commented, “They were not obviously understanding what I was saying.” The SO spoke of the difficulty to relay that message. He further explained, “I was more concerned about the knot if he’s been there,” then stated that actually a belt had been used.

At 12:57 p.m., the OPP dispatcher called WO #5 and updated him that the Complainant was being transported to the hospital, but he was still VSA. WO #5 was told a belt was used around his neck.

Audio Recording #5
London EMS communications centre called the OPP communications centre reporting that they got a call from the OPP requesting EMS to tell the fire department personnel not to cut down the patient if it looked like he had been there awhile. The OPP dispatcher acknowledged the call and that that was the case. The London EMS communications centre caller stated, “We are not going to call fire and say that. You can,” and advised that this was not their protocol, that their protocol was to get the person down and reasserted they would not tell the CEFS to refrain from cutting the Complainant down.

Materials obtained from Police Service

Upon request the SIU obtained and reviewed the following materials and documents from the OPP:
  • Communications audio recordings;
  • Event Details;
  • General Report;
  • Notes of the SO, WO #1, WO #2, WO #3, and WO #4;
  • Occurrence {Person}-the Complainant;
  • Occurrence Details (x2);
  • Occurrence Summary;
  • OPP Witness Statement of CW #1 and CW #6;
  • OPP Witness Statement- CW #1;
  • SIU Request Letter with OPP markings-June 18, 2018.

Incident Narrative

The material events in question are relatively clear on the information gathered in the SIU investigation, which included statements from the subject officer, the paramedics and several firefighters, as well as a review of the communication recordings from the police, the fire department (FD) and the emergency medical service (EMS). On June 9, 2018, shortly after 12:30 p.m., a 911 call was received by the EMS indicating that the Complainant was found hanging in his residence. The call was placed by one of the Complainant’s sisters, and the EMS call taker asked if the caller was able to cut the Complainant down in preparation for medical treatment with the arrival of first responders. She replied she was not sure.

The SO, the road supervisor in the area, learned of the event while at another call for service. Reviewing the details that were known at the time from his mobile data terminal, the officer came to understand that the Complainant was vital signs absent. He was also aware that the EMS 911 call taker was attempting to have someone at the scene cut down the Complainant. The SO communicated with the OPP dispatcher and asked that the EMS dispatcher be contacted with the request that the Complainant not be cut down if “the male’s been there for a while.” If the Complainant was clearly dead, then the officer was of the view that as little as possible be done to disturb the scene so that the police might investigate the matter to rule out any possible foul play.

The SO’s direction made its way via the OPP communications centre through to the FD dispatch and ultimately the firefighters at the scene, who were the first emergency responders to arrive at the residence at about 12:40 p.m. The FD communications indicate that when the firefighters arrived the Complainant was still hanging and was believed to be vital signs absent. This message was conveyed and FD dispatch requested that he be left as is until the OPP arrived. It was now about two minutes since the firefighters had arrived at the scene. At 12:45 p.m., two paramedics with the EMS arrived at the residence and one noted that the Complainant was warm to the touch and still alive. The Complainant was cut down by the paramedics and brought outside, where the paramedics and firefighters collaborated in administering life-saving measures.

The Complainant was transported by ambulance to hospital and ultimately diagnosed with an unrecoverable hypoxic brain injury. He was declared dead on June 13, 2018. The pathologist who performed the post mortem examination concluded in his report that the immediate cause of the Complainant’s death was “hanging”. 

Cause of Death

A physician ascertained that the Complainant sustained an anoxic brain injury secondary to suicide attempt by hanging. There was no hope for any meaningful neurologic recovery and the Complainant became deceased in hospital on June 13, 2018. On June 18, 2018, at 2:58 p.m., an anatomical pathologist with the London Health Sciences Centre (LHSC) advised the SIU that the post-mortem examination of the Complainant was limited to an external examination and that the findings were consistent with hanging by the neck and with the history obtained.

Relevant Legislation

Section 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.

Analysis and Director's Decision

The Complainant was pronounced deceased on June 13, 2018 at St. Thomas Elgin General Hospital when he was removed from life support. The Complainant had been brought to the hospital with vital signs absent by ambulance on June 9, 2018. The paramedics had responded to the Complainant’s residence in Port Stanley following a 911 call by his family indicating he had been discovered hanging. Elgin County firefighters and OPP officers, including the SO, had also been dispatched to the scene. For the reasons that follow, there are no reasonable grounds, in my view, to believe that the SO committed a criminal offence in connection with the circumstances surrounding the Complainant’s death.

