Director's Report Details

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.

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, 204:

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.

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 36-year-old woman (the “Complainant”).

Notification of the SIU[1]

On August 21, 2024, at 1:41 p.m., the Stratford Police Service (SPS) contacted the SIU with the following information.

The Complainant was arrested at 2:00 a.m., August 21, 2024, for attending an address she was not to attend, and found in possession of what was believed to be fentanyl. She was taken to SPS headquarters and lodged in a cell. At about 11:09 a.m., Special Constable #1 notified dispatch they were administering Narcan to the Complainant. Witness Official (WO) #2 was present. Officers administered four doses of Narcan. Paramedics arrived at 11:13 a.m. and were en route to Stratford General Hospital at 11:29 a.m. Fentanyl was found in the Complainant’s bra at the hospital. At 1:15 p.m., WO #1 notified an inspector that the Complainant had been admitted to hospital.

The Team

Date and time team dispatched: 2024/08/21 at 2:07 p.m.

Date and time SIU arrived on scene: 2024/08/23 at 10:11 a.m.

Number of SIU Investigators assigned: 3

Number of SIU Forensic Investigators assigned: 0

Affected Person (aka “Complainant”):

36-year-old female; interviewed; medical records obtained and reviewed

The Complainant was interviewed on August 23, 2024.

Subject Official (SO)

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

Witness Officials

WO #1 Interviewed; notes received and reviewed

WO #2 Interviewed; notes received and reviewed

WO #3 Interviewed; notes received and reviewed

The witness officials were interviewed on September 10, 2024.

The Scene

The events in question transpired in the booking and cell block area of SPS Headquarters, 17 George Street West, Stratford.

Video/Audio/Photographic Evidence[2]

Body-worn Camera (BWC) Footage

Starting at about 2:43:49 a.m., August 21, 2024, WO #3 activates his body camera as he approaches a female, the Complainant, standing next to a picnic table. WO #3 calls to the Complainant by name and tells her she is under arrest for failing to comply with a release order. A bag is visible on the seat of the bench. The Complainant has her hands inside her coat pockets. WO #3 asks the Complainant to step out from behind the bench and place her hands behind her back. He then places handcuffs on her wrists.

Starting at about 2:47:38 a.m., WO #3 picks up a purse, water bottle and a large bag from the picnic table, and begins to walk the Complainant towards his vehicle parked on the street. WO #3 does a search of the outer pockets on the Complainant’s coat and removes a tinfoil package from her right front coat pocket.

Starting at about 2:50:19 a.m., the Complainant is placed in the rear driver’s side seat of the police vehicle. There is no further search of the Complainant’s person.

Starting at about 2:51 a.m., WO #3 goes to the rear of the police vehicle, opens a package and asks the Complainant what the product is: “meth or fentanyl”. The Complainant replies that she thinks it is fentanyl.

In-car Camera (ICC) Footage

Starting at about 2:50:16 a.m., August 21, 2024, the rear driver’s side door of the police vehicle opens and the Complainant with her hands handcuffed behind her back enters the rear secure seat of the vehicle. The Complainant is distraught but appears to be alert and is responding appropriately to questions from WO #3.

Starting at about 3:00:42 a.m., the vehicle enters the well-lit SPS sally port. The Complainant exits the vehicle without assistance and walks away.

Video footage - Booking and Cell Area

Search Room

Starting at about 3:04:42 a.m., the Complainant, dressed in pants, sandals and a hoodie sweater, is shown into the room by WO #3.

Starting at about 3:05:42 a.m., the Complainant removes her sweater, revealing a T-shirt. The Complainant then proceeds to empty her pants pockets onto the table, raises her shirt slightly and can be seen from the rear with her hands inside the front of her shirt appearing to remove items that end up on the table. WO #3 is standing to her rear right at the time and observing.

Starting at about 3:06:13 a.m., the SO enters the room carrying a blue bin. The Complainant’s property is placed in a property bag and her clothes inside the bin as WO #3 has a discussion with the Complainant while the SO looks on.

Starting at about 3:07:48 a.m., the officers leave the Complainant alone in the room.

Starting at about 3:10:01 a.m., the Complainant sits on the floor with her back up against the wall directly under the camera position and pulls her arms inside of her T-shirt so that her hands are not visible.

Starting at about 3:12:34 a.m., the Complainant is moving her hands around her chest, after which she brings her right hand up near her mouth and appears to put her thumb to her lips before returning her hands into her shirt. The Complainant places her face within the collar of her shirt.

Starting at about 3:18:22 a.m., the Complainant removes her right hand from her shirt and a bra strap can be seen under her shirt. She then removes her left hand and sits down on the stool.

