SIU Director’s Report - Case # 23-PCI-380
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Mandate of the SIU
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.
Special Investigations Unit Act, 2019Pursuant 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 ActPursuant 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, 2004Pursuant to this legislation, any information related to the personal health of identifiable individuals is not included.
Other proceedings, processes, and investigationsInformation 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.
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 41-year-old man (the “Complainant”).
Notification of the SIU On September 16, 2023, at 5:45 a.m., the Ontario Provincial Police (OPP) notified the SIU of an injury to the Complainant.
According to the OPP, on September 15, 2023, the Complainant called for an ambulance in Huron County and was taken to South Huron Hospital (SHH). While at SHH, the Complainant went into the washroom and refused to come out. The washroom was a small, one-person washroom in the Emergency Department (ED). Hospital staff called the OPP to assist. At 9:00 p.m., police officers arrived and attempted to communicate with the Complainant without success. The police officers forced the washroom door open, gained entry and located the Complainant in an elevated position in the ceiling. Police officers and SHH staff placed mattresses on the floor in the event the Complainant fell from the ceiling. The Complainant eventually decided to come down from the ceiling and was assisted by the police officers. When examined by medical staff, it was determined that the Complainant had sepsis and a fractured rib. He was admitted for medical treatment and placed on a 72-hour Mental Health Act Form.
The TeamDate and time team dispatched: 09/16/2023 at 6:30 a.m.
Date and time SIU arrived on scene: 09/16/2023 at 7:18 a.m.
Number of SIU Investigators assigned: 4
Number of SIU Forensic Investigators assigned: 0
Affected Person (aka “Complainant”):41-year-old male; interviewed; medical records obtained and reviewed
The Complainant was interviewed on September 18, 2023.
Civilian WitnessesCW #1 Interviewed
CW #2 Interviewed
The civilian witnesses were interviewed between September 16, 2023, and October 16, 2023.
Subject OfficialsSO #1 Declined interview and to provide notes, as is the subject official’s legal right
SO #2 Declined interview and to provide notes, as is the subject official’s legal right
SO #3 Declined interview and to provide notes, as is the subject official’s legal right
Witness OfficialsWO #1 Interviewed; notes received and reviewed
WO #2 Interviewed; notes received and reviewed
WO #3 Notes reviewed; interview deemed not necessary
WO #4 Notes reviewed; interview deemed not necessary
The witness officials were interviewed on October 3, 2023.
The Scene The events in question transpired in a bathroom and adjacent treatment room in the Emergency Department of SHH, 24 Huron Street West, Exeter.
Figure 1 - OPP Scenes of Crime Officer (SOCO) photograph of washroom after police officers forced entry
Figure 2 - OPP SOCO photograph of duct and wiring in the ceiling of the treatment room adjacent to the washroom.
The Complainant was positioned lying on his stomach on the duct work.
Figure 3 - OPP SOCO photograph of the treatment room from where the Complainant was taken down from the ceiling.
The photograph depicts the damage caused, one of the ladders used to access the Complainant and, underneath the ladder, a hospital bed mattress.
Video/Audio/Photographic Evidence 
Body-worn Camera (BWC) footage – SO #1Starting at about 9:38:06 p.m., September 15, 2023, SO #1 was captured standing in an ED examination room. Two other OPP officers and a nurse were standing in a doorway outside the room. They looked up towards the area of the ceiling, and a nurse spoke with the Complainant. The room appeared in disarray with several ceiling tiles missing. The nurse told the Complainant that he appeared to have consumed bad drugs and was on a really bad trip. She asked the Complainant to come down as his mother and father were worried about him. The nurse asked the Complainant to come down before he fell and injured himself. An unknown male voice was heard telling the Complainant not to touch an electrical box.
SO #1 introduced himself to the Complainant and asked him to come down. SO #1 attempted to build a rapport with the Complainant and advised that everyone was just there to help him. The nurse contacted a member of the Complainant’s family and allowed the Complainant to speak with her. The Complainant refused to come down. He was allowed to speak with his child as well. The nurse requested the Complainant come down as he had cuts and blood all over him.
The Complainant expressed concerns about what would happen to him if he came down from the ceiling. An OPP police officer [believed to have been WO #4] climbed a ladder and removed a ceiling tile in the room in an attempt to convince the Complainant to come down. A nurse also climbed the ladder and attempted to convince the Complainant to come down. The Complainant was allowed to speak with his mother, who also attempted to convince the Complainant to come down. Multiple unsuccessful attempts were made by police officers and the nurse to negotiate with and convince the Complainant to come down on his own.
