SIU Director’s Report - Case # 24-OCI-246
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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.
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 Personal 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 serious injury of a 65-year-old man (the “Complainant”).
The Investigation
Notification of the SIU[1]
On June 11, 2024, at 1:24 a.m., the London Police Service (LPS) notified the SIU of a person in the custody of the LPS who was hospitalized.
According to the LPS, they received a 911 call on June 10, 2024, at 2:07 p.m., regarding a man unconscious inside a vehicle. At 2:15 p.m., LPS officers arrived on scene and began to interact with the man – the Complainant. The Complainant appeared to be impaired by drugs. In the course of his arrest, the Complainant reported he had ingested fentanyl. The Complainant was transported to the LPS custody facility and paraded in front of the supervising sergeant. He was then placed in a “phone room” to speak to his lawyer. At no time was the Complainant lodged in a cell. A drug recognition expert (DRE) officer was summoned to assess the Complainant. At some point after the Complainant was placed in the phone room, the arresting officer searched her police vehicle and located a small baggy containing suspected fentanyl. Following an officer shift change, the incoming custody area sergeant summoned emergency medical services for the Complainant, who was transported to London Health Science Centre (LHSC) by paramedics. The Complainant became vital signs absent twice while at LHSC, but he was revived by hospital staff. He was then admitted and placed on a naloxone intravenous drip. At the time of notification, the Complainant was reportedly in stable condition in the Intensive Care Unit.
The Team
Date and time team dispatched: 2024/06/11 at 10:35 a.m.
Date and time SIU arrived on scene: 2024/06/11 at 10:49 a.m.
Number of SIU Investigators assigned: 3
Number of SIU Forensic Investigators assigned: 1
Affected Person (aka “Complainant”):
65-year-old male; interviewed; medical records obtained and reviewed
The Complainant was interviewed on June 12, 2024.
Evidence
The Scene
The events in question transpired in various locales inside the LPS police station located at 601 Dundas Street, London.
On arrival into the sally port of the LPS station, persons in custody enter the booking hall and appear before a supervisor. The person in custody then enters the custody area.
There are two interview rooms in the custody area that allow for individuals to meet with persons in custody, separated by a glass partition. There is also a telephone in each of the interview rooms that allow for prisoners to receive telephone calls. There is a small wooden bench in each of the interview rooms.
Down a short hallway from the interview rooms is a breath sample room.
All of the in-custody areas are video recorded.
Video/Audio/Photographic Evidence[2]
LPS Communications Recordings
On June 10, 2024, at 2:06 p.m., a person at 1315 Commissioners Road East called 911 and requested an ambulance. They reported the driver of a vehicle in the parking lot was unconscious behind the wheel. The caller indicated they had knocked on a window and the man inside the vehicle roused somewhat, but not very much. The caller said the man was alone in the vehicle.
LPS Custody Area Surveillance Recordings
On June 10, 2024, at 2:38 p.m., the Complainant arrived in the police station sally port in the rear of LPS Officer #1’s vehicle. He was not handcuffed. He exited the vehicle and slowly, in a very laboured fashion, walked over to a wall to be searched. Once searched, the Complainant was escorted into the police station to be paraded before the Headquarters Detention Unit (HDU) sergeant.
At 3:04 p.m., the Complainant was escorted into the fingerprinting room to be searched again. While removing his sweater, something fell onto the floor and the cadet conducting the search picked up the item and took it out of the room. The cadet and LPS Officer #1 entered the room and LPS Officer #1 showed the item to the Complainant, who shrugged his shoulders and appeared to deny knowledge of the item. LPS Officer #1 exited the fingerprinting room, while the cadet completed the search of the Complainant. He was then lodged in an interview room.
While seated on a bench in the interview room, the Complainant had great difficulty sitting upright and staying awake. He slumped forward to the point his chest was resting on his thighs, almost falling onto the floor. On multiple occasions a cadet entered the room to rouse the Complainant.
