Director's Report Details

The Special Investigations Unit is a civilian law enforcement agency that investigates incidents involving police officers where there has been death, serious injury or allegations of sexual assault. The Unit’s jurisdiction covers more than 50 municipal, regional and provincial police services across Ontario.

Under the Police Services Act, the Director of the SIU must determine based on the evidence gathered in an investigation whether an officer has committed a criminal offence in connection with the incident under investigation. If, after an investigation, there are reasonable grounds to believe that an offence was committed, the Director has the authority to lay a criminal charge against the officer. Alternatively, in all cases where no reasonable grounds exist, the Director does not lay criminal charges but files a report with the Attorney General communicating the results of an investigation.

Freedom of Information and Protection of Personal Privacy Act (“FIPPA”)

Pursuant to section 14 of FIPPA (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 whose release 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 of FIPPA (i.e., personal privacy), protected personal information is not included in this document. This information may include, but is not limited to, the following:

• subject officer name(s)
• witness officer name(s)
• civilian witness name(s)
• 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 (“PHIPA”)

Pursuant to PHIPA, any information related to the personal health of identifiable individuals is not included.

Other proceedings, processes, and investigations

Information may have also 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.

The Unit’s investigative jurisdiction is limited to those incidents where there is a serious injury (including sexual assault allegations) or death in cases involving the police.

“Serious injuries” shall include those that are likely to interfere with the health or comfort of the victim and are more than merely transient or trifling in nature and will include serious injury resulting from sexual assault. “Serious Injury” shall initially be presumed when the victim is admitted to hospital, suffers a fracture to a limb, rib or vertebrae or to the skull, suffers burns to a major portion of the body or loses any portion of the body or suffers loss of vision or hearing, or alleges sexual assault. Where a prolonged delay is likely before the seriousness of the injury can be assessed, the Unit should be notified so that it can monitor the situation and decide on the extent of its involvement.

This report relates to the SIU’s investigation into the death of a 45-year-old man following contact with police on August 9, 2017.

Notification of the SIU

At approximately 11:25 a.m. on August 11, 2017, the Woodstock Police Service (WPS) notified the SIU of the death of the Complainant, a man that the WPS had been trying to locate.

On August 9, 2017, Elgin County Ontario Provincial Police (OPP) sent a Canadian Police Information Centre (CPIC) message to WPS requesting WPS locate the Complainant. The Subject Officer (SO) went to the Complainant’s residence but the Complainant was not at home.

At 8:14 p.m., on that same date, the SO called the Complainant on his cellular telephone and advised the Complainant that the OPP wanted to arrest him for breaching his probation order. The Complainant had allegedly breached the conditions of his probation when he communicated with his wife. The Complainant told the SO that he would meet the police officers in 45 minutes at his home. The police officers checked the Complainant’s residence again, but he was still not at home. WPS then sent the OPP a CPIC message advising them of the action they had taken.

On August 10, 2017, the OPP sent another CPIC message to the WPS advising that the OPP had a warrant to arrest the Complainant. The WPS made several attempts to locate the Complainant at his home but the other tenants had not seen him.

On August 11, 2017, at 7:33 a.m., staff at the Woodstock General Hospital (WGH) contacted WPS to report someone sleeping in a vehicle in the parking lot. The occupant of the vehicle [now known to be the Complainant] was deceased. The closed-circuit television (CCTV) from the hospital revealed that the Complainant’s vehicle had been in the parking lot from 9:31 p.m. on August 9, 2017.

The Team

Number of SIU Investigators assigned: 3

Number of SIU Forensic Investigators assigned: 1

The forensic investigator attended and photographed both the scene in the hospital parking lot as well as the residence of the Complainant. CCTV footage was located and seized.

