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 33-year-old man (the “Complainant”).

Notification of the SIU[1]

On February 12, 2025, at 1:55 a.m., the York Regional Police (YRP) notified the SIU of the death of the Complainant.

According to the YRP, the Complainant attended the YRP police station in Richmond Hill and turned himself in on an arrest warrant for breach of probation. The Complainant’s arrest was handled by WO #1, WO #2 and WO #3. The Complainant was escorted to the custody area and the intake process was completed without incident, after which he was lodged in a cell. On February 12, 2025, at about 1:00 a.m., the Complainant was observed by the Service Employee Witness (SEW) on video monitor experiencing a seizure. The Subject Official (SO) and Witness Official (WO) #7 immediately performed life-saving measures and York Emergency Medical Services (EMS) were called to the police station. The Complainant was transported to Mackenzie Health Centre (MHC), where, at 1:48 a.m., he was pronounced deceased.

The Team

Date and time team dispatched: 2025/02/12 at 2:20 a.m.

Date and time SIU arrived on scene: 2025/02/12 at 3:50 a.m.

Number of SIU Investigators assigned: 3

Number of SIU Forensic Investigators assigned: 1

Affected Person (aka “Complainant”):

33-year-old male; deceased

Subject Official

SO Interviewed, but declined to submit notes, as is the subject official’s legal right

The subject official was interviewed on March 4, 2025.

Witness Official

WO #1 Interviewed

WO #2 Interviewed

WO #3 Interviewed

WO #4 Interviewed

WO #5 Interviewed

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 between February 14, 2025, and February 21, 2025.

Service Employee Witness

SEW Interviewed

The service employee witness was interviewed on February 21, 2025.

The Scene

The events in question transpired in and around a cell in the YRP 2 District police station at 177 Major MacKenzie Drive, Richmond Hill.

Physical Evidence

At 5:16 a.m., February 12, 2025, a SIU forensic investigator attended YRP 2 District police station. The cell in question had been sealed with a police tape seal. Inside the cell was a pair of jeans, a black T-shirt, and McDonald’s food wrappers and debris. An automated external defibrillator (AED) and two empty Narcan packages were present. The cell was photographed. The cell was also measured, and found to be 1.55 metres wide and 1.85 metres deep.

Video/Audio/Photographic Evidence[2]

YRP Front Desk, Booking and Custody Video

On February 11, 2025, at 2:58 p.m., the Complainant entered the front lobby of the YRP 2 District. He walked diagonally across the foyer and entered the washroom at the right side of the screen.

Starting at about 3:02:30 p.m., the Complainant exited the washroom and approached a counter located at the top of the screen.

Starting at about 3:13 p.m., the Complainant sat and dug his left hand into his left jacket pocket.

Starting at about 3:18 p.m., the Complainant retrieved a small black container with his left hand from either his left jacket pocket or his backpack. He opened the container and, in two throws, he spread on the floor a layer of red powder in the shape of a “V”. He then stood and approached the counter, standing with his back to the camera.

Starting at about 3:24 p.m., a male police officer - WO #1 - approached from the counter. The Complainant walked out the front door followed by WO #1 [now known to smoke a cigarette] and they returned at 3:28 p.m.

Starting at about 3:41 p.m., a police officer entered the foyer with a vacuum cleaner and vacuumed the red powder. The Complainant was then approached by WO #1 and a second uniformed, male police officer - WO #2.

Starting at about 3:42 p.m., WO #1 handcuffed the Complainant with his hands to the front, as the Complainant sat on a bench.

Starting at about 3:43 p.m., the Complainant was stood up and led away through the doorway the police officers had come from.

Starting at about 3:45 p.m., they entered the booking area. A uniformed sergeant - WO #4 - entered the room and went behind the counter. [The camera directly above the booking counter was the only camera in the custody area with an audio capture feature.] The Complainant was made to place his hands against a wall by WO #2. The Complainant took off his coat and his belt. A third police officer - WO #3 - was present. WO #2 performed a frisk search of the Complainant and found a small plastic bag containing a white powder. WO #3 took possession of the small bag [later suspected to contain a small amount of crystal methamphetamine], which he placed in an evidence bag.

