SIU Director’s Report - Case # 21-OCD-036
Warning:
This page contains graphic content that can shock, offend and upset.
Contents:
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.
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 34-year-old man (the “Complainant”).
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 34-year-old man (the “Complainant”).
The Investigation
Notification of the SIU
On February 2, 2021, at 10:50 a.m., the London Police Service (LPS) contacted the SIU and relayed the following information.On February 1, 2021, at about 3:30 p.m., the Complainant had been arrested by LPS officers for breaching recognizance conditions. He was returned to LPS headquarters where he was processed. At 4:05 p.m., the Complainant was lodged, and held for a bail hearing.
On February 2, 2021, at about 9:07 a.m., the Complainant advised officers he was not feeling well. EMS was contacted, attended the cells, and transported him to the London Health Sciences Centre -Victoria Hospital.
At 9:52 a.m., the LPS were informed that the Complainant had been pronounced dead.
The Team
Date and time team dispatched: 02/02/2021 at 12:26 p.m.Date and time SIU arrived on scene: 02/02/2021 at 1:43 p.m.
Number of SIU Investigators assigned: 5
Number of SIU Forensic Investigators assigned: 1
Civilian Witnesses
CW Not interviewed (Next-of-kin)
Subject Officials
SO Declined interview and to provide notes, as is the subject official’s legal right
Witness Officials
WO #1 Interviewed
WO #2 Interviewed
WO #3 Interviewed
WO #4 Interviewed
WO #5 Interviewed
WO #6 Interviewed
WO #7 Interviewed
The witness officials were interviewed between February 6, 2021 and April 21, 2021.
Affected Person (aka “Complainant”):
34-year-old male, deceasedCivilian Witnesses
CW Not interviewed (Next-of-kin)Subject Officials
SO Declined interview and to provide notes, as is the subject official’s legal rightWitness Officials
WO #1 Interviewed WO #2 Interviewed
WO #3 Interviewed
WO #4 Interviewed
WO #5 Interviewed
WO #6 Interviewed
WO #7 Interviewed
The witness officials were interviewed between February 6, 2021 and April 21, 2021.
Service Employee Witnesses
SEW #1 Interviewed SEW #2 Interviewed
SEW #3 Interviewed
SEW #4 Interviewed
The service employee witnesses were interviewed between February 9, 2021 and March 9, 2021.
Delay in Report Submission
This report was written chronologically, behind the reports generated for other files, as the lead investigator waited for the final post-mortem results. Those results became available on September 23, 2021.Evidence
The Scene
Attended and processed on February 2, 2021, at 1:43 p.m., by an SIU forensic investigator, the scene was a cell in the LPS Headquarters Detention Unit (HDU). The cell was in a row of cells in a corridor two corridors from the booking area. Populated with the common amenities of police facility holding cells, at the time of examination the bunk was littered with a blanket, shirt, boot liners, a mask, and some uneaten cereal bars. The floor held boots, jeans, and more uneaten cereal bars. The toilet was filled with disposable cups and other debris.The hallway adjacent the cell was littered with medical debris including two spent Narcan nasal spray containers, an automated external defibrillator (AED), with used AED pads and its carrying case, and a spare set of pads, a respirator mask, miscellaneous ripped medical equipment packages and disposable gloves.
The scene was photographed, and the medical debris and AED were collected before the scene and remaining property were released to the LPS at 2:40 p.m.
Below is a digital image capturing the cell corridor.
Figure 1 - The row of cells in the LPS HDU.
The next image captured the interior of the cell.
Figure 2 - The interior of the Complainant's cell.
Physical Evidence
The LPS AED used upon the Complainant was collected to analyze the internal data [1] that recorded the Complainant’s cardio rhythm during life-saving efforts. The Complainant’s belongings were left with LPS members who returned them to his family, and the medical waste and garbage was left in situ.Forensic Evidence
The following items were submitted for analysis to the Centre of Forensic Sciences (CFS) on February 8, 2021: • Hospital serum;• Heart blood;• Femoral blood (three samples);• Urine; and• Liver.
The results, received on April 30, 2021, detected methamphetamines [2] and amphetamines [3] in the hospital serum. The femoral blood had those same chemicals present in addition to naloxone [4] and amiodarone. [5] The heart blood contained tetrahydrocannabinol (THC), [6] carboxy tetrahydrocannabinol, [7] and hydroxy tetrahydrocannabinol. [8] Ethanol [9] was not present in any of the samples.