Complainant:

45-year-old male, deceased

Civilian Witnesses

CW #1 Interviewed

CW #2 Interviewed

CW #3 Interviewed

CW #4 Interviewed

CW #5 Interviewed

CW #6 Not Interviewed, next of kin

CW #7 Interviewed

Witness Officers

WO #1 Notes reviewed, interview deemed not necessary

WO #2 Notes reviewed, interview deemed not necessary

WO #3 Interviewed, notes received and reviewed

WO #4 Interviewed, notes received and reviewed

Subject Officers

SO #1 Declined interview and to provide notes, as is the subject officer’s legal right

At approximately 3:18 p.m. on August 9, 2017, the Elgin County OPP contacted the WPS and requested they locate and arrest the Complainant, who was wanted for breaching the conditions of his probation order, by contacting an ex-girlfriend.

As a result, at approximately 8:04 p.m., the SO and Witness Officer (WO) #4 went to the Complainant’s residence in the City of Woodstock, but he was not at home. Moments later, the SO called the Complainant on his cellular telephone while WO #4 listened in on the conversation. The SO explained to the Complainant that he was wanted by the OPP and asked the Complainant to either meet the police officers at his home or at the police station. The Complainant said he would surrender himself to the police in about 45 minutes. The police officers did not hear from the Complainant again.

At approximately 6:46 p.m. on August 10, 2017, the Elgin County OPP advised the WPS that a warrant had been issued for the Complainant’s arrest for the offence of breach of probation contrary to s.733.1 of the Criminal Code. The SO and WO #4 returned to the Complainant’s residence, but he was still not there. The police officers then searched for the Complainant and his motor vehicle.

At approximately 7:29 a.m. on August 11, 2017, a security guard at WGH was alerted to a man sleeping in his vehicle in the parking lot. The security guard went to the parking lot and found the Complainant dead in his vehicle and police were contacted to attend.

Cause of Death

Death was pronounced by the coroner at 7:40 a.m. on Friday, August 11, 2017. The coroner advised the police at that time that there was no anatomical cause of death.

The post-mortem examination was conducted on August 12, 2017. The post-mortem report concluded that the immediate cause of death of the Complainant was “Quetiapine-clonazepam toxicity.”

Under Comment/Opinion, the following is noted:

There was no anatomical cause of death.

Postmortem toxicologic analysis determined that there was a fatal level of quetiapine in the femoral blood. The CFS report stated that the fatal concentration for this medication can range from 7 to 18 mg/L. Although the level of clonazepam was within the therapeutic range, the findings at the scene suggested that clonazepam could also have contributed to the cause of death.

The Scene

The scene was located in the south parking lot at WGH in the City of Woodstock, Ontario. The parking lot was for the Reynolds Wing of WGH and had controlled access. The parking lot was monitored by CCTV. The SIU investigators retrieved the CCTV recordings.

The Complainant’s vehicle was parked on the east side of the parking lot with four other vehicles parked from north to south. The Complainant’s vehicle was reversed into the parking spot and facing a westerly direction. The Complainant’s body had been removed from the vehicle prior to the arrival of the SIU. The interior of the Complainant’s vehicle had papers, coffee cups, cigarette packs, and clothing. Notably, there were three Pharmasave prescription pill bottle tops found on the front passenger side floor of the vehicle, but no bottles were found. There were several prescription receipts for Quetiapine, Clonazepam, and Escitalopram.

Physical Evidence

SIU Forensic Investigators attended the WPS where a sealed evidence bag was received from police containing a Samsung cellular telephone, four prescription pill bottles, and a partially empty bottle of Forty Creek Whisky; the prescriptions were for Quetiapine, Clonazepam, and Bupropion.

Forensic Evidence

Biological samples obtained from the Complainant during the post-mortem examination were submitted to the Centre of Forensic Sciences (CFS) for analysis. A toxicology report provided by the CFS revealed that the femoral blood of the Complainant contained a fatal level of Quetiapine and a level of Clonazepam within the therapeutic range.

Expert Evidence

The post-mortem report was dated November 30, 2017, and was received by the SIU on January 16, 2018. It indicated that the body showed no signs of trauma and there was no anatomical cause of death. The cause of death was determined to be “Quetiapine-Clonazepam toxicity”.

