Director's Report Details

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.

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: 

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 serious injury a 26-year-old man (the “Complainant”) suffered.

Notification of the SIU

On November 19, 2021, at 1:42 p.m., the Belleville Police Service (BPS) notified the SIU of an injury to the Complainant. BPS advised that the Complainant was arrested on November 18, 2021, at 7:04 p.m., on outstanding warrants and lodged in BPS cells. On November 19, 2021, at 1:40 a.m., the Complainant was found hanging in his cell. He was cut down and Emergency Medical Services (EMS) called.

The Complainant was transported by EMS with police escort to Belleville General Hospital (BGH). He had been admitted to the Intensive Care Unit and intubated. He might have suffered brain damage from a lack of oxygen, but the extent of other injuries was unknown at the time of notification.

The cell was being held for examination.

The Team

Date and time team dispatched: 11/19/2021 at 3:08 p.m.

Date and time SIU arrived on scene: 11/19/2021 at 5:50 p.m.

Number of SIU Investigators assigned: 4

The Scene

The incident took place within the confines of the BPS cell block in a cell. There was paper debris scattered on the inside and immediately outside the cell door. Two aluminum foil blankets were bound in a knot and wrapped around the food intake window on the cell door. The intake window could be opened and closed with a mechanism that was located on the outside of the window; it was in working order.

Physical Evidence

On November 19, 2021, at 5:50 p.m., a SIU Forensic Investigator attended the BPS station to complete an examination and photographs of the cell area. Two aluminum foil blankets bound together with a knot were found in the Complainant’s cell. The aluminum foil blankets were seized.


Figure 1 – Aluminum foil blankets

Video/Audio/Photographic Evidence [1]

BPS Custody Area Video Footage

BPS provided the SIU with the custody area video on November 24, 2021. The following is a summary of the relevant video footage.

Booking Room Video

• On November 18, 2021, at 7:11:40 p.m., the Complainant was escorted into the booking area by WO #1 and WO #3.
• The Complainant was handcuffed to the back and made to stand facing the wall to the left of the frame.
• The handcuffs were removed, the Complainant was directed to put his hands on the wall, and he was searched.
• The SO approached the Complainant and asked him his date of birth and address, and if he had any injuries to report.
• The Complainant answered the SO’s questions and reported he had no injuries.
• The SO asked the Complainant if he took any medications, and the Complainant replied, “Yes,” and that there was a medication he was supposed to pick up.
• The SO asked the Complainant if he had any medical concerns and the Complainant replied, “No, not at the moment.”
• The SO asked the Complainant if he had ever tried to harm himself or if he had consumed drugs. The Complainant did not answer either question, and sat holding his head.
• At 7:17:13 p.m., the Complainant told the SO he did not have his medication, trazadone, and was waiting for it all day.
• The Complainant told the SO he needed to be taken to the hospital.
• The SO asked the Complainant what the medication was for and if he wanted to talk to a lawyer.
• The Complainant told the SO he needed to talk to a doctor - “Otherwise you guys are going to make me psych.”
• The SO asked the Complainant which drug store had his medication.
• The Complainant told the SO, “Shoppers Drug Mart,” and told them he was supposed to speak with Telemed about getting Suboxone in the morning.
• The Complainant repeated himself three times, stating he needed Suboxone. The SO interrupted him and told the Complainant his appointment was for tomorrow and, “Don’t play games with us.”
• At 7:21:22 p.m., the Complainant was led out of the booking area by the SO and WO #1.