The offence that arises for consideration is that of criminal negligence causing death contrary to section 220 of the Criminal Code. The offence is predicated, in part, on conduct that amounts to a marked and substantial departure from the level of care that a reasonable person would have exercised in the circumstances: see R v F(J), [2008] 3 SCR 215. In the context of this case, the question is whether the SO’s instruction amounted to criminal negligence. [1] While I harbour concerns about the manner in which the SO’s message was communicated, I am satisfied on reasonable grounds that the SO exercised a level of care that fell within the limits prescribed by the criminal law.

The 911 call that triggered the emergency response related to a man that was potentially dead or, at the very least, dying. Precision in communication on the part of first responders was of the essence to ensure they were working with accurate information and in the best position to do what they could to render assistance as quickly as possible. Regrettably, it appears the SO’s communiqués were something less than precise. At about 12:34 p.m., the officer said the following to the OPP dispatcher, “If the male’s been there for a while if we can have the ambulance not, instruct them not to cut the male down that would be fantastic.” He quickly followed with, “Obviously that depends how long he’s been there.” At about 12:38 p.m., the SO is assured by the OPP dispatcher that his message has been conveyed to the EMS, and responds by saying, “Unless they are trying to save his life, but if he’s been there a while we will take care of everything.” While I accept that the SO was not attempting to delay or bar the Complainant’s body from being cut down short of it being apparent that he was obviously dead, the officer would have been better advised to have made that crystal clear. He could have used those words exactly – “obviously dead” – particularly as it appears to be a term of art among first responders differentiating the condition from a “vital signs absent” diagnosis, instead of referring to the length of time the Complainant may have been hanging to get his point across. As it turns out, that message appears to have resulted in confusion as it was relayed via dispatchers to the firefighters at the scene, who were of the view that they were being asked to stand down pending the OPP’s arrival. Unfortunately, the SO, when informed at about 12:44 p.m. that the firefighters would not be cutting the Complainant down because he was obviously vital signs absent, failed to appreciate and make clear that they should act unless the Complainant was obviously dead, not simply without vital signs. His failure to do so may well have contributed to at least part of the delay incurred in cutting the Complainant down and rendering life-saving measures.

On the other hand, the SO was not wholly responsible for the confusion on the ground among the firefighters as to the true nature of his request. While the officer could have chosen his words more carefully, I am satisfied on a fair reading of his transmissions that he was asking that the Complainant’s body not be disturbed once it was determined he was obviously deceased. The fact that the SO’s message was miscommunicated and/or misinterpreted in the process of it being transmitted among and between the OPP, the FD and the EMS is highly regrettable, but not completely the SO’s fault. It is also important to note that the emergency personnel who responded to the scene ahead of the police were in a position to make their own assessments of the situation and act accordingly. While some of them may have felt constrained in their actions given what they believed was an instruction from the OPP, they were surely duty bound to take steps to save a life if they believed that was possible. Whether or not they took adequate steps in the circumstances, the fact they were present and in a position to do something further attenuates the SO’s responsibility, regardless of the merits of his communiqués.

In the final analysis, while the SO’s conduct in responding to the 911 call involving the Complainant was not perfect, he had a legitimate basis for asking that the Complainant not be cut down if he was clearly dead so as to preserve a viable investigation for potential criminality. Thereafter, as I am satisfied that he was not entirely responsible for the confusion that surrounded his request, the officer’s conduct did not in my view amount to a marked and substantial departure from a reasonable level of care in the circumstances. Accordingly, this file is closed.

Date: June 27, 2019

Original signed by

Joseph Martino
Interim Director
Special Investigations Unit


  • 1) The offence is also not made out unless the impugned conduct can be said to have caused the death in question, in the sense that it was “a significant contributing cause” of the fatality: R v Nette, [2001] 3 SCR 488. While I have decided to resolve the liability analysis on the basis of whether the SO’s message and the manner in which it was delivered constituted a marked and substantial departure from a reasonable level of care in the circumstances, it should be noted that causation was a live issue in this case. [Back to text]


The signed English original report is authoritative, and any discrepancy between that report and the French and English online versions should be resolved in favour of the original English report.