Video/Audio/Photographic Evidence

CCTV WGH

The SIU investigators retrieved CCTV recordings from the hospital parking lot for the dates of August 9, 2017, August 10, 2017 and August 11, 2017.

CCTV 109, 117 and 176

On August 9, 2017, at 8:09 a.m., the Complainant is seen leaving the hospital and walking to his vehicle. The Complainant’s vehicle was parked in the Athlone parking lot. After 24 minutes, he drove away.

CCTV 178-02

On August 9, 2017, at 9:31 p.m., the Complainant is seen driving his vehicle back into the Athlone parking lot through the security gate.

Athlone Avenue Entrance WGH Parking Lot CCTV

On August 9, 2017, at 9:31 p.m., the Complainant’s motor vehicle is seen entering the parking lot and reversing into a parking spot. The lights on the vehicle were turned off. The vehicle did not move from the time it was parked until it was discovered on August 11, 2017. Prior to 7:18 a.m. on August 11, 2017, three vehicles are seen to enter the parking lot and park. At 7:28 a.m., a security guard is seen to exit the hospital and approach the Complainant’s vehicle on the passenger side. He is seen to walk to the driver’s door and look in. He then opens the driver’s door and leans into the vehicle.

At 7:31 a.m., two hospital staff approach the vehicle. At 7:32 a.m., another security guard arrives; at 7:39 a.m., EMS arrives; at 7:42 a.m., the fire department arrives, and at 7:44 a.m., two WPS vehicles arrive.

Communications Recordings

WPS Communication Recordings

The WPS provided four communication recordings to the SIU. The time stamps were one hour behind E.S.T.

Vital Signs Absent (VSA) Call

At about 6:31 a.m. on August 11, 2017, WPS dispatch received a call from a security guard at the WGH. The caller said he got a report of a person sleeping in their vehicle and the person had also been noticed the day before. A WGH staff member had seen the Complainant in the vehicle the previous night when she left work and when she returned to work on August 11, 2017, she noticed the Complainant had not moved. She contacted security.

A security guard opened the Complainant’s vehicle door and shook the Complainant, but he did not wake up. The Complainant was deceased. The vehicle was parked in the Athlone parking lot.

Vital Signs Absent (VSA) – Dispatch Calls

At 6:34 a.m., the WPS contacted EMS requesting they attend the hospital for a male with VSA. At 6:35 a.m., the Woodstock Fire Department (WFD) was also dispatched.

At 6:36 a.m., dispatch called one of the units to confirm the vehicle was registered to the Complainant. The Complainant had previous MHA incidents and a previous suicide attempt.

At 6:37 a.m., a unit mentioned that they had been trying to locate the Complainant for the past couple of nights for a domestic breach of probation warrant from Elgin County OPP. At 6:42 a.m., dispatch confirmed the Complainant had been pronounced dead at 7:33 a.m.

Materials obtained from Police Service

Upon request, the SIU obtained and reviewed the following materials and documents from the WPS

• Arrest Warrant for the Complainant
• CPIC (Canadian Police Information Centre) Messages
• Police Transmissions and VSA Call communications recordings
• Event Searches (x3)
• List of Involved Officers and Roles
• List of Witnesses
• Scene Photos
• Notes of WO #s 1-4
• Occurrence (Person) Report for the Complainant
• Occurrence Summaries (x4)
• Procedure: Arrest and Prisoner Care and Control
• Procedure: Emotionally Disturbed, Mental Illness, Developmental Disability
• Supplementary Occurrence Report, and
• WPS Written Witness Statements for five undesignated witnesses

The SIU obtained and reviewed the following materials and documents from other sources:

• Medical Records of the Complainant from recent prior discharge
• Post Mortem Report of the Complainant
• Toxicology Report from Centre of Forensic Sciences
• Incident Reports authored by Hospital Security Officers, and
• Screen Shot of messages on Complainant’s Facebook page

Sections 219, 220 and 221, Criminal Code - Criminal negligence Causing Death or Bodily Harm

219 (1)Every one is criminally negligent who

1. in doing anything, or
2. 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

1. 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
2. in any other case, to imprisonment for life

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.