At 3:32 p.m., a cadet opened the interview room door and pointed to the telephone on the wall. The Complainant picked up the telephone, but he very quickly displayed difficulty sitting upright and holding the telephone to his ear.
At 3:35 p.m., the telephone dropped from his hand as the Complainant crumpled forward and slowly collapsed onto the floor. The interview room door opened, and the Complainant was woken up again, and the phone was placed back into its cradle.
At 3:50 p.m., the Complainant arose and stood facing the corner of the room, with his back towards the surveillance camera. He appeared to be manipulating something at the front of his pants and was likely urinating in the corner of the room. He could be seen shaking his hand afterward, as though trying to cast off liquid. He returned to sitting on the bench.
At 4:04 p.m., the Complainant collapsed onto his hands and knees on the floor of the interview room. He then fell forward and appeared to strike his head on the floor. He remained in that position for approximately one minute, until a male cadet entered the room and woke him. The Complainant returned to sitting on the bench. As soon as the cadet exited the room, the Complainant again slumped forward and collapsed onto the floor. LPS Officer #1 entered the room and roused him, and he sat on the bench again.
At 4:11 p.m., the DRE officer, LPS Officer #2, and LPS Officer #1 took the Complainant to the breath sample room. Once in the breath sample room, the Complainant started to lean forward. He was asked to state his name three times before he did so. He was able to spell his name when asked to do so. LPS Officer #2 asked the Complainant to sit in a chair and explained he was a DRE officer. LPS Officer #2 asked LPS Officer #1 to report the incident to him, while on camera.
LPS Officer #1 explained police were dispatched to a report of a man slumped over inside a vehicle. She stated she was the first officer to arrive, and she observed the Complainant in the driver’s side of a vehicle, slumped over with his head in his lap. He was alone inside the vehicle. She reported she also observed a piece of foil with burnt residue on it. LPS Officer #1 reported she opened the vehicle door and that caused the Complainant to rouse. She noted that his pupils were “pinpointed”. The Complainant could not say where he was or why he was there. His speech was slow, and he appeared to be sluggish and drowsy. The Complainant exited the vehicle when she asked him to do so, and he walked over to her police vehicle. She then arrested him for impaired operation of a vehicle.
As LPS Officer #1 made her report to LPS Officer #2, the Complainant was slumped forward in the chair. LPS Officer #2 woke the Complainant and asked him if he heard what LPS Officer #1 said. The Complainant said he had. When asked, the Complainant also indicated he understood what she reported. LPS Officer #2 commented it was extremely difficult for the Complainant to stay awake, but he needed the Complainant to try to do so.
At 4:16 p.m., LPS Officer #2 asked the Complainant if he had spoken to a lawyer, and the Complainant responded he had not done so. LPS Officer #2 asked if he wished to speak to a lawyer, and the Complainant responded he did. LPS Officer #2 then asked, “You didn’t have a conversation with a lawyer in that room?” and the Complainant responded, “No.”
LPS Officer #2 went to the hallway to advise LPS Officer #1 that the Complainant denied speaking to a lawyer. LPS Officer #1 responded, although her response was difficult to make out, and LPS Officer #2 asked the Complainant if he had spoken to a lawyer. The Complainant answered, “No.” LPS Officer #1 entered the room and stated the Complainant had indeed spoken to his lawyer. LPS Officer #2 stated they would place the Complainant back into the interview room and get the lawyer on the telephone again. The Complainant was placed back into the interview room.
At 4:20 p.m., LPS Officer #2 entered the interview room and pointed to the telephone on the wall. The Complainant picked up the telephone but within one minute he started to slump forward again, and again the telephone dropped from his hand.
At 4:23 p.m., LPS Officer #2 entered the interview room and indicated for the Complainant to come with him.
LPS Officer #2 started to escort the Complainant back to the breath sample room, but they returned to the interview room and the Complainant was once again secured in the room.
