SIU Director’s Report - Case # 21-OCD-023

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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 49-year-old man (the “Complainant”).

The Investigation

Notification of the SIU

On January 19, 2021, at 10:51 p.m., the Ottawa Police Service (OPS) notified the SIU of the death of the Complainant. Reportedly, on January 19, 2021, at 4:45 p.m., OPS police officers had executed a Controlled Drugs and Substances Act search warrant at the residence of the Complainant in Ottawa. The Complainant was arrested, transported to OPS Central Cells at 474 Elgin Street, and lodged. At approximately 9:30 p.m., the Complainant was found unresponsive and Emergency Medical Services (EMS) were called. EMS found him to be without vital signs.

The Team

Date and time team dispatched: 01/20/2021 at 12:08 a.m.

Date and time SIU arrived on scene: 01/20/2021 at 2:30 a.m.

Number of SIU Investigators assigned: 2
 
Number of SIU Forensic Investigators assigned: 1

Affected Person (aka “Complainant”):

49-year-old male, deceased

Civilian Witnesses (CW)

CW #1 Not interviewed (unable to locate)
CW #2 Not interviewed (unable to locate)
CW #3 Not interviewed (next-of-kin)
CW #4 Not interviewed (next-of-kin)

Subject Officials (SO)

SO #1 Interviewed, and notes received and reviewed
SO #2 Interviewed, and notes received and reviewed

The subject officials were interviewed between January 21, 2021, and February 1, 2021.

Witness Officials (WO)

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

The witness officials were interviewed between January 21 and 22, 2021.

[Note: A witness official is an official (whether a police officer, a special constable of the Niagara Parks Commission or a peace officer with the Legislative Protective Service) who, in the opinion of the SIU Director, is involved in the incident under investigation but is not a subject official in relation to the incident.

Upon request by the SIU, witness officials are under a legal obligation pursuant to the SIU Act to submit to interviews with SIU investigators and answer all reasonable questions. The SIU is also entitled to a copy of their notes.]

Service Employee Witnesses (SEW)

SEW #1 Interviewed
SEW #2 Interviewed
SEW #3 Interviewed
SEW #4 Interviewed
SEW #5 Interviewed

The service employee witnesses were interviewed between January 21, 2021, and March 1, 2022.

Evidence

The Scene

The scene was a cell in the custody area of the OPS at 474 Elgin Street, Ottawa.

On January 20, 2021, the SIU Forensic Investigator attended the scene. The cell was photographed and video recorded, along with the hallways leading from the sally port to the booking area and to the cell.

The cell was configured with a combination toilet / sink at the back wall and a concrete bed on the right side. There was a wall-mounted camera, which faced the cell opposite the door. A defibrillator case was on the floor close to the door.

Physical Evidence

Prisoner Log - January 19, 2021

The prisoner check sheet generated in connection with the Complainant’s time in cells was provided to the SIU. The following is a summary of the record.
  • At about 5:40 p.m., the Complainant was taken out of his cell to call a lawyer.
  • At about 6:07 p.m., the Complainant was provided a meal by SEW #1. The record contained the following notation: “Observations: OK.”
  • At about 6:19 p.m., the Complainant was checked by SEW #1. The record contained the following notation: “Observations: OK.”
  • At about 6:53 p.m., the Complainant was checked by SEW #1. The record contained the following notation: “Observations: OK.”
  • At about 7:35 p.m., the Complainant was checked by SEW #1. The record contained the following notation: “Observations: OK.”
  • At about 8:12 p.m., the Complainant was checked by SEW #1. The record contained the following notation: “Observations: OK.”
  • At about 8:46 p.m., the Complainant was checked by SEW #1. The record contained the following notation: “Observations: OK.”
  • At about 9:11 p.m., the Complainant was checked by SEW #1. The record indicated that the Complainant was grey-coloured and confused, and that the officer-in-charge (SO #2) was notified.
  • At about 9:50 p.m., the Complainant was taken out of cell.
  • At about 9:50 p.m., the Complainant was transported to hospital.

Video/Audio/Photographic Evidence [1]

Communications Recordings

On January 19, 2021, at 5:14 p.m., WO #2 and WO #3 attended the Complainant’s residence to transport him to OPS central custody following the execution of a drug search warrant. They arrived at central custody at 5:30 p.m.

