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, 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.

Pursuant to section 15 of the SIU Act, the SIU may investigate the conduct of officials, be they police officers, special constables of the Niagara Parks Commission or peace officers under the Legislative Assembly Act, that may have resulted in death, serious injury, sexual assault or the discharge of a firearm at a person.

A person sustains a “serious injury” for purposes of the SIU’s jurisdiction if they: sustain an injury as a result of which they are admitted to hospital; suffer a fracture to the skull, or to a limb, rib or vertebra; suffer burns to a significant proportion of their body; lose any portion of their body; or, as a result of an injury, experience a loss of vision or hearing.

In addition, a “serious injury” means any other injury sustained by a person that is likely to interfere with the person’s health or comfort and is not transient or trifling in nature.

This report relates to the SIU’s investigation into the death of a 39-year-old man (the “Complainant”).

Notification of the SIU[1]

On May 28, 2024, at 6:00 a.m., the Thunder Bay Police Service (TBPS) contacted the SIU with the following information.

On May 27, 2024, at 3:30 p.m., TBPS officers apprehended the Complainant under the authority of a Mental Health Act (MHA) form issued by a physician. The Complainant was transported to the Thunder Bay Regional Health Sciences Centre (TBRHSC) to be examined. At 6:00 p.m., the Complainant was discharged from the TBRHSC. He had several outstanding arrest warrants with the TBPS, and was taken to the police station to await a court appearance. The custodial intake was without incident and the Complainant interacted without concern. He was lodged in a cell. Throughout the night, the Complainant was checked in his cell and there was nothing of significance to report. On May 28, 2024, at 4:11 a.m., the Complainant was checked, as per policy, and again there was no issue. At 4:19 a.m., the Complainant was slumped over in his cell and police officers entered to check on him. He was found to be vital signs absent. Cardiopulmonary resuscitation (CPR) was initiated. Paramedic services were called to the scene and the Complainant regained a pulse. He was transported to TBRHSC where he remained on life support.

The Team

Date and time team dispatched: 2024/05/28 at 6:20 a.m.

Date and time SIU arrived on scene: 2024/05/28 at 10:00 p.m.

Number of SIU Investigators assigned: 3

Number of SIU Forensic Investigators assigned: 1

Affected Person (aka “Complainant”):

39-year-old male; deceased

Civilian Witnesses (CW)

CW #1 Interviewed

CW #2 Interviewed

The civilian witnesses were interviewed between May 29, 2024, and August 1, 2024.

Subject Official (SO)

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

Witness Officials (WO)

WO #1 Interviewed; notes received and reviewed

WO #2 Interviewed; notes received and reviewed

WO #3 Interviewed; notes received and reviewed

WO #4 Interviewed; notes received and reviewed

WO #5 Not interviewed; notes reviewed and interview deemed unnecessary

WO #6 Not interviewed; notes reviewed and interview deemed unnecessary

WO #7 Not interviewed; notes reviewed and interview deemed unnecessary

The witness officials were interviewed on June 4, 2024.

Service Employee Witnesses (SEW)

SEW #1 Interviewed; notes received and reviewed

SEW #2 Not interviewed

The service employee witness was interviewed on June 4, 2024.

Investigative Delay

The Report of Postmortem Examination was received by the SIU from the Coroner’s Office on March 14, 2025.

The Scene

The events in question transpired in and around a cell in the TBPS cells area located at 1200 Balmoral Avenue, Thunder Bay.

Physical Evidence

On May 28, 2024, at 10:00 p.m., a SIU forensic investigator attended the TBPS cells area located at 1200 Balmoral Avenue, Thunder Bay. The Complainant had been lodged in one of the cells. The area was climate controlled at 21 degrees Celsius at the time of examination. There were surveillance cameras located throughout the facility with a camera located opposite each cell to view the occupants. The real-time video could be monitored from a central office.

On the floor of the Complainant’s cell was medical debris, including discarded packaging, an automated external defibrillator, an intubation tube, intravenous tubing, and a bag-valve mask. There was a folded blanket near the opened cell door with a stained corner. There were empty drink boxes from meals provided to persons in custody. No foreign objects or substances were located within the cell.

At 10:55 p.m., the scene was released to TBPS.

Forensic Evidence

The Report of Postmortem Examination concluded that the Complainant’s death was attributable to cocaine toxicity, and that cardiomegaly with left ventricular hypertrophy contributed to the death.

