SIU Director’s Report - Case # 22-PCD-124


This page contains graphic content that can shock, offend and upset.

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 36-year-old man (the “Complainant”).

The Investigation

Notification of the SIU

On May 5, 2022, at about 11:59 a.m., the OPP contacted the SIU with the following information.

On May 5, 2022, at approximately 9:30 a.m., the Complainant was arrested without incident for public intoxication. The location of the arrest was on Front Street in the City of Quinte West-Trenton. A criminal records check of the Complainant revealed that he was wanted on several warrants. The Complainant was transported to the OPP Quinte West Detachment and placed in a cell at 9:58 a.m. At 10:33 a.m., upon a regular cell check, the Complainant was found to have urinated on the floor and was unresponsive. Emergency Medical Services (EMS) were called. Police officers commenced CPR on the Complainant, used an Automated External Defibrillator (AED), and administered naloxone. EMS arrived and undertook further life-saving measures. All attempts at reviving the Complainant were unsuccessful, and he was pronounced dead at 11:14 a.m.

The Team

Date and time team dispatched: 05/05/2022 at 1:19 p.m.

Date and time SIU arrived on scene: 05/05/2022 at 2:31 p.m.

Number of SIU Investigators assigned: 3
Number of SIU Forensic Investigators assigned: 1

Affected Person (aka “Complainant”):

36-year-old male; deceased

Civilian Witnesses (CW)

CW #1 Interviewed
CW #2 Not interviewed; next-of-kin
CW #3 Not interviewed; next-of-kin

The civilian witness was interviewed on May 6, 2022.

Subject Official (SO)

SO 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 on May 13, 2022.

Service Employee Witnesses (SEW)

SEW #1 Interviewed
SEW #2 Interviewed

The service employee witnesses were interviewed on May 13, 2022.


The Scene

The events in question took place in and around a cell of the OPP Quinte West Detachment. The cell was a standard-sized cell. There was a concrete bed and a stainless steel sink/toilet combo in the cell. The cell was monitored by a video camera mounted in the northwest corner of the ceiling.

The Complainant, deceased, was located lying supine on the floor with his head towards the bed at the back of the cell, and his feet towards the open cell door. There were obvious signs of medical intervention on the body.

Video/Audio/Photographic Evidence [1]

Radio Communications

On May 5, 2022, at 9:36:36 a.m., WO #1 requested that the dispatcher run a check for warrants for the Complainant. WO #1 reported the Complainant having an “episode” on the Dundas Street bridge in Trenton, Ontario, and he was getting the Complainant off the bridge. The dispatcher informed WO #1 that the Complainant had flags for prior charges and ‘fail to comply’ with probation. WO #1 reported he had moved his police vehicle onto Front Street. The dispatcher informed WO #1 that the Complainant had a warrant out of Brantford, Ontario. WO #1 informed the dispatcher he was transporting the Complainant to the police detachment.

At 10:35:19 a.m., a police officer called EMS and requested an ambulance. A forty-year-old person in custody - the Complainant - was said to be highly intoxicated and under the influence of illegal substances, and his wellness required assessment. The Complainant was awake and breathing okay. The dispatcher confirmed the ambulance was en route.

A police officer called the EMS dispatcher to update the call and requested the ambulance expedite their arrival because naloxone had been given to an unconscious Complainant. A police officer called someone and asked them to keep an eye on the sally port because the ambulance was on its way. The police officer informed that person that the Complainant was in the cells, overdosing on drugs. Another person confirmed the AED was administered eight times with no shock advised six times. The SO informed this person to make a note of the incident as a sudden death.

Town of Quinte West-Trenton CCTV

On May 5, 2022, at 9:38:58 a.m., a black unmarked OPP SUV entered the video frame and pulled into the parking lot of The Grind coffee shop. At 9:39:30 a.m., WO #1 exited the SUV, stood at the driver’s door, and leaned in. At 9:39:58 a.m., WO #1 opened the driver’s side rear door and a man [now known to be the Complainant] exited the vehicle. At 9:40:39 a.m., the Complainant stood next to the SUV near the rear wheel, faced the SUV, and put his hands behind his back. WO #1 handcuffed the Complainant behind his back. At 9:41:13 a.m., WO #1 searched the Complainant.

At 9:41:50 a.m., a black unmarked OPP SUV entered the right video frame and parked behind WO #1’s police vehicle. At 9:42:02 a.m., WO #2 exited his police vehicle and approached WO #1 and the Complainant. The Complainant rocked side to side, bent his knees slightly, returned to a standing position several times, and jerked his arms up behind his back.

At 9:43:16 a.m., WO #1 completed searching the Complainant and he was placed into the backseat of WO #1’s SUV.

At 9:46:01 a.m., WO #1’s SUV exited the left video frame, followed by WO #2’s police vehicle.

Custody Video Footage

Sally Port and Cell Block Video

On May 5, 2022, at 9:47:55 a.m., a black unmarked OPP SUV entered the sally port. At 9:48:29 a.m., the Complainant – handcuffed – exited the SUV. The Complainant rocked back and forth, jerked his arms up and down, and side-stepped around. WO #1 opened a door at the top of the video frame and held it open for the Complainant.

