SIU Director’s Report - Case # 22-TCD-176


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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 26-year-old man (the “Complainant”).

The Investigation

Notification of the SIU

On July 10, 2022, at approximately 1:02 a.m., the Toronto Police Service (TPS) contacted the SIU with the following information.
On July 9, 2022, at approximately 10:29 p.m., police were requested to respond to a residence on Tree Sparroway, North York, after a complaint was received that a man suffering from a mental health disorder [known to be the Complainant] was threatening his mother with a knife. The Complainant’s two brothers were also in the home, restraining their brother on the ground until the police arrived. Once the police arrived, the Subject Official (SO) and Witness Official (WO) #1 took custody of the Complainant and handcuffed him, after which the Complainant fell into medical distress. The police officers removed the handcuffs and notified emergency medical services (EMS). Once EMS arrived, the Complainant was transported to North York General Hospital (NYG) at 4001 Leslie Street in North York. Resuscitation attempts were made. At 12:02 a.m., the Complainant was pronounced deceased.

The scene had been held awaiting examination.
The responding officers, equipped with body-worn cameras (BWC), returned to 33 Division.
The Regional Supervising Coroner had been advised.

The involved officers were WO #1, the SO and WO #2.

The Team

Date and time team dispatched: 07/10/2022 at 1:27 a.m.

Date and time SIU arrived on scene: 07/10/2022 at 3:45 a.m.

Number of SIU Investigators assigned: 6

Number of SIU Forensic Investigators assigned: 1

Affected Person (aka “Complainant”):

26-year-old male; deceased.

Civilian Witnesses (CW)

CW #1 Interviewed
CW #2 Interviewed
CW #3 Interviewed
CW #4 Interviewed

The civilian witnesses were interviewed between July 10 and 14, 2022.

Subject Official (SO)

SO Interviewed; notes received and reviewed

The subject official was interviewed on August 25, 2022.

Witness Officials (WO)

WO #1 Interviewed
WO #2 Interviewed

The witness officials were interviewed between July 15 and 19, 2022.


The Scene

The scene was located at a residence on Tree Sparroway, North York. The unit had a kitchenette and living room on the first level and the bedrooms on the second level. The incident took place just outside the kitchenette entrance, in the southwest corner of the dining room.

Scene Diagram

Physical Evidence

The SIU collected the following item:

- Multi-tool knife (blade length about 9 centimetres).

Figure 1 – The Complainant’s multi-tool knife

Video/Audio/Photographic Evidence [1]

The SO’s BWC Footage

The SO’s BWC footage was two hours and ten minutes long, and began on July 9, 2022, at 10:53 p.m. The following is a summary of the pertinent footage.

The SO arrived on scene and was met by CW #1 on the sidewalk. The SO followed WO #1 and CW #1 into the apartment building up the stairs to the apartment.

At 10:53:58 p.m., the SO and WO #1 entered the apartment. CW #4 was sitting in the living room. CW #2 was sitting on the ground near the kitchen entrance and behind CW #2 was CW #3, who appeared prone with his head towards the kitchen, on top of the Complainant. The SO said, “Stay on him.” CW #2 started to get up. The SO went to the area by the head of CW #3.

At 10:54:13 p.m., the camera captured the Complainant face down on the floor; his hands were above his head and touching. CW #3 was lying face down on the Complainant’s back. The SO told the Complainant that he was taking his arm and with both hands grabbed the wrist area of the left arm. As the Complainant’s left arm was brought out to the side, the camera moved to the upper back of CW #3. A police officer asked CW #3 to move his left hand. CW #2 was still against the Complainant and CW #3. At 10:54:23 p.m., both CW #3 and CW #2 moved to get out of the way, as a handcuff was placed on the left wrist of the Complainant.

The SO told the Complainant he was going to bring his arm back and began to reposition the right arm behind his back. CW #3 was in a seated position on the Complainant’s waist and assisted with handcuffing. The SO said “No, [the Complainant], don’t fight with me.” as the right arm was maneuvered to the centre of his back. The hand appeared to get tangled in clothes and the clothes were moved out of the way.

