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 42-year-old man (the “Complainant”).

Notification of the SIU[1]

On January 12, 2024, at 6:46 p.m., the North Bay Police Service (NBPS) notified the SIU of the death of the Complainant.

According to the NBPS, on January 12, 2024, at 4:45 p.m., the Complainant was found unresponsive in the North Bay Court of Justice (NBCJ) holding cells by a special constable. Cardiopulmonary resuscitation (CPR) was initiated, and paramedics transported him to the North Bay Health Centre where he was later pronounced deceased.

The Team

Date and time team dispatched: 2024/01/12 at 7:54 p.m.

Date and time SIU arrived on scene: 2024/01/13 at 4:07 p.m.

Number of SIU Investigators assigned: 2

Number of SIU Forensic Investigators assigned: 1

Affected Person (aka “Complainant”):

42-year-old male; deceased

Subject Official (SO)

SO Interviewed; notes received and reviewed

The subject official was interviewed on February 7, 2024.

Service Employee Witnesses (SEW)

SEW #1 Interviewed; notes received and reviewed

SEW #2 Interviewed; notes received and reviewed

SEW #3 Interviewed; notes received and reviewed

The service employee witnesses were interviewed on January 25, 2024.

Investigative Delay

The Report of Postmortem Examination (including Toxicology Report) was received by the SIU from the Coroner’s Office on October 29, 2024.

Delay was also incurred because of workload pressures in the Director’s Office.

The Scene

The events in question transpired in the cells area of the NBCJ, 360 Plouffe Street, North Bay.

Video/Audio/Photographic Evidence[2]

Video Footage – NBCJ Cells

On January 12, 2024, starting at about 9:09:57 a.m., the Complainant was placed in a cell, and he sat on the concrete bed as the door was closed.

Starting at about 10:13:30 a.m., the Complainant was escorted from his cell by a special constable, and then returned to his cell at 10:18:20 am.

Starting at about 10:20:38 a.m., the Complainant sat on the cell toilet and placed both hands between his legs and underneath him into the toilet. He got up from the toilet and flushed it as he placed his right hand inside his sweatpants.

Starting at about 10:22:05 a.m., while seated on the concrete bed, he pulled something from his sweatpants with his right hand and placed it on the bed to his left out of camera view. The Complainant was partially obscured by the metal cell door frame and was not observed ingesting anything at that time.

Starting at about 11:28:02 a.m., the Complainant was escorted from his cell by a special constable for a scheduled bail court appearance.

Starting at about 11:36:20 a.m., the Complainant was returned to his cell, showing no signs of difficulty walking. He was observed speaking with the special constables. His handcuffs were removed, and he pulled his shirt over his head and laid face down on the concrete bed.

Starting at about 11:41:17 a.m., the Complainant was captured pounding the concrete bed with both fists.

Starting at about 11:43:30 a.m., food was delivered to the Complainant as he stood up and moved about his cell without difficulty. He finished eating and again laid down on the concrete bed.

Starting at about 12:58:34 p.m., the Complainant was seated on the concrete bed as he waved at the video camera and continued to move about the cell without difficulty, sitting and laying, and at one point standing at the cell door.

Starting at about 1:48:13 p.m., the Complainant sat on the concrete bed with his right side facing the camera. He was partially blocked from camera view by the cell door frame. His face and the front of his body were obscured as he fumbled with his clothing and threw something unidentifiable into the toilet. As a result of the cell door frame, which obstructed the view of the Complainant’s face, and partially the front of his body, it could not be discerned whether the Complainant ingested anything.

Starting at about 3:07:11 p.m., while seated on the concrete bed, the Complainant threw something unidentifiable into the toilet before laying down.

Starting at about 4:05:50 p.m., a special constable conducted the final cell check of the Complainant captured on video.

Starting at about 4:06:41 p.m., the Complainant sat up on the bed, leaned forward and appeared to vomit. The view was once again obscured by the cell door frame. He remained seated on the bed and appeared to struggle to remain conscious as his head nodded and his movements now appeared lethargic.

Starting at about 4:11:41 p.m., the Complainant fell forward off the bed, onto the toilet with his head/shoulders on the toilet seat. He remained in the same position with little to no movement until he was discovered.

At 4:55:15 p.m., a special constable opened the Complainant’s cell door and then spoke into his radio.

Starting at about 4:56:14 p.m., two special constables and the cell sergeant entered the cell and began CPR.

Starting at about 5:04:04 p.m., Emergency Medical Services (EMS) arrived, and life-saving measures continued. The Complainant was placed on a stretcher at 5:22:48 p.m. and escorted out of camera view.

Starting at about 5:28:37 p.m., the cell was taped-off by the special constables.

The video concluded at 5:59:46 p.m.