Video/Audio/Photographic Evidence[2]

Body-worn Camera (BWC) Footage

On May 27, 2024, at 3:22:48 p.m., WO #7, WO #1, WO #5 and WO #2 arrived at a residence in Fort William First Nation. The Complainant sat outside in a chair with his arms raised in the air. WO #7 told the Complainant he would be apprehended and taken to the hospital. The Complainant was cooperative. He said his anxiety level was high and he did not recall the past few days. He stood up and placed his hands behind his back. Police officers handcuffed him. WO #5 and WO #1 conducted a pat-down search. The Complainant wore a T-shirt, pants and shoes. WO #2 and WO #1 turned his pockets inside out. They patted down his legs and ankles. The Complainant was escorted to a police vehicle and placed in the rear prisoner compartment.

At 3:28:50 p.m., the Complainant told WO #2 he had consumed drugs the day prior. He said he had come to the residence after a “drug bender”. He said he normally consumed crack cocaine. He spoke coherently throughout the police interaction.

In-car Camera System (ICCS) Footage

On May 27, 2024, at 3:27:45 p.m., the Complainant was placed in the rear prisoner compartment of the police vehicle assigned to WO #2 and WO #1. He appeared tired throughout the trip to TBRHSC and said he could not remember the last time he had slept.

At 5:39:31 p.m., the Complainant was in the rear prisoner compartment of a police vehicle. He was transported from TBRHSC to a TBPS station. Throughout the transport, he presented as lucid and coherent. He was handcuffed with his hands behind his back.

Custody Footage

On May 27, 2024, at 5:51:46 p.m., the Complainant was escorted into the booking area by two police officers - WO #1 and WO #2. He sat on a bench.

At 5:52:38 p.m., WO #1 asked the Complainant if he had any drugs or alcohol in his system. The Complainant denied he had consumed anything. WO #1 asked if he had any drugs on his person, and then quickly said, “Obviously not because we just had you in a gown at the hospital.” WO #1 asked if he had anything in his underwear. The Complainant denied he did. WO #1 asked if he had any injuries. The Complainant denied he had any injuries. WO #1 asked if he had any medical conditions. The Complainant said he had high blood pressure. WO #1 asked if he took any medications for his high blood pressure. The Complainant said he had not taken his medication for a long time. WO #1 asked if the Complainant “felt like hurting or killing yourself at all?” The Complainant replied in the negative. WO #2 scanned the Complainant with a metal detector wand.

At 5:54 p.m., the Complainant was escorted to a cell. The handcuffs were removed and he was lodged in the cell. He sat on the bench in the cell. The police officers left the cell block.

The cell was checked at approximately 30-minute intervals between the time he was lodged and approximately 11:39 p.m.[3] The cells checks were conducted by WO #3 and SEW #1. During this time, the Complainant sat on the bench and consumed some food, after which he laid down on the bench and covered himself with a blanket. He appeared to be asleep.

At approximately 11:39 p.m., the Complainant sat up on the bench. He consumed some more food. The lower half of his body was covered with a blanket. He leaned back against the wall as he clutched his chest with both hands. A few minutes later, he placed his hands under the blanket. He leaned forward off the bench while still seated on it. He changed positions on the bench multiple times and appeared restless.

On May 28, 2024, at 12:09 a.m., SEW #1 conducted a cell check. There was no conversation between SEW #1 and the Complainant.

At approximately 12:40 a.m., 1:11 a.m. and 1:56 a.m., SEW #1 conducted cell checks. There was no conversation between SEW #1 and the Complainant. The Complainant laid down on the bench.

At approximately 2:30 a.m., the Complainant appeared restless. He paced around his cell and stood by the doors as SEW #1 conducted a cell check. There was no conversation between SEW #1 and the Complainant.

At approximately 3:06 a.m., SEW #1 conducted a cell check. The Complainant laid down on the bench. There was no conversation between SEW #1 and the Complainant.

At approximately 3:40 a.m., the SO conducted a cell check. The Complainant sat on the bench with his back to the cell wall. There was no conversation between the SO and the Complainant.

The Complainant alternated between positions where he sat on the edge of the bench and leaned over towards the ground, sat upright on the bench as he wrapped his arms around his knees, and laid down. He appeared restless. He moved to the floor and sat with his back against the cell wall. He held his knees.

At approximately 4:06 a.m., the Complainant moved closer to the toilet bowl. He moved to the cell door and placed his back against the cell door, then moved back to his original position on the floor.