At 10:55:01 p.m., the SO and WO #1 completed the handcuffing. The SO said, “Once your locked, we are going to wrap his feet with a soft leg restraint.” CW #3 was sitting on the Complainant’s legs. The SO and WO #1 congratulated CW #3 and CW #2 for a job well done and WO #1 double-locked the handcuffs.

At 10:55:25 p.m., a police officer asked CW #3 to pull up the Complainant’s pants. Four seconds later, the SO asked if the Complainant was breathing. He said the Complainant’s name, after which the Complainant was rolled over onto his left side. At 10:55:41 p.m., the SO checked for a pulse on the Complainant’s neck, the the officer lifted the Complainant’s head, which was limp.

At 10:56:12 p.m., the Complainant rolled onto his back. His left pupil could be seen but his eye lid was partly closed. The SO laid the Complainant’s head on the floor and instructed WO #1 to call EMS. The Complainant’s mouth was slightly open with his top teeth showing. The SO reported the Complainant was unconscious and not breathing, and WO #1 repeated this on the police radio. At 10:56:13 p.m., a chest rub was performed but there was no response. One of the brothers asked if he was breathing and was told no.

At 10:56:23 p.m., the SO moved to the left side of the Complainant and began CPR. The police officer asked if the Complainant had any medical conditions and someone said he had a mental health disorder. The police asked how long the Complainant was pinned down and someone said “five”. Toronto Fire Service (TFS) was requested with a defibrillator.

At 10:58 p.m., WO #1 removed the handcuffs. The brothers were asked to meet and bring TFS and the EMS as quickly to the scene as they could. The SO and WO #1 continued CPR.

At 11:00 p.m., a police officer [known to be WO #2] arrived. The SO explained to WO #2 that the brothers were holding the Complainant down when he and WO #1 arrived. The Complainant was handcuffed, he felt for a pulse and the handcuffs were removed. They went right to CPR.

At 11:01 p.m., a towel was put under the Complainant’s head to tilt the chin back.

At 11:04 p.m., TFS and EMS arrived and were told CPR was ongoing for four minutes and there had been no response to pain stimulus. The SO explained that CW #2 and CW #3 had taken a knife from the Complainant and held him down. Once handcuffed and secured the police officers noticed there was no pulse and they started CPR right away. This would be repeated to another paramedic and the SO added, “At some point he stop breathing.”

At 11:08 p.m., the SO asked CW #2 and CW #3 how long they had held the Complainant down and CW #2 replied four to five minutes. The SO again spoke with WO #2 and told him what happened, adding that when they rolled the Complainant over his eyes were rolling back and that all happened within one minute. WO #2 was told that the Complainant suffered from a mental health disorder.

At 11:31 p.m., the Complainant was removed from the apartment.

At 11:34 p.m., CW #1 said she hid the knife in her washroom. At 11:35 p.m., the SO and WO #1 were assigned to stay at the scene, and WO #2 advised the SIU had not been called yet.

At 11:37 p.m., the SO and WO #1 returned to the apartment. At 11:38 p.m., CW #1 got the knife and gave it to the SO and said that she had been cut “a little bit”. CW #1 explained what happened to the SO and WO #1, and explained to them her sons told her how they had taken the knife away.

At 11:48 p.m., the SO received a call, walked into the hallway and muted the BWC. At 11:50 p.m., the SO turned the sound back on and entered the apartment. He described how sharp the knife was and that it could take a finger off. CW #1 said the Complainant would have killed all of them, and CW #4 asked why she opened the door. There was a conversation about mental health not being a joke and the Complainant had been doing this for years.

At 12:23 a.m., a detective spoke with the family and advised the SIU was coming. At 12:34 a.m., a detective said the Complainant died but the family would be told after the SO and WO #1 had left.

WO #1’s BWC Footage

WO #1’s BWC footage was one hour and 58 minutes in length, and began on July 9, 2022, at 10:53 p.m. WO #1 was partnered with the SO. WO #1’s BWC footage was substantially the same as the SO’s BWC footage.