On January 19, 2021, at 9:27 p.m., a request was made from the custody sergeant [now known to be SO #2] for two police officers to accompany an ambulance to the hospital.

At 9:31 p.m., the transport police officers were dispatched, arriving at the custody area at 9:40 p.m.

At 9:54 p.m., the Complainant was transported to the Ottawa Civic Hospital.

At 10:09 p.m., the communications centre was advised that the Complainant had been pronounced deceased.

Cell Corridor Footage for January 19, 2021

The camera for the corridor was motion-activated, though at times recorded when initially there was no motion in front of the camera. Across the corridor from the doorway of each cell was a camera-mounted above door height, which covered the interior of each cell. The cell cameras were motion-activated by a button on the wall. There was no audio captured by the corridor or cell cameras.

The following is a summary of the footage.

At 5:38:21 p.m., the Complainant was placed in a cell by SEW #1, accompanied by another special constable.

At 6:04:55 p.m., the Complainant was provided food by SEW #1.

At 6:53 p.m., the Complainant was removed from the cell.

At 7:14:30 p.m., the Complainant was returned to his cell, and a police officer in street clothes stood outside the cell door and conversed with the Complainant until 7:15:13 p.m.

At 7:34:05 p.m., the video re-started and, at 7:34:22 p.m., SEW #1 walked past the door to the Complainant’s cell.

From 7:35:30 p.m., to 7:52:15 p.m., there was no recording as no motion was observed.

From 7:52:34 p.m., to 7:53:43 p.m., a cleaner was seen mopping in the corridor.

From 7:57:04 to 8:45 p.m., there was no recording.

From 8:45:30 p.m., the Complainant was taken out of the cell by SEW #1.

At 8:46:57 p.m., another prisoner was placed in a cell next to the Complainant’s cell by two police constables and a special constable.

At 8:59:53 p.m., SEW #1 returned the Complainant to his cell, accompanied by SEW #4 and, at 9:02:13 p.m., both special constables left the corridor.

At 9:03:16 p.m., SEW #1 returned to the front of the cell and then left at 9:08 p.m.

At 9:09 p.m., SEW #1 returned to the cell and stood outside until 9:14:20 p.m., at which time he entered the cell.

At 9:14:27 p.m., SEW #1 kicked the wall opposite the entrance to the cell (video started to record).

At 9:14:33 p.m., SEW #4 responded and entered the cell.

Sally Port, Booking Area and Cell Video for January 19, 2021

The following is a summary of the video footage.

At 5:25 p.m., a fully marked OPS SUV entered the sally port and two uniformed male police officers [now known to be WO #2 and WO #3] exited the police vehicle.

At 5:33 p.m., the Complainant exited from the rear passenger door, unassisted. The Complainant was handcuffed with his hands behind his back. He walked to a door, which led to the booking area, unassisted.

At 5:34 p.m., the Complainant was accompanied into the booking area. The booking sergeant, SO #2, could not be seen but heard. The Complainant stood erect with his hands behind his back. The Complainant was dressed in a dark top with blue jeans. He wore a COVID-19 face mask. The Complainant did not appear to have any injuries. WO #2 communicated the charges to SO #2 and the fact that the Complainant had answered ‘no’ to all the standard booking questions.

At 5:38 p.m., the Complainant, accompanied by two special constables, walked down the hallway without assistance and entered a cell.

At 9:14 p.m., a special constable [now known to be SEW #1] stood in front of the door to the Complainant’s cell. The Complainant lay on his back with his feet hanging off the bench towards the door. The Complainant’s head faced toward the back wall. The Complainant’s legs and arms started to shake, after which he appeared to go stiff.

At 9:14:20 p.m., SEW #1 entered the cell.

At 9:15:50 p.m., SO #2 stood outside the Complainant’s cell, and the Complainant’s legs continued to shake. The Complainant was placed into the recovery position, lying on his left side and facing the wall.

At 9:16:10 p.m., SEW #1 left the cell [now known that he was going to assist the EMS with entry to the cell block]. At the same time, SEW #4 entered the cell and held the Complainant’s head. SO #2, who had entered the cell, held the Complainant’s right leg. It was hard to see the Complainant because the police officers blocked the view.

