SIU Director’s Report - Case # 23-OOD-193


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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 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. 
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 35-year-old man (the “Complainant”).

The Investigation

Notification of the SIU

On May 24, 2023, at 2:22 a.m., the Niagara Regional Police Service (NRPS) contacted the SIU with the following information.

At 12:39 a.m., NRPS officers responded to a possible domestic dispute at an address in the area of Cushman Road and Welland Avenue, St. Catharines. The 911 caller reported hearing a female yell, “Please help me.” When the caller looked outside, she observed a naked man lying on the ground and a female leaving the scene. Upon the arrival of NRPS officers, they located a naked man, the Complainant, thrashing about on the front lawn. When Emergency Medical Services (EMS) arrived shortly thereafter, they opined that the Complainant was exhibiting signs of excited delirium. He was immediately placed into an ambulance and became Vital Signs Absent (VSA). NRPS officers travelled in the ambulance to the St. Catharines Hospital (SCH). At 1:55 a.m., the Complainant was pronounced deceased.

The Team

Date and time team dispatched: 05/24/2023 at 3:16 a.m.

Date and time SIU arrived on scene: 05/24/2023 at 5:07 a.m.

Number of SIU Investigators assigned: 3
Number of SIU Forensic Investigators assigned: 2

Affected Person (aka “Complainant”):

35-year-old male; deceased

Civilian Witnesses (CW)

CW #1 Interviewed
CW #2 Interviewed
CW #3 Not interviewed
CW #4 Interviewed
CW #5 Interviewed
CW #6 Interviewed

The civilian witnesses were interviewed between May 24, 2023, and June 12, 2023.

Witness Officials (WO)

WO #1 Not Interviewed; notes reviewed and interviewed deemed unnecessary
WO #2 Interviewed
WO #3 Not Interviewed; notes reviewed and interviewed deemed unnecessary
WO #4 Interviewed
WO #5 Not Interviewed; notes reviewed and interviewed deemed unnecessary
WO #6 Not Interviewed; notes reviewed and interviewed deemed unnecessary
WO #7 Not Interviewed; notes reviewed and interviewed deemed unnecessary

The witness officials were interviewed on May 28, 2023.


The Scene

The events in question transpired outside a residence in the area of Cushman Road and Welland Avenue, St. Catharines, and inside an ambulance as it travelled from the residence to SCH.

On May 24, 2023, at 5:17 a.m., SIU forensic investigators attended at the ambulance that had transported the Complainant, as it remained at the SCH. The rear treatment area was scattered with medical debris. There was nothing of evidentiary value located in this area.

At 8:00 a.m., SIU forensic investigations attended the Complainant’s residence. It was secured by a NRPS officer. On the front lawn was an area of scattered medical debris that was consistent with medical intervention.

Video/Audio/Photographic Evidence [1]

Video Footage – Witness #1

On June 12, 2023, Witness #1 provided the SIU cell phone video footage of the incident under investigation.

The video captured a NRPS officer standing over a naked male - the Complainant - as he faced down. He was on the sidewalk and a marked NRPS cruiser was nearby. The Complainant moved about on the ground in an uncontrolled fashion as if he were having a seizure. A second NRPS officer arrived. The officers appeared to assist the Complainant near his head. A short time later, EMS arrived. NRPS officers and EMS paramedics lifted the Complainant, and placed him onto a gurney and then inside an ambulance.

Communications Recordings

On May 26, 2023, the NRPS provided the SIU with the 911 call placed by CW #2.

On May 24, 2023, at 12:38 a.m., CW #2 called NRPS to report what was believed to be a domestic disturbance at a residence in the area of Cushman Road and Welland Avenue, St. Catharines. The caller had heard a woman whimpering and yelling, “Please help.”

Several officers were dispatched.

A short time later, CW #2 called back to report that the Complainant was on the front lawn and was “completely naked and freaking out”.

NRPS officers arrived and found the Complainant as he rolled on the ground and thrashed about. WO #4 told the communications operator that the Complainant appeared to be suffering from excited delirium.

EMS arrived.

An officer stated that no officers had physically engaged with the Complainant.

NRPS communications were updated on several occasions that EMS was “frantically working” on the Complainant and that he continued to thrash. It was later reported that WO #2 was riding in the back of the ambulance, and that officers were required to handcuff the Complainant to a gurney.