WO #2’s BWC Footage

WO #2’s BWC footage went from 10:59:15 p.m. to 11:45:23 p.m.
At 10:59:27 p.m., WO #2 arrived and was met by CW #1. At 11:00:26 p.m., WO #2 entered the apartment. The SO and WO #1 were performing chest compressions on the Complainant. Three men were also inside the apartment. WO #2 told one of the men to go outside and wait for paramedics.
The SO told WO #2 that when he entered the apartment with WO #1, the men were holding down the Complainant. They handcuffed the Complainant and checked for a pulse but there was no pulse. They removed the handcuffs and started CPR.

At 11:03:00 p.m., WO #2 went outside to meet the paramedics. At 11:03:51 p.m., WO #2 escorted TFS into the apartment. A man said the Complainant had a knife and the police officers took it.

At 11:06:05 p.m., paramedics arrived.

At 11:09:23 p.m., CW #1 told WO #2, “This was not the first time he…,” after which she became upset and did not finish the sentence. WO #2 spoke with the SO and was told the Complainant suffered from a mental health disorder and did not take narcotics.

At 11:29:10 p.m., WO #2 went outside to prepare for the emergency run to hospital. WO #2 told the SO and WO #1 to stay at the scene; he was going to do the emergency run.

At 11:37:58 p.m., WO #2 began the emergency run to NYG and, at 11:41:36 p.m., he arrived at the hospital.

Communications Recordings

The TPS provided communications recordings from July 9, 2022, at 10:30:06 p.m. to July 10, 2022, at 12:46:47 a.m.

At 10:30:06 p.m., the dispatcher requested that available units attend an apartment building for a person with a knife. The caller [known to be CW #1] had said that the Complainant had a knife but there were no injuries.

At 10:41:47 p.m., dispatch indicated that 33 Division did not have any officers available because of a shooting call. Two additional 42 Division officers were dispatched.

Dispatch advised that the Complainant had a mental health disorder, and he had a knife in the living room. His brothers were holding him down; he did not have a knife at the time but was trying to stand up. There were five people on scene.

At 10:48:08 p.m., the first unit told dispatch they were responding. Dispatch updated that CW #1 had taken the knife away from the Complainant and the brothers were still holding him down.

At 10:55:54 p.m., the first unit requested EMS. The Complainant was unconscious and not breathing. CPR was being performed and a rush on EMS was requested.

At 10:59:24 p.m., the first unit told dispatch CPR had been administered for two minutes. At 11:06:42 p.m., the second unit, EMS and TFS were on scene, and EMS took over CPR.

At 11:17:10 p.m., the second unit said they were leaving because they were not required.

At 11:25:44 p.m., the first unit advised dispatch an emergency run to hospital would be required.

At 11:37:27 p.m., a third unit advised dispatch that the first unit would remain at the scene and the third unit would escort the ambulance to NYG on the emergency run.

At 11:41:06 p.m., the third unit and EMS arrived at NYG.

On July 10, 2022, at 12:46:47 a.m., the first unit requested EMS because one of the Complainant’s brothers was experiencing chest pains.

911 Recordings

The TPS provided 911 recordings from July 9, 2022. The recording began at 10:29 p.m. The following is a summary of the pertinent information contained in the recordings.

At 10:29:20 p.m., CW #1 asked for police to attend because her son, the Complainant, had a knife. He was in the living room. CW #1 was hysterical and panicking. The Complainant was trying to find a knife and kill people. The Complainant had a mental health disorder and was medicated. He had not been drinking or on narcotics. He did not live with CW #1. There were five people in the apartment. The Complainant’s brothers were holding him down, but he was trying to get up.

At 10:42:12 p.m., CW #1 called back to ask when the police would attend.

CW #1 called again at 10:51:36 p.m. to say the police had not arrived and the Complainant’s brothers were still holding him down. The police arrived at the end of the call at 10:53:09 p.m.