The detected methamphetamine concentration could cause death; however, it was noted that there is an overlap of concentrations that have been reported in recreational use and those associated with fatalities. The amphetamine detected could arise as a metabolite of methamphetamine or could have been ingested as a drug by itself.
The cannabinoids detected were in a concentration consistent with prior use of a cannabis product depending on the dose, route, and pattern of administration of that cannabis product. It was noted that the amiodarone concentration has been associated with a therapeutic range and is an anti-arrhythmia drug that may have been given in hospital during a resuscitation attempt.
Expert Evidence
AED Data Interpretation
On February 8, 2021, the Middlesex-London Paramedic Service downloaded and printed the data from the AED used upon the Complainant on February 2, 2021. The data revealed the AED did not deliver a ‘shock’ upon the Complainant while it was used. It prompted continued CPR efforts while it analyzed the patient’s heart rhythm and a shock application was contraindicated. The two reasons an AED analysis would contraindicate shock were if the heart was beating normally or if the analysis revealed ‘flatline’.Cause/Manner of Death Case Conference
On June 30, 2021, a video case conference was hosted by the regional supervising coroner, attended by an investigating coroner, a pathologist, a CFS toxicologist and the SIU. In consultation, after an explanation and interpretation of the toxicology analysis, and the pathologist’s opinion of LPS custody video, the cause of death was unanimously and undisputedly determined to be methamphetamine toxicity. The manner of death was described as accidental.
The absence of prescription medications the Complainant disclosed he was taking as prescribed did not contribute to his death, nor did his withdrawal from alcohol.
The expert analysis of the toxicology also revealed the methamphetamine the Complainant overdosed on entered his system mere minutes before he entered into seizure. That time frame was determined by comparing the amount of methamphetamine in his blood with the amphetamine levels. Amphetamine is a metabolite of methamphetamine and metabolizes at a known rate. The relatively small concentration of amphetamine allowed the scientists to conclude very little time had passed between the methamphetamine consumption and the death.
Video/Audio/Photographic Evidence [10]
The SIU obtained audio, video, and photographic records of relevance, as set out below. Booking and Custody Video
Requested February 2, 2021, the initially received footage from 18 cameras arrived in the SIU Central Registry on February 8, 2021. That video captured the Complainant’s booking and custody in segmented pieces. A second request was made, and additional footage was received into the Central Registry on February 18, and March 1, 2021. The additional footage captured the entire over 16 hours of the Complainant’s detention. Some of the video also included audio.Of import, the video captured the Complainant’s booking, where the Complainant was talkative. His behaviour was erratic but cooperative. The Complainant stated he was not suicidal. At 4:05:10 p.m., he was steady on his feet, not shaking, and had full function of his hands. A sergeant asked if the Complainant had consumed drugs or alcohol, and the Complainant responded that he had “a couple of shots” earlier in the day. The Complainant said he tested positive for the COVID-19 virus and had been recently quarantined. The sergeant asked the Complainant if he was feeling ill and what symptoms he had. The Complainant replied, “Look at me I’m fucking …. nik,” but did not give any further information. The Complainant told the sergeant he had a shot of vodka at 9:30 a.m. He said he had three shots in total before his arrest. The sergeant asked if the Complainant had used any drugs in the past 24 hours, and the Complainant told him he had not. When asked if he had any medical conditions, the Complainant responded he was an alcoholic and was going to be going into withdrawal. He said in the morning he would require large doses of sugar. The Complainant told the sergeant he had been prescribed naltrexone, trazadone, and olanzapine and, though his medications were at his girlfriend’s house, she would likely not give them to him. The Complainant was lodged in a cell and did not display any shaking.
At 4:40:27 a.m., the next day, camera 13 recorded the Complainant standing at a sink shaking noticeably.
At 5:41:47 a.m., camera 03 captured SEW #3’s returns from a cell check. He told SEW #4, “Holy…he is fucking hurting.”
At 5:50:09 a.m., camera 03 recorded SEW #3 telling SEW #2 there was a person
in custody going through withdrawal and shaking.