At 4:24 p.m., after the Complainant was placed back into the interview room, LPS Officer #2 entered the room, shook the Complainant, and pointed to the telephone. The Complainant picked up the telephone and LPS Officer #2 left the room. Again the Complainant started to slump forward, and the mouthpiece of the telephone was at his forehead. He then slumped further forward, and the telephone once again fell from his hand.
At 4:27 p.m., the Complainant was removed from the interview room, and placed into an interview room next to the room he had occupied. A female cadet handed him the telephone and she exited the room. The Complainant again dropped the telephone.
At 4:29 p.m., LPS Officer #2 escorted the Complainant to the breath sample room. The Complainant was asked to sit and LPS Officer #2 confirmed the Complainant had spoken to his lawyer, which the Complainant acknowledged. The Complainant continued to exhibit great difficulty remaining awake. LPS Officer #2 said he would continue to wake the Complainant as often as needed in order to work through the examination. LPS Officer #2 read the Complainant a primary caution and he asked the Complainant if he understood. The Complainant appeared to have fallen asleep again. LPS Officer #2 continued to read the examination demand to him. LPS Officer #2 then woke the Complainant and asked him if he understood what was read to him. The Complainant responded, “Yes.” The Complainant, when asked, also responded there was no reason he could not perform the examination. He then slumped forward and appeared to fall asleep again.
LPS Officer #2 asked the Complainant when his last drink was. The Complainant responded it was a half-hour prior. LPS Officer #2 repeatedly asked the Complainant what time he thought it was, but the Complainant did not respond. LPS Officer #2 stated the Complainant was making no effort to stay awake, so he might need to read the caution regarding refusing the examination. He continued to ask the Complainant what time he thought it was and the Complainant eventually responded he believed it was four o’clock in the afternoon.
The Complainant stated he had last slept the day before, but he did not sleep very long. He denied he was sick or injured and denied taking any medication or drugs. He was slumped over while responding to the questions put to him.
LPS Officer #2 used his pen, and he asked the Complainant to follow the movement of his pen with his eyes. While LPS Officer #2 moved the pen back and forth, the Complainant slowly slumped forward and collapsed onto himself. LPS Officer #2 asked the Complainant how they were going to address his falling asleep. The Complainant responded he was starting to feel more awake, but he then fell asleep again. LPS Officer #2 took hold of the Complainant’s shoulder to stop him from falling forward.
At 4:42 p.m., LPS Officer #2 stated he was going to take the Complainant back to the interview room.
At 4:43 p.m., the Complainant was placed back into the second interview room. He sat on the bench in the room and immediately started to slump forward. He fell onto the floor but was able to stand up again. A female cadet opened the door and motioned for the Complainant to sit on the floor.
The Complainant rolled onto his knees, pulled up his pants and sat on the bench. He then started to slump forward again.
At 4:48 p.m., the room opened and a sergeant with short grey hair entered the room. He appeared to speak to the Complainant, who continued to have a challenging time sitting upright. The sergeant then exited the room, and the Complainant again collapsed onto himself.
At 4:50:31 p.m., while the Complainant was slumped over, he vomited onto the floor of the interview room. LPS Officer #2 and LPS Officer #1, the sergeant and a female cadet were standing in the hallway outside the interview room having a conversation.
At 4:51 p.m., a female cadet standing outside the door tapped on the door window twice. LPS Officer #1 then entered the room and grabbed onto the Complainant’s sweater and lifted him up. LPS Officer #2 entered the room and he and LPS Officer #1 held the Complainant upright. The Complainant went down onto one knee and then sat on the floor. He displayed ongoing difficulty in sitting up, and LPS Officer #1 shook him to keep him awake. The Complainant stood up but was unsteady on his feet and he soon sat on the bench.
At 4:57 p.m., a female sergeant arrived in the hallway, and she looked into the interview room.
At 5:02 p.m., a bald male police officer entered the hallway and stood at the door of the interview room.
At 5:05 p.m., paramedics arrived at the interview room. At 5:08 p.m., they escorted the Complainant from the interview room. He was able to walk on his own to the stretcher in the hallway.