Section 733.1, Criminal Code – Failure to Comply with Probation Order

733.1 (1) An offender who is bound by a probation order and who, without reasonable excuse, fails or refuses to comply with that order is guilty of

1. an indictable offence and is liable to imprisonment for a term of not more than four years; or
2. an offence punishable on summary conviction and is liable to imprisonment for a term of not more than 18 months, or to a fine of not more than $5000, or to both

On August 9, 2017, the Elgin County Ontario Provincial Police (OPP) Detachment sent a message to the Woodstock Police Service (WPS) requesting assistance in attempting to locate and arrest the Complainant on charges of breaching the conditions of his court ordered releases by making contact with an ex-girlfriend for whom he was on court ordered conditions to have no contact. The request for assistance was sent at 3:18:33 p.m. As a result, the SO and WO #4 attended the residence of the Complainant at approximately 8:04 p.m. and knocked at his door, but there was no response. The police officers left the house and later called the Complainant on his cell phone and spoke with him.

The SO advised the Complainant that there was a warrant for his arrest for breaching the terms of his probation and that the Complainant could either return to his residence, and the officers would transport him to the station, or he could attend at the police station. The Complainant advised the SO that he needed 45 minutes and that he would then either attend the police station or contact the WPS by phone.

Further information obtained by the SIU revealed that the Complainant had attempted to take his own life less than two weeks before, following which he had been admitted to hospital.

On August 9, 2017, at 8:03 a.m., the Complainant had signed himself out of hospital against medical advice.

The Complainant received the telephone call advising him of the outstanding charges for his arrest shortly after 8:04 p.m. that same evening.

The CCTV recordings from the hospital revealed that the Complainant had left the hospital at 8:09 a.m. on the morning of August 9 and was seen to walk to his vehicle, which was parked in the Athlone parking lot, and drive away shortly thereafter.

At 9:31 p.m. on August 9[1], the Complainant was seen on the CCTV recordings returning to the Athlone parking lot, where he was seen to reverse his vehicle into a parking spot and park. The motor vehicle was seen by hospital staff in the early morning hours of August 10, then again later in the day, and again in the same location on August 11. On each occasion, the witnesses saw someone inside the vehicle with his head slumped forward and assumed that he was texting. In the early morning hours of August 11, 2017, the motor vehicle and occupant were again seen with the occupant appearing to be slumped forward, and hospital security were notified and attended the parking lot where they located the Complainant’s motor vehicle with the Complainant inside, apparently deceased. The coroner arrived shortly thereafter, and at 7:33 a.m., the Complainant was pronounced dead. Seized from the front seat of the Complainant’s motor vehicle were four prescription pill bottles for Quetiapine, Clonazepam, and Bupropion, along with a partially empty bottle of Forty Creek Whisky and his cell phone.

The post-mortem and toxicology reports support the initial opinion of a variety of individuals to the effect that the complainant took his own life by overdosing. This conclusion seems quite evident from the witnesses observations of the complainant in the hospital parking lot; from the presence of the prescription bottles and whisky in the vehicle; the Complainant’s previous suicide attempt, which he had recorded and posted on Facebook of himself taking large amounts of prescription pills and alcohol, as well as the CCTV footage which confirmed that the Complainant drove into the parking lot on August 9, 2017 at 9:31 p.m. and that no other person either approached, entered or exited the vehicle between when it was first parked and when the Complainant’s body was discovered on August 11, 2017 at 7:29 a.m.

The post-mortem examination confirmed that there was no anatomical cause of death (or physical trauma to his body) and that the Complainant took his own life by overdosing on prescription drugs, specifically Quetiapine and Clonazepam. It is also clear that it was the Complainant’s intent to end his life as evidenced both by his previous attempt on July 28^th, 2017, and by his subsequent admissions and utterances both to civilian witnesses, and through Facebook posts and texts, that he intended to again make an attempt on his life even before he received the telephone call from the SO advising him of the outstanding charges that he faced.