At 9:48:50 a.m., the Complainant walked through the door and kicked his legs out with every step.

At 9:57:20 a.m., the Complainant was escorted to a cell by WO #1 and WO #2. The Complainant walked unsteadily.
At 10:02:56 a.m., SEW #1 entered the hallway and looked in the Complainant’s cell. At 10:03:10 a.m., SEW #1 continued down the hall and looked in another cell. At 10:03:20 a.m., SEW #1 looked in the Complainant’s cell on her way out of the hallway. At 10:04:45 a.m., SEW #1 exited the hallway. At 10:08:05 a.m., SEW #1 entered the hallway and looked in the Complainant’s cell. At 10:08:10 a.m., SEW #1 exited the hallway.

At 10:23:33 a.m., SEW #2 entered the hallway and looked in the Complainant’s cell as she passed to attend another cell. At 10:24:15 a.m., SEW #2 exited the hallway and looked in the Complainant’s cell on her way out.

At 10:26:56 a.m., SEW #1 entered the hallway and looked in the Complainant’s cell. At 10:27:02 a.m., SEW #1 exited the hallway. At 10:28:43 a.m., SEW #1 entered the hallway and looked in the Complainant’s cell. SEW #1 opened the hatch, bent over, and looked in the cell.

At 10:29:35 a.m., SEW #2 entered the hallway and joined SEW #1 in front of the Complainant’s cell. SEW #1 and SEW #2 bent over and looked in the cell. At 10:29:49 a.m., SEW #1 closed the hatch. At 10:29:54 a.m., SEW #1 and SEW #2 exited the hallway.

At 10:33:31 a.m., WO #3 entered the hallway and attended the Complainant’s cell. WO #3 knocked on the glass. At 10:33:45 a.m., the SO entered the hallway and attended the cell. At 10:34:12 a.m., the SO and WO #3 exited the hallway as SEW #1 entered the hallway and looked in the cell. At 10:34:18 a.m., SEW #1 exited the hallway.

At 10:35:18 a.m., WO #3 and the SO entered the hallway and attended the Complainant’s cell. The SO unlocked the cell door and he and WO #3 entered the cell. At 10:35:50 a.m., WO #1 entered the cell. At 10:37:32 a.m., WO #3 exited the Complainant’s cell and hurried to exit the hallway. At 10:37:46 a.m., WO #3 entered the hallway and entered the Complainant’s cell with something in his hands.

At 10:42:21 a.m., fire personnel entered the hallway and entered the Complainant’s cell. At 10:55:48 a.m., EMS personnel entered the hallway and entered the cell.

Booking Video

On May 5, 2022, at 9:48:50 a.m., the Complainant was escorted into the booking area by WO #1. He sat on a metal bench and moved around in his seat with jerking motions. The Complainant jutted his legs out and back in, leaned forward, and pulled himself back in swift movements.

At 9:49:27 a.m., WO #2 entered the booking area and stood next to WO #1, across from the Complainant. The Complainant moved incessantly, bobbed his head up and down, and jerked his legs in and out.

At 9:52:19 a.m., the Complainant stood up and WO #1 removed the handcuffs. The Complainant jumped up and down, grabbed his pants, leaned forward, and stood. The Complainant struggled to remove his sweatshirt due to the convulsive movements. The Complainant moved uncontrollably back and forth on the bench.

At 9:57:20 a.m., the Complainant was escorted from the booking area by WO #1 and WO #2.

Video from the Complainant’s Cell

On May 5, 2022, at 9:57:26 a.m., a man [now known to be the Complainant] stumbled into the cell. The Complainant stumbled around the cell, crouched, and pulled at his clothing. The Complainant jumped up and down, and swung his arms around. The Complainant bent over and stumbled backward into the cell door.

At 9:59:54 a.m., the Complainant was bent over, and fell forward, hitting his head on the floor. The Complainant was on his knees, with his arms to his sides and his head on the floor face down.

At 10:35:37 a.m., the SO and WO #3 entered the cell. At 10:35:41 a.m., the SO shook the Complainant’s right shoulder. At 10:35:49 a.m., WO #1 entered the cell. WO #1 pulled the Complainant forward by his shirt and the SO rolled the Complainant onto his back.

At 10:36:21 a.m., WO #1 began chest compressions on the Complainant, and the SO put something [now known to be naloxone] by the Complainant’s face. WO #3 took naloxone from WO #1’s side and passed it to the SO, and the SO put it near the Complainant’s face.

At 10:37:32 a.m., WO #3 exited the cell and shortly returned with an AED in his hand. At 10:38:55 a.m., the AED was applied to the Complainant. At 10:40:22 a.m., WO #1 continued chest compressions.

At 10:42:28 a.m., the chest compressions were stopped and fire department personnel arrived outside the cell door. At 10:42:48 a.m., chest compressions were resumed. At 10:43:24 a.m., a fire department personnel applied an air bag on the Complainant.

At 10:43:57 a.m., the SO stood and exited the cell, and fire department personnel took over life-saving procedures.