Starting at about 10:04:57 p.m., members of the South Huron Fire Department (SHFD) arrived in the ED and attempted to convince the Complainant to descend. The Complainant could be heard moving around in the ceiling area.
A female voice was heard warning the Complainant several times not to set something on fire in the ceiling area. The Complainant could be seen crawling through the rafters above the room. He opened a water valve, and water poured onto the floor of the room. The valve was shut off by the SHFD at 10:16:50 p.m.
SO #2 entered the room and was briefed by SO #1. There was a discussion between SO #1 and SO #2 about how to limit the Complainant’s ability to move around in the ceiling area and to continue to negotiate with the Complainant. SO #1 discussed with a member of the SHFD the possibility of airbags or scaffolding to keep the Complainant safe. The primary discussion revolved around preventing the Complainant from being injured.
SO #1 told the Complainant that all of his demands (phone calls to his family) had been met, and insisted that the Complainant come down from the ceiling. The Complainant was argumentative and refused to come down. SO #1 told the Complainant that the police and fire department were there to help him. SO #1’s demeanour was calm, patient and reassuring. SO #1 told the Complainant that everyone was there to help him and that they wanted him to come down of his own free will. He asked the Complainant if he would come down on his own if a ladder was provided. The Complainant refused.
The Complainant opened a valve in the ceiling and water began to pour onto the floor. The valve was closed by a member of the HSFD. A member of the maintenance staff entered the room to assess the damage. Maintenance advised it was a heating valve that had been opened and not fire suppression. SO #2 attempted to convince the Complainant to come down with a bottle of water. A police officer and members of the SHFD began removing items from the room and putting mattresses or cushions on the floor under the Complainant.
Starting at about 11:11:50 p.m., SO #2 climbed a ladder and attempted to engage the Complainant in conversation and convince him to come down. The Complainant could be heard saying, “Ow,” and groaning in pain. SO #2 descended the ladder, spoke with SO #1, and continued to negotiate with the Complainant. The Complainant was reassured that the police were was not there to hurt him, and only wanted to help.
SO #1 told the Complainant to stop touching a box with electrical wires and advised it was dangerous. SO #2 ascended a ladder to obtain a view of the Complainant. SO #2 descended the ladder quickly. The Complainant could be heard moving in the ceiling. The lights went out in the room. SO #1 advised the Complainant that if he kept touching the electrical wires, that OPP would have to act, and again asked the Complainant to come down. SO #1 continued to negotiate with the Complainant and advised him that he had been provided with everything he had asked for and it was time for him to give something and come down. The Complainant refused.
The Complainant expressed doubt that the OPP officers were actually police officers. SO #2 offered to allow the Complainant to speak with a supervisor. SO #1 reassured the Complainant that everyone was telling him the truth and treating him with respect, and that all everyone wanted was for him to come down. The Complainant requested a female police officer to come into the room.
Starting at about 12:19:30 a.m., SO #3 moved some mattresses within the treatment room to below the Complainant. The Complainant asked for a witness in case the police pulled him down. The presence of a sergeant was offered as a witness if the Complainant came down. The Complainant was reassured that the mattresses were being moved in case he fell from the ceiling.
SO #3 climbed a ladder and appeared to look into the ceiling. The Complainant yelled for help several times and begged not to be killed. The Complainant was again reassured that nobody would harm him. A second ladder was brought into the room. The Complainant continued to yell for help. A female OPP officer (believed to be WO #4) identified herself as “the OPP sergeant” to the Complainant and asked him to put his feet down onto a ladder that was directly below him. The Complainant refused to come down and continued yelling for help.
Starting at about 12:31:30 a.m., SO #1 climbed a silver ladder, while SO #3 stood at the top of a yellow step ladder. The Complainant appeared to be in an area of the ceiling located between the two ladders. SO #1 asked the Complainant if he was going to come down, or if the police officers were going to have to come up, and that they had been negotiating with the Complainant for five hours. A male voice (believed to be SO #3) was heard saying, “You’re going to come down one way or the other, now let’s go.” SO #3 could be seen reaching into the ceiling area above the ceiling tiles.
