SIU Director’s Report - Case # 23-OCI-046
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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 section 14 (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 32-year-old woman (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 32-year-old woman (the “Complainant”).
The Investigation
Notification of the SIU [1]
On February 14, 2023, the Niagara Regional Police Service (NRPS) contacted the SIU with the following information.On February 13, 2023, the Complainant was arrested at her residence in Welland on outstanding warrants. She was transported to the NRPS cells at 5700 Valley Way in Niagara Falls and held for a bail hearing the following morning. The Complainant was denied bail and remanded to the Vanier Centre for Women in Milton. While waiting for transport to Milton, the Complainant was observed experiencing convulsions in her cell. Custody staff called Emergency Medical Services (EMS) and went to her aid. A bottle of cleaning solution was located inside the Complainant’s cell. The Complainant was transported to the Greater Niagara General Hospital (GNGH) where she was admitted for observation.
A review of the custody video indicated the Complainant had reached under her cell door and taken the bottle of cleaning solution off the cart used by the janitorial staff while cleaning cells. She poured the cleaning solution, “Sani blend,” into a disposable paper cup and consumed an undetermined quantity of the cleaning solution, after which she started experiencing convulsions.
EMS had taken the bottle with the Complainant to the hospital so doctors could see what she had ingested.
The Team
Date and time team dispatched: 02/15/2023 at 2:20 p.m.Date and time SIU arrived on scene: 02/15/2023 at 5:56 p.m.
Number of SIU Investigators assigned: 3
Number of SIU Forensic Investigators assigned: 1
Affected Person (aka “Complainant”):
32-year-old female; interviewed; medical records obtained and reviewedThe Complainant was interviewed on February 19, 2023.
Witness Officials (WO)
WO #1 Interviewed WO #2 Interviewed
WO #3 Interviewed
The witness officials were interviewed between March 1 and April 3, 2023.
Service Employee Witnesses (SEW)
SEW #1 Interviewed SEW #2 Interviewed
SEW #3 Interviewed
SEW #4 Interviewed
The service employee witnesses were interviewed between March 1 and March 8, 2023.
Evidence
The Scene
The events in question transpired in a cell of the NRPS Central Holding facility at 5700 Valley Way, Niagara Falls. Upon SIU arrival at the cell, there was one cup close to the cell entrance and on the bed containing a yellow liquid.
Figure 1 - Cup containing yellow liquid
Physical Evidence
The following items were collected in the course of the SIU investigation:- McDonald’s beverage cup containing yellow liquid;
- Assorted McDonald’s wrappers;
- McDonald’s take-out cup (empty);
- Surgical mask from door; and
- ‘Sani blend’ cleaner bottle.
Video/Audio/Photographic Evidence [2]
911 Call
On February 13, 2023, a man placed a 911 to the NRPS. The man stated he was at a residence in Welland, and needed the police to attend to the residence - a rooming house. He explained the landlord was on the main floor of the house dealing with a female resident, the Complainant, and a male visitor. He stated that the male visitor was verbally abusive, and the man was afraid the interaction would become physical as the male visitor was threatening to hurt everyone present. He stated there were six individuals inside the residence, none of them children.When asked about weapons, the man said there was a butcher knife in the kitchen and the male visitor was situated in a bedroom beside the kitchen. The interaction had been ongoing for a half-hour prior to the 911 call. The man described the male visitor. The man did not believe there were any drugs or alcohol involved.
The 911 dispatcher told the man police officers were being dispatched to attend the residence and to call back if conditions changed.
Cell Block Video
Starting at about 1:08:19 p.m., a male employee of the NRPS entered the hallway with a cleaning cart. He left the cart standing directly in front of and close to the door of a cell. The employee began cleaning the immediate area, which consisted of the hallway and three empty cells. Starting at about 1:09:35 p.m., the Complainant got onto all fours on the floor, looked up at the ceiling camera, then covered her head with her blanket. Her arm could be seen sticking out of the bottom of the door of the cell. A large bottle was removed from the side of the cleaning cart and taken into the cell by the Complainant.