At 11:14:33 a.m., life-saving procedures ceased.

Figure 1 – The AED

Figure 1 – The AED

Materials Obtained from Police Service

Upon request, the SIU obtained and reviewed the following materials from the OPP:
  • City of Quinte West security camera video footage;
  • Communications recordings;
  • Quinte West Detachment - custody video footage;
  • Persons Detail Report – the Complainant;
  • Event Summary ;
  • Canadian Police Information Centre Reports;
  • Guard Handover Brief;
  • General Report;
  •  Notes of witness officials;
  • Prisoner Care and Control Policy
  • Prisoner Custody Report – the Complainant; and
  • Prisoner Security Check – the Complainant.

Materials Obtained from Other Sources

The SIU obtained the Report of Postmortem Examination from the Coroner’s Office on August 12, 2022.

Incident Narrative

The following scenario emerges from the evidence collected by the SIU, including interviews with several officers who had dealings with the Complainant during his time in police custody. The investigation was also assisted by video footage of the Complainant’s time in custody. As was his legal right, the SO chose not to interview with the SIU or authorize the release of his notes.
In the morning of May 5, 2022, WO #1, while on patrol in his cruiser, came across the Complainant on the Dundas Street East Bridge, east of Front Street, Trenton. The Complainant was leaning over the railing on the south side of the bridge and jumping up and down. Concerned for his safety, WO #1 pulled up beside the Complainant in the westbound lane and exited his cruiser to speak with him. The officer concluded that the Complainant was intoxicated and a danger to himself. He also learned that there was a warrant out for his arrest. The Complainant was arrested and escorted into the backseat of WO #1’s cruiser.
WO #1 travelled a short distance to a parking lot on Front Street, where he searched and handcuffed the Complainant before returning him to the cruiser and transporting him to the detachment.
The Complainant was lodged in a cell at the detachment at about 10:00 a.m. Shortly thereafter, the Complainant fell down, hitting his head on the floor, and relieved himself of urine. Just before 10:30 a.m., the civilian custodian assigned to monitor the Complainant – SEW #1 – advised police personnel that the Complainant was unresponsive in cells.
The SO, the officer responsible for the overall care and control of prisoners at the detachment, together with WO #3 and WO #1, arrived at the cell and began to administer first-aid. An AED was employed (advising against shocks), naloxone was given to the Complainant, and chest compressions were performed.
The fire department arrived on scene at about 10:40 a.m., followed by paramedics, and took over the lead role in the Complainant’s care. Continued efforts at resuscitation were unsuccessful, and the Complainant was pronounced deceased at 11:14 a.m.

Cause of Death

The pathologist at autopsy attributed the cause of the Complainant’s death to ‘multiple drug intoxication (methamphetamine, fentanyl, methadone, bromazolam, cocaine)’.

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.

Section 220, Criminal Code -- Criminal negligence causing death

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 died while in the custody of the OPP on May 5, 2022. The SIU was notified and identified one of the Complainant’s custodians – the SO – as the subject official in its ensuing 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 death.

The offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing death contrary to section 215 and 220 of the Criminal Code, respectively. Both require something more than a simple want of care to give rise to liability. 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 premised on even more egregious conduct that demonstrates a wanton or reckless disregard for the lives or safety of other persons. It is not made out unless the neglect constitutes a marked and substantial departure from a reasonable standard of care. In the instant case, the question is whether there was any want of care on the part of the SO, sufficiently serious to attract criminal sanction, that endangered the Complainant’s life or caused his death. In my view, there was not.
The Complainant was lawfully in police custody at the time of the events in question. In light of the outstanding warrant in effect for his arrest, and his apparent intoxication and erratic behaviour on a bridge, WO #1 was within his rights in apprehending him for public intoxication under the Liquor Licence Act and pursuant to the warrant.

Once in custody, I am satisfied that the Complainant was treated with due care and regard for his health and safety. The decision to lodge him in cells instead of taking him to hospital was arguably a reasonable one. The Complainant was behaving strangely but that in itself would not have been inconsistent with someone under the influence of drugs but not necessarily on the precipice of acute medical distress. Moreover, the officers were not aware of the nature and extent of the drugs in the Complainant’s system. The civilian custodian assigned to monitor the Complainant’s time in cells – SEW #1 – personally checked him repeatedly in about a half-hour’s time before she became sufficiently concerned for his well-being that she beckoned for the intervention of police officers. It might be that SEW #1 ought to have raised a flag sooner than she did – the Complainant was largely motionless on the floor for much of that time. However, she was satisfied with his breathing and only alerted a sergeant when it became shallow and she was unable to rouse him with sound. Once notified of the situation, the involved officers, including the SO, acted with reasonable dispatch and vigilance. Paramedics were quickly summoned and emergency care was provided.
In the result, there are no reasonable grounds to believe that the SO, or any of the other officers who dealt with the Complainant during his time in custody, transgressed the limits of care prescribed by the criminal law. Accordingly, there is no basis for proceeding with criminal charges in this case. The file is closed.

Date: September 2, 2022

Electronically approved by

Joseph Martino
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.