SIU Director’s Report - Case # 20-OCI-354


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Mandate of the SIU

The Special Investigations Unit is a civilian law enforcement agency that investigates incidents involving an official where there has been death, serious injury, the discharge of a firearm at a person or an allegation of sexual assault. Under the Special Investigations Unit Act, 2019 (SIU Act), officials are defined as police officers, special constables of the Niagara Parks Commission and peace officers under the Legislative Assembly Act. The SIU’s jurisdiction covers more than 50 municipal, regional and provincial police services across Ontario.

Under the SIU Act, the Director of the SIU must determine based on the evidence gathered in an investigation whether there are reasonable grounds to believe that a criminal offence was committed. If such grounds exist, the Director has the authority to lay a criminal charge against the official. Alternatively, in cases where no reasonable grounds exist, the Director cannot lay charges. Where no charges are laid, a report of the investigation is prepared and released publicly, except in the case of reports dealing with allegations of sexual assault, in which case the SIU Director may consult with the affected person and exercise a discretion to not publicly release the report having regard to the affected person’s privacy interests.

Information Restrictions

Special Investigations Unit Act, 2019

Pursuant to section 34, certain information may not be included in this report. This information may include, but is not limited to, the following: 
  • The name of, and any information identifying, a subject official, witness official, civilian witness or affected person. 
  • Information that may result in the identity of a person who reported that they were sexually assaulted being revealed in connection with the sexual assault. 
  • Information that, in the opinion of the SIU Director, could lead to a risk of serious harm to a person. 
  • Information that discloses investigative techniques or procedures.  
  • Information, the release of which is prohibited or restricted by law.  
  • Information in which a person’s privacy interest in not having the information published clearly outweighs the public interest in having the information published. 

Freedom of Information and Protection of Privacy Act

Pursuant to section14 (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 that 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 (i.e., personal privacy), protected personal information is not included in this report. This information may include, but is not limited to, the following: 
  • The names of persons, including civilian witnesses, and subject and witness officials; 
  • 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

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

Other proceedings, processes, and investigations

Information may also have 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

Pursuant to section 15 of the SIU Act, the SIU may investigate the conduct of officials, be they police officers, special constables of the Niagara Parks Commission or peace officers under the Legislative Assembly Act, that may have resulted in death, serious injury, sexual assault or the discharge of a firearm at a person.

A person sustains a “serious injury” for purposes of the SIU’s jurisdiction if they: sustain an injury as a result of which they are admitted to hospital; suffer a fracture to the skull, or to a limb, rib or vertebra; suffer burns to a significant proportion of their body; lose any portion of their body; or, as a result of an injury, experience a loss of vision or hearing.

In addition, a “serious injury” means any other injury sustained by a person that is likely to interfere with the person’s health or comfort and is not transient or trifling in nature.

This report relates to the SIU’s investigation into serious injuries sustained by a 54-year-old woman (the “Complainant”).

The Investigation

Notification of the SIU

On December 16, 2020, at 2:11 p.m., the Belleville Police Service (BPS) notified the SIU of an injury to the Complainant.

The BPS advised that on December 15, 2020, at 11:30 p.m., BPS received a call to assist Emergency Medical Services (EMS) at a residential address in Belleville. The Complainant had left the Belleville General Hospital (BGH) and they wanted her returned.

When the police officers arrived, they assisted the paramedics and the Complainant was taken to the BGH. The BGH staff refused to take the Complainant indicating she had already been discharged. The police officers decided to arrest the Complainant for breach of the peace and took her to the police station, arriving at 11:55 p.m. The Complainant was lodged in a cell.

On December 16, 2020, at 2:15 a.m., the Complainant was observed to be vomiting and EMS was called. She was taken back to the BGH and placed on a life support system.      

The Team  

Date and time team dispatched:     12/19/2020 at 10:39 a.m.

Date and time SIU arrived on scene:     12/21/2020 at 11:30 a.m.

Number of SIU Investigators assigned:      3

Three SIU investigators were assigned to investigate the incident. Due to the Coronavirus pandemic and Covid-19 protocols, arrangements were made to have SIU investigators conduct interviews with the Complainant, civilian witnesses and witness officials by telephone. 
Following a preliminary investigation, the Subject Official (SO) was designated as a subject official on December 17, 2020. The SO presented for a teleconference interview with his counsel on January 14, 2021, but did not consent to the release of his notebook entries to the SIU.