Figure 2 - Screenshot of video depicting the Complainant reaching her arm under the cell door
Figure 3 - Screenshot of video depicting the Complainant retrieving a bottle of cleaning solution
The NRPS cleaner moved the cart a short distance from its original position outside of the cell.
Starting at about 1:13:25 p.m., the Complainant stood up, head exposed, and walked to the toilet at the back of the cell. She bent over, shielded behind the privacy wall. Because of the position of her blanket, the wall and the video privacy square, her actions were not discernible. A sandwich and beverage were delivered by a special constable, passed through an opening in the middle of the door to the cell.
Starting at about 1:37:54 p.m., two special constables opened the door to the cell. The Complainant was handcuffed and left in the hallway. The Complainant was then returned to the cell, the handcuffs were removed, and the door was closed.
Starting at about 1:45:18 p.m., an object appeared in the opening at the base of the door of the cell. SEW #2 noticed it from the main hallway. He grabbed the item on the floor - a large bottle with no lid. The Complainant stood up and walked to the back of the cell. She turned, faced the front of the cell, and pointed at the floor. There was an inner spray attachment lid laying on the floor in front of the bench. SEW #2 opened the door of the cell. The Complainant took the lid to the plastic bottle and placed it on the bottle. SEW #2 screwed the lid on and closed the door of the cell.
Starting at about 1:50:21 p.m., the Complainant sat up, grabbed a cup from the bench and walked to the toilet, also carrying her blanket. She bent over the top of the toilet and then crouched down. Her activities were indiscernible. The Complainant then stood up and walked to the bunk where she covered her body and laid down facing away from the camera.
Starting at about 2:32:00 p.m., SEW #1 entered the hallway and knocked on the window of the cell. He immediately left, walked into the main hallway, returned and used a key to open the cell door, and entered the cell. He shook the Complainant’s leg, attempting to rouse her, unsuccessfully. He left for seconds and then returned, performing a sternum rub on the Complainant, which was also unsuccessful. SEW #1 left the cell, walked to the main hallway and returned to the Complainant’s cell seconds later. He then left the Complainant’s cell and stood at the end of the hallway. SEW #1 looked in both directions down the main hallway and returned into the cell.
Starting at about 2:32:53 p.m., the Complainant turned onto her left side and began thrashing, appearing to be suffering a seizure. SEW #1 left the cell and returned seconds later. He walked to the toilet and looked on the floor. He grabbed a cup from behind the privacy wall and walked out of sight, leaving the cell with it. SEW #1 returned and began shaking the Complainant, attempting to rouse her. WO #2 entered the cell and she steadied the Complainant during frequent seizures.
Members of the Niagara Regional Fire Department arrived, followed very shortly by paramedics, and the Complainant was carried out of the cell.
Miscellaneous Evidence
Cell Check Log
The Cell Check Log indicated that the Complainant was checked every half-hour or so throughout her period in cells. Materials Obtained from Police Service
Upon request, the SIU received the following materials from the NRPS between February 17 and April 13, 2023:- Records of computer-assisted dispatch;
- Prosecution Summary;
- Initial Report;
- Supplementary Report;
- Communications recordings;
- Cell Check Log;
- Cell Watch;
- Policy – Persons in Custody;
- Policy – Central Holding Facility;
- Notes-SEW #1;
- Notes-SEW #2;
- Notes-SEW #3;
- Notes-SEW #4;
- Notes-WO #1;
- Notes-WO #2;
- Notes-WO #3;
- NRPS cell block video footage; and
- Release Order – the Complainant
Materials Obtained from Other Sources
The SIU obtained and reviewed the following records from other sources:- The Complainant’s medical records from GNGH, received March 3, 2023.
Incident Narrative
The evidence collected by the SIU, including interviews with the Complainant and officers entrusted with her care, as well as video footage that captured much of her time in custody, gives rise to the following scenario.