At 5:56:56 a.m., camera 03 recorded the SO being briefed by WO #5. Most of that briefing was inaudible as the cadets’ conversation overwhelmed the microphone. WO #5 was heard saying the Complainant was shaking.
At about 6:13 a.m., SEW #1 conducted a cell check. The Complainant’s shakes were not as noticeable.
At 6:03:37 a.m., the SO told SEW #2, “Keep him comfortable,” before the shift had a conversation about two LPS sergeants who were on administrative leave due to the investigation of an in-custody death.
Cell checks continued, including checks made by the SO.
At 7:01:43 a.m., camera 19 captured the SO’s return to the Complainant’s cell. The Complainant was sitting up, appeared alert, and answered questions by moving his head. He had noticeably shaking legs.
At 7:03:11 a.m., camera 03 captured the SO telling the cadets, “We might need a wheelchair to get this guy to court, I don’t think he can walk.” SEW #1 asked the SO how much alcohol one would have to drink and how often to cause the Complainant’s symptoms. The SO responded, “More than you ever had in your life.”
At 7:04:23 a.m., the SO left the desk saying, “If I wave, come.” He moved to camera 19 and spoke to the Complainant, who had wrapped a blanket around his waist and was sitting on the toilet. The Complainant cleaned himself and got back to the bench.
By 7:40:40 a.m., camera 13 captured that the Complainant’s shakes had increased.
At 7:58:49 a.m., camera 03 recorded a telephone conversation, off camera. The SO said, “Good morning staff sergeant how are you…great thank you...we are holding one…not bad at all…he is an alcoholic…and he is fatigued but that’s it…Ah, he says it is pretty bad…you would think there is an earthquake in his cell right now…(inaudible)…I have considered it, he says he is okay, we are pumping him full of fluids, he is conscious, he is aware but, I have consider it…(inaudible)…He is not old enough…(inaudible)…that kind of state, but he has certainly been hitting it hard…I am, staff sergeant, thank you, no sir, thanks again… (inaudible)…I think I have texted you at that number before, thanks staff.”
At around 8:09:08 a.m., camera 03 captured the SO say, “Yeah he is in rough shape.”
At 8:09:03 a.m., the SO and the cadets discussed the in-custody death of someone who had fentanyl secreted in his rectum. The SO expressed that that person was somewhat to blame for their own demise because he did not disclose he had any drugs secreted in his body. He went on to say it was his job, no matter what, to look after a person in his custody and he would do whatever was necessary to ensure their safety.
At 8:20:40 a.m., camera 13 captured that the Complainant’s whole body was shaking; he was sweaty and uncomfortable. He was unsteady on his feet and fell backwards onto the bunk.
At 8:24:14 a.m., camera 19 captured SEW #1’s return to the Complainant’s cell. He placed a drink on the floor at the base of the cell door. The Complainant’s shaking had increased again. He attempted to drink from a cup, using two hands, but spilled the liquid due to shaking. SEW #1 returned to the custody desk and told SEW #2 he gave the Complainant more cereal bars and the Complainant had asked for something with sugar. He told her the Complainant could not drink because he was shaking so badly. They were uncertain what to do and agreed to speak with the SO upon his return. SEW #1 mentioned that if the Complainant needed the sugar, he thought he would try to drink the juice and eat the cereal bars he was given and had not touched.
At 8:25:51 a.m., camera 13 recorded the Complainant trying to fill a paper cup with water from the sink. His hands were not functioning properly - he had to use two hands to bring the cup to his mouth. He crushed the cup as he tried to drink the water, spilling it all over himself and the cell.
At 8:27:32 a.m., camera 03 recorded the SO’s return to the cell block. SEW #1 told him the Complainant wanted sugar, like a chocolate bar, but still had juice. He also told the SO the Complainant had a difficult time drinking because he shook so badly. SEW #1 asked if there was anything else they could give him and the SO replied, “There is nothing else we can give him, the only thing else I can do is send him to hospital and they will give him a sedative…(inaudible)…and that is kind of where I am at.” The SO then walked to the side of the custody desk and said, “If he continues to get worse, fuck he’s not.”
