SIU Director’s Report - Case # 22-OCI-144
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Contents:
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.
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.
- 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 serious injury of a 52-year-old man (the “Complainant”).
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 of a 52-year-old man (the “Complainant”).
The Investigation
Notification of the SIU
On June 1, 2022, at about 5:30 p.m., the Ottawa Police Service (OPS) contacted the SIU to report an injury to the Complainant. In a subsequent communication, the OPS provided the following details about the incident. On May 31, 2022, at 6:30 p.m., the Complainant had been arrested for domestic assault and held in police cells. The Complainant was diabetic and was provided with his insulin while in custody, which he self-administered. At 2:30 a.m., June 1, 2022, a special constable found the Complainant on the floor, foaming from the mouth. Narcan was administered twice without effect. Paramedics transported the Complainant to the Ottawa Civic Hospital (OCH) where he was intubated. The Complainant had returned to breathing on his own in hospital.
The Team
Date and time team dispatched: 06/02/2022 at 8:59 a.m.Date and time SIU arrived on scene: 06/02/2022 at 9:30 a.m.
Number of SIU Investigators assigned: 3
Number of SIU Forensic Investigators assigned: 0
Affected Person (aka “Complainant”):
52-year-old male; interviewed; medical records obtained and reviewedThe Complainant was interviewed on June 13, 2022.
Subject Official (SO)
SO Interviewed, and notes received and reviewed The subject official was interviewed on June 21, 2022.
Witness Officials (WO)
WO #1 Interviewed WO #2 Not interviewed, but notes received and reviewed
The witness official was interviewed on June 8, 2022.
Service Employee Witnesses
SEW #1 Interviewed SEW #2 Interviewed
SEW #3 Interviewed
SEW #4 Interviewed
The service employee witnesses were interviewed on June 8, 2022.
Evidence
The Scene
The scene was located in a cell in the custody area of the OPS Central Cellblock, 474 Elgin Street, Ottawa. Video/Audio/Photographic Evidence [1]
Custody Video
The following is a summary of the pertinent video footage of the Complainant’s time at the police station. [2]At 5:28 p.m., May 31, 2022, the Complainant was brought into the sally port in a fully marked OPS SUV operated by WO #1.
The Complainant was booked in front of WO #2. He was verbally aggressive and admitted he had consumed alcohol; he appeared to be intoxicated. WO #1 advised WO #2 that the Complainant was diabetic. The Complainant denied he was diabetic and claimed he had no injuries. The Complainant was questioned about the insulin medication. The Complainant denied that the insulin belonged to himself.
At 5:44 p.m., the Complainant’s property was video recorded as it was itemized. The property included a plastic shopping bag, which contained six pharmacist-type boxes (now known to contain NovoRapid insulin). Also included was a small blue case, which contained a sugar test kit.
At 5:59 p.m., the Complainant was placed in a cell by a special constable. Regular cell checks were conducted on the Complainant.
At 10:39 p.m., the Complainant was taken out of the cell by SEW #1 and led to the search corridor where he was allowed to administer insulin to himself. At 10:43 p.m., the Complainant was placed back in the cell by SEW #1.
Checks of the cell and the Complainant were conducted by SEW #2 at 11:04 p.m., and 11:30 p.m. SEW #1 conducted cell checks on June 1, 2022, at 12:15 a.m., 12:46 a.m., 1:16 a.m., 1:47 a.m., and 2:16 a.m.
At 2:29 a.m., June 1, 2022, SEW #3 was observed standing outside the door to the cell for about 16 seconds. SEW #3 then opened his ASP baton and appeared to lean into the cell with the ASP in his left hand. SEW #3 entered the cell and, after a short period of time, he exited at 2:30 a.m. and hit the panic alarm on the wall. SEW #3 entered the cell again and, at 2:31:55 a.m., he came out of the cell, swung his arms above his head and then hit the panic alarm again. SEW #3 re-entered the cell and, at 2:32:33 a.m., SEW #1 arrived followed by SEW #2. At 2:33:57 a.m., the SO arrived outside the cell.
At 2:34:31 a.m., SEW #1 dragged the Complainant out of the cell by his feet. The Complainant did not have a shirt on; he wore blue jeans. The Complainant was placed on his right side in the recovery position.
At 2:47 a.m., two paramedics arrived on scene and tended to the Complainant.
At 2:52 a.m., two paramedics, wearing green tactical-style uniforms, arrived on scene.
At 2:54 a.m., the Complainant was loaded onto a gurney.
At 3:01 a.m., the Complainant was wheeled out of the cellblock area.