Starting at about 3:52:57 a.m., WO #3 and a second male uniform SPS officer enter the room. The Complainant is sitting on the floor in the opposite corner to the camera.

Starting at about 3:56:18 a.m., the second officer opens the door and leaves the room followed by the Complainant and WO #3. There appears to be no debris left in the room visible to the camera.

Hallway Camera

Starting at about 3:56:33 a.m., the Complainant is escorted to the female cell area by WO #3 and a second male SPS officer.

Starting at about 6:34:31 a.m., a uniform SPS sergeant enters the hallway [known to have been WO #2] and then enters the female area and can be heard calling to the Complainant and asking if she needs anything. WO #2 then leaves the hallway.

Starting at about 7:18:37 a.m., WO #2 enters the hallway and goes to the female cells area where he converses with the Complainant before leaving.

Starting at about 7:49:26 a.m., WO #1 enters the hallway and goes to the female cell block where he can be heard speaking to the Complainant before leaving the cell area.

Starting at about 8:41:31 a.m., Special Constable #2 enters the cell block and attends the female area, speaks with the Complainant, and then leaves.

Starting at about 8:44:55 a.m., Special Constable #3 enters the female cell area and leaves moments later; no conversation can be heard.

Starting at about 9:10:58 a.m., Special Constable #3 attends and speaks with the Complainant, and asks if she is all right before leaving.

Starting at about 9:24:06 a.m., Special Constable #2 enters the female cell area and calls to the Complainant from the hall doorway asking if she is okay.

Starting at about 10:03:54 a.m., Special Constable #2 enters the female cell area, and calls to the Complainant asking if she is okay.

Starting at about 11:08 a.m., WO #2 and Special Constable #1 enter the hallway and then go into the female cell area.

Starting at about 11:09:38 a.m., WO #2 and Special Constable #1 exit the female cell area and retrieve the cell keys, before re-entering the cell area.

Starting at about 11:10:55 a.m., Special Constable #1 comes back into the hallway and uses his police radio to request that paramedics attend the cell block.

Cell

Starting at about 3:57:17 a.m., the Complainant is placed in a cell, with a concrete bed, toilet, and barred door, by WO #3.

Starting at about 3:59:00 a.m., the Complainant is given a blanket by WO #3 and a cup of liquid. The Complainant is unsteady on her feet and in some discomfort. She sits on the bench and continually rocks forward, spilling her drink before abruptly sitting up as if she is falling asleep while sitting upright.

Starting at about 4:02:42 a.m., the Complainant sits back on the bench with her back to the rear wall and her feet drawn up under her. She again leans forward, spilling her drink on the bench, before dropping the glass. She suddenly sits up again and picks up the now empty glass. The Complainant is falling asleep or under the influence of something.

Starting at about 4:43:37 a.m., the Complainant has remained motionless sitting bent 90 degrees at the waist. She then begins involuntary movements and sits up partially before returning to the same sleeping position.

Starting at about 5:45:30 a.m., the Complainant sits up with her head leaned forward apparently still asleep, and constantly falls forward, catches herself and repeats.

Starting at about 6:35:50 a.m., WO #2 goes to the cell door and kicks the base of the door; the Complainant awakes and lifts her head. There is very muted sound. He asks the Complainant if she needs anything and if she is good. The Complainant has no meaningful communication with the sergeant. The Complainant then slumps back into the corner and falls asleep as the sergeant leaves.

Starting at about 7:18:42 a.m., WO #2 can be seen opposite the Complainant’s cell and to the left. The Complainant appears to wake up and sits upright, and is asked if she would like some food. The Complainant advises she is not hungry, and the person asks, “Are you coming down?” before leaving.

Starting at about 7:49:34 a.m., WO #1 arrives at the cell and speaks with the Complainant. He asks if she would like to have something to eat, and the Complainant declines. WO #1 appears to look closely into the cell to see the Complainant’s condition before leaving.

Starting at about 8:41:49 a.m., Special Constable #2 comes into the cell block repeatedly calling out the Complainant’s name. When she gets no answer, she goes to the cell and continues talking to the Complainant until she sits up and converses with her.

Starting at about 11:08:28 a.m., WO #2 attends the female cells and attempts to wake the Complainant without success.

Starting at about 11:10:17 a.m., WO #2 enters the cell and shakes the Complainant, who does not wake up. Special Constable #1 enters the cell to assist. A nasal dosage of what is known to have been Narcan is administered to the Complainant by Special Constable #1 followed by a second dosage.