At 8:30:38 a.m., the SO made a telephone call asking for police officers to transport the Complainant to hospital. He told the cadets he was not sending the Complainant to hospital via ambulance because he did not believe that was required, but the Complainant’s condition had progressed beyond the point they were able to care for him. SEW #1 agreed and the SO said, “Yep, it’s not an emergency, but…”
At 8:29:34 a.m., camera 13 showed the Complainant shaking uncontrollably, stiff legged and unsteady on his feet; his hands were curled in on themselves as his condition deteriorated.
At 8:37:32 a.m., WO #3 and WO #4 arrived in the cell block. The SO said they needed to transport the Complainant to hospital but would brief them once they used the washroom facilities.
At 8:38:44 a.m., camera 13 captured the Complainant laid out across the bed, up against the cell bars. He then turned on his back, arms out to his sides, looking at the ceiling with the lower part of his body hanging off the bed. He appeared unable to sit up and eventually rolled onto his stomach and knelt on the floor, facing the bed.
At 8:39:00 a.m., the SO entered the cell block directly to the Complainant’s cell. He stood looking into cell. SEW #2 walked into the cell corridor and watched from approximately three metres away. The SO used his police radio and then spoke to SEW #2 who left the cell block as SEW #1 arrived. By 8:39:00 a.m., the Complainant was on the floor of the cell with his feet against one wall, his body arched and his elbows on the bed. He appeared to be attempting to speak with the SO who was at the cell door speaking to him. The Complainant’s hands were curled and shook violently. He arched his head backward and appeared in agonizing discomfort.
At 8:39:50 a.m., the SO used his police radio again as SEW #1 watched him bent at the waist looking down at the Complainant.
At 8:40:05 a.m., SEW #2 returned with a pair of leg restraints. The Complainant’s body movements had almost completely stopped, wedged between the wall and bed with his body and head arched backward in an unnatural position.
At 8:40:21 a.m., SEW #1 and SEW #2 silenced the cell check alarms.
At 8:40:43 a.m., the Complainant’s hands slowly folded toward his chest, his wrist and hands curled inward. SEW #1 left the cell block to complete the cell checks.
At 8:40:53 a.m., camera 19 recorded the SO open the door to the Complainant’s cell and drag the Complainant from the cell, into the corridor, by his left arm. The SO turned the Complainant to his back between himself and SEW #2, who was on the Complainant’s right-hand side. The Complainant’s right arm was bent 90 degrees and his fingers were curled. SEW #1 returned and the Complainant was rolled onto his right side. The SO said something to SEW #2, who got up and left the SO knelt behind the Complainant’s upper body and SEW #1 in front of his legs.
At 8:41:07 a.m., camera 03 recorded WO #3 telling WO #5 that the SO had called an ambulance.
At 8:41:49 a.m., camera 03 captured SEW #2 entering the area of the custody desk. WO #3 asked what was happening. SEW #2 replied, “He is turning blue.” WO #3 moved to the cell block and WO #5 left to move his police vehicle from the sally port.
At 8:41:53 a.m., camera 19 recorded WO #3 enter the cell block area. The SO rolled the Complainant to his back and started chest compressions. SEW #1 was at the Complainant’s feet. WO #3 used her police radio before leaving the cell area to fetch the AED. The SO continued chest compressions. The Complainant’s right arm was still held up at a 90-degree angle from the floor.
At 8:42:42 a.m., WO #3 returned to the control desk and asked for the AED, saying the Complainant did not have a pulse. WO #3 returned to the Complainant with the AED. The SO used a knife to cut the Complainant’s T-shirt. SEW #1 produced Narcan from his vest and gave it to WO #3, who administered it to the Complainant. Live-saving measures were continued and, at 8:44:29 a.m., a camera recorded WO #3 applying AED pads to the Complainant and activating the device. All life-saving efforts stopped while the AED analyzed the Complainant’s vital signs. The automated voice of the AED announced, “Stand clear,” as the rhythmic beeping sound of the AED sounded.
At 8:45:10 a.m., WO #3 applied chest compressions. Both the Complainant’s arms were bent at 90 degrees to his body, and his hands and forearms in the air at 45 degrees to the floor with his fingers curled.
At 8:45:23 a.m., WO #5 arrived in the cell area.
At 8:47:47 a.m., camera 04 captured EMS personnel entering the police station. At 8:48:21 a.m., they reached the cell area. From that point forward, the Complainant’s care was conducted by paramedics and he was taken from the police facility.