At approximately 4:11 a.m., the SO conducted a cell check. The Complainant sat on the floor with his back against the cell wall as he held his knees. There was no conversation between the SO and the Complainant. The Complainant moved closer to the toilet bowl again.

At approximately 4:16 a.m., the Complainant waved his arms in the air and held the back of his head. He held a kneecap with each hand, and appeared to tremble. The trembling became more vigorous. He kicked his legs in the air and slid over to his right side. He laid curled on the floor between the wall and the bench. He continued to kick. He no longer moved and laid supine on the floor with his head oriented towards the cell door. He continued to breathe as indicated by the visible rise and fall of his chest.

At approximately 4:19 a.m., the SO entered the cell block and looked at the Complainant on the ground. He left the cell block and, about a minute later, returned with WO #4. The SO opened the cell. WO #4 entered the cell, grabbed the Complainant by the arm, and pulled the Complainant out of the cell. He was partially pulled out of frame of the camera. Additional police officers arrived. A police officer searched the cell but did not appear to find anything. The Complainant’s legs appeared to move with minor convulsions.

At approximately 4:31 a.m., the police officers rolled the Complainant onto his back. A police officer performed chest compressions. Approximately three minutes later, paramedic services arrived.

At approximately 4:53 a.m., the ambulance left the TBPS station.

Police Radio Transmissions

On May 25, 2024, at 7:41 a.m.,[4] TBPS received a phone call from TBRHSC. The unidentified caller advised the Complainant had been brought to the hospital by a family member. The Complainant had been placed on a Form 1 and subsequently fled the hospital.

On May 27, 2024, at 1:39 p.m., the Complainant called TBPS and advised he would turn himself in. He said he had stolen a vehicle from the hospital. He said he was at a family member’s house and would be at the TBPS station in 30 minutes.

At 2:13 p.m., the Complainant called TBPS again. He asked if police officers were coming to pick him up. The dispatcher advised police were waiting for him at the police station. He said he was “on the reserve”.

At 2:27 p.m., the Complainant called TBPS again and provided an address. His family member would not drive him to the TBPS station.

Materials Obtained from Police Service

Upon request, the SIU obtained the following records from the TBPS on May 29, 2024:

• CAD Report;
• Scene photographs;
• Communications recordings;
• BWC footage;
• ICCS footage;
• Custody footage;
• Search Urgency Chart;
• Missing Person Report;
• MHA Form 1;
• General Occurrence Report;
• Supplementary Reports;
• Adult Accused Charge Report;
• Committal Warrant;
• Warrant for Arrest;
• PMS Log;
• Jailer Fob Report;
• Notes – WO #5;
• Notes – WO #2;
• Notes – WO #6;
• Notes – WO #1;
• Notes – WO #3;
• Notes – SEW #1
• Notes – WO #7;
• Notes – WO #4; and
• Policy - Care and Handling of Prisoners.

Materials Obtained from Other Sources

The SIU obtained the following records from other sources between July 2, 2024, and March 14, 2025:

• The Complainant’s medical records from TBRHSC; and
• Report of Postmortem Examination from the Coroner’s Office.

The evidence collected by the SIU, including interviews with members of the TBPS who dealt with the Complainant through the events in question, and video footage that captured his 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.

In the afternoon of May 27, 2024, the Complainant was at an address in Fort William First Nation when he contacted TBPS to turn himself in. An order of apprehension under the Mental Health Act was in effect authorizing his admission at hospital for examination. He had absconded from hospital a couple of days earlier, but now wished to return. Officers attended at the address and arrested the Complainant without incident. He was searched, placed in a police cruiser and taken to the TBRHSC.

The parties arrived at hospital at about 4:00 p.m. The Complainant removed his clothing, which was searched by the officers, and donned a hospital gown. Asked if he had anything in his underwear, the Complainant answered in the negative. He was medically assessed and subsequently discharged into the care of the police. As there was another warrant in effect authorizing his arrest with respect to several criminal offences, the Complainant was again taken into custody, and transported to the police station.

During the booking procedure at the station, the Complainant denied that he had any drugs or alcohol in his system. He mentioned he had high blood pressure, and had not taken his medication in a while. At about 6:00 p.m., the Complainant was lodged in a cell.

