SIU Director’s Report - Case # 20-OOD-355


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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 the death of a 32-year-old man (the “Complainant”) that may have resulted from criminal conduct by an official.

The Investigation

Notification of the SIU

On December 16, 2020, the Niagara Regional Police Service (NRPS) reported the following:

On December 4, 2020, the Complainant hung himself from a tree. Police officers had contact with the Complainant on four separate calls for service between December 3, 2020 and December 4, 2020. [1] On December 3, 2020, at 11:55 p.m., police officers attended a residence in the area of Scott Street and Vine Street in St. Catharines for a domestic incident. The Complainant was removed from his girlfriend’s apartment as it appeared their relationship was ending.

On December 4, 2020, at 4:46 p.m., police officers attended 105 Queenston Street, St. Catharines, for a welfare check call regarding the Complainant. The Complainant was upset about recent life events and had taken three points of crystal meth. He refused medical attention and did not want to go to hospital. He told police officers he was not suicidal. There were no grounds to apprehend him under the Mental Health Act (MHA).

At 6:34 p.m., December 4, 2020, police officers attended the Big Bee convenience store at 81 Queenston Street, St. Catharines, for an unwanted persons call. The Complainant was in the store parking lot and the store owner wanted him removed. When police arrived, he had left the parking lot.

At 7:15 p.m., December 4, 2020, police officers attended 5 Lundy’s Lane, St. Catharines, for a suicidal threat call for service. At this time, the Complainant stated he was on the property looking for a place to sleep as he was homeless. He told the police officers he was not suicidal, and they had no grounds for an MHA apprehension.

At 8:06 p.m., December 4, 2020, NRPS received an assist ambulance call. The caller reported they thought they could see someone hanging from a tree. Police officers responded and located the Complainant hanging from a cable attached to a tree on the south side of Gales Crescent near Frank Street.

The Team

Date and time team dispatched: 12/17/2020 at 8:44 a.m.

Date and time SIU arrived on scene: 12/17/2020 at 8:45 a.m.

Number of SIU Investigators assigned: 3
Number of SIU Forensic Investigators assigned: 0
Number of SIU Collision Reconstructionists assigned: 0

Affected Person (aka “Complainant”):

32-year-old male, deceased

Civilian Witnesses (CW)

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

The civilian witnesses were interviewed between December 21, 2020 and January 21,

Subject Official (SO)

SO Declined interview, as is the subject official’s legal right. Notes received and reviewed.

Witness Officials (WO)

WO #1 Interviewed
WO #2 Interviewed
WO #3 Interviewed
WO #4 Interviewed
WO #5 Interviewed
WO #6 Interviewed
WO #7 Interviewed
WO #8 Notes reviewed, interview deemed not necessary
WO #9 Notes reviewed, interview deemed not necessary
WO #10 Notes reviewed, interview deemed not necessary

The witness officials were interviewed between December 28 and 29, 2020.


The Scene

The scene was located on the south side of Gale Crescent in between Frank Street and Lundy's Lane. At the base of a tree was a cinder block. It is believed that the Complainant stood on this cinder block prior to hanging himself. Similar looking cinder blocks were located by NRPS in the backyard of 5 Lundy's Lane. The ligature used by the Complainant was some type of coaxial cable wire. It is believed this cable may have been taken from either 5 Lundy's Lane or 3 Lundy's Lane as both residences had similar exposed wire and were under renovation. There was a loaded syringe found on the ground beside the Complainant, along with drug paraphernalia in his pockets.

Video/Audio/Photographic Evidence

Cell Phone Video Footage

The video depicted the Complainant leaning against a black pickup truck. He was wearing a tuque, turtleneck and Toronto Maple Leafs jersey with a hoodie, jacket, pants and running shoes. The Complainant was looking into the rear passenger window and was heard saying, “Talk to me like that,” and, “Fucking someone and then.”

The truck owner walked towards his pickup truck with his cellular telephone in his hands and was heard saying, “Why you broke the glass? Why, why you broke it. I will call police now.” The Complainant was heard saying as he was still looking into the pickup truck, “I didn’t do anything.” The Complainant turned around and faced the truck owner, who was heard saying, “Why you call, why you broken, tell me why you broken, it’s my truck.”

The Complainant turned his back towards the truck owner and began to look into the front passenger side window of the pickup truck. The Complainant was heard saying, “Yah it’s your truck, why is there someone in your truck.” He then turned and faced the truck owner. The Complainant was seen with his right hand up to his face rubbing his thumb and index finger together.