In the afternoon of February 13, 2023, the Complainant was arrested in her residence in Welland by a NRPS officer. Officers responding to the address in connection with a reported domestic disturbance involving the Complainant and her estranged partner determined she was in breach of a number of bail conditions. The Complainant was transported to the NRPS Central Holding facility in Niagara Falls.
At the facility, the Complainant was booked and lodged in a cell at about 6:00 p.m. Regular checks were performed on the Complainant through the morning and early afternoon of the following day.
At about 1:10 p.m. of February 14, 2023, a member of the cell block cleaning staff entered the corridor beside a cell pushing a cart of cleaning supplies, which he left in front of the Complainant’s cell. As the cleaner was busy cleaning an empty cell, the Complainant reached under the cell door and retrieved a bottle containing cleaning fluid from the cart. The Complainant proceeded to drink most of the fluid.
Shortly thereafter, the Complainant was removed from her cell to attend a video bail hearing. She was returned to her cell within minutes.
At about 1:45 p.m., a special constable monitoring the area of the cells located an empty bottle outside the Complainant’s cell. Having consumed the fluid, the Complainant had pushed it out under the cell door. The Complainant told the special constable that the bottle had fallen from the cleaning cart. The special constable reported this information to a colleague. At about 2:20 p.m., the same special constable attended at the Complainant’s cell and learned from her that she had consumed the liquid in the bottle. The constable advised the officer-in-charge – WO #2 - of this development.
WO #2 reviewed the video footage and realized that the Complainant had retrieved the bottle from the cleaning cart and had consumed its contents. She directed a special constable – SEW #1 – to check on the Complainant.
SEW #1 arrived at the Complainant’s cell at about 2:33 p.m. and quickly realized she was in medical distress. He asked that paramedics be called. SEW #4 did so at about 2:33 p.m.
Paramedics arrived on scene at about 2:40 p.m. and took charge of the Complainant’s care. She was transported to hospital and treated for ‘toxic ingestion’.
In the afternoon of February 13, 2023, the Complainant was arrested in her residence in Welland by a NRPS officer. Officers responding to the address in connection with a reported domestic disturbance involving the Complainant and her estranged partner determined she was in breach of a number of bail conditions. The Complainant was transported to the NRPS Central Holding facility in Niagara Falls.
At the facility, the Complainant was booked and lodged in a cell at about 6:00 p.m. Regular checks were performed on the Complainant through the morning and early afternoon of the following day.
At about 1:10 p.m. of February 14, 2023, a member of the cell block cleaning staff entered the corridor beside a cell pushing a cart of cleaning supplies, which he left in front of the Complainant’s cell. As the cleaner was busy cleaning an empty cell, the Complainant reached under the cell door and retrieved a bottle containing cleaning fluid from the cart. The Complainant proceeded to drink most of the fluid.
Shortly thereafter, the Complainant was removed from her cell to attend a video bail hearing. She was returned to her cell within minutes.
At about 1:45 p.m., a special constable monitoring the area of the cells located an empty bottle outside the Complainant’s cell. Having consumed the fluid, the Complainant had pushed it out under the cell door. The Complainant told the special constable that the bottle had fallen from the cleaning cart. The special constable reported this information to a colleague. At about 2:20 p.m., the same special constable attended at the Complainant’s cell and learned from her that she had consumed the liquid in the bottle. The constable advised the officer-in-charge – WO #2 - of this development.
WO #2 reviewed the video footage and realized that the Complainant had retrieved the bottle from the cleaning cart and had consumed its contents. She directed a special constable – SEW #1 – to check on the Complainant.
SEW #1 arrived at the Complainant’s cell at about 2:33 p.m. and quickly realized she was in medical distress. He asked that paramedics be called. SEW #4 did so at about 2:33 p.m.
Paramedics arrived on scene at about 2:40 p.m. and took charge of the Complainant’s care. She was transported to hospital and treated for ‘toxic ingestion’.
