Director's Report Details

• 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.

Number of SIU Forensic Investigators assigned: 1

Affected Person (aka “Complainant”):

51-year-old male interviewed, medical records obtained and reviewed

The Complainant was interviewed on August 19, 2021.

Civilian Witness (CW)

CW Not interviewed [1]

Subject Officials (SO)

SO #1 Declined interview and to provide notes, as is the subject official’s legal right
SO #2 Declined interview and to provide notes, as is the subject official’s legal right
SO #3 Declined interview and to provide notes, as is the subject official’s legal right

Witness Officials (WO)

WO #1 Interviewed
WO #2 Interviewed
WO #3 Interviewed

The witness officials were interviewed between October 25, 2021 and November 8, 2021.

Service Employee Witnesses (SEW)

SEW #1 Interviewed
SEW #2 Interviewed
SEW #3 Interviewed
SEW #4 Interviewed
SEW #5 Interviewed
SEW #6 Interviewed
SEW #7 Interviewed
SEW #8 Interviewed
SEW #9 Interviewed

The service employee witnesses were interviewed between October 25, 2021 and November 3, 2021.

Video/Audio/Photographic Evidence [2]

Closed-circuit Television (CCTV) Data – WPS Custody Video

The SIU obtained CCTV data of the WPS custody area and the cell relevant to the Complainant’s custody. The following is a summary of the relevant audio-video data from the WPS custody area and the cell occupied by the Complainant between 1:13:58 p.m., on August 12, 2021, and 12:39:59 a.m., on August 13, 2021, by which time the Complainant had been fully removed from his cell by paramedics after he was found unconscious in the cell.

The audio-recorded aspect of the Complainant’s custody was virtually impossible to discern due to the cavernous echo created by the cell block architecture, the ambient sounds from the heating, ventilation and air conditioning system, and WPS personnel performing their duties in the area of the cell occupied by the Complainant.

The toilet component of the toilet/sink unit in the cell was obscured with a white rectangle screen by the CCTV data recording equipment proprietary software, for privacy/dignity of the prisoner. There was no technological ‘override’ to remove the white privacy/dignity screen.

Attributing precise spoken words to specific WPS personnel and to the Complainant was impossible due to the wearing of PPE masks by WPS personnel and the Complainant. The times noted are all approximate and recorded here from the timestamps associated with the CCTV data.

Custody Area

1:13:58 p.m. – The Complainant entered the booking area escorted by one WPS special constable/civilian member of the WPS. They approached and stood at the booking desk, staffed by two WPS special constables. The Complainant, who was not in handcuffs, was holding up his short pants with his left hand while his right hand fidgeted with his pants pockets. Throughout, the Complainant appeared to be trying to adjust something in his pockets/pants. He used his right hand to sign a document in a binder on the desk while holding his pants up with his left hand.

1:15:51 p.m. – The Complainant had been moved to and was seated in the fingerprinting room after hitching his pants up to his hips as he approached the chair. The fingerprinting process done by a WPS special constable was uneventful.
 
Cell

1:20:00 p.m. – The Complainant entered a cell and settled on his back on the bunk. He was wearing a PPE mask. His hands were visible on his chest with his right leg crossed over his left leg at his ankles. He appeared to be sleeping.

1:48:00 p.m. – By this time, the Complainant had changed his position to laying on his left side – head toward the back of the cell where the toilet/sink were situated, and his legs drawn up at the knees to about 45-degrees in relation to the wall behind him. He appeared to be sleeping.

1:56:00 p.m. – The Complainant had repositioned himself to sitting on the bunk with his knees drawn up to his chest and his sweater pulled down tight to his toes concealing his buttocks, legs, and feet from the focal range of the camera.

2:06:00 p.m. – The Complainant had removed both arms from his sleeves to conceal his hands and arms from the focal range of the camera. Using his shirt that was still pulled down at its hem to conceal his lower body, the Complainant had essentially created a tent to conceal all but his head from the focal range of the camera. He had his face downward also away from the focal range of the camera. Forty-eight seconds later, the Complainant had drawn his knees even closer to his chest under the sweater.

2:07:26 p.m. – The Complainant started to put his hands inside his sweater first using his right hand to pull his left sleeve to extract his left arm to the inside of his sweater. He then used his left hand inside his tented sweater to manipulate his right arm and hand in a similar fashion to get both hands and arms inside his tented sweater; thus, concealing his upper extremities completely. The Complainant concealed his face from view throughout these movements by pulling his head nearly completely inside his sweater at the neck. During the ensuing minutes, the Complainant made purposeful movements with his hands under his sweater while keeping his face concealed inside his sweater; these movements ceased at about 2:07:43 p.m. These movements did not appear to be mere fidgeting with his pants and sweater for comfort. He remained seated on the cell bunk in the same position described herein with his face in his hands exhibiting only his fingers near his forehead.