Custody video evaluated by Pathologist
Sections of CCTV footage were provided to the forensic pathologist to assist in the cause of death determination. During the course of his review, the pathologist observed the Complainant licking a piece of material before discarding it in the cell toilet. The pathologist considered the way the Complainant licked the material consistent with the ingestion of methamphetamine and would explain the high levels of that drug found in the Complainant’s system upon toxicology analysis. The pathologist made his thoughts known to investigators during the June 30, 2021 case conference. SIU investigators conducted a further review of the footage and determined the section in question recorded the Complainant as he ripped the bottom off one of the paper cups of juice and soup that had been given to him in. He then ripped the cup in two and brought that to his mouth. The Complainant looked to his right, put the cup to his face, licked the cup, and rubbed it on his gums before he discarded it in the toilet.
Forensic tests upon the cups discarded in the cell could not be conducted as they were not collected.
Another comprehensive review of all video footage, however, failed to find evidence of the Complainant removing any secreted item while he was in custody.
Materials Obtained from Police Service
The SIU obtained and reviewed the following records from the LPS:• Email from LPS-Training Records and Disclosure;• LPS AED Records;• LPS Computer-assisted Dispatch-Call Summary;• LPS Cell Check Report;• LPS Information Folder Hardcopy-the Complainant;• LPS Occurrence - Arrest;• LPS Policy - Persons in Custody Care and Detention;• LPS Position Description-Sergeant-Headquarters-Detention Unit;• LPS - the SO Transfer Date;• Narrative of WO #1, WO #2, WO #3, WO #5 and the SEWs; and• Notes – WO #1, WO #2, WO #3; WO #5, SEW #1 and SEW #2.
Materials Obtained from Other Sources
The SIU obtained and reviewed the following records from the following other sources: • Toxicology report from the CFS;• Preliminary autopsy findings from the Ontario Forensic Pathology Service;• Coroner’s case conference document; and• Post-mortem Report from the Coroner’s Office.
Incident Narrative
The following scenario emerges from the evidence collected by the SIU, which included interviews with police personnel who dealt with the Complainant during his custody, and a review of the medical evidence in relation to the cause of the Complainant’s death. As was his legal right, the SO chose not to interview with the SIU or authorize the release of his notes.
In the afternoon of February 1, 2021, the Complainant was arrested by WO #1 and WO #2. Called to the scene of a reported domestic disturbance, the officers took the Complainant into custody for being in violation of a judicial order that he not associate with a woman. He was transported by WO #2 to the LPS detention unit.
The Complainant was lodged in a police cell shortly after his booking at about 4:08 p.m. Asked about his condition, the Complainant told the sergeant in charge of the cells that he had earlier consumed three shots of alcohol and would be experiencing alcohol withdrawal symptoms at some point. He denied having consumed any drugs prior to being arrested.
The first sign that something was amiss was at about 1:40 a.m. WO #5, then the sergeant in charge of the detention unit, had stopped at the Complainant’s cell to check on him. The Complainant, shaking, told the officer he was cold and suffering from alcohol withdrawal. Asked what the sergeant could do to help him, the Complainant replied that he needed sugary drinks. WO #5 shortly returned with juice and cereal bars, and assured him he would do whatever he could to make him comfortable through the night.
At about 2:00 a.m., while being transferred to another cell, the Complainant told WO #5 that he was concerned his condition would deteriorate to the point of seizure. The Complainant went on to explain that he was not predisposed to seizures but believed he was at risk because of the amount of alcohol he had consumed the last few months. WO #5 reminded the Complainant to tell staff if at any point he believed he needed help, and help would be obtained. He went on to speak to the two cadets assisting him with cell checks – SEW #3 and SEW #4 – advising them to keep a close eye on the Complainant and to inform him of any changes in his condition.
The SO came on duty shortly before 6:00 a.m. and took over from WO #5. With him, replacing SEW #3 and SEW #4, were SEW #1 and SEW #2. The SO and WO #5 talked about the Complainant and his symptoms of alcohol withdrawal. At about 8:00 a.m., the SO had a telephone conversation with WO #7 about the condition of prisoners. By that time, the Complainant’s whole body had started to shake. The SO noted that the Complainant was the only person in cells and that he was experiencing alcohol withdrawal. The SO told WO #7 that the Complainant was shaking severely; however, he was young and not in bad shape. WO #7 cautioned the SO to continue to monitor the Complainant and to take him to hospital if his condition deteriorated.