Starting at about 12:33:15 a.m., a male voice could be heard to say, “Get the fuck down now.” The Complainant could be seen atop a heating duct. SO #2 appeared to be standing at the top of the yellow step ladder and reaching into the area above the heating duct. A male voice could be heard telling the Complainant not to kick. SO #2 could be seen punching into the area of the heating duct with his right hand approximately four times. There were sounds of a struggle, and male voices could be heard telling the Complainant to “get down now”. A male voice (believed to be SO #1) could be heard saying, “I’m gonna drive stun him.”
Starting at about 12:35:24 a.m., the Complainant fell from the area of the ceiling. He appeared to fall buttocks first and was closest to SO #2 and the yellow step ladder. He grunted in pain and said, “I’m sorry,” several times. SO #1 descended the ladder. Two police officers [believed to be SO #2 and WO #1] knelt beside the Complainant, who lay on a blue mattress. A nurse stepped away from the Complainant and held a syringe in her right hand. WO #4 and SO #3 stood behind SO #2 and WO #1.
A stretcher was wheeled into the room. SO #1 could be heard to reassure the Complainant that nobody was going to hurt him. The Complainant was in a seated position on the blue mattress with his hands apparently handcuffed to the rear. The Complainant was lifted by the police officers and placed onto the stretcher. Leg restraints were applied by a nurse. SO #1 reassured the Complainant that they would get him help.
During the course of the BWC footage, the ED appeared to be in disarray, heavily damaged, and unable to operate as a functioning emergency department. The OPP officer with the most interaction with the Complainant was SO #1. Medical staff at SHH (specifically, a nurse) appeared to negotiate extensively with the Complainant.
OPP Communications RecordingsStarting at about 8:43 p.m., September 15, 2023, a nurse at SHH called 911 to report that the Complainant had been transported to the hospital by ambulance and had been doing lines of cocaine. The Complainant had attempted to defecate in a garbage can and had been taken to the bathroom where he had locked himself for about 30 minutes. It sounded like the Complainant was destroying the bathroom. The nurse requested OPP assistance.
Officers were dispatched to the hospital for a disturbance. They were advised that the Complainant had locked himself in a bathroom and was up in the ceiling. SO #1 advised he would also attend SHH.
The police officers advised OPP dispatch that they could see the Complainant in the ceiling. WO #3 and WO #4 reported that they were responding to the hospital. WO #3 requested SHFD be advised and asked to stand by. SO #3 was dispatched to attend the hospital and SO #2 advised dispatch he would also attend the hospital.
WO #4 spoke with a Mobile Crisis Intervention Response Team (MCIRT) officer and asked how long it would take for him to attend SHH. The MCIRT officer advised he was a distance away, and he was told to disregard.
Starting at about 9:41 p.m., WO #3 called an OPP Sergeant. She advised that the Complainant had been at SHH receiving treatment for a non-police-related issue, and he had locked himself in a bathroom, caused damage and climbed to the ceiling area. WO #3 advised that the Complainant possessed a lighter, and that the emergency department had been evacuated.
The dispatcher advised the OPP sergeant that two OPP Emergency Response Team (ERT) members had been dispatched to SHH. WO #3 advised that she had the SHFD on standby, and that toxicology reports on the Complainant indicated the presence of cocaine in his blood.
The dispatcher spoke with an OPP inspector, briefed him and asked if the incident would require Critical Incident Command (CIC). The dispatcher advised the OPP inspector that OPP officers were speaking with the Complainant, but no attempt had been made to apprehend him. The dispatcher advised that a third ERT officer [known to be SO #2] had been dispatched to SHH.
The OPP inspector advised that the incident did not meet the definition of a barricaded individual, and the CIC was not required. The OPP inspector indicated the ERT could remove the Complainant from the ceiling.
The dispatcher advised that the OPP inspector would not be attending, and that police officers on scene could formulate a plan to remove the Complainant from the ceiling.
The dispatcher advised that SHH was closed for patients and requested other area hospitals be notified of the closure.
WO #1 advised that the Complainant was in custody. The time was confirmed as 12:36:54 a.m.
Materials Obtained from Police ServiceUpon request, the SIU obtained the following records from the OPP between September 20, 2023, and November 14, 2023:
- Occurrence Summary;
- General Occurrence;
- Memo Book Notes – WO #3;
- Memo Book Notes – WO #4;
- Memo Book Notes – WO #2;
- Memo Book Notes – WO #1;
- BWC footage – SO #3;
- BWC footage – SO #2;
- BWC footage – SO #1;
- Communications recordings; and
- Photographs of scene.
