SIU Director’s Report - Case # 22-PCD-079
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Mandate of the SIU
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, 2019Pursuant 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 ActPursuant 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.
- 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, 2004Pursuant to this legislation, any information related to the personal health of identifiable individuals is not included.
Other proceedings, processes, and investigationsInformation 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.
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 26-year-old man (the “Complainant”).
Notification of the SIUOn March 14, 2022, at 4:12 a.m., the Ontario Provincial Police (OPP) notified the SIU of an incident involving the Complainant, who resided in St. Eugene.
According to the OPP, on March 14, 2022, at 12:14 a.m., four OPP officers responded to a call for service involving a reportedly suicidal male, the Complainant. The call was made by his mother, Civilian Witness (CW) #2. Police officers arrived and were met outside by CW #2. CW #2 advised that her son was suicidal and in possession of an edged weapon. The home was contained; yelling could be heard inside. Attempts were made by a crisis negotiator to contact the Complainant without success. After 2:00 a.m., the home became quiet, and police officers became concerned for his safety. Once more officers arrived, including one Emergency Response Team (ERT) officer, six police officers went into the residence and found the Complainant in a hallway closet hanging. They cut him down and found him with a very faint pulse. He was transported to Hawkesbury General Hospital (HGH).
The TeamDate and time team dispatched: 03/14/2022 at 6:33 a.m.
Date and time SIU arrived on scene: 03/14/2022 at 2:40 p.m.
Number of SIU Investigators assigned: 4
Number of SIU Forensic Investigators assigned: 1
Affected Person (aka “Complainant”):26-year-old male, deceased
Civilian WitnessesCW #1 Interviewed
CW #2 Not interviewed (Next-of-kin)
CW #3 Not interviewed
The civilian witness was interviewed on March 15, 2022.
Subject Official (SO)SO Declined interview, as is the subject official’s legal right. Notes received and reviewed.
Witness Officials (WO)WO #1 Interviewed
WO #2 Interviewed
WO #3 Interviewed
WO #4 Not interviewed, but notes received and reviewed
WO #5 Not interviewed, but notes received and reviewed
WO #6 Not interviewed, but notes received and reviewed
WO #7 Not interviewed, but notes received and reviewed
WO #8 Not interviewed, but notes received and reviewed
WO #9 Not interviewed, but notes received and reviewed
The witness officials were interviewed on March 21, 2022.
The Scene The scene was a two-story house, separated into multiple apartments in St. Eugene.
In the kitchen, blood smears and blood drops were visible on the floor and parts of the wall. A single razor blade with blood and blood smear was found on a small table within the kitchen. A black-handled knife was resting on a small wall section between the kitchen and living room area. Blood was visible near the knife. No blood was visible on the knife blade.
A hallway from the living room and kitchen area led to a room with a closet. The closet was open. A wooden dowel extended from one end to the opposite end of the closet. A black electrical cord (part of the ligature) was knotted around the approximate centre of the dowel. The distance from the dowel to the floor was 162 centimetres. Medical intervention debris was scattered on the floor.
Black electrical cord
Black electrical cord
Video/Audio/Photographic Evidence 
Social Media - Live Video FootageThe Complainant appeared agitated, speaking quickly, in emotional distress, crying and yelling. He stated that he was disappointed because he was not the same as everyone else. He never wanted to be a burden on his mother. He was no longer able to endure the hurt he was causing. He said “drugs keep me together and one day, I became schizophrenic, literally schizophrenic.” The Complainant advised that part of his brain burst, but the other side of his brain worked.
He barricaded the door to his apartment and said that if he committed suicide they would enter and taser him, it would be hot to capture it on camera. He stated that he had cut himself open, and showed his arms and chest with lacerations.
The Complainant said he was sorry to do it this way. He stated that he was sorry for what was going to happen tonight, asking someone to look after his dog and saying that he was a burden to society.
OPP Radio CommunicationsThe SIU was provided the communications recordings from the OPP in relation to this incident on March 14, 2022.
The following is a summary of the recordings.
On March 14, 2022, at 12:12:23 a.m., CW #3 called 911 to report that her son’s friend, the Complainant, had opened a video on a social media platform 55 minutes prior, and cut himself on his arms and chest. The Complainant was said to have mental health challenges, barricaded himself in the house, and spoken of committing suicide. The Complainant lived in St. Eugene.