Starting at about 3:53 p.m., WO #1 searched the Complainant’s jackets and bag, and located a crack pipe in his bag. WO #3 had the Complainant stand against the wall, and he did a second frisk search in the booking room. WO #4 asked the Complainant if he was injured, and he replied his leg was injured, but it was a pre-existing injury. He said he was struck by a car two years ago. WO #4 asked him if he wanted to go to the hospital, and he replied in the negative. The Complainant was asked if he knew why he was there, and he replied, “A warrant.” WO #4 told him the area was audio and video-recorded. WO #4 asked the Complainant if he understood his rights and whether he wanted to call duty counsel, and he replied, “No.” The Complainant was asked if he had any mental health issues, and he replied in the negative. He was asked if he was on medication, and he replied that he was on a medication, which he had taken before he turned himself in. The medication was in his bag. The Complainant was asked if he was hungry, and he said he could eat. He was asked if he took medication for heart disease or high blood pressure, and he replied in the negative. WO #3 requested permission to conduct a strip search. WO #4 denied the request. WO #2 and WO #3 led the Complainant to the cells.

Starting at about 3:58 p.m., the Complainant was placed in a cell, which was in the female cell corridor. The camera was located on the ceiling of the cell, which was constructed of solid blocks with a solid metal door. The Complainant appeared agitated; he kept shaking his left leg and looked at the palm of his right hand.

Starting at about 4:25 p.m., the Complainant seemingly tried to go to sleep.

Starting at about 4:51 p.m., WO #1 entered the cell with a meal for the Complainant.

Starting at about 5:09 p.m., the Complainant sat on his knees and leaned forward with his head on top of his arms on the bench, as if in a praying position.

Starting at about 5:52 p.m., WO #2 and WO #3 attended the cell and served papers on the Complainant.

Starting at about 6:58 p.m., the cell door window opened on the outside and the word ‘police’ could be seen on a police vest – the SO was checking on the Complainant. The same occurred at 7:49 p.m.

Starting at about 9:16 p.m., the SO opened the door and gave the Complainant food, which the Complainant ate.

Starting at about 10:21 p.m., the SO stood outside the cell door and looked in, as the Complainant slept.

Starting at about 10:56 p.m., the Complainant sat on the edge of the bench with his head in his hands. He seemed agitated and rocked on his rear-end. He drank from what appeared to be a paper cup with coffee inside.

Starting at about 11:39 p.m., while he sat on the bench, the Complainant kept putting his right hand into his crotch area.

Starting at about 11:50 p.m., the Complainant lay on his right side with his knees bent up in the direction of his waist. With his back to the camera, it looked like he undid his shirt buttons with his left hand.

Starting at about 11:57 p.m., the Complainant picked up something [appeared to be a food container] from the floor at the back wall, next to the toilet. He then turned onto his left side with his knees bent and retrieved something from inside his underwear at his buttocks. He leaned over and formed a white line with what appeared to be a powder by using the square edge of the food container.

Starting at about 11:59:25 p.m., the Complainant leaned over and appeared to snort with his right nostril the white line of powder. He used the food container to shape another line with the remaining powder and snorted it with his left nostril. He then stood up with the cup, filled it with water from the sink, and sat back down.

Starting at about 12:06 a.m., February 12, 2025, the Complainant stood and faced the door with his left knee on the bench and his head against the cell door. He stood in the same position for some time with what appeared to be movement from his arms; however, the view of his arms was obstructed by his body.

Starting at about 12:11 a.m., the Complainant lifted his left hand up to his mouth. He then put something else in his mouth and drank from the cup.

Starting at about 12:13 a.m., the Complainant undid the buttons on the front of his shirt, and walked about in the cell.

Starting at about 12:16 a.m., the Complainant urinated and then washed his hands.