Materials Obtained from Other SourcesThe SIU obtained the following records from the following other sources between September 25, 2023, and October 13, 2023:
- Medical records from Alexandra Marine and General Hospital; and
- Medical records from SHH.
In the evening of September 15, 2023, the Complainant found himself in the Emergency Department of the SHH, Exeter. He had been taken there in ambulance after ingesting cocaine and acting strangely in the parking lot of an A & W restaurant. Paranoid and losing touch with reality, the Complainant attempted to defecate in a refuse bin at the hospital before being directed to the bathroom. Once in the bathroom, the Complainant climbed into the space between the roof and ceiling and clung to some ductwork. Hospital staff heard what they believed to be property being destroyed in the bathroom and called the OPP. The time was about 8:45 p.m.
WO #1 was the first to arrive on scene, joined shortly by WO #2. They entered a room adjacent the bathroom and noticed that ceiling tiles had been knocked down. The Complainant was straddling a duct. To no avail, the officers spoke with the Complainant attempting to encourage him to come down. The Complainant was delusional. He was convinced the officers were not, in fact, officers and that members of his family had been murdered even after they had been placed in touch with the Complainant over speakerphone. When concerns started to grow about the Complainant’s access to gas and electrical lines, firefighters and additional officers, including SO #1, SO #2 and SO #3 of ERT, were summoned to the scene.
The ERT officers took over negotiations with the Complainant but they too were stymied. The Complainant refused all entreaties to come down. Instead, he attempted to light some insulation on fire with a lighter and had set off the sprinkler system, which caused the shutdown of the ED.
At about 12:30 a.m., it was decided to take the Complainant into custody for the property destruction and under the provisions of the Mental Health Act. With the use of ladders, the ERT officers climbed up towards the Complainant and engaged him physically. Several punches were directed at the Complainant’s hands and arms by SO #2. The Complainant was forced off a duct and fell onto the floor below.
Following his arrest, the Complainant was diagnosed with three rib fractures.
Section 25(1), Criminal Code -- Protection of Persons Acting Under Authority
(a) as a private person,(b) as a peace officer or public officer,(c) in aid of a peace officer or public officer, or(d) by virtue of his office,
Section 17, Mental Health Act -- Action by Police Officer
(a) has threatened or attempted or is threatening or attempting to cause bodily harm to himself or herself;(b) has behaved or is behaving violently towards another person or has caused or is causing another person to fear bodily harm from him or her; or(c) has shown or is showing a lack of competence to care for himself or herself,
(d) serious bodily harm to the person;(e) serious bodily harm to another person; or(f) serious physical impairment of the person,
Analysis and Director's Decision
Pursuant to section 25(1) of the Criminal Code, police officers are immune from criminal liability for force used in the course of their duties provided such force was reasonably necessary in the execution of an act that they were required or authorized to do by law.
By the time the ERT officers made physical contact with the Complainant, he was clearly subject to arrest under section 17 of the Mental Health Act and for the offence of ‘mischief’ under the Criminal Code. The Complainant’s behaviour had given the officers cause to believe that he had purposefully damaged property, and that he was of unsound mind and a threat to himself and others.
I am also satisfied that the force used in aid of the Complainant’s arrest was legally justified. This came after an hours’ long police effort to have him voluntarily lower himself from the ceiling. It also came when it had become clear that the Complainant’s behaviour was now threatening his own well-being and the health and safety of others – the ED had been forced to shut down and the Complainant had attempted to light insulation on fire. The force appears to have consisted in the main in the officers pulling the Complainant off a duct. Several punches were delivered. These were aimed at the Complainant’s hands and arms, which he was using to hold the duct and resist the officers’ efforts. In its totality, I am satisfied that this quantum of force was commensurate with the exigencies of the moment. It should be noted that the officers had been mindful of avoiding injury to the Complainant by having mattresses placed on the floor.
It remains unclear when and how the Complainant was injured. There is evidence to suggest his rib fractures likely occurred as he initially scaled into the ceiling. Be that as it may, as I am unable to reasonably conclude that any of the ERT officers comported themselves other than within the limits of the criminal law, there is no basis for proceeding with charges in this case. The file is closed.
Date: January 12, 2024
Electronically approved by
Special Investigations Unit
- 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]
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.