911 Call Regarding Domestic incident

On December 3, 2020, at 11:55 p.m., CW #2’s mother called 911 and asked for the police at her daughters’ home near Scott Street and Vine Street [address provided] in St. Catharines. When she was being asked questions by the operator, she suggested that her daughter was probably being beaten up. The operator asked CW #2’s mother what had happened, and she said her daughter had asked her to call the police as a guy that was with her was flipping out. She stated the incident had occurred two minutes earlier.

The caller gave the guy’s name as one of two, including the Complainant’s name. She said she was very anxious and just wanted the police to get to her daughter’s address. She provided the address and phone number. No weapons had been mentioned as having been used. All her daughter said was to call the police and send them to her address. When asked if the disturbance was physical or verbal, CW #2’s mother said she did not know.

CW #2’s mother provided a description of the Complainant. She provided the Complainant’s name again and suggested the operator look him up. She provided the operator with her daughter’s name, date of birth, and physical description. When asked, she said she believed her daughter was in danger. There were no children at the address, and she was unaware if anyone was using alcohol or drugs. She was unaware if anyone needed medical attention.

911 Call from the Out of the Cold (OOTC) Shelter in St. Catharines

At 1:59 a.m., on December 4, 2020, CW #3 from the OOTC shelter called police to advise that the Complainant was found outside unconscious. CW #3 was able to wake the Complainant up and he had expressed that he intentionally tried to commit suicide and that he did not intend to wake up. He told her that he was going to find more (drugs) and that it was going to happen tonight one way or another.

The Complainant did not want to come inside, and CW #3 did not feel comfortable leaving him outside knowing he had intentions of committing suicide. She advised that there were no weapons involved and that the Complainant was using substance abuse to attempt suicide. She told the call-taker that NRPS police officers had dropped the Complainant off a few hours prior to her telephone call. She was told that police were on their way and ambulance was also on the telephone line.

911 Calls made by CW #4 from the Consumption and Treatment Services Site (CTSS)

On December 4, 2020, at 4:30 p.m., CW #4 called 911 from the CTSS and reported they had a man [now known to have been the Complainant] at their premises whom she thought was in mental health distress. The Complainant was sitting on cars, jumping on cars and appeared to be in a state of psychosis. CW #4 did not know his name.

CW #4 and her staff were worried mostly about the Complainant’s safety as well as the community’s safety. She requested that if the Mobile Crisis Rapid Response Team (MCRRT) was available, that they be sent to the call. The Complainant was not violent, had no weapons, and was talking to two staff members on the property lot. CW #4 provided a description of the Complainant and what he was wearing. She did not believe she or anyone else was in danger from the Complainant and indicated that no one needed medical attention.

At 4:39 p.m., CW #4 called 911 a second time and reported that the Complainant was standing on a person’s vehicle and screaming at neighbours. CW #4 felt he was a danger to himself and others.

At 4:47 p.m., CW #4 called 911 a third time and reported she was calling again as the situation had escalated. She reported that they had just noticed that the Complainant had a knife in his back pocket and due to his extreme paranoia, they were concerned that he might use the knife. The operator confirmed that the location was the Addictions Clinic. CW #4 reported that the Complainant had told one of her colleagues that he was going to do more shit (drugs) later. She felt he was not in the right frame of mind at that time. She informed the operator the police had arrived.

911 Call made by a Man from the Big Bee Convenience Store

On December 4, 2020, at 6:22 p.m., a man called 911 and asked for the police immediately as some guy [now known to have been the Complainant] had broken into his car. The man would not initially provide the address he was calling from and said the Complainant had something in his hand. He told the operator he was at the Big Bee Store at 83 Queenston.

When asked by the operator, the man agreed that he was parked at the Big Bee and someone had broken into his car. When asked for his phone number, the man could be heard shouting at the Complainant and the call was dropped.

At 6:33 p.m., the 911 operator called the man back. He reported that the Complainant had broken the glass on his car. He thanked the operator and the call was dropped a second time.

911 Call from CW #1

At 6:57 p.m., on December 4, 2020, CW #1 called police to advise that a man [known to be the Complainant] was outside arguing with a woman. The Complainant was in the backyard of a home located at 5 Lundy’s Lane, two houses down from Gale Crescent. CW #1 advised the 911 operator that the Complainant was overheard saying, “I can’t believe you did this to me.” The Complainant’s girlfriend had cheated on him. The Complainant went into the second house on Lundy’s lane, exited the house, went to the backyard and stood on a cinder block wall, and tied a rope to a tree.

The Complainant appeared to be drunk or high on drugs, and CW #1 was afraid he was going to kill himself. He did not see any weapons and described the Complainant’s appearance. He had no idea how the Complainant arrived in the area and believed the woman the Complainant had been speaking about was in the backyard. He was advised by the 911 operator that the police were on their way.