Starting at about 12:22 a.m., the Complainant removed his shirt and lay on his back.

Starting at about 12:25 a.m., the Complainant removed his jeans and had his right hand under his underwear.

Starting at about 12:35 a.m., the Complainant stood up and approached the cell door wearing only his underwear. He then lay down and held his head. His legs shook uncontrollably, and he held his head and then grabbed at his crotch.

Starting at about 12:48 a.m., a uniformed police officer - WO #6 - entered the cell.

Starting at about 12:49 a.m., a second uniformed police officer - WO #7 - and the SO appeared at the cell door. The SO subsequently left.

Starting at about 12:54 a.m., the Complainant’s hand shook, and he appeared to suffer a seizure.

Starting at about 12:56:47 a.m., WO #7 and WO #6 placed the Complainant on his right side in the recovery position.

Starting at about 12:57:30 a.m., WO #6 started to perform CPR. The Complainant appeared to be unconscious.

Starting at about 12:59 a.m., the SO placed an AED on the floor and the electrodes were connected to the Complainant’s chest by a uniformed male police officer. The police officers stood back and then CPR was resumed.

Starting at about 12:59:43 a.m., a paramedic could be seen at the doorway.

Starting at about 1:01 a.m., four police officers carried the Complainant out of the cell.

Communications Recordings

On February 12, 2025, at 12:48 a.m., the YRP communications centre received a call from the custody area of YRP 2 District regarding a male prisoner, the Complainant, who suffered a seizure. A request was made for an ambulance to attend at the sally port.

Starting at about 12:54 a.m., WO #6 and another police officer were dispatched.

Starting at about 12:56 a.m., EMS had received a call for service and, at 12:57 a.m., EMS were dispatched.

Starting at about 12:59 a.m., WO #5 was on scene, as were EMS.

Starting at about 1:00:42 a.m., someone broadcast that Narcan and an AED had been administered three minutes prior.

Starting at about 1:06 a.m., CPR was still being performed on the Complainant in the ambulance, which was in the sally port.

Starting at about 1:15 hrs, a police officer advised that they were continuing to do CPR in the sally port.

Starting at about 1:23 a.m., the Complainant was transported to MHC and CPR was continued en route.

Starting at about 1:50 a.m., a police officer advised that the Complainant had been pronounced deceased at 1:48 a.m.

Materials Obtained from Police Service

The SIU obtained the following records from the YRP between February 12, 2025, and February 19, 2025.

• Custody video footage
• Communications recordings
• Cell logs
• Call History
• Criminal Record – the Complainant
• Arrest warrant – the Complainant
• YRP History – the Complainant
• Next-of-kin information
• Notes – the SEW
• Notes of the WOs
• Record of Physical Checks – the Complainant
• Information regarding YRP front counter video
• CPIC records
• Breach of Probation Arrest Report
• Death Report
• Policies - Processing the Offender; Search of Persons; and, Prisoner Care and Control

Materials Obtained from Other Sources

The SIU obtained the following records from the following other sources between February 13, 2025, and April 2, 2025:

• The Complainant’s medical records from MHC
• Preliminary Autopsy Findings Report from the Ontario Forensic Pathology Service
• Ambulance Call Reports from York EMS

The evidence collected by the SIU, including interviews with the SO and police witnesses, and video footage that largely captured the events in question, gives rise to the following scenario.

In the afternoon of February 11, 2025, aware of a warrant for his arrest for a breach of a probation order, the Complainant turned himself in at YRP 2 District. Officers at the station confirmed the warrant, handcuffed the Complainant, and escorted him to the lower level to be booked.

WO #4 was the booking officer at the time. He asked the Complainant a series of questions regarding his health. The Complainant indicated he was fine and declined an opportunity to go to the hospital. A couple of searches conducted in the booking area of the Complainant’s person, clothing and belongings revealed the presence of a crack pipe and a small amount of suspected crystal methamphetamine. Asked by one of the search officers – WO #3 – for permission to strip search the Complainant, WO #4 denied the request.