On all of this evidence, it is evident that the Complainant, due to a break down in his relationship and his poor mental state, had decided to take his own life and that he did so thereafter without any interaction with police, other than the telephone notification that he received from the SO on August 9, 2017, shortly after 8:04 p.m. It is further not subject to dispute that the Complainant had already voiced his intention to take his own life to a number of persons, and by way of electronic media, prior to his ever having been informed of the new charges that he would be facing and he had already put his suicide plan into effect some two weeks prior to ever having heard from the SO. As such, there is no doubt whatsoever that the Complainant took his own life by his own hand without any involvement by police.

In contacting the Complainant by phone, after the unsuccessful attempt to reach the Complainant at his home, the SO was acting in accordance with his duties and was giving the Complainant the opportunity to turn himself in rather than having the police go out and arrest him. This offer was within the discretion of the SO and would have given the Complainant the opportunity of turning himself in without a public arrest and handcuffing in the community.

On all of the evidence, it appears unlikely that the call from the SO was the deciding factor in the Complainant taking his own life, as he had apparently already determined to do so long before the call was received. However, even if the call about the outstanding charges was the ‘straw that broke the camel’s back’, I cannot find that the SO’s telephone call, which was a courteous use of his discretion, was inappropriate in the circumstances. Clearly, police are required to notify persons with outstanding warrants of the existence of such warrants and allow them to voluntarily turn themselves in[2] and I can find no fault with the SO in having done so.

The only charge to be considered in these circumstances would be one of criminal negligence (s.219) thereby causing death contrary to s.220 of the Criminal Code, which has the following essential elements:

Definition of criminal negligence s.219:

219. (1) Everyone is criminally negligent who

1. In doing anything, or
2. 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.

The Ontario Court of Appeal has further defined the essential elements of criminal negligence in R v Sharp (1984), 12 CCC (3d) 428 (Ont. C.A.), as follows:

… the accused may be convicted on proof of driving amounting to a marked and substantial departure from the standard of a reasonable driver in circumstances where the accused either recognized and ran an obvious and serious risk to the lives and safety of others or, alternatively, gave no thought to that risk.

While Sharp relates specifically to an offence involving driving, the courts have made it clear that the same principles apply to other behaviour as well.

On this record, there is no evidence that the SO’s decision to contact the Complainant and notify him about his pending charges, or the manner in which the conversation progressed, amounted to “a marked and substantial departure” from the standard of a reasonable police officer in the circumstances, or that it was in any way foreseeable that the Complainant might take his own life as a consequence, especially in light of the fact that the Complainant was already facing far more serious charges than those with which he was now to be charged.

Furthermore, as the Complainant took his own life without the involvement of the SO in any way, there is no causal connection between the actions of the SO and the death of the Complainant and there is certainly no evidence that the SO showed a wanton and reckless disregard for the life of the Complainant in his dealing with him.

It is clear on these facts that the Complainant had already formulated a plan to end his life well before he received the call from the SO. However, even if the phone call advising him of the outstanding warrant was the deciding factor in the Complainant’s decision, there is certainly nothing in the facts known to the SO at the time that suggests that the Complainant’s drastic action would be foreseeable and thus there would be no onus on the SO to take any additional steps to check on the Complainant, other than those he had already taken.

In conclusion, it is clear on all of the evidence that there was no criminal wrongdoing on the part of the SO in notifying the Complainant of his pending charges and, on this record, the evidence does not satisfy me on reasonable grounds that any criminal offence was committed and thus no charges will issue.

Date: June 15, 2018

Original signed by

Tony Loparco
Director
Special Investigations Unit

Endnotes

• 1) [1] Approximately one hour and 15 minutes after talking to the SO on his cellphone. [Back to text]
• 2) [2] There are obvious exceptions to this, for instance, where notification might create danger for someone or where the person notified is a known flight risk, etc. [Back to text]