Police Communications Recordings
The following is a summary of the pertinent information captured on the communications recordings.On May 31, 2022, at 4:12 p.m., an OPS police officer advised dispatch that WO #1 had the Complainant under arrest for assault.
At 4:00 p.m., WO #1 was at the police station with the Complainant.
On June 1, 2022, at 2:35 a.m., the SO from the central custody area called 911. He asked to be put through to paramedics. The SO advised the Emergency Medical Services that they had a person in custody who was unconscious and having trouble breathing. The paramedic call-taker wanted more information about the breathing to determine whether chest compressions were necessary. Narcan had been administered and it had had no effect on the man. The SO advised there was no response to pain stimuli.
At 2:49 a.m., a constable was dispatched to the police station to assist the paramedics.
At 3:10 a.m., the constable was inside the ambulance.
Materials Obtained from Police Service
Upon request, the SIU obtained and reviewed the following materials from the OPS between June 2, 2022, and July 11, 2022:- Booking Sheet;
- Computer-assisted Dispatch report;
- Cell Checks List;
- List of Charges;
- List of Involved Officers;
- Reference Manual-Central Cellblock;
- Notes- WO #2;
- Notes- SEW #3;
- Notes- the SO;
- Notes- SEW #2;
- Notes- SEW #1;
- Notes-WO #1;
- Occurrence Report- WO #1;
- Communications recordings;
- Custody video;
- Policy - Prisoner Care and Control;
- Prisoner Transport Sheet;
- Property Sheet; and
- Written Statement – the SO.
Materials Obtained from Other Sources
The SIU obtained and reviewed the following records from the following other sources: - Ambulance Call Report from paramedic service; and
- Medical Records from OCH.
Incident Narrative
The evidence collected by the SIU, including interviews with the Complainant and the SO, and video footage of the Complainant’s time in custody, gives rise to the following scenario.
The Complainant was arrested in the late afternoon of May 31, 2022, for an alleged assault against an acquaintance. He was taken to the police station and lodged in a cell. While being booked, the Complainant denied that he was diabetic and said that the insulin that had been brought with him to the station was not his. In fact, the Complainant was diabetic and the insulin was his.
At about 10:30 p.m., the Complainant asked to take his insulin. He was escorted to the special constable’s desk at the station and allowed to self-administer the medication, after which he was returned to his cell.
At about 2:30 a.m. of the next day, a special constable conducting cell checks – SEW #3 – noticed the Complainant laying on the cell floor with laboured breathing. Unable to rouse the Complainant, SEW #3 summoned the assistance of other officers.
SEW #2 and SEW #1, together with the SO, made their way to the cell. The Complainant was removed from the cell and provided emergency first-aid. Narcan was provided, CPR was administered, and an AED (which advised ‘no shock’) was used. Paramedics were called to the scene.
The paramedics arrived in the cell area at about 2:45 a.m. and took charge of the Complainant’s care. He was transported to hospital, intubated, and treated for altered consciousness and hypoglycemia brought about by an insulin overdose.
The Complainant was arrested in the late afternoon of May 31, 2022, for an alleged assault against an acquaintance. He was taken to the police station and lodged in a cell. While being booked, the Complainant denied that he was diabetic and said that the insulin that had been brought with him to the station was not his. In fact, the Complainant was diabetic and the insulin was his.
At about 10:30 p.m., the Complainant asked to take his insulin. He was escorted to the special constable’s desk at the station and allowed to self-administer the medication, after which he was returned to his cell.
At about 2:30 a.m. of the next day, a special constable conducting cell checks – SEW #3 – noticed the Complainant laying on the cell floor with laboured breathing. Unable to rouse the Complainant, SEW #3 summoned the assistance of other officers.
SEW #2 and SEW #1, together with the SO, made their way to the cell. The Complainant was removed from the cell and provided emergency first-aid. Narcan was provided, CPR was administered, and an AED (which advised ‘no shock’) was used. Paramedics were called to the scene.
The paramedics arrived in the cell area at about 2:45 a.m. and took charge of the Complainant’s care. He was transported to hospital, intubated, and treated for altered consciousness and hypoglycemia brought about by an insulin overdose.
Relevant Legislation
Section 221, Criminal Code -- Criminal negligence causing bodily harm
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.Analysis and Director's Decision
On June 1, 2022, the Complainant, while in the custody of the OPS, lapsed into acute medical distress and was taken to hospital. The SIU initiated an investigation of the incident and named the SO – the officer with overall responsibility for the care of prisoners at the time – the subject official. 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 incident.