The Complainant was lodged in a cell at about 4:00 p.m. Over the course of the next eight hours, he was checked via video monitors every half hour or so. The Complainant was also checked personally by the SO on three occasions. He slept and ate for portions of this time.

Just before midnight, the Complainant retrieved a quantity of drugs from inside his underwear, formed lines of white powder with the substance, and snorted them. At about 12:11 a.m., February 12, 2025, he put something in his mouth and drank from a cup. Shortly after, the Complainant began to remove his outer clothing and became restless. His legs started to shake uncontrollably as he lay on the cell bench.

WO #5 and the SEW noticed the Complainant shaking via the monitors at the station’s front counter. They alerted other officers to check on the Complainant and contacted paramedics.

Officers attended the Complainant’s cell and attempted to communicate with him. The Complainant was unable to communicate other than to agree when asked if he suffered from seizures. The officers placed the Complainant into the recovery position. The Complainant soon lost vital signs. CPR was performed and a dose of nasal Narcan administered. An AED connected to the Complainant advised that no shock should be delivered. Paramedics arrived at about 1:00 a.m. and took over the Complainant’s care.

The Complainant was taken to Mackenzie Health Centre where he was pronounced deceased at 1:48 a.m.

Cause of Death

The pathologist at autopsy was unable to provide a preliminary view regarding the cause of death, noting the determination would have to wait for receipt of toxicological examination.

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 lapsed into acute medical distress while in the custody of the YRP on February 12, 2025. He would subsequently pass away a short time later in hospital. The SIU was notified of the incident and 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 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 police custodians charged with the Complainant’s supervision while in custody, including 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 live issues as far as the liability analysis is concerned are how it was that the Complainant was able to bring what appear to have been illicit substances into a police cell, and then consume them. The first requires an assessment of the searches that were conducted of the Complainant prior to his being placed in the cell. These searches, consisting of searches of and over his clothing, and of a bag he had with him, turned up a quantity of drugs and drug paraphernalia. The searches seem to have been conducted in a thorough fashion. And, as the drugs the Complainant accessed while in the cell appear to have been secreted in his underwear and/or, possibly, in his person, it is not surprising that the searches failed to discover them. It might well be that a strip search would have revealed the substances that the Complainant would later consume. Indeed, the officers did consider conducting a strip search, but the request was denied by WO #4. As the Supreme Court of Canada made clear in R v Golden, [2001] 3 SCR 679, given their inherently humiliating nature, a strip search is only permissible where there are reasonable and probable grounds to conclude that it is necessary. Given the circumstances that prevailed – a detainee having turned himself in seemingly good health and unimpaired – I am unable to reasonably conclude that a strip search was necessarily warranted in this case.

The second issue is concerned with the adequacy of the supervision received by the Complainant while in custody. Here, too, I am satisfied that the Complainant’s custodians did not run afoul of the criminal law. While the Complainant was not routinely physically checked by police personnel, the evidence indicates that he was checked via video monitor every 30 minutes or so while in cells, and that none of those checks gave rise for concern. Again, had the Complainant been deemed a higher risk prisoner, it is conceivable he would have received more frequent checks and that his drug consumption could have been detected sooner than it was, or, possibly, even prevented. That said, there was no particular reason to believe the Complainant was a high risk. To reiterate, he appeared in good health and seemed sober, and drugs had already been confiscated from his clothing.

Lastly, it is important to note that the Complainant’s drug consumption was, in fact, detected in fairly short order, and that the officers acted quickly to render medical care while waiting for paramedics to arrive.

In the result, while the cause of the Complainant’s death remains unascertained at this time, I am satisfied that it is not attributable to any conduct on the part of the SO or any other

police officer that transgressed the limits of care prescribed by the criminal law. As such, there is no basis for proceeding with criminal charges in this case. The file is closed.

Date: May 23, 2025

Electronically approved by

Joseph Martino

Director

Special Investigations Unit