By about 8:00 a.m., the Complainant’s condition had deteriorated to the point that he was very unsteady on his feet and barely able to drink from a cup because his shaking was so bad. Shortly after his 8:20 a.m. cell check, SEW #1, growing increasingly worried about the Complainant’s health, conveyed his concerns to the SO. The SO contacted two officers at 8:30 a.m. and arranged to have them transport the Complainant to hospital. Those plans were derailed when, after visiting the Complainant in his cell at about 8:40 a.m., it was apparent to the SO that he needed immediate medical attention.
The SO entered the cell, took hold of the Complainant’s left arm, and dragged him into the corridor. Over the course of the next several minutes, the SO, SEW #1, and WO #3 and WO #4 (the officers who had been summoned to take the Complainant to hospital) administered live-saving measures, including chest compressions, the administration of naloxone, and the use of an AED.
Paramedics arrived at the cells at about 8:50 a.m. and took charge of the Complainant’s care. He was transported to hospital in ambulance, and pronounced deceased at about 9:42 a.m.
Cause of Death
The pathologist at autopsy attributed the Complainant’s death to methamphetamine – amphetamine toxicity.
In the afternoon of February 1, 2021, the Complainant was arrested by WO #1 and WO #2. Called to the scene of a reported domestic disturbance, the officers took the Complainant into custody for being in violation of a judicial order that he not associate with a woman. He was transported by WO #2 to the LPS detention unit.
The Complainant was lodged in a police cell shortly after his booking at about 4:08 p.m. Asked about his condition, the Complainant told the sergeant in charge of the cells that he had earlier consumed three shots of alcohol and would be experiencing alcohol withdrawal symptoms at some point. He denied having consumed any drugs prior to being arrested.
The first sign that something was amiss was at about 1:40 a.m. WO #5, then the sergeant in charge of the detention unit, had stopped at the Complainant’s cell to check on him. The Complainant, shaking, told the officer he was cold and suffering from alcohol withdrawal. Asked what the sergeant could do to help him, the Complainant replied that he needed sugary drinks. WO #5 shortly returned with juice and cereal bars, and assured him he would do whatever he could to make him comfortable through the night.
At about 2:00 a.m., while being transferred to another cell, the Complainant told WO #5 that he was concerned his condition would deteriorate to the point of seizure. The Complainant went on to explain that he was not predisposed to seizures but believed he was at risk because of the amount of alcohol he had consumed the last few months. WO #5 reminded the Complainant to tell staff if at any point he believed he needed help, and help would be obtained. He went on to speak to the two cadets assisting him with cell checks – SEW #3 and SEW #4 – advising them to keep a close eye on the Complainant and to inform him of any changes in his condition.
The SO came on duty shortly before 6:00 a.m. and took over from WO #5. With him, replacing SEW #3 and SEW #4, were SEW #1 and SEW #2. The SO and WO #5 talked about the Complainant and his symptoms of alcohol withdrawal. At about 8:00 a.m., the SO had a telephone conversation with WO #7 about the condition of prisoners. By that time, the Complainant’s whole body had started to shake. The SO noted that the Complainant was the only person in cells and that he was experiencing alcohol withdrawal. The SO told WO #7 that the Complainant was shaking severely; however, he was young and not in bad shape. WO #7 cautioned the SO to continue to monitor the Complainant and to take him to hospital if his condition deteriorated.
By about 8:00 a.m., the Complainant’s condition had deteriorated to the point that he was very unsteady on his feet and barely able to drink from a cup because his shaking was so bad. Shortly after his 8:20 a.m. cell check, SEW #1, growing increasingly worried about the Complainant’s health, conveyed his concerns to the SO. The SO contacted two officers at 8:30 a.m. and arranged to have them transport the Complainant to hospital. Those plans were derailed when, after visiting the Complainant in his cell at about 8:40 a.m., it was apparent to the SO that he needed immediate medical attention.
The SO entered the cell, took hold of the Complainant’s left arm, and dragged him into the corridor. Over the course of the next several minutes, the SO, SEW #1, and WO #3 and WO #4 (the officers who had been summoned to take the Complainant to hospital) administered live-saving measures, including chest compressions, the administration of naloxone, and the use of an AED.