Cell Block

• On November 18, 2021, at 7:21:27 p.m., the Complainant was led into a cell by the SO and WO #1.
• The Complainant asked if he could get something to eat and the SO replied, “You gonna work with me if we get you something to eat, like, I’m not going to listen to this I have to go to the hospital stuff all night?”
• The Complainant said, “I really need my medication,” and pointed to his head with his left hand.
• At 12:55:26 a.m., the SO attended the cell, spoke with the Complainant, and exited the frame.
• At 12:57:25 a.m., the SO attended the cell, passed a box containing donuts through the hatch to the Complainant, and exited the frame.
• At 1:35:44 a.m., the SO entered the cell hallway and approached the Complainant’s cell.
• The SO pulled the hatch open, tried to pull on the foil blanket, and ran out of the cell hall.
• At 1:36:34 a.m., the SO entered the cell hall, used keys to open the cell door, and radioed for EMS.
• The Complainant’s head fell into the cell hall, and the SO attempted to wake him and encouraged him to breathe.
• At 1:38:46 a.m., four uniformed police officers entered the cell hall and stood by the Complainant’s cell.
• At 1:44:38 a.m., EMS entered the cell hall with a stretcher.
• Police officers assisted with placing the Complainant on the stretcher and EMS tended to him.
• At 1:49:34 a.m., the Complainant was led from the cell hall on the stretcher.

The Complainant’s Cell

• At 7:21:29 p.m., the Complainant entered the cell.
• The Complainant requested his medication several times while pointing at his head with both index fingers.
• The Complainant spent time kneeling, lying on the floor, sitting, and lying on the bench.
• On November 19, 2021, at 12:48:04 a.m., the Complainant got up and stood by the cell door, knocking.
• At 12:54:29 a.m., the Complainant called out, “What’s going on with my medication?”
• At 12:55:26 a.m., the SO attended the cell and the Complainant asked for something to eat.
• At 12:57:30 a.m., the Complainant was passed two donuts in a box through the hatch. He sat down, and ate them.
• At 1:18:36 a.m., the Complainant stood abruptly, went to the cell door, and slammed the hatch up and down.
• At 1:28:08 a.m., the Complainant said through the hatch, “Yo, why do people have to fucking hurt themselves to get your fucking attention?”
• At 1:28:38 a.m., the Complainant picked up the two foil blankets and wrapped them around the hatch.
• The Complainant tied the ends together, forming a loop, and tugged on the sides.
• The Complainant put his coat over his head. It was not clear what he was doing.
• At 1:30 a.m., the Complainant turned his back to the cell door and leaned forward, pulling his jacket from his head.
• The foil was wrapped around the Complainant’s neck and he was coughing.
• The Complainant slid to the floor and moved around clenching his fists.
• At 1:33:03 a.m., the Complainant was still.
• At 1:35:48 a.m., the SO opened the hatch and tried to pull the foil blanket.
• At 1:36:14 a.m., the SO opened the cell door, cut the blanket around the Complainant’s neck, and called for EMS to attend the cell.
• The Complainant let out a gasp and made attempts to breathe. The SO sat him up and encouraged him to breathe.
• At 1:46:05 a.m., the Complainant was carried from the cell by the SO, a police officer, and a paramedic.

Materials Obtained from Police Service

Upon request, the SIU received the following materials and documents from the BPS between November 24, 2021, and December 3, 2021:

• Custody Area Video Footage;
• Occurrence Reports (x3);
• Shift Schedule;
• Prisoner Care and Control Procedure;
• Computer Log-in Data – the SO;
• Notes-WO #2;
• Notes-WO #5;
• Notes-WO #3;
• Notes-the SO;
• Notes-WO #4;
• Notes-WO #1; and
• Duty Roster.

The following scenario emerges from the evidence collected by the SIU, which included interviews with the SO and other officers who dealt with the Complainant while in police custody. The investigation was also assisted by police video footage that captured the incident.

In the evening of November 18, 2021, the Complainant was arrested by WO #1 and WO #4 at a residence in Belleville. The officers had been dispatched to the address in response to a complaint about a possible weapon in the residence. In the course of that investigation, they ascertained that there were warrants out for the arrest of the Complainant – an occupant of the residence – and took him into custody. The arrest was uneventful.

Back at the police station, the Complainant became upset when advised that he would not be released ahead of a bail hearing in the morning. Asked by the booking officer – the SO – whether he took any medications, the Complainant replied that he did and asked to be released so he could pick up his prescription or attend hospital. He denied having any medical concerns, and said nothing when the SO inquired whether he had ever tried to harm himself or consumed drugs.