At 9:19:10 p.m., the Complainant’s legs continued to shake.

At 9:20:05 p.m., SEW #4 shone a flashlight in the area of the Complainant’s head.

At 9:21:30 p.m., the Complainant’s legs continued to shake.

At 9:23:25 p.m., two paramedics appeared on camera at the cell door. At 9:23:33 p.m., a paramedic carried a bag into the cell.

At 9:24:12 p.m., SEW #4 performed CPR.

At 9:25 p.m., it appeared that a paramedic used a defibrillator on the Complainant.

At 9:25:19 p.m., SEW #4 continued to perform CPR on the Complainant.

At 9:26:02 p.m., a paramedic exited the cell and gowned-up followed by another paramedic.

At 9:28:17 p.m., SEW #3 stood at the cell door and, at 9:29:47 p.m., SEW #3 took over CPR from SEW #4.

At 9:31:05 p.m., it appeared that a paramedic used the defibrillator again; however, the view was partially blocked.

At 9:31:10 p.m., two more paramedics appeared at the cell door.

At 9:31:40 p.m., SEW #4 stood on the bench next to the Complainant’s legs.

At 9:31:55 p.m., SEW #4 relieved SEW #3 with CPR.

At 9:33 p.m., the paramedics carried the Complainant out of the cell and off camera.

At 9:42 p.m., the Complainant was wheeled into the vestibule from the cell hallway and then out into another hallway. A police officer performed CPR on the Complainant and paramedics also worked on him.

At 12:14 a.m., January 20, 2021, the door to the Complainant’s cell was closed. Medical debris was observed on the bench and yellow caution tape on the door.

Video Footage of Search of the Complainant

Two cameras were located in a hallway, which was referred to as the Search Corridor, that ran from the booking area to the doorway into the cell block. The following is a summary of the footage.

Video Search Corridor 1
The camera afforded a view from the booking area and showed the hallway where the search was conducted and the doorway, which led into the cell block area.

At 5:35:45 p.m., the Complainant walked into the screen from the booking area accompanied by SEW #5. The Complainant acted normal and the communications were amicable. The Complainant was handcuffed with his hands behind his back. The handcuffs were removed and SEW #5 conducted a pat down search, and the Complainant’s pockets were checked. A metal detector wand was used over the Complainant’s body. The Complainant removed his watch and was asked if he had any other jewelry. He replied that he did not believe so. At one point, a uniformed police officer showed the Complainant some documentation. There were other special constables present who entered the screen at times. During the bulk of the search, the Complainant could only be seen partially, at the bottom of the screen.

Video Search Corridor 2
This was a reverse view of the other search corridor view - the camera was located on the doorway which led to the cell block and it afforded a complete view of the search corridor and the entrance to the booking area. SEW #5 conducted a pat-down search. Two other special constables were present, as was a uniform constable. The Complainant’s pockets were searched, as were his feet. A metal detector was also used. The Complainant appeared normal. He was seen to swipe his forehead as if he was sweating. The Complainant’s watch was removed; however, no contraband was found and the search was uneventful. The search ended at 5:38:02 p.m.

Materials Obtained from Police Service

Upon request, the SIU received the following materials and documents from the OPS between January 20, 2021, and March 2, 2021:
  • Computer-assisted Dispatch (CAD) Call (Drug Warrant);
  • CAD Call (Medical Emergency);
  • Communications recordings;
  • Narrative-SEW #4;
  • Narrative-WO #2;
  • Narrative-WO #1;
  • Narrative-SEW #3;
  • Narrative-WO #3;
  • Narrative-SEW #1;
  • Narrative-SO #2;
  • Narrative-SO #1 (Tactical Team Report);
  • Narrative-SO #1;
  • Narrative-SEW #2;
  • Notes-WO #2;
  • Notes-WO #1;
  • Notes-SEW #3;
  • Notes-WO #3;
  • Notes-SEW #5;
  • Notes-SEW #4;
  • Notes-SEW #1;
  • Notes-SO #2;
  • Notes-SO #1;
  • Notes-SEW #2;
  • Central Cell block Schedule;
  • Cell Block Video;
  • Search Video;
  • List of Involved Officers;
  • Photos-Scene and Hospital;
  • Policy-Arrest;
  • Policy-Use of Force;
  • Policy-Prisoner Care and Control;
  • Booking Sheet;
  • Prisoner Check Sheet; and
  • Training Records-SO #1.