Starting at about 11:18:45 a.m., paramedics attend the cell area and treat the Complainant.

Materials Obtained from Police Service

Upon request, the SIU received the following materials from SPS between August 23, 2024, and September 5, 2024:

• Computer-assisted Dispatch Report;
• General, Supplementary and Arrest Reports;
• Booking and cell block footage;
• BWC footage;
• ICC footage;
• Photographs and reports of scene;
• Policy - Prisoner Care;
• Notes - WO #3;
• Notes - WO #2;
• Notes - WO #1; and
• Prisoner Log Sheet.

Materials Obtained from Other Sources

The SIU obtained the Complainant’s medical records from Stratford General Hospital on August 26, 2024.

The evidence collected by the SIU, including interviews with the Complainant and video footage that largely captured her time in custody, gives rise to the following scenario. As was his legal right, the SO did not agree an interview with the SIU or the release of his notes.

The Complainant was arrested by WO #3 at about 2:45 a.m., August 21, 2024, for contravening a condition of a release order. She had with her a quantity of fentanyl, which was confiscated by the officer. Transported to the police station and lodged in a search room, WO #3 stood by as the Complainant emptied her pockets and removed her top to reveal a T-shirt she was wearing underneath. She reached under her shirt and removed a lighter, change and a driver’s licence. Starting at about 3:10 a.m., while alone in the search room, the Complainant seemingly retrieved something from under her shirt before bringing her right thumb up to her mouth. At about 3:57 a.m., the Complainant was taken from the search room and lodged in a cell. The SO was the officer-in-charge of the station with overall responsibility for the welfare of prisoners through this chain of events.

At about 11:00 a.m., a special constable tasked with monitoring the Complainant found her in medical distress. He alerted WO #2 and returned with him to the cell. The officers attempted but were unable to wake the Complainant. Paramedics were called to the cells and multiple doses of Narcan were administered.

The Complainant was transported to hospital and treated for drug overdose. A container of suspected fentanyl was located in the Complainant’s bra. Toxicology testing established the presence of cocaine, methamphetamine, amphetamine, benzodiazepines and fentanyl in her system.

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.

On August 21, 2024, the SPS contacted the SIU to report that a female they had earlier arrested and taken into custody – the Complainant – had been admitted to hospital. The SIU initiated an investigation naming the SO the subject official. The investigation is now concluded. On my assessment of the evidence, there are no reasonable grounds to believe that the SO committed a criminal offence in connection with the Complainant’s hospitalization.

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 the SO, sufficiently serious to attract criminal sanction, that endangered the Complainant’s life or contributed to her medical crisis. In my view, there was not.

There is evidence to indicate that the Complainant was lawfully in the custody of the police through the series of events culminating in her medical crisis. In apparent violation of a release order, a GPS device had tracked the Complainant to a location where she was prohibited from being present.

With respect to the care afforded the Complainant while in police custody, I am unable to reasonably conclude that her custodians, including the SO, transgressed the limits of care prescribed by the criminal law. There are certainly aspects of the Complainant’s treatment, or lack thereof, that are subject to scrutiny. The searches conducted of the Complainant’s person did not disclose what appears to have been a quantity of fentanyl concealed in her bra. It might well be that a more thorough search conducted by an officer of the same sex, or even a strip search, for which there were probably grounds, would have discovered the drugs and prevented their apparent ingestion by the Complainant while she was being detained in the search room. It would also seem that the Complainant was not subjected to regular 15-minute in-person checks while in custody, or sent to hospital as soon as she should have been pursuant to SPS policy. For example, SPS policy provides that medical treatment be immediately secured for persons known for ingesting illicit substances and who have been arrested in relation to the consumption of such substances. The Complainant met that criteria, and yet was maintained in police custody for hours before paramedics were summoned to the scene. On the other hand, the Complainant was searched on a couple of occasions and a quantity of fentanyl seized. She was also monitored, if not in-person as required in policy, by way of video checks and the occasional in-person visit. Nothing short of continuous monitoring would have ensured the Complainant’s apparent consumption of fentanyl was detected, but there was nothing in the circumstances as the officers understood them to warrant this level of surveillance. Lastly, it appears the Complainant’s custodians acted quickly once they discovered her in medical distress to administer Narcan and arrange for prompt medical attention.

For the foregoing reasons, whatever the shortcomings in the care provided the Complainant, they did not amount to a marked departure from a reasonable standard of care. As such, there is no basis for proceeding with criminal charges in this case. The file is closed.

Date: December 18, 2024

Electronically approved by

Joseph Martino

Director

Special Investigations Unit