911 Call from a Woman at Centennial Gardens

At 8:06 p.m., on December 4, 2020, a woman called police to advise that a man [known to be the Complainant] was hanging from a tree in Centennial Gardens across the road from Gale Crescent. The closest building was 46 Gale Crescent. She and her friend were driving by and saw the Complainant hanging. She had yelled out to the Complainant and there was no response, and the Complainant was not moving.

The operator told her that paramedics were on their way and to activate her emergency hazard lights. She advised the operator that she could hear the paramedics. A man’s voice could be heard saying, “It’s [name] with ambulance.” The operator was heard saying, “Our guys are on scene at Lundy’s Lane and Frank Street, and it looks pretty obvious.” 

NRPS Radio Communications

Incident 1 - Start Time 12:01:17 a.m.

Dispatch advised of a domestic call for service at an address in St. Catharines. The woman called NRPS stating that her daughter’s (CW #2) boyfriend was flipping. The Complainant, 32 years old, had previously been charged with prohibited firearm, and robbery with a weapon. The dispatcher advised that there had been domestic calls to the address. The caller did not have the buzz code to get into the front of the building and the back door might be unlocked. Later, the dispatcher advised the attending police officers that there were no intakes after 11:00 p.m. available at South Ridge; however, there was room at the OOTC shelter for the Complainant.

Incident 2 – Start Time 2:03:13 a.m. 

Dispatch advised of a suicide threat at the OOTC shelter located at 180 Queenston Street. Staff members had found a man outside unconscious. The man was currently conscious, identified as the Complainant, and a physical description was provided including that he was wearing a hat, dark jacket and jeans.

Incident 3 – Start Time 4:42:56 p.m.

Mental health call to 105 Queenston Street. A man appeared to be in mental health distress and was seen jumping on cars. NRPS had received a couple of calls on this incident. A physical description was provided including that he was wearing a dark jacket and a Toronto Maple Leafs shirt. The man was in the back parking lot and may have a knife in his back pocket. Officers were advised to use caution.

Incident 4 – Start time 6:33:49 p.m.

Dispatch advised of an unknown disturbance at the Big Bee located at 81 Queenston Street. The caller said there was a man screaming on his phone at someone, and that his car was broken into.

Incident 5 – Start time 6:59:19 p.m.

Dispatch advised of a suicide call on Lundy’s Lane and Gale Crescent area. A man was fighting with someone, and the caller advised there was a woman in the backyard shed crying. The man was threatening to kill himself and was hanging a rope to a tree. The caller advised that the man was in the backyard of the second house down from Gale Crescent. The man was either drunk or high and was yelling about a relationship. The caller described the man as being in his twenties, and wearing a Toronto Maple Leafs sweater with a hoody and light-coloured jeans. Dispatch was heard talking to a police officer. The police officer advised that he was on scene and that there was no noose or rope and that the man known to be the Complainant was not suicidal.

Incident 6 – Start Time 8:08:00 p.m.

Dispatch advised of an assist ambulance call at 46 Gale Crescent and Lundy’s Lane. A caller had advised that she saw someone hanging on the Centennial Gardens side of Gale Crescent and Frank Street. She called out to the person and they did not respond. The caller would have her hazard lights flashing. Several NRPS units attended and one police officer reported, “It was obvious.” A police officer took down civilian witness information. The Complainant’s criminal conviction history was provided.

Materials Obtained from Police Service

Upon request, the SIU received the following materials and documents from NRPS between December 17, 2020 and February 1, 2021:
  • Forensic Services Unit (FSU) Photos;
  • FSU Report;
  • General Order – Communications Systems;
  • General Order – Domestic-Family Violence;
  • General Order – Mentally Ill Persons;
  • Incident Reports (x6);
  • Notes-WO #1;
  • Notes-WO #8;
  • Notes-WO #5;
  • Notes-WO #3;
  • Notes-WO #6;
  • Notes-WO #4;
  • Notes-WO #10;
  • Notes-WO #9;
  • Notes-WO #7;
  • Notes-WO #2;
  • Notes-the SO;
  • Criminal History;
  • General Occurrences (x6);
  • Incident Report; and
  • Radio Communications Details (x6).

Materials Obtained from Other Sources

The SIU obtained and reviewed the following records from other sources:

  • Ambulance Call Report from Niagara Paramedic Services received on January 14, 2021;
  • Postmortem Report from Niagara Health System received on January 6, 2021; and
  • Cell phone footage from the truck owner at Big Bee convenience store received on December 21, 2020.