Through the evening and into the morning hours of the following day, the Complainant was checked at regular intervals of about 30 minutes. He was provided juice and food. Starting at about 4:16 a.m., May 28, 2024, the Complainant started to tremble. He kicked his legs in the air and slid onto his right side, laying curled on the floor between the wall and cell bench. He eventually became still, his chest still rising and falling, in a supine position.

The SO, responsible for cell checks at the time, entered the cell area at about 4:19 a.m. He looked at the Complainant on the floor and promptly left to retrieve the officer-in-charge, WO #4. The two returned about a minute later, and WO #4 pulled an unconscious Complainant out of the cell. An ambulance was requested. CPR and doses of naloxone were administered while police waited for the arrival of paramedics.

Paramedics attended at about 4:53 a.m. and took charge of the Complainant’s care. He was transported to hospital.

On May 31, 2024, with the withdrawal of care, the Complainant passed away.

Cause of Death

The pathologist at autopsy was of the view that the Complainant’s death was attributable to cocaine toxicity. The pathologist also concluded that cardiomegaly with left ventricular hypertrophy contributed to the death.

Section 215, Criminal Code - Failure to Provide Necessaries

215 (1) Every one is under a legal duty

(c) to provide necessaries of life to a person under his charge if that person

(i) is unable, by reason of detention, age, illness, mental disorder or other cause, to withdraw himself from that charge, and

(ii) is unable to provide himself with necessaries of life.

(2) Every person commits an offence who, being under a legal duty within the meaning of subsection (1), fails without lawful excuse to perform that duty, if

(b) with respect to a duty imposed by paragraph (1)(c), the failure to perform the duty endangers the life of the person to whom the duty is owed or causes or is likely to cause the health of that person to be injured permanently.

Sections 219 and 220, Criminal Code - Criminal Negligence Causing Death

219 (1) Every one is criminally negligent who

(a) in doing anything, or

(b) in omitting to do anything that it is his duty to do,

shows wanton or reckless disregard for the lives or safety of other persons.

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

220 Every person who by criminal negligence causes death to another person is guilty of an indictable offence and liable

(a) where a firearm is used in the commission of the offence, to imprisonment for life and to a minimum punishment of imprisonment for a term of four years; and

(b) in any other case, to imprisonment for life.

The Complainant passed away in hospital in Thunder Bay on May 31, 2024. He had been taken to hospital from the cells area of the TBPS on May 28, 2024, after lapsing into medical crisis. The SIU was notified of the incident and initiated an investigation, naming one of the Complainant’s custodians – 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 medical event and subsequent death.

The offences that arise for consideration are failure to provide the necessaries of life and criminal negligence causing death contrary to sections 215 and 220 of the Criminal Code, respectively. Both require something more than a simple want of care to give rise to liability. The former is predicated, in part, on conduct that amounts to a marked departure from the level of care that a reasonable person would have exercised in the circumstances. The latter is premised on even more egregious conduct that demonstrates a wanton or reckless disregard for the lives or safety of other persons. It is not made out unless the neglect constitutes a marked and substantial departure from a reasonable standard of care. In the instant case, the question is whether there was any want of care on the part of the SO, sufficiently serious to attract criminal sanction, that endangered the Complainant’s life or contributed to his death. In my view, there was not.

The Complainant was lawfully in custody through the events in question. His initial apprehension had been authorized pursuant to the Mental Health Act. His subsequent arrest was effected pursuant to an arrest warrant.

With respect to the care afforded the Complainant while in police custody, I am satisfied his custodians, including the SO, comported themselves with due regard for his health and wellbeing. By the time the Complainant was placed in a cell, he had been searched three times – at his family member’s place, at the hospital, and at the police station. None of those searches revealed the presence of drugs on his person that he might have accessed during his time in cells. Nor is it apparent on the video footage that the Complainant did, in fact, retrieve drugs from his person and ingest them while in police custody. On the other hand, the footage does establish that the Complainant was regularly monitored in cells pursuant to police policy. He first showed signs of medical distress at about 4:16 a.m., approximately five minutes from the last cell check conducted by the SO. The officer appears to have taken note of the Complainant’s distress at about 4:19 a.m., some time before the next scheduled cell check, and acted quickly to summon help. About a minute later, additional officers attended at the cell and emergency care was provided, including CPR and naloxone.

For the foregoing reasons, I am unable to reasonably conclude that the SO transgressed the limits of care prescribed by the criminal law in relation to the Complainant’s health crisis and subsequent death. The file is closed.

Date: March 18, 2025

Electronically approved by

Joseph Martino

Director

Special Investigations Unit