The Complainant was transported from the police station.
Materials Obtained from Police Service
Upon request, the SIU received the following materials from the LPS between June 14, 2024, and June 18, 2024:
- HDU video recordings;
- 911 telephone communications;
- Dispatch audio – initial complaint regarding unconscious motorist;
- Dispatch audio – request for medical response in cells area;
- Arrest Report;
- Computer-aided Dispatch Report;
- General Occurrence Report;
- Detention Record;
- Detention Unit – Timeline Report;
- General Order – Persons in Custody Care and Control;
- General Order – Searches of Person in Custody;
- General Order – Medical Care and Accommodation of Persons in Custody; and
- Person Hardcopy Report – the Complainant.
Materials Obtained from Other Sources
The SIU obtained the following records from other sources on July 19, 2024:
• The Complainant’s medical records from the LHSC.
Incident Narrative
The evidence collected by the SIU, including video footage that largely captured the Complainant’s time in custody, gives rise to the following scenario.
In the afternoon of June 10, 2024, following a call to police about a man – the Complainant – seemingly unconscious in a vehicle parked at 1315 Commissioners Road East, London, LPS Officer #1 arrived on scene and arrested the male for impaired operation of a motor vehicle. The Complainant was confused and lethargic, but managed to walk to the officer’s cruiser.
The Complainant was transported to the station, where his lethargy continued on full display. He repeatedly slumped over while in interview rooms, where he had been placed to contact a lawyer. On those occasions the Complainant managed to hold onto the telephone receiver, he quickly lost power and dropped the phone. The drug recognition officer – LPS Officer #2 – tried unsuccessfully on several occasions to conduct a drug examination; the Complainant kept falling asleep. Paramedics were eventually called to the station and took the Complainant to hospital.
The Complainant was diagnosed with “likely polysubstance overdose”.
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 221, Criminal Code - Criminal Negligence Causing Bodily Harm
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.
221 Every person who by criminal negligence causes bodily harm to another person is guilty of (a) an indictable offence and liable to imprisonment for a term of not more than 10 years; or (b) an offence punishable on summary conviction.
Analysis and Director’s Decision
The Complainant lapsed into acute medical distress in hospital on June 10, 2024, following a stint in the custody of the LPS. 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 LPS officer committed a criminal offence in connection with the Complainant’s medical event.
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 of the Complainant’s custodians, sufficiently serious to attract criminal sanction, that endangered the Complainant’s life or caused his medical event. In my view, there was not.
I am satisfied that the Complainant was lawfully in the custody of police at all material times. On the evidence, it would appear that LPS Officer #1 had grounds to arrest the Complainant for impaired operation of a motor vehicle.
While the care afforded the Complainant during his time in custody is subject to legitimate scrutiny, the evidence falls short of establishing that any officer transgressed the limits of care prescribed by the criminal law. The video footage of the Complainant at the police station depicts a man who could barely keep his eyes open and repeatedly slumped over unable to support himself. Arguably, given his arrest for driving while impaired and what appears to have been evidence available to his custodians of illicit drug use, officers ought to have acted quicker to arrange for medical attention. That said, it bears noting that the Complainant does appear to have been regularly monitored while in custody. Each time he slumped over or fell to the floor, it was not long before a police service member entered the room to rouse him. Nor was the entire length of time from the moment the Complainant arrived at the station to the arrival of paramedics, about two-and-a-half hours, during which period the Complainant was sometimes able to operate on his own power, an egregiously long time in the circumstances. On this record, whether the Complainant’s custodians should have acted quicker than they did to call for an ambulance, their conduct did not amount to a marked departure from a reasonable standard of care, let alone a marked and substantial one.
In the result, there is no basis for proceeding with criminal charges in this case. The file is closed.
Date: September 25, 2024
Electronically approved by
Joseph Martino
Director
Special Investigations Unit
Endnotes
- 1) Unless otherwise specified, 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]
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.