Witness Official (WO) #1, WO #2 and WO #3 were designated as witness officials. After review of their notebook entries and occurrence reports, it was later determined they were not directly involved in the interaction with the Complainant at the BPS station and would not offer any further evidentiary value to the investigation.

Affected Person (aka “Complainant”):

54-year-old female interviewed, medical records obtained and reviewed

The Complainant was interviewed on December 21, 2020.

Civilian Witnesses

CW #1     Interviewed
CW #2     Not interviewed (Medical professional, report received)
CW #3     Not interviewed (Medical professional, report received)

CW #1 was interviewed December 21, 2020

Subject Officials 

SO Interviewed, but declined to submit notes, as is the subject official’s legal right.

The SO was interviewed on January 14, 2021.

Witness Officials 

WO #1     Not interviewed and had no notes [1]
WO #2     Not interviewed, but notes received and reviewed
WO #3     Not interviewed, but notes received and reviewed
WO #4     Interviewed
WO #5     Interviewed

The witness officials were interviewed on December 22, 2020.

Investigative Delay

Obtaining the Complainant’s medical records and interviewing the civilian witnesses were delayed due to the holidays.



The Scene 

The scene was not examined by the SIU in this investigation. It was located at the BPS station inside cell 1. The cell was monitored by the officer in charge of the station and was both video and audio recorded.

Video/Audio/Photographic Evidence

EMS and BPS Dispatch and Communications Summary:

December 15, 2020

At 11:11:35 p.m., EMS called into the BPS communications section requesting assistance of police officers at a call they were responding to at a residential address in Belleville. A 50-year-old woman was at the home, agitated, violent and possibly overdosed;

At 11:12:51 p.m., WO #4 and WO #5 were dispatched to the address and an ambulance was on the way;

At 11:13:48 p.m., the address came back to the Complainant, who was flagged with medical issues, violent and suicidal;

At 11:14:05 p.m., the address was noted as having a history for ambulance assist, drug offences and Mental Health Act (MHA) issues;

At 11:17:36 p.m., WO #5 advised she was on scene along with EMS;

At 11:27:58 p.m., WO #5 told the BPS dispatcher that the Complainant was in the police vehicle and they were transporting her to BGH. The Complainant was being transported by police because she was too uncooperative with the paramedics to go in the ambulance; and

At 11:49:14 p.m., WO #5 told the BPS dispatcher that there was a change of plans as the Complainant could not stay at the BGH and they were bringing her to the BPS station for causing a disturbance. The Complainant was heard yelling in the background.

December 16, 2020

At 1:09:36 a.m., CW #1 called the BPS station enquiring about the Complainant. CW #1 stated she had called the BGH and they did not have the Complainant there. She was told by a police officer that the Complainant was at the BPS station because she was turned down at the BGH by medical staff because she was causing problems. The Complainant was in a cell and asleep. CW #1 was concerned because the Complainant had been violent and had taken a large amount of medication earlier. CW #1 was told they were monitoring her in the cell. CW #1 was concerned the Complainant may have a seizure like she did a couple years ago. She told the police officer the Complainant had gone to the hospital before and they refused her at that time as well. She wanted to know if it was legal for the hospital to turn her away like that. CW #1 said there was nothing she could do. The police officer said they would look after her;

At 2:05:39 a.m., the SO radioed the BPS dispatcher to have EMS attend the BPS station for the Complainant as she had vomited in the cell and possibly had blood coming out of her nose; and

At 2:05:59 a.m., the BPS dispatcher called EMS in Belleville to have paramedics attend in an ambulance to the cell block to transport the Complainant to the BGH. The dispatcher told the EMS dispatcher that the Complainant was the same woman they had attended to at the call earlier on December 15, 2020.

Cell Video Summary

The cell was concrete with a concrete bed/seat on one side of the cell and a stainless-steel sink/basin and toilet on the opposite side of the cell. A closed-circuit television (CCTV) camera was mounted in one corner of the ceiling, near the cell doorway and bed area.