On March 14, 2022, at 12:23:19 a.m., a man called 911 to request that police attend the Complainant’s address in St. Eugene. The Complainant, about 25-years-old, had cut himself and created a video. The Complainant wanted to commit suicide. CW #2, the Complainant’s mother, had asked him to call 911.
On March 14, 2022, at 12:40:09 a.m., another man called 911 to report that he had found a video of his friend [now known to be the Complainant] who was reporting suicidal ideation. The Complainant lived in St. Eugene, but he did not know the address. His mother came to the phone to request a wellness check for the Complainant. The dispatcher informed the caller someone else had already called. The man tried to reach the Complainant through Facebook but could not reach him.
On March 14, 2022, an OPP dispatcher called a sergeant, Officer #1, to inform him of a suicide threat in St. Eugene. A request was made for a ‘ping’ on a cell phone number.
The dispatcher called the ambulance service to request their attendance at the Complainant’s address in St. Eugene. A 26-year-old man was said to be actively cutting himself and bleeding, and the ambulance service was asked to stage near the residence.
The dispatcher called Officer #1 and informed him the man [now known to be the Complainant] had a history of barricading himself.
The dispatcher spoke with a man who informed her that he had a crisis negotiator - WO #9 - on the way.
The dispatcher was informed by an ambulance attendant they were staged behind the OPP officer’s patrol car.
The dispatcher called WO #1 advising that the Complainant had a caution on police records for being armed and dangerous. The Complainant reportedly hid butcher knives in the baseboards and WO #1 was cautioned to be careful because the Complainant could have knives hidden. WO #1 informed the dispatcher he had not yet received a call from the Critical Incident Commander and the dispatcher informed him she would follow up on that.
The dispatcher called the ambulance service to ask that they attend immediately because the Complainant was hanging. Police officers had removed the Complainant from the closet and performed CPR on the scene until the ambulance service took over.
WO #3 called the dispatcher and indicated that the Complainant had been pronounced deceased at 4:19 a.m. at the hospital.
On March 14, 2022, a police officer informed the dispatcher that the Hawkesbury Detachment was borrowing a few of their police officers for a suicidal party at an address in St. Eugene. Negotiators were requested, as were the ERT and Tactical Rescue Unit (TRU). Ambulance services were subsequently called as the Complainant was found hanging.
On March 14, 2022, the dispatcher informed the Hawkesbury Detachment of a call for a threat of suicide by the Complainant in St. Eugene. A video had been shown about 55 minutes prior. The Complainant had a possible diagnosis of bipolar disorder and had prior interactions with police. The 911 caller did not know the Complainant’s address. WO #2 requested a ping on the Complainant’s cell phone and reported he would try to call him.
WO #6 informed the dispatcher that he had spoken with the Complainant’s mother, CW #2, who informed him of the Complainant’s address. WO #6 requested the dispatcher call out the EMS because the Complainant was cutting himself.
WO #1 informed the dispatcher some of the police officers were familiar with the Complainant and requested a search on the RMS for any cautions. The dispatcher informed WO #1 that the Complainant had a caution flag for being armed and dangerous.
WO #1 assigned the police officers to move in pairs - WO #2 would have access to a lethal use of force option; WO #7, a less lethal use of force option. WO #1 informed the police officers their mission was to contain the Complainant on the property in the building and attempt to have him exit.
WO #1 requested that WO #9 attend to negotiate.
WO #6 told WO #1 he was informed by CW #2 that the Complainant had placed furniture in front of the front door.
The dispatcher announced that the Complainant had a flag for spitting at police officers.
An officer informed the dispatcher the Hawkesbury Detachment was borrowing some of their units for a suicide call in St. Eugene, and two police officers were on the way.
WO #9 informed WO #1 that all his attempts to reach the Complainant by phone were going to voicemail.
WO #2 informed WO #1 that CW #1 informed him he had heard the Complainant say he was armed.
WO #1 informed the dispatcher he had spoken with CW #2 who informed him the Complainant said his goodbyes, was suicidal, and believed he was a burden on society.
WO #1 informed the dispatcher that the Complainant had a diagnosis of borderline personality disorder and was not taking his medication. The Complainant lived alone with a dog, and had no firearms or crossbows but had access to knives.
An officer informed the dispatcher that the Complainant had been pronounced deceased at 4:19 a.m.