NBPS Communications Recordings

At approximately 4:55 p.m., January 12, 2024, SEW #1 requested the door to the Complainant’s cell be opened and further advised “VSA”. SEW #2 called 911 and requested EMS.

At 5:03 p.m., SEW #2 was contacted by dispatch and advised that EMS was on scene. He advised dispatch that he was aware and was in the process of allowing EMS entry into the NBCJ.

Materials Obtained from Police Service

Upon request, the SIU obtained the following records from the NBPS between January 16, 2024, and May 17, 2024:

• Court House Cell Check Sheet / Court House Cell Log
• Computer-aided Dispatch Report
• Radio communications recordings
• Sudden Death Report
• Remand Warrants for the Complainant
• OPP fingerprints of the Complainant
• NBCJ cell recordings - the Complainant
• Prisoner Care and Control Policy
• Notes – SEW #1, SEW #2, SEW #3, the SO, Officer #1, Officer #2, Officer #3, Officer #4, Special Constable #1, Special Constable #2, Special Constable #3, Special Constable #4 and Special Constable #5

Materials Obtained from Other Sources

The SIU obtained the Report of Postmortem Examination (including Toxicology Report) from the Coroner’s Office on October 29, 2024.

The evidence collected by the SIU, including interviews with the Complainant’s custodians, and video footage that captured his time in cells, gives rise to the following scenario.

The Complainant was transported from the North Bay District Jail to the NBCJ in the morning of January 12, 2024, to attend his bail hearing. He was searched prior to transport and then again at the NBCJ prior to being lodged in a cell at about 9:10 a.m. to await his hearing.

The Complainant was removed from his cell at about 11:28 a.m. for his hearing and returned shortly thereafter, at about 11:36 a.m.

At about 4:11 p.m., the Complainant fell forward off his cell bench onto the toilet seat. He remained in that position until about 4:55 p.m., when he was discovered by a special constable. The special constable entered the cell, ascertained that the Complainant was in medical crisis and called for help.

CPR was performed by special constables. An automated external defibrillator was used. It advised against a shock.

Paramedics arrived on scene and assumed care of the Complainant at about 5:04 p.m., the Complainant was transported to hospital and pronounced deceased at 5:50 p.m.

Cause of Death

The pathologist at autopsy was of the view that the Complainant’s death was attributable to acute fentanyl and methamphetamine intoxication.

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 was pronounced deceased in hospital on January 12, 2024, after being found vital signs absent while detained in a cell of the NBCJ earlier that day. The SIU was notified of the incident and initiated an investigation. The NBPS officer with overall responsibility for the care of prisoners at the court house – the SO – was identified as 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 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 caused his death. In my view, there was not.

The evidence indicates that the Complainant was lawfully in custody through the series of events on January 12, 2024, culminating in his death.

The evidence further indicates that the level of care provided the Complainant at the NBCJ did not transgress the requirements of the criminal law. The Complainant was checked regularly by special constables, whether in-person or via video monitor. Through most of his time in custody, he appeared well and gave no cause for concern. In light of the distinct possibility that he was able to ingest fentanyl and methamphetamine while a prisoner at the court house, the question arises how that might have been allowed to happen. As the Complainant was subjected to a pat-down or frisk search on two occasions the morning of January 12, 2024, prior to being lodged at the court house cells, with negative results, any drugs he accessed might well have been concealed in his underwear or within his person and only detectable via a strip search or body cavity search. Certainly, while not definitive, the video footage of the Complainant’s time in cells is highly suggestive of either scenario. Strip searches, however, are only permissible in exceptional cases where there are reasonable and probable grounds to believe they are necessary: R. v. Golden, [2001] 3 SCR 679. I am unable to reasonably conclude on the evidence that any such necessity was in play. The Complainant appeared well, had been subjected to two prior searches, and had arrived at the court house from another custodial facility. If there were no grounds to justify a strip search, then a body cavity search, which practice is even more constricted, would not have been available. The time that elapsed from the moment the Complainant became motionless to the time he was discovered in medical distress - about 50 minutes - is also subject to legitimate scrutiny. Pursuant to police policy, the Complainant ought to have been checked at least every 20 minutes. Arguably, the failure to attend to the Complainant with medical attention sooner than happened placed his well-being in jeopardy. On the other hand, in the context of a detainee who seemed fine through most of his time in custody, it is unclear whether what was in essence a single missed check amounted to a marked lapse in care, much less a marked and substantial one. Moreover, the extent to which any such indiscretion can be visited upon the SO, who was not personally responsible for prisoner checks and acted in a supervisory capacity, is tenuous at best.

For the foregoing reasons, there is no basis for proceeding with criminal charges in this case. The file is closed.

Date: April 11, 2025

Electronically approved by

Joseph Martino

Director

Special Investigations Unit