Incident Narrative

The material events in question are relatively clear thanks to interviews with a number of police officers and civilians who had dealings with the Complainant on December 4, 2020. Though the SO declined, as was his legal right, to interview with the SIU, he did authorize the release of his notes.

Shortly after 8:00 p.m., the NRPS received a 911 call from a woman. The woman, a passenger in a motor vehicle travelling east on Gale Crescent, called to report a man hanging from a tree in Centennial Gardens, across from a building located at 46 Gale Crescent. Police officers, firefighter and paramedics were dispatched to the scene. The Complainant was cut down from the tree and life-saving measures were administered by the first responders. After ten to 15 minutes of efforts to resuscitate the Complainant, he was declared dead at 8:31 p.m.

Earlier that day, at about 7:00 p.m., CW #1 had called police about the Complainant. He had observed the Complainant in the backyard of the home at 5 Lundy’s Lane. The Complainant appeared impaired by either alcohol or drugs, was overheard complaining that his girlfriend had cheated on him, had tied a rope to a tree and was standing on a cinder block. CW #1 expressed concern that the Complainant was going to kill himself. The call-taker indicated that officers were being dispatched to investigate.

The SO and WO #5 arrived at 5 Lundy’s Lane. The latter spoke with the Complainant, who approached them at the fence separating the driveway from the backyard, while the SO went into the backyard to look around. When asked, the Complainant assured WO #5 that he was not suicidal. He went on to explain that he had broken up with his girlfriend, and was homeless and hoping to sleep in the shed in the backyard of the home. Advised that he could not stay at the property and asked whether he wanted a ride to a shelter, the Complainant told the officers he preferred to sleep in the park. As the Complainant appeared lucid and was dressed appropriately for the weather, and no rope had been found in the backyard or on the Complainant’s person by the SO that might have been used to hang himself, the officers decided to leave without apprehending him.

The NRPS’s involvement with the Complainant on December 4, 2020 started just after midnight when officers – WO #1 and WO #2 - arrived to deal with a domestic disturbance at the home of the Complainant’s girlfriend – CW #2. The two had been engaged in an argument. Concerned for her safety as the Complainant’s behaviour escalated, CW #2 had contacted her mother, who, in turn, called the police. CW #2 and the Complainant continued to argue in the presence of the officers. Despite the Complainant’s pleadings, CW #2 was insistent that he leave her residence. The officers attempted to mediate the dispute and it was eventually agreed that the Complainant would be driven to the Out of the Cold shelter to spend the night. No mention was made of any mental health issues nor was there any indication that the Complainant was labouring under the influence of alcohol or drugs. The Complainant collected some belongings and was taken by WO #2 in his cruiser to the Out of the Cold shelter, arriving at about 1:10 a.m.

Not more than an hour after he had been dropped off at the shelter, staff at the facility contacted police to report that the Complainant had been found unconscious outside their premises. When he awoke, the Complainant indicated that he had tried to commit suicide by overdosing and had not wanted to wake up. WO #6 and WO #7 were dispatched to the shelter, as were paramedics. The officers spoke with the Complainant, who denied making any utterances of wanting to kill himself. He explained that he had children and wanted to be there for them. According to the Complainant, he had inadvertently overdosed on fentanyl. As the Complainant was alert and talkative, had denied wanting to harm himself, was properly attired for the weather, and had been cleared medically by the paramedics following an examination, the officers concluded there were no grounds to apprehend the Complainant. The officers left on the understanding that the Complainant would be spending the rest of the night at the shelter.

Starting at about 4:30 p.m., the NRPS received the first of three 911 call from staff at the Consumption and Treatment Services Site, a safe drug consumption site located at 105 Queenston Street, St. Catharines. The caller – CW #4 – reported that the Complainant, whom she believed to be in mental health crisis, was jumping on cars in the parking lot, screaming at neighbours and extremely paranoid. Though there had been no physical violence, CW #4 noted that the Complainant had a knife in his back pocket and she was concerned for his safety as well as the safety of others. She asked that the MCRRT attend.
An MCRRT team, consisting of WO #4 and CW #5 of the Canadian Mental Health Association – Niagara Region, was dispatched and arrived at about 4:50 p.m. The Complainant was angry and agitated. He was asked by WO #3 to take the knife out of his pocket and he complied. When asked what was troubling him, the Complainant explained that he was angry with his girlfriend whom he thought had cheated on him. He went on to note that he had consumed crystal methamphetamine at the safe injection site earlier and had experienced a “bad trip”. Repeatedly asked if he had intentions of killing or hurting himself or others, the Complainant responded in the negative. The Complainant was offered medical attention, but declined. As the Complainant had calmed substantially and was able to communicate in a rational manner with the police, neither WO #3 nor CW #5 believed there were any grounds to apprehend him for his own safety. The officers departed the scene assured by the Complainant that he had plans for spending the night.