2:45:51 p.m. – The Complainant’s attention was suddenly drawn to someone or some other sound outside his cell. He stood up immediately and, fidgeting with his pants, exited his cell holding his pants up at the waist.

3:02:39 p.m. – The Complainant returned to his cell and sat on the bunk near the cell door. His hands and arms were still concealed inside his sweater. He fidgeted with his pants and then, at 3:02:57 p.m., he stood up and approached the door, apparently speaking to someone outside the door. After several seconds, he sat again on the bunk with his head turned downward away from and blocking the camera’s focal range of the Complainant’s torso.

3:08:00 p.m. – The Complainant stood up and, with his hands and arms still concealed in his sweater, stepped close to the cell door and looked out the cell door window briefly before pacing the length of his cell twice with his hands and arms concealed under his sweater, thereafter looking through the cell door window again. His head nodded several times as though he were speaking to someone at the closed door of his cell. He then resumed pacing in his cell and, at 3:09:02 p.m., sat on the bunk near the door with his hands, arms and head tucked in his sweater and making purposeful movements under his sweater with his hands.

3:09:10 p.m. - The Complainant stood up and, quickly putting his arms and hands back into his sleeves, approached the toilet/sink with his PPE mask below his chin and pressed on the sink tap with the palm of his right hand. His left hand was not completely visible. He bent down and sipped water from the tap, stood upright and swallowed. He then sipped again from the tap and stood upright to swallow, but this time, the Complainant quickly jerked his head back slightly as though to accelerate a substance down his throat before returning to the edge of the bunk.

3:09:24 p.m. - The Complainant, while bending at the waist with his back toward the bunk, had his left hand concealed under his sweater and was rummaging for something in his front pants pocket using his right hand. The Complainant then returned to the toilet/sink unit where he appeared to thrust something into the sink or toilet with his left hand while pressing a tap open with his right. A full view of the toilet and sink were obstructed by the Complainant and the white rectangular privacy/dignity screen. He appeared to be checking either the sink or toilet bowl briefly before returning to the bunk.

3:09:41 p.m. – The Complainant had returned to the bunk where, after sitting down, he again removed his arms and hands from his sweater sleeves, and lay down on the bunk with his left leg crossed over his right leg at the ankles; feet toward the cell door and head toward the back wall of the cell. He appeared to be staring at the ceiling and blinking with his PPE mask still attached to his ears but below his chin.

4:55:43 p.m. – The Complainant appeared to have been sleeping/snoring until this time, still on his back with an audible respiration rate of about seven breaths per minute [normal adult male rate = 12 to 16 breaths per minute], when a special constable entered the cell and tried to rouse the Complainant. It took the special constable a period of time of calling out the Complainant’s given name loudly and close to the Complainant’s head to rouse the Complainant, finally yelling, “Get on your feet!” to get the Complainant’s attention. The Complainant slowly responded by scratching his abdomen, back, arms, head and inner ears, and other parts of his body incessantly while not appearing to be even aware of the shouting special constable’s presence. The Complainant exhibited significant difficulty getting his arms back into his sweater sleeves and was not able to easily stand up, reseating himself on the bunk as he struggled with his sweater. At one point, the Complainant lost all focus on the task of getting his sweater put on properly and just stared at the garment around his neck. Without his sweater on properly, the Complainant slowly stood up and had to steady himself with his left hand on the wall opposite the bunk. He sat back down again on the bunk and resumed his struggle with his sweater.

4:58:49 p.m. – A special constable entered the cell beckoning and encouraging the Complainant to hurry. The audio quality was poor. The Complainant slowly got to his feet with the help of the special constable steadying the Complainant’s upper left arm while the Complainant reached for and held onto the cell doorway as he exited into the hallway.

5:02:31 p.m. – The Complainant was returned to the cell by the same special constable who assisted him out of the cell. The special constable steadied the Complainant as he was seated on the bunk near the cell door. The Complainant bent over at the waist twice, ‘bobbing’ toward the floor before bending fully over at the waist while seated and slept, nearly falling head-first to the floor. The Complainant remained in this position snoring and wheezing loudly until 5:49:30 p.m., when he stirred from his sleep when a woman’s voice (believed to be a special constable) near the cell door was heard.