The Complainant was lodged in a cell at about 7:21 p.m. by the SO. He told the officer again that he needed his medication, pointing to his head as he did so.

Over the course of the next five-and-a-half hours or so, the Complainant spent time lying on the floor and cell bench, kneeling and sitting. At about 12:50 a.m., he rose from the bench, stood by the cell door, and knocked. At about 12:55 a.m., he called out, “What’s going on with my medication?” The SO attended the cell and spoke with the Complainant, who indicated he was hungry. A couple of minutes later, the officer returned with two donuts, passing them to the Complainant through a hatch in the cell door. The Complainant sat down and ate the donuts.

At about 1:18 a.m., the Complainant rose again, approached the cell door, and slammed the hatch up and down. Ten minutes later, he said through the hatch, “Yo, why do people have to fucking hurt themselves to get your fucking attention?” The Complainant picked up the two foil blankets he had been provided, looped them around the cell door hatch, and tied their ends together. He proceeded to wrap the ligature around his neck and, with his back to the cell door, leaned forward and slid down the door to a seated position. After a period of coughing, the Complainant became still. The time was about 1:33 a.m.

The SO arrived at the Complainant’s cell at about 1:35 a.m. He left and returned again at 1:36 a.m., opening the cell door, and cutting the foil loop from the Complainant’s neck. The officer called for EMS to attend and sought the assistance of other officers. The Complainant’s breathing was laboured and the SO sat him up attempting to clear his airway of any saliva.

At 1:46 a.m., the Complainant was carried from the cell by officers and a paramedic, and taken to hospital. He had suffered a torn ligament in the neck. It is unknown whether the Complainant suffered any other injuries.

Section 215, Criminal Code - Failure to Provide Necessaries

(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.

(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.

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

(a) in doing anything, or

(b) in omitting to do anything that it is his duty to do,

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

The Complainant suffered a serious injury while in the custody of the BPS on November 19, 2021. The officer with overall responsibility for the care of prisoners at the time – the SO – was identified as the subject official for purposes of the ensuing SIU investigation. The investigation is 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 injury.

The offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing bodily harm contrary to section 215 and 221 of the Criminal Code, respectively. The former is premised, in part, on conduct that amounts to a marked departure from the level of care that a reasonable person would have 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. The departure from a reasonable standard of care must be both marked and substantial. In the instant case, the issue is whether there was a want of care on the part of the SO, sufficiently egregious to attract criminal sanction, that contributed to the Complainant’s injury or endangered his life. In my view, there was not.

There is no suggestion in the evidence that the Complainant’s arrest was unlawful. There were warrants outstanding for his arrest for having breached the terms of a release order, and WO #1 and WO #4 were within their rights in taking the Complainant into custody.

With respect to the Complainant’s time in cells, I am satisfied that he was treated with due care and regard for his health and well-being by the SO. Though he was only checked physically for the first time by the SO about five-and-a-half hours after he had been lodged in the cell, there is nothing to dispute the officer’s evidence that he regularly checked the Complainant via cell monitors. Nor was there any particular reason to be concerned that the Complainant was at risk of self-harm through most of his time in custody - there were no such warnings on the Complainant’s police record, he had never given any indication of such in the SO’s prior dealings with him, and the Complainant did not suggest he was suicidal when specifically asked at the time of his booking. The SO took seriously the Complainant’s request for prescription medication and acted reasonably, in my view, when he decided not to retrieve the medication. He had arranged to have the pharmacy contacted, whose staff advised that the Complainant did not need the medication that night. Most importantly, the SO acted with haste - in so doing, likely saving the Complainant’s life - when he noticed the Complainant silent and still on the cell floor, and rushed to cut him loose of the ligature at 1:36 a.m., about six minutes after the Complainant had tried to hang himself. Thereafter, he rendered aid to the Complainant while waiting for paramedics to attend the cells.

In the result, as I am satisfied for the foregoing reasons that the SO did not transgress the limits of care prescribed by the criminal law, there is no basis for proceeding with criminal charges in this case.


Date: March 7, 2022

Electronically approved by

Joseph Martino
Director
Special Investigations Unit