Regrettably, the Complainant did not have plans for spending the night. Within a couple of hours, the Complainant found himself in and around the area of 5 Lundy’s Lane where he was able to find coaxial cable from the interior of a home under renovation. Though he once again denied any suicidal intentions to responding officers, the Complainant was able to make good on his plan to end his life shortly after the officers’ departure.

Cause of Death

The pathologist at autopsy attributed the Complainant’s death to “hanging (suicidal)”.

Relevant Legislation

Sections 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

On December 4, 2020, the Complainant decided to take his own life. His body was discovered by passing motorists hanging from a tree in Centennial Gardens, between Lundy’s Lane and Frank Street, St. Catharines. As the Complainant had had several interactions with NRPS officers on the day of his death, the SIU was notified of the incident and commenced an investigation. 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 death.

The offence that arises for consideration is criminal negligence causing death contrary to section 220 of the Criminal Code. The offence is predicated on conduct resulting in death that demonstrates a wanton or reckless disregard for the health and safety of others. It is not made out unless the conduct in question 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 by the SO that caused or contributed to the Complainant’s death and was so derelict as to attract criminal sanction. In my view, there was not.

Though it is apparent in hindsight that the Complainant was intent on harming himself from the moment he was escorted from his partner’s premises in the early morning of December 4, 2020, the SO’s potential criminal liability must be assessed in the light of the circumstances as they prevailed at the time of the events in question. He had been advised via dispatch of CW #1’s 911 call to the effect that a male – the Complainant – was in the backyard of 5 Lundy’s Lane, possibly high or drunk, seemingly preparing to kill himself with a rope tied to a tree. He and WO #5 arrived to find the Complainant exactly where he was reported to be – in the backyard of 5 Lundy’s Lane. According to WO #5, the Complainant gave a plausible explanation for his presence in the area which did not include suicide, namely, that he was homeless following a fight with his girlfriend and was intending to spend the night in the backyard shed. When asked specifically whether he had designs on hurting himself, the Complainant was adamant that he did not. Meanwhile, the SO searched the backyard and did not find a rope or a noose, nor was any such item located on the Complainant when the SO searched his person. The Complainant was offered a ride to the Out of the Cold shelter to spend the night, but declined saying he would prefer to sleep in the park. As he was properly attired for the weather, and had been coherent in conversation, the officers left the area satisfied they did not have grounds to apprehend the Complainant under the Mental Health Act.

Under section 17 of the Mental Health Act, police officers may take a person into custody for psychiatric examination at hospital where, inter alia, there are reasonable and probable grounds to believe that the person has acted or is acting in a disorderly manner, there is reasonable cause to believe that the person has threatened or attempted to cause bodily harm to themselves, and it appears that the person is apparently suffering from a mental disorder that is likely to result in serious bodily harm to themselves or others.

On the aforementioned-record, I am unable to reasonably conclude that the officers who last engaged with the Complainant before his death failed in their duty of care to the Complainant by not apprehending him under the Mental Health Act. WO #5 and the SO put their minds to whether there were grounds for arresting the Complainant, but decided following their investigation that the Complainant was not a danger to himself. Had a rope or noose been found, or the Complainant given any indication that he was intent on hurting himself, it might well have been that the officers’ judgment would, indeed, ought to, have been different. As it was, I am unable to fault the officers for making the determination they did.

Nor does the fact that other NRPS officers had had previous encounters with the Complainant, which raised some of the same concerns, alter that calculus. For starters, it remains unclear whether and to what extent the SO was aware of those previous calls for service. And even if he was aware, only two of them had raised issues regarding the Complainant and possible suicidal ideations and, in each case, the officers, as well as a mental health professional in one of those occasions, had decided against apprehension for reasons which, in my view, were demonstrably justified. In the circumstances, while I accept that a history of this nature is an important part of the context when considering the merits of what the SO did or did not do, I am not persuaded that it would or should have tipped the balance in this case in favour of apprehension.

In the result, as I am not reasonably satisfied for the foregoing reasons that the SO transgressed the limits of care in his dealings with the Complainant prior to his death, there is no basis for proceeding with criminal charges in this case.

Date: April 13, 2021

Electronically approved by

Joseph Martino
Special Investigations Unit


  • 1) Investigators established that the NRPS had in fact five calls for service concerning 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.