5:49:50 p.m. – The Complainant stirred again and pushed himself back up to the bunk. He appeared unsteady and his right palm slipped from the edge of the bunk before he resumed scratching his lower back with the same hand. He tried to adjust his posture but was distracted by scratching his back and head. He ‘bobbed’ slowly toward the floor several times, nearly slipping from the bunk, head-first to the floor, at 5:51:30 p.m. The Complainant managed to finally push himself backward on the bunk toward the wall against which he eventually leaned, but not before 7:39:33 p.m., after sleeping, snoring, and sliding at the edge of the bunk with the Complainant nearly collapsing on the floor several times.

Between 7:39:57 p.m., and August 13, 2021, at 12:15:37 a.m., the Complainant remained in the same slumped position, at times with audible, observably shallow, and sporadic respiration sounds, and at times with none. At 12:15:37 a.m., a special constable partially entered the cell and called out to the Complainant by his first name, who failed to respond in any way. Then, at 12:15:47 a.m., the same special constable slapped the Complainant’s right knee with a paper file folder, over a dozen times, nudged the Complainant’s right foot with the toe of his boot and pushed the back of his hand several times against the outer aspect of the Complainant’s right thigh. He also briefly applied a sternum rub to the Complainant’s chest. There was no response from the Complainant whatsoever. The Complainant’s PPE mask was on the cell floor and his sweater exhibited moisture at the front of the neck hole from drool.

12:16:33 a.m. – The special constable had continuously called out to the Complainant and garnered no response as a second special constable entered the cell to assist the first one and the Complainant.

12:16:43 a.m. – Both special constables carefully lifted the Complainant’s legs from the edge of the bunk and laid him on his back. Another member of the WPS was seen partially in the doorway putting on PPE gloves. The special constables got the Complainant turned on his right side as one of the special constables was heard saying, “Yeah, he’s not good,” and one special constable was seen operating his portable radio calling for assistance.

During the ensuing five minutes, three special constables and a WPS sergeant [now known to be SO #3] called out to the Complainant, saying “Wakey, wakey!” and encouraged the Complainant to keep breathing. By 12:24:30 a.m., one of the special constables had administered three successive doses of naloxone provided by SO #3 from an emergency kit, and applied periodic sternum rubs to elicit a response. One of the WPS members was heard asking, “What’s he in for?” The response from another WPS member was, “Drug possession.” During this time, the Complainant was never left alone or unattended and he did not slip to the floor or onto his back.

12:28:06 a.m. – SO #3 left the cell to make room for the paramedics arriving while two special constables remained in the cell observing the Complainant and keeping him in the recovery position on his right side.

12:28:16 a.m. – The first of two paramedics entered cell and took over the care of the Complainant.

Materials Obtained from Police Service

Upon request, the SIU received the following materials and documents from WPS between August 13, 2021 and November 2, 2021:

• Computer-aided Dispatch Call Print Out;
• Prisoner Care and Control Directive;
• Detention Centre Directive;
• Search of Persons Directive;
• Booking Sheet (Prisoner Transport and Registry Form);
• Cell Check List 1 – the Complainant;
• Cell Check List 2 – the Complainant;
• Cell Check-Written Hard Copy;
• Cell - In and Out- the Complainant;
• Cell History- the Complainant;
• Cell List-Integrated Booking (Versa);
• Cell List-the Complainant;
• Cells-Lawyer Phone Log Sheet-Redacted;
• List of involved officers;
• Narrative-SEW #2 (Supplementary Report);
• Narrative-SEW #4 (Supplementary Report);
• Narrative-WO #1 (Supplementary Report);
• Narrative-WO #2 (Initial Officers Report);
• Narrative-SEW #3 (Supplementary Report);
• Narrative-SEW #1 (Supplementary Report);
• Notes-SEW #9;
• Notes-WO #3;
• Notes-SEW #2;
• Notes-SEW #4;
• Notes-SEW #8;
• Notes-SEW #5;
• Notes-WO #1;
• Notes-SEW #7;
• Notes-WO #2;
• Notes-SEW #3;
• Notes-SEW #1;
• Notes-SEW #6;
• Custody Video; and
• SIU Disclosure Log.

Materials Obtained from Other Sources

The SIU obtained the following record from other sources on August 24, 2021:

• The Complainant’s WRH records relevant to the incident.

215 (1) Every one is under a legal duty

(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

219 (1) Every one is criminally negligent who

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.