Paramedics arrived at the cells at about 8:50 a.m. and took charge of the Complainant’s care. He was transported to hospital in ambulance, and pronounced deceased at about 9:42 a.m.
Cause of Death
The pathologist at autopsy attributed the Complainant’s death to methamphetamine – amphetamine toxicity.Relevant Legislation
Section 219, 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.
Section 220, Criminal Code -- Criminal negligence causing death or bodily harm
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.
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
The Complainant lapsed into unconsciousness while in an LPS cell on February 2, 2021, and subsequently died that morning after resuscitative efforts at hospital were unsuccessful. The SIU was notified of the incident by the LPS and initiated an investigation, identifying the SO as the subject official. The investigation has now concluded. 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 offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing death contrary to sections 215 and 220 of the Criminal Code, respectively. The former is predicated, in part, on conduct that amounts to a marked departure from the level of care that a reasonable person would have exercised in the circumstances. The latter is reserved for more serious cases of neglect that demonstrate a wanton or reckless disregard for the lives or safety of other persons. It is not made out, inter alia, unless the neglect amounts to a marked and substantial departure from a reasonable standard of care. In the instant case, the issue is whether there was a want of care in the manner in which the SO exercised his custodial responsibilities over the Complainant that caused or contributed to his death and / or was sufficiently egregious to attract criminal sanction. In my view, there was not.
Though it might have been advisable to take the Complainant to hospital sooner than was the case, I am unable to reasonably conclude that the SO transgressed the limits of care prescribed by the criminal law in acting as he did. For much of the roughly two-and-a-half hour period that the Complainant was in the officer’s custody, his condition had been much as it was for most of his time in the cells. The Complainant was experiencing signs of purported alcohol withdrawal – he was nauseous, sweaty, cold, and shaking – but was otherwise conscious, lucid, and breathing easily. Having told his custodians that he would need sugary drinks to help him with his withdrawal, the Complainant was regularly offered juice and cereal bars. Nor did the Complainant ask to be taken to the hospital, despite being offered whatever assistance he needed. Indeed, there is some evidence that he expressly declined to go to hospital when it was suggested by one or more of the cell personnel. Moreover, the SO would have found affirmation in the manner in which he was proceeding after his phone conversation with WO #7. Though he acknowledged that alcohol withdrawal and, more specifically, the apparent onset of delirium tremors in the Complainant, could require hospitalization, WO #7, who was trained as a paramedic, saw no particular need to direct that the Complainant be taken to hospital based on the SO’s description of the situation. Finally, it bears noting that the Complainant was regularly checked in his cell and that the SO acted with reasonable dispatch as soon as he was advised that the Complainant’s condition had taken a decided turn for the worse.
The SO’s liability might have tipped in the other direction had he been aware that the Complainant had methamphetamine secreted on, and likely, in, his person. As the post-mortem examinations concluded, the Complainant died of methamphetamine-amphetamine toxicity – not of alcohol withdrawal. The Complainant, however, had denied consuming any drugs as he was being booked prior to being lodged in cells. Nor is there any suggestion that the custodial staff, including the SO, was derelict in allowing the Complainant to retrieve and consume drugs while in cells. This, together with the medical evidence indicating the methamphetamines were very likely absorbed by the Complainant’s system within minutes of his medical episode, raises the possibility that the drugs were secreted inside the Complainant’s body while he was in custody. In the circumstances, I am unable to fault the SO for not acting with the greater expedition that might have been warranted had he known of the methamphetamines.
In the result, while it may be that the SO ought to have sent the Complainant to hospital sooner than he did, there is insufficient evidence to reasonably conclude on balance that the officer’s failure to do so amounted to a marked departure from a reasonable standard of care, let alone a marked and substantial one. Accordingly, there is no basis for proceeding with criminal charges in this case, and the file is closed.
Date: November 8, 2021
Electronically approved by
Joseph Martino
Director
Special Investigations Unit
The offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing death contrary to sections 215 and 220 of the Criminal Code, respectively. The former is predicated, in part, on conduct that amounts to a marked departure from the level of care that a reasonable person would have exercised in the circumstances. The latter is reserved for more serious cases of neglect that demonstrate a wanton or reckless disregard for the lives or safety of other persons. It is not made out, inter alia, unless the neglect amounts to a marked and substantial departure from a reasonable standard of care. In the instant case, the issue is whether there was a want of care in the manner in which the SO exercised his custodial responsibilities over the Complainant that caused or contributed to his death and / or was sufficiently egregious to attract criminal sanction. In my view, there was not.