December 16, 2020

At 12:03:04 a.m., the Complainant was led into the cell by WO #5;

At 12:03:09 a.m., The Complainant was helped by WO #5 to sit on the bed. WO #5quickly exited the cell and the door closed. The Complainant remained seated on the bed and was very restless, moving her legs and arms constantly;

At12:56:36 a.m., the Complainant attempted to stand from a seated position on the bed and had difficulty in doing so; she sat back down on the bed;

At 12:53:21 a.m., the Complainant stood up from a seated position, was very unsteady on her feet and displayed difficulty in maintaining balance. She stumbled to the floor of the cell onto her right side;

At 12:57:45 a.m., the Complainant laid on the floor. She constantly moved around and lightly banged her head off the base of the concrete bed numerous times. She continued to move around on the floor and banged the top of her head several times moderately hard against the side of the concrete bed. She paused, moved to a forward position on both knees, and then banged her head a little harder seven times against the concrete bed;

At 12:59:19 a.m., the Complainant was seated on the floor, swinging her upper body back and forth. She almost struck her head on the stainless-steel sink and toilet. She laid back down on the floor and slowly rolled from face down to on her back. She constantly rolled from the front prone position to her back position. She was still wearing her protective (Covid) face mask. Shortly after, she fell asleep on the floor on her back. Her upper body area constantly moved;

At 2:03:28 a.m., the Complainant rolled over onto her stomach in the prone position and a small amount of vomit was seen on the floor near the call door and sink area. The Complainant rolled back over and vomited a second time in the same area;

At 2:06:20 a.m., a uniformed police officer came into the cell, and bent over and down towards the Complainant. She was laying on her back on the floor with her head under the sink area. The police officer was wearing a protective mask and black-coloured gloves. He stood up and walked to the cell door area where he stood looking at the Complainant;

At 2:07:15 a.m., another uniformed police officer with sergeant epaulets, believed to be the SO, came into view standing at the cell doorway. The first police officer left the cell and the SO entered into the cell, then turned and quickly left;

At 2:08:24 a.m., the first police officer entered into the cell and stood, watching the Complainant who was still laying on the floor. He left after about 25 seconds;

At 2:24:10 a.m., a female paramedic, dressed in a yellow-coloured jacket, entered into the cell followed by a second female paramedic dressed similarly. Both paramedics walked to the left side of the Complainant, who was still laying on the floor. Two police officers entered into the cell. The two paramedics with the assistance of the two uniformed police officers attempted to sit the Complainant up to a seated position. They had difficulty. All four assisted the Complainant in standing to her feet. The Complainant appeared very unsteady on her feet and not able or willing to stand on her own; and

At 2:26:22 a.m., the two paramedics, two police officers and the Complainant left the cell and went out of camera view.


CCTV from Booking Area

December 15, 2020

At 11:59:00 p.m., the Complainant was seen walking in the cell booking area of her own accord and constantly swearing loudly. She was yelling at the police officers in the cell booking area.

CCTV from Sally Port Vestibule

December 15, 2020

At 11:57:38 p.m., a uniformed police officer walked in through a door from the sally port garage area and was heard speaking with another police officer, believed to be the SO. This police officer said, “We got told when we got to the hospital that she left before she got assessed and she was not cooperating with EMS. We took her to the hospital to get assessed and [the Complainant] left on her own. She just went crazy.” The Complainant could be heard in the sally port garage area yelling very loudly, screaming and swearing at the police officers.

Cell #1 Audio

December 15, 2020

The Complainant went into the cell and constantly swore. This went on for almost an hour. When she was laying on the floor, she could be heard breathing heavily and snoring. When she vomited, she was heard coughing. A police officer came in and said, “[The Complainant], what is going on here, take your mask off.” This police officer was the first to enter the cell.

At 2:06:39 a.m., the same police officer said, “[The Complainant], do you want to go to the hospital and do you want a drink of water.” He repeated the same thing twice to the Complainant. One of the paramedics was later heard telling the Complainant, “Open your eyes,” and, “Can we sit you up?” The Complainant was helped from the cell by the two paramedics and two police officers, and placed on a stretcher in the cell hallway.

Materials Obtained from Police Service

The SIU obtained the following records from the BPS on December 23, 2020:

  •  Arrest Report;
  •  Belleville Police Disclosure;
  •  Communications recordings;
  •  Custody video;
  •  Arrest Procedure;
  •  Prisoner Care and Control Procedure;
  •  In Custody Detention Log and Booking Sheet for the Complainant; and
  • Notes of WO #2, WO #3, WO #4 and WO #5.

Materials Obtained from Other Sources

The SIU obtained and reviewed the following records from the BGH:

  • Medical records of the Complainant, received February 10, 2021.