Materials Obtained from Police Service

Upon request, the SIU reviewed the following materials from the TPS between July 10, 2022, and August 22, 2022:
  • Event Details Report;
  • Communications recordings;
  • BWC footage;
  • General Occurrence and Supplemental Reports;
  • Notes- the SO;
  • Notes- WO #1;
  • Notes- WO #2;
  • Civilian Witness List;
  • Interactions with Subject;
  • Policy - Death in Police Custody; and
  • Policy - Medical Emergencies.

Incident Narrative

The evidence collected by the SIU, including interviews with eyewitnesses to the events in question and BWC footage that captured the incident in parts, gives rise to the following scenario.

At about 10:48 p.m. of July 9, 2022, the SO and WO #1 were dispatched to a residence on Tree Sparroway, Toronto. CW #1, who resided at the address with her family, had called 911 to report a disturbance involving one of her sons, the Complainant.

The Complainant, who did not live at the address, had arrived at the residence to collect his mail. The Complainant, in possession of a knife, made threatening comments and his brothers, CW #2 and CW #3, intervened physically. The brothers were able to force the Complainant to the floor on his back, and used their greater manpower to keep him pinned. In short order, CW #2 dispossessed the Complainant of the knife. Fearing that he would retrieve another knife if they lost control of him, CW #2 and CW #3 kept the Complainant on the ground while they waited for the police to arrive.

CW #1 had reached a 911 operator at about 10:30 p.m. She indicated that the Complainant had a knife and was threatening to hurt people. She further noted that the Complainant, who suffered from a mental health disorder, was being held down by his brothers. In subsequent calls to police at 10:42 p.m. and 10:51 p.m., CW #1 explained that the knife had been taken away from the Complainant. [2]

The SO and WO #1 arrived on scene at about 10:53 p.m. They observed the Complainant lying prone on the ground in a dining room area just off the kitchen. Lying prone on top of the Complainant was CW #2. The officers took control of the Complainant’s arms and, with CW #2 now off his brother, handcuffed them behind his back.

Shortly after securing the restraints, the SO noticed that something was wrong; the Complainant’s eyes were not blinking and he was not breathing. WO #1 contacted EMS. The handcuffs were removed from the Complainant and the officers started CPR while they waited for the attendance of paramedics.

Paramedics and firefighters arrived about ten minutes later and took charge of resuscitative efforts.

The Complainant was transported to hospital and declared deceased at 12:02 a.m., July 10, 2022.

Cause of Death

An autopsy was conducted on July 11, 2022. The cause of the Complainant’s death remains pending.

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 or bodily harm

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

On July 10, 2022, the Complainant, while in the custody of the TPS, was pronounced deceased. In the ensuing SIU investigation, one of the officers who had arrested the Complainant – the SO – was identified as 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 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 SO and WO #1 were lawfully placed and in the execution of their duties throughout their engagement with the Complainant. They had been dispatched to a domestic disturbance call involving a weapon – a knife – and were within their rights in taking the Complainant into custody given what they knew of his behaviour from the 911 call. As police officers, they were also duty-bound to do what they could by way of emergency first-aid when they noticed the Complainant in medical distress shortly after he was handcuffed.

In the short time that the SO and WO #1 dealt with the Complainant, I am satisfied that they comported themselves with due care and regard for his health and wellbeing. In light of what they knew of the 911 call, involving a knife, and what they observed upon arriving at the scene – CW #2 lying prone on his brother, himself prone on the ground, as if trying to keep him from getting up – it would appear the decision to immediately handcuff the Complainant was a reasonable one made in the interests of everyone’s safety. Thereafter, the officers acted expeditiously as soon as they noticed that the Complainant was in medical crisis, contacting EMS and administering CPR.

In the result, while the cause of the Complainant’s death remains unknown at this time, there are no reasonable grounds to believe it is attributable to any unlawful conduct on the part of the subject official. As such, there are no grounds to proceed with criminal charges. The file is closed.

Date: November 7, 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]
  • 2) There were no officers available to respond immediately to CW #1’s initial call to police as it seems they were tied up with a shooting that had occurred in their division. [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.