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 221, Criminal Code -- Criminal Negligence Causing Death or 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
The Complainant was seriously injured on February 14, 2023, while in the custody of the NRPS. She was taken to hospital and treated for the ingestion of a toxic substance. The SIU initiated an investigation of the incident, which is now concluded. On my assessment of the evidence, there are no reasonable grounds to believe that any NRPS officers committed a criminal offence in connection with the Complainant’s period in custody and health episode.
The offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing bodily harm contrary to sections 215 and 221 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 any police officer, sufficiently serious to attract criminal sanction, that endangered the Complainant’s life or contributed to her medical episode. In my view, there was not.
The Complainant was lawfully in police custody at the time of the events under investigation. She was discovered residing at an address in contravention of a condition of her bail and was subject to arrest on that basis.
As for her time in police custody, I am satisfied that the officers who dealt with her and were responsible for her care comported themselves with due regard for the Complainant’s health and wellbeing. The record up to the point she was able to access the bottle of cleaning solution suggests she was regularly monitored in her cell. The fact that she was able to access the cleaning solution in the manner she did, by slipping her arm through the gap between the floor and the bottom of the cell door, is a matter of some concern, but I am unable to visit these failings on any of the Complainant’s custodians during her time in custody. [3] Nothing less than continual, uninterrupted monitoring of the Complainant could have avoided that contingency from materializing, and I am not satisfied that such oversight was called for in the circumstances. Nor would it appear that the involved officers failed to act with the requisite dispatch once alerted to the Complainant’s plight. As soon as she learned of the possibility that the Complainant had consumed a cleaning solution, WO #2 acted with haste in having her condition checked and arranging for medical intervention.
In the result, as there are no reasonable grounds to believe that any officer transgressed the limits of care prescribed by the criminal law in the course of the Complainant’s time in custody, there is no basis for proceeding with criminal charges in this case. The file is closed.
Date: June 14, 2023
Electronically approved by
Joseph Martino
Director
Special Investigations Unit
The offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing bodily harm contrary to sections 215 and 221 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 any police officer, sufficiently serious to attract criminal sanction, that endangered the Complainant’s life or contributed to her medical episode. In my view, there was not.
The Complainant was lawfully in police custody at the time of the events under investigation. She was discovered residing at an address in contravention of a condition of her bail and was subject to arrest on that basis.
As for her time in police custody, I am satisfied that the officers who dealt with her and were responsible for her care comported themselves with due regard for the Complainant’s health and wellbeing. The record up to the point she was able to access the bottle of cleaning solution suggests she was regularly monitored in her cell. The fact that she was able to access the cleaning solution in the manner she did, by slipping her arm through the gap between the floor and the bottom of the cell door, is a matter of some concern, but I am unable to visit these failings on any of the Complainant’s custodians during her time in custody. [3] Nothing less than continual, uninterrupted monitoring of the Complainant could have avoided that contingency from materializing, and I am not satisfied that such oversight was called for in the circumstances. Nor would it appear that the involved officers failed to act with the requisite dispatch once alerted to the Complainant’s plight. As soon as she learned of the possibility that the Complainant had consumed a cleaning solution, WO #2 acted with haste in having her condition checked and arranging for medical intervention.
In the result, as there are no reasonable grounds to believe that any officer transgressed the limits of care prescribed by the criminal law in the course of the Complainant’s time in custody, there is no basis for proceeding with criminal charges in this case. The file is closed.
Date: June 14, 2023
Electronically approved by
Joseph Martino
Director
Special Investigations Unit
Endnotes
- 1) The information in this section reflects the information received by the SIU at the time of notification and does not necessarily reflect the SIU’s finding of facts following its investigation. [Back to text]
- 2) 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]
- 3) The SIU was advised by NRPS that the cleaning carts have since been re-designed and cleaners are being trained to mitigate the risk of a similar occurrence moving forward. [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.