On March 14, 2022, the dispatcher called the OPP Provincial Communications Centre to request a ping on a cell phone for a suicidal person [now known to be the Complainant].
Officer #1 called the SO to inform her the Hawkesbury Detachment had a suicidal man [now known to be the Complainant]. The Complainant’s friends had called his family to let them know. The family contacted the police. The Complainant told his mother he had barricaded himself in his unit. The police arrived on scene. A neighbour told police the Complainant said he was armed. It was unknown what weapons the Complainant had. The SO inquired if the police had made contact with the Complainant and Officer #1 informed her the police officers had made attempts when the Complainant came to the window. The Complainant seemed agitated and shouted at the police officers, but they were unable to discern what he was saying. Officer #1 informed the SO that the Complainant had a long history of mental health issues, had been apprehended many times, and had barricaded himself in the past. The Complainant spat at police officers and was violent during prior interactions.
WO #1 informed Officer #1 that WO #9 had called the Complainant several times and could not make contact.
The SO called Officer #1 and informed him at 1:50 a.m. that the Complainant had gone silent. A request was made that Officer #1 get resources moving to the scene for an integrated response as she did not want the police officers breaching doors. The SO requested an ERT, a TRU, a crisis negotiator lead, [named officer], a scribe and [named officer] attend. She reported she was getting ready to head to the scene as well.
Officer #1 contacted the dispatcher and requested that TRU attend the scene.
Officer #1 called a sergeant, Officer #2, and informed him of the incident details. Officer #2 said, “No one’s broken the door down to get in to help the guy?” Officer #1 said, “…they don’t feel comfortable doing that.” Officer #2 said, “They’re going to have break the door down and help this guy out.” Officer #1 suggested he speak with the officer in charge and provided WO #1’s phone number.
Officer #2 informed Officer #1 he had activated ERT police officer WO #3 from the Hawkesbury Detachment and requested six additional ERT police officers. Officer #1 subsequently cancelled the call-outs because the Complainant had been located hanging.
Officer #2 informed Officer #1 that police officers entered the unit under the preservation of life authority because there was an ERT member on scene.
The dispatcher informed Officer #1 that the Complainant had been pronounced deceased.
Materials Obtained from Police ServiceUpon request, the SIU received the following materials and documents from the OPP between March 15 and 24, 2022:
- Communications recordings;
- Social media live video;
- Notes-WO #2;
- Notes-WO #4;
- Notes-WO #9;
- Occurrence Reports;
- Notes-WO #1;
- POC Critical Incident Information Form;
- Notes-WO #8;
- GeoWarehouse Property Details-the Complainant’s Address;
- Notes-WO #5;
- Notes-WO #3;
- Notes-WO #1 (Additional Notes);
- Notes-the SO;
- Occurrence Details and Reports;
- Photographs - HGH;
- Notes-WO #6; and
- Notes-WO #7.
Materials Obtained from Other SourcesThe SIU obtained and reviewed the following records from other sources:
- Voicemail – goodbye message to next-of-kin;
- Preliminary Autopsy Findings from Ontario Forensic Pathology Service;
- Eastern Ontario Regional Forensic Pathology Unit Exhibit Continuity Form-Ligature; and
- Video footage from a Residence.
Shortly after midnight of March 14, 2022, the OPP began receiving 911 calls expressing concern about the Complainant’s well-being. The Complainant had posted a video on social media in which he talked about harming himself and displayed cuts that he had inflicted on his chest and arms. Friends and family, having seen the video, reported the matter to police. Officers were dispatched to investigate.
The Complainant suffered from mental illness and was in distress at the time. He had earlier called his mother, and said he was very depressed and intent on killing himself. The Complainant was highly agitated – he yelled and threw things within the apartment. When his mother later attended at his residence to speak with him, the Complainant refused to open the door.
WO #1, WO #2, WO #7, WO #5 and WO #4, travelled to the scene – a house in Saint-Eugene – arriving at about 12:40 a.m. The Complainant occupied an apartment on the second floor of the multi-dwelling building. There were doors to the second floor accessible via external stairs at the front and rear of the structure. He could be heard screaming from within the apartment. The officers took up positions around the building, spoke with the Complainant’s mother and CW #1 (the Complainant’s neighbouring tenant), evacuating the latter from his residence, and came to learn that the Complainant was cautioned on police records for being armed and dangerous – he had a history of hiding knives in his apartment.