Materials Obtained from Other Sources

The SIU obtained and reviewed the following records from other sources:
  • EMS Records-Ottawa Paramedic Services, received February 10, 2021;
  • Post-mortem Report from the Office of the Chief Coroner received September 21, 2021; and,
  • Preliminary Autopsy Findings Report from the Ontario Forensic Pathology Services received January 20, 2021.

Incident Narrative

The following scenario emerges from the evidence collected by the SIU, which included interviews with SO #1 and SO #2, and other officers who had dealings with the Complainant throughout his period in police custody.

The Complainant was arrested inside his residence in Ottawa. Officers had entered the home on the strength of a search warrant under the Controlled Drugs and Substances Act. SO #1 found the Complainant in the basement of the home and took him into custody without incident. He was subsequently transferred into the custody of WO #2 and WO #3 for transport back to the station at 474 Elgin Street, Ottawa.

The Complainant was lodged in a cell at about 5:40 p.m. Sometime between 9:10 and 9:15 p.m., SEW #1, who had checked on him throughout the evening, found the Complainant in medical distress. He notified the officer-in-charge – SO #2, who, in turn, had paramedics called to the station. SEW #1, SO #2 and others attended at the Complainant’s cell to render first aid - including the administration of CPR - while waiting for the ambulance to arrive.

Paramedics arrived on scene at about 9:25 p.m. and assumed the lead role in the Complainant’s care at about 9:35 p.m. The Complainant was transported in ambulance to hospital, where he was pronounced deceased at about 10:04 p.m.

Cause of Death

The pathologist at autopsy attributed the Complainant’s death to ‘acute cocaine toxicity’.

Relevant Legislation

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.

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

The Complainant passed away on January 19, 2021. He had been lodged in OPS cells that day, found in medical distress, and taken to hospital where he died of a drug overdose. The SIU was notified of the incident and initiated an investigation, identifying SO #1 and SO #2 as subject officials. The investigation is now concluded. On my assessment of the evidence, there are no reasonable grounds to believe that either subject official 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 unless the impugned behaviour constitutes a marked and substantial departure from a reasonable level of care. In the instant case, the issue is whether there was any want of care in the manner in which the subject officials dealt with the Complainant sufficiently egregious to attract criminal sanction. In my view, there was not.

There is no suggestion in the evidence that the Complainant was unlawfully in the custody of the OPS. The Complainant had been arrested in the course of the execution of a facially valid warrant authorizing the search of his residence for illicit substances and drug paraphernalia.

Moreover, once in police custody, there is no evidence to suggest that the Complainant was the recipient of substandard care by his custodians. The record indicates that he was checked about every half-hour from the moment he was placed in a cell, which seems a reasonable schedule given the Complainant appeared unimpaired and in good condition when he was arrested and then booked, and had denied consuming any drugs or alcohol. In retrospect, it appears the Complainant first began giving signs of being in distress shortly after 9:00 p.m. when he was seen shaking on his cell bench. The behaviour caught the attention of SEW #1, who proceeded to the Complainant’s cell to check on him. He described the Complainant’s breathing as ‘panicked’, but as he was asleep, the officer concluded he was having a nightmare and left him alone. Given the absence of any disconcerting antecedent behaviour by the Complainant, I am unable to fault SEW #1 for the action he took. Shortly thereafter, SEW #1 went back to check on the Complainant after he observed him on the video monitor sitting up and fidgeting. This time, confronted by a largely unreceptive Complainant whose eyes were unfocused and moving rapidly, SEW #1 quickly advised SO #2 of the medical emergency, after which the officers promptly provided medical attention. In all of this, it should be noted that there is no evidence that the Complainant had drugs with him in the cell; that is to say, his drug consumption, ultimately resulting in his death, occurred before he was arrested.

In the result, as there are no reasonable grounds to believe that either subject official transgressed the limits of care in connection with the Complainant’s time in police custody, there is no basis for proceeding with criminal charges in this case. The file is closed.


Date: April 20, 2022

Electronically approved by

Joseph Martino
Director
Special Investigations Unit

Endnotes

  • 1) 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]

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.