Though it might have been advisable to take the Complainant to hospital sooner than was the case, I am unable to reasonably conclude that the SO transgressed the limits of care prescribed by the criminal law in acting as he did. For much of the roughly two-and-a-half hour period that the Complainant was in the officer’s custody, his condition had been much as it was for most of his time in the cells. The Complainant was experiencing signs of purported alcohol withdrawal – he was nauseous, sweaty, cold, and shaking – but was otherwise conscious, lucid, and breathing easily. Having told his custodians that he would need sugary drinks to help him with his withdrawal, the Complainant was regularly offered juice and cereal bars. Nor did the Complainant ask to be taken to the hospital, despite being offered whatever assistance he needed. Indeed, there is some evidence that he expressly declined to go to hospital when it was suggested by one or more of the cell personnel. Moreover, the SO would have found affirmation in the manner in which he was proceeding after his phone conversation with WO #7. Though he acknowledged that alcohol withdrawal and, more specifically, the apparent onset of delirium tremors in the Complainant, could require hospitalization, WO #7, who was trained as a paramedic, saw no particular need to direct that the Complainant be taken to hospital based on the SO’s description of the situation. Finally, it bears noting that the Complainant was regularly checked in his cell and that the SO acted with reasonable dispatch as soon as he was advised that the Complainant’s condition had taken a decided turn for the worse.
The SO’s liability might have tipped in the other direction had he been aware that the Complainant had methamphetamine secreted on, and likely, in, his person. As the post-mortem examinations concluded, the Complainant died of methamphetamine-amphetamine toxicity – not of alcohol withdrawal. The Complainant, however, had denied consuming any drugs as he was being booked prior to being lodged in cells. Nor is there any suggestion that the custodial staff, including the SO, was derelict in allowing the Complainant to retrieve and consume drugs while in cells. This, together with the medical evidence indicating the methamphetamines were very likely absorbed by the Complainant’s system within minutes of his medical episode, raises the possibility that the drugs were secreted inside the Complainant’s body while he was in custody. In the circumstances, I am unable to fault the SO for not acting with the greater expedition that might have been warranted had he known of the methamphetamines.
In the result, while it may be that the SO ought to have sent the Complainant to hospital sooner than he did, there is insufficient evidence to reasonably conclude on balance that the officer’s failure to do so amounted to a marked departure from a reasonable standard of care, let alone a marked and substantial one. Accordingly, there is no basis for proceeding with criminal charges in this case, and the file is closed.
Date: November 8, 2021
Electronically approved by
Joseph Martino
Director
Special Investigations Unit
Endnotes
- 1) AED data analysis below. [Back to text]
- 2) Methamphetamine is a potent central nervous system stimulant mainly used as a recreational drug. [Back to text]
- 3) Amphetamines are a stimulant that may be prescribed and legally taken. [Back to text]
- 4) Naloxone is used as an opioid antagonist to treat opioid overdose. [Back to text]
- 5) Amiodarone is an antiarrhythmic medication used to treat and prevent a number of types of irregular heartbeats [Back to text]
- 6) Tetrahydrocannabinol is the principal psychoactive constituent of cannabis. [Back to text]
- 7) Carboxy tetrahydrocannabinol is the main secondary metabolite of THC, which is formed in the body after cannabis has been consumed [Back to text]
- 8) Hydroxy tetrahydrocannabinol is the main active metabolite of tetrahydrocannabinol, which is formed in the body after decarboxylated cannabis has been consumed. [Back to text]
- 9) Ethanol is the chemical compound of alcohol. [Back to text]
- 10) The following records contain sensitive personal information and are not being released pursuant to section 34(2) of the Special Investigations Unit Act, 2019. The material portions of the records are summarized below. [Back to text]
- 11) While WO #7 had paramedic training, the investigation gathered evidence suggesting that custodial staff did not receive formal training in the types of medical emergencies they might encounter in the detention unit, such as alcohol withdrawal. [Back to text]
Note:
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.