Incident Narrative

The following scenario emerges from the evidence collected by the SIU, which included interviews with the Complainant and the SO, as well as video recordings of the Complainant’s time in police custody. At about 11:12 p.m. of December 15, 2020, officers were dispatched to a residential address in Belleville, to assist paramedics with a patient – the Complainant. Earlier that evening, the Complainant had been to BGH and returned home against medical advice.

WO #4 and WO #5 attended at the home and, after a period attempting to persuade the Complainant to accompany the paramedics to hospital, handcuffed the Complainant and took her into their custody. Their intention was to return the Complainant to the hospital. However, once there, the officers were advised that the Complainant had earlier been assessed and was no longer welcome at the hospital because of her disruptive behaviour. As the Complainant was screaming, yelling obscenities and causing a commotion, WO #4 and WO #5 arrested and transported her to the station.

Arriving at the station at about 11:55 p.m., the Complainant was paraded before the SO and then placed in a cell.

Shortly after 2:00 a.m., the SO observed the Complainant on a video monitor attempting to vomit on the cell floor and proceeded to call paramedics to the station. The attending paramedics, with the help of police officers, loaded the Complainant onto a stretcher and took her to hospital.

The Complainant was treated in hospital for an overdose.


Relevant Legislation

Sections 219 and 221, Criminal Code - Criminal Negligence Causing Bodily Harm

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.

221 Every one who by criminal negligence causes bodily harm to another person is guilty of an indictable offence and liable to imprisonment for a term not exceeding ten years

Section 215, Criminal Code - Failure to Provide Necessaries

215 (1) Every one is under a legal duty

(c) to provide necessaries of life to a person under his charge if that person
(i) is unable, by reason of detention, age, illness, mental disorder or other cause, to withdraw himself from that charge, and
(ii) is unable to provide himself with necessaries of life.

(2) Every person commits an offence who, being under a legal duty within the meaning of subsection (1), fails without lawful excuse to perform that duty, if
(b) with respect to a duty imposed by paragraph (1)(c), the failure to perform the duty endangers the life of the person to whom the duty is owed or causes or is likely to cause the health of that person to be injured permanently.

Analysis and Director's Decision

In the early morning hours of December 16, 2020, the Complainant was in a BPS cell when she fell into acute medical distress and was transported to hospital. The officer with overall responsibility for the care of prisoners at that time – the SO – was identified as the subject official 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 medical condition.

The offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing bodily harm contrary to sections 215 and 221 of the Criminal Code, respectively. The former is premised, in part, on conduct that amounts to a marked departure from the level of care that a reasonable person would have observed in the circumstances. The latter is a more serious offence and requires as an element of the offence that the impugned conduct constitute a marked and substantial departure from a reasonable level of care. In the instant case, the issue is whether there was any want of care on the part of the SO that caused or contributed to the Complainant’s illness and was sufficiently egregious as to attract criminal sanction. In my view, there was not.

At the outset, I accept that the Complainant was lawfully in the custody of the BPS when she was taken to the station and lodged in a cell. The evidence indicates that she had been loud, belligerent and aggressive on her second trip to the hospital, and in fact had to be restrained by three police officers at times as they spoke with medical staff. In the circumstances, it would appear that there were grounds to arrest the Complainant for a breach of the peace. In addition, I am also satisfied that part of the concerns animating the officers’ decision to apprehend the Complainant was the disturbance she was causing in the hospital, further justifying the Complainant’s arrest on the basis that she was causing a disturbance under section 175 of the Criminal Code.

Thereafter, I am satisfied that the SO exercised a level of care having full regard for the Complainant’s health and well-being while she remained in a cell. The officer knew that she had consumed a large quantity of prescription pills but had been turned away from BGH. He made a point of paying close attention to her. As soon as the Complainant vomited and it appeared that her condition had taken a turn for the worse, the SO acted promptly to summon the attendance of paramedics. On this record, I am unable to reasonably conclude that the SO transgressed the limits of care prescribed by the criminal law.

In the result, as there are no reasonable grounds to believe that the SO conducted himself other than lawfully throughout the Complainant’s period of custody, there is no basis for proceeding with criminal charges in this case and the file is closed.

Date: April 1, 2021

Electronically approved by

Joseph Martino
Special Investigations Unit


  • 1) WO #1 was determined to have had no interaction with the Complainant. [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.