A critical incident commander – the SO – was assigned and assumed overall control of police operations.
At about 1:45 a.m., about half-an-hour after he had last been heard in the apartment, officers were deployed at the SO’s direction to attempt to make contact with the Complainant. The officers climbed the rear staircase, approached and knocked on the Complainant’s door, and shouted into the apartment seeking a response from the Complainant indicating he was alive. There was no response. The door was locked. Entering via CW #1’s apartment, the officers approached another door to the Complainant’s apartment and knocked. They could see through the broken door glass a chair blocking the door and a refrigerator blocking a hallway. Still, the Complainant did not answer the officers’ calls.
On hearing that there had been no response from within the apartment, the SO directed that the officers on scene refrain from forcing entry into the apartment pending the arrival of tactical officers. A trained negotiator – WO #9 – had attempted to call the Complainant, but was unable to reach him. He was directed to attend the scene and continue with his efforts. Those too were to no avail.
With the arrival of an Emergency Response Team officer on scene at about 3:15 a.m., WO #3, the decision was made to force entry into the apartment. A team of officers, including WO #2 with a Plexiglas shield and other officers with lethal and less lethal weapons at the ready, approached the door with the broken glass at about 3:30 a.m. WO #1 rammed the door open and the officers entered searching for the Complainant. He was located hanging from a closet rod with a black electrical cord tied around his neck.
The Complainant was quickly cut down from the rod and CPR was administered. A team of paramedics staging in the area arrived and took over the Complainant’s care. He was transported to hospital and pronounced deceased at 4:19 a.m.
Cause of DeathThe pathologist at autopsy was of the preliminary view that the Complainant’s death was attributable to ‘Hanging’.
Sections 219 and 220, Criminal Code -- Criminal Negligence Causing Death
(a) in doing anything, or(b) in omitting to do anything that it is his duty to do,
(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 offence that arises for consideration is criminal negligence causing death contrary to section 220 of the Criminal Code. The offence is reserved for serious cases of negligence that demonstrate a wanton or reckless disregard for the lives or safety of other persons. A simple want of care will not suffice to give rise to liability; rather, what is required, in part, is a marked and substantial departure from the level of care that a reasonable person would have exercised in the circumstances. In the instant case, the issue is whether there was any shortcomings in the police response, sufficiently egregious to attract criminal liability, that caused or contributed to the Complainant’s death. In my view, there was not.
The officers who had a role in the police operations that unfolded in and around the Complainant’s apartment in the early hours of March 14, 2022, were lawfully placed throughout the events in question. A police officer’s foremost obligation is the protection of life. Aware of the Complainant’s acts of self-harm and public intentions to do himself further harm, the officers were duty bound to do what they reasonably could to prevent that from happening.
With respect to the manner in which the officers went about their duties under the command of the SO, I am satisfied they comported themselves with due care and regard for the Complainant’s health and safety. In particular, I am unable to reasonably conclude that the decision to delay police entry into the apartment until about 3:30 a.m., almost three hours after the initial officers had arrived on scene, transgressed the limits of care prescribed by the criminal law. The Complainant was of unsound mind at the time and in possession of a knife that he had used to self-inflict injury. The officers were also aware of threats he had made to anyone attempting to enter the apartment and police cautions arising from previous encounters that he was known to use knives. In the circumstances, I am unable to fault the SO for deferring a forced entry into the apartment until the arrival of a tactical officer with specialized training in these scenarios. In the meantime, the officers under her command had taken reasonable measures to ensure the safety of the public around the scene – the apartment was contained, a tenant from an adjacent apartment had been evacuated, and paramedics were staged nearby. Might a more proactive posture have saved the Complainant’s life? Perhaps. It seems he was last heard from at about 1:13 a.m. The balance of competing risks, however, was not such as to rule out the course the SO adopted. Though he had not been heard from, there remained a real danger that a silent Complainant was still ready and able to inflict harm on persons entering the apartment. The SO was entitled to mitigate that risk by waiting for the arrival of specialized resources at the scene.
In the result, as there are no reasonable grounds to believe that the SO or the officers under her command conducted themselves other than within the bounds of the criminal law, there is no basis for proceeding with criminal charges in this case. The file is closed.
Date: July 8, 2022
Electronically approved by
Special Investigations Unit
- 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]
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.