The offence that arises for consideration is criminal negligence causing bodily harm contrary to section 221 of the Criminal Code. The offence is reserved for serious cases of neglect that demonstrate a wanton or reckless disregard for the lives or safety of other persons. It is predicated, in part, on conduct that amounts to 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 a want of care on the part of the SO, sufficiently egregious to attract criminal sanction, that caused or contributed to the Complainant’s medical event. In my view, there was not.
There is no question raised on the evidence with respect to the lawfulness of the Complainant’s arrest and subsequent time in custody for an assault reportedly perpetrated on an acquaintance.
I am satisfied that the SO comported himself with due care and regard for the Complainant’s well-being during his time in custody. As soon as he was alerted to a problem in the cell, he acted promptly to ensure emergency medical care – he authorized the administration by special constables of Narcan and CPR, and quickly called for paramedics. Though it seems the Complainant took an overdose of insulin, I am unable to attribute this act – whether intentional or not – to any neglect on the part of the sergeant - police policy prohibited members of the service from administering drugs to prisoners. Moreover, while he had presented as inebriated when he arrived at the station, it was now about five hours later and the Complainant did not appear without control of his faculties.
The investigation did reveal problems in the level of supervision accorded to the Complainant while in custody. Intoxicated prisoners are to be physically checked every 15 minutes to ensure their well-being pursuant to police policy. However, the cell check sheet indicates that the Complainant was only checked about every 30 minutes. In the circumstances of this case, however, it would be unreasonable to visit these indiscretions on the SO. Special constables at the station were directly responsible for ensuring the checks were performed, and the SO had no reason to believe they were not following policy. Moreover, as the last of these checks prior to the Complainant’s medical distress at about 2:30 a.m. was recorded as having occurred at 2:16 a.m., it would not appear that lapses in the Complainant’s supervision had any material bearing on his prognosis.
In the result, as there are no reasonable grounds to believe that the SO transgressed the limits of care prescribed by the criminal law in connection with the Complainant’s time in custody, there is no basis for proceeding with criminal charges in this case.
Date: September 28, 2022
Electronically approved by
Joseph Martino
Director
Special Investigations Unit
The offence that arises for consideration is criminal negligence causing bodily harm contrary to section 221 of the Criminal Code. The offence is reserved for serious cases of neglect that demonstrate a wanton or reckless disregard for the lives or safety of other persons. It is predicated, in part, on conduct that amounts to 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 a want of care on the part of the SO, sufficiently egregious to attract criminal sanction, that caused or contributed to the Complainant’s medical event. In my view, there was not.
There is no question raised on the evidence with respect to the lawfulness of the Complainant’s arrest and subsequent time in custody for an assault reportedly perpetrated on an acquaintance.
I am satisfied that the SO comported himself with due care and regard for the Complainant’s well-being during his time in custody. As soon as he was alerted to a problem in the cell, he acted promptly to ensure emergency medical care – he authorized the administration by special constables of Narcan and CPR, and quickly called for paramedics. Though it seems the Complainant took an overdose of insulin, I am unable to attribute this act – whether intentional or not – to any neglect on the part of the sergeant - police policy prohibited members of the service from administering drugs to prisoners. Moreover, while he had presented as inebriated when he arrived at the station, it was now about five hours later and the Complainant did not appear without control of his faculties.
The investigation did reveal problems in the level of supervision accorded to the Complainant while in custody. Intoxicated prisoners are to be physically checked every 15 minutes to ensure their well-being pursuant to police policy. However, the cell check sheet indicates that the Complainant was only checked about every 30 minutes. In the circumstances of this case, however, it would be unreasonable to visit these indiscretions on the SO. Special constables at the station were directly responsible for ensuring the checks were performed, and the SO had no reason to believe they were not following policy. Moreover, as the last of these checks prior to the Complainant’s medical distress at about 2:30 a.m. was recorded as having occurred at 2:16 a.m., it would not appear that lapses in the Complainant’s supervision had any material bearing on his prognosis.
In the result, as there are no reasonable grounds to believe that the SO transgressed the limits of care prescribed by the criminal law in connection with the Complainant’s time in custody, there is no basis for proceeding with criminal charges in this case.
Date: September 28, 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]
- 2) The footage of the booking process and the search corridor captured audio; however, the audio function for footage captured by some other cameras was not working. There was a camera located in the hallway, across from the entrance to a cell (in which the Complainant had been lodged), which showed the interior of the cell. The recording of the video from this camera had to be activated manually and, in this case, it was not activated. [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.