EMS and officers performed cardiopulmonary resuscitation on the Complainant and tried to “bring him back to life”.

Starting at about 1:18 a.m., WO #2 and WO #4 assisted EMS and drove the ambulance to SCH. The Criminal Investigation Bureau were called to the scene.

Starting at about 1:30 a.m., it was reported that the Complainant was VSA in the ambulance.

Starting at about 1:55 a.m., it was reported that the Complainant had been pronounced deceased at the SCH.

Materials Obtained from Police Service

Upon request, the SIU received the following materials from the NRPS between May 24 and 26, 2023:
  • Communications recordings;
  • General Occurrence Report;
  • Record of computer-aided dispatch;
  • Previous Interactions with the Complainant;
  • Fingerprints – the Complainant;
  • List of Involved NRPS Officers;
  • Notes – WO #5;
  • Notes – WO #2;
  • Notes – WO #6;
  • Notes – WO #7;
  • Notes – WO #3;
  • Notes – WO #1;
  • Notes – WO #4;
  • Scene of Crime Officer Photographs;
  • Policy – Use of Force; and
  • Policy – Mentally Ill Persons.

Materials Obtained from Other Sources

The SIU obtained the following records from other sources between May 24, 2023, and June 12, 2023:
  • Video footage from Witness #1;
  • Photographs from CW #6;
  • Ambulance Call Report from Niagara Emergency Medical Services;
  • Preliminary Autopsy Findings from Ontario Forensic Pathology Services; and
  • Evidence Collection Report from Ontario Forensic Pathology Services.

Incident Narrative

The material events in question, clear on the evidence collected by the SIU, may briefly be summarized.

In the early morning of May 24, 2023, police and paramedics were called to a home in the area of Cushman Road and Welland Avenue, St. Catharines. A person had contacted police about a possible domestic disturbance inside the residence. The same caller subsequently noted that a male was outside on the front lawn of the residence; he was naked and very agitated.

Police officers were the first to arrive on scene. They realized that the male – the Complainant – was in medical crisis and possibly having a seizure. Paramedics arrived shortly after and began to administer care to the Complainant. They asked one of the officers on scene – WO #2 – to assist as they knew him to be a former paramedic. At the medics’ request, the officer applied a blood pressure cuff and cardiac monitor leads to the Complainant. The Complainant was a large man, and officers assisted paramedics in placing him on a gurney and into an ambulance. Because he was flailing his body and limbs, officers handcuffed his arms to the gurney railing at the request of the paramedics.

WO #2 was asked by the paramedics to ride with them in the back of the ambulance. However, before departure, the Complainant’s lost vital signs and the officer was asked to drive the ambulance to the hospital.

The ambulance arrived at hospital at about 1:30 a.m. The Complainant was pronounced deceased at 1:55 a.m.

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.

Sections 219 and 220, Criminal Code -- Criminal negligence causing death

219 (1) Every one is criminally negligent who
(a) in doing anything, or
(b) in omitting to do anything that it is his duty to do,
shows wanton or reckless disregard for the lives or safety of other persons.

(2) For the purposes of this section, duty means a duty imposed by law.

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 passed away on May 24, 2023, in St. Catharines. Because police had been called to the scene of the Complainant’s residence, where he was discovered in medical distress, the SIU was notified of the incident and initiated an investigation. The investigation is now concluded. On my assessment of the evidence, there are no reasonable grounds to believe that any NRPS officer 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 sections 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 any of the involved NRPS officers, sufficiently serious to attract criminal sanction, that endangered the Complainant’s life or caused his death. In my view, there was not.

There is no evidence that the officers on scene with the Complainant failed to comport themselves with due care and regard for his health and safety. They promptly appreciated that they were dealing with a medical issue, and refrained from intervening physically appreciating the risks that could entail and knowing the paramedics were moments away. When the paramedics arrived, the officers assisted in placing the Complainant on a stretcher so he could be taken to hospital as soon as possible. One of them – a former paramedic – also assisted with the Complainant’s medical care under direction by the attending paramedics. Officers also secured the Complainant’s arms to the stretcher railing, again at the direction of the paramedics. That action was meant to ensure that medical care would not be delayed because of interference caused by the Complainant’s agitation.

In the result, as I am satisfied that no NRPS officer transgressed the limits of care prescribed by the criminal law in their dealings with the Complainant, there is no basis for proceeding with charges in this case. The file is closed.

Date: September 20, 2023

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.