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 59-year-old man (the “Complainant”).

Notification of the SIU[1]

On September 12, 2024, at 9:39 a.m. [ET],[2] the Ontario Provincial Police (OPP) contacted the SIU with the following information.

On September 11, 2024, in the afternoon, OPP were called to the Northern Store in Pickle Lake for intoxicated males hanging around the front of the store. While officers were dealing with certain individuals, they heard someone fall from behind them. It sounded like the person had struck his head on the ground. The officers went to check on the person – the Complainant – and called for Emergency Medical Services (EMS). EMS responded and medically cleared the Complainant. There were no visible injuries, and the Complainant did not complain of any pain. Having been cleared by EMS, officers arrested the Complainant for public intoxication. He did not resist, and no use of force was required. The Complainant was transported to the OPP detachment. He was conscious, lucid and conversing with officers inside the cruiser en route to the detachment. Video at the detachment showed the Complainant getting out of the cruiser and walking into the custody unit on his own. He was processed, lodged in a cell, and monitored at regular intervals. At about 2:40 a.m., the custody officer noted the Complainant was having breathing issues; he was unresponsive and gasping. EMS were called and the Complainant was transported to the Mishkeegogamang Nursing Station where his condition worsened. Doctors called his family, and the Complainant was airlifted to the Thunder Bay Regional Health Sciences Centre (TBRHSC).[3]

The Team

Date and time team dispatched: 2024/09/12 at 5:00 p.m.

Date and time SIU arrived on scene: 2024/09/12 at 5:42 p.m.

Number of SIU Investigators assigned: 3

Number of SIU Forensic Investigators assigned: 1

Affected Person (aka “Complainant”):

59-year-old male; deceased

Civilian Witnesses (CW)

CW #1 Interviewed

CW #2 Interviewed

CW #3 Interviewed

CW #4 Interviewed

The civilian witnesses were interviewed between October 7, 2024, and October 15, 2024.

Subject Officials (SO)

SO #1 Declined interview, as is the subject official’s legal right; written statement received and reviewed

SO #2 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 Interviewed

The witness officials were interviewed between October 10, 2024, and May 7, 2025.

Service Employee Witness (SEW)

SEW Interviewed

The service employee witness was interviewed on October 15, 2024.

Investigative Delay

An expert opinion relating to the Complainant’s death was received by the SIU from the Ontario Forensic Pathology Service on November 7, 2025.

The Scene

The events in question transpired outside the Northern Store, 6 Koval Street, Pickle Lake, and in a cell of the OPP Pickle Lake Detachment.

Expert Evidence

Postmortem Examination and Toxicology Reports

The Complainant died at TBRHSC on September 14, 2024.

On September 18, 2024, a pathologist conducted a postmortem examination of the Complainant. The final report was completed January 24, 2025.

The postmortem examination revealed blunt force head trauma with no visible surface injury to the scalp. There was a linear fracture of the right temporal-parietal bone and subsequent underlying epidural hematoma, brain edema, midline shift, and herniation. The injuries to the head could be explained by a fall onto a blunt surface. The delay in the onset of the Complainant’s loss of consciousness was common in the setting of an epidural hematoma. This was commonly referred to as the ‘lucid interval’, during which time the size of the epidural hematoma continues to expand until a person’s neurological status rapidly deteriorates.

Toxicologic testing detected tetrahydrocannabinol, cannabidiol, carboxytetrahydro-cannabinol, beta-hydroxybutyrate, acetone, and ethanol. The concentration of beta-hydroxybutyrate was elevated but below the range considered pathologically significant (>250 mg/L).

Death was attributed to blunt force head trauma.

Consultation Report from Ontario Forensic Pathology Service

By way of letter to the SIU dated November 7, 2025, the Ontario Forensic Pathology Service made the following observations in relation to the Complainant’s death:

• I agree with the findings and opinions in the autopsy report and the cause of death. The cause of death was a head injury with skull fracture causing a fatal epidural hematoma. The epidural hematoma was inevitably fatal. The only chance for survival was neurosurgical intervention.

• The underlying issue in this case is the extent to which non-medical onlookers would necessarily conclude that urgent medical/surgical care was imperative. I cannot answer that question.

Video/Audio/Photographic Evidence[4]

Video Footage - Northern Store

[The recordings only revealed a portion of the activity in front of the Northern Store and did not capture the Complainant falling.]

On September 11, 2024, starting at about 3:09:38 p.m., a male wearing a blue T-shirt and brown jacket, and carrying a backpack, staggered along the front of the Northern Store. Three other males hung out in front of the Northern Store. A fifth male joined the group. CW #2 joined the group at the front of the store, followed by CW #1, at which point there were seven people in the group. The group at the front of the store subsequently dispersed.

Starting at about 3:12:15 p.m., two marked OPP cruisers arrived at the Northern Store and stopped. The cruisers were driven by WO #2 and WO #1. WO #2 was captured walking with a male wearing a red T-shirt from the left side of the Northern Store. The male wearing the brown jacket, CW #2 and CW #1 walked to the right end of the Northern Store, away from the cruisers. WO #1 walked to WO #2’s cruiser and assisted him with loading the male with a brown jacket inside.

Starting at about 3:16:15 p.m., WO #1 went inside the Northern Store. He later exited and carried what was believed to be a towel.

Starting at about 3:23:14 p.m., an ambulance arrived at the Northern Store and a paramedic spoke to the officers. The paramedic went out of sight on the left side of the store.

Starting at about 3:25:14 p.m., the paramedic went to the ambulance and returned with a medical bag.

Starting at about 3:30:48 p.m., the paramedic packed his equipment into the ambulance.

Starting at about 3:31:25 p.m., the Complainant was captured standing and walking with the paramedic and WO #2. He had a backpack on. The Complainant walked along the driver’s side of the ambulance and then out of sight. CW #1 was also present. The paramedic went inside the Northern Store.

Starting at about 3:34:20 p.m., WO #2 departed in his cruiser.

In-car Camera (ICC) Footage – WO #2’s Cruiser (Times Denoted in ET)

On September 11, 2024, starting at about 4:32:35 p.m., the back driver’s side door opened. WO #2 tried to coax the Complainant into the cruiser; the Complainant was reluctant. WO #2 said, “It is a safe spot for you to go.” A female [believed to be CW #1] spoke to the Complainant. Some indecipherable words were spoken, but she was heard to say to the Complainant, “Listen.” The officer said, “Listen to your little one here,” and the Complainant got in the back seat. The Complainant wore jeans, a grey shirt, and a dark jacket. He was not handcuffed. He appeared intoxicated. WO #2 told the dispatcher that EMS had cleared the Complainant, and he had been arrested for public intoxication. The Complainant sat quietly in the back seat.

Starting at about 4:39:24 p.m., WO #2 said, “You good, [the Complainant’s first name]?” The Complainant said, “Uh-huh.”

Starting at about 4:43:24 p.m., the driver side back door was opened. The officer helped move the Complainant’s left leg out of the cruiser. The Complainant got out and the officer said, “Do you remember falling down?” The Complainant said, “No.” The officer said, “Do you want to take my hand?” The Complainant replied, “No.”

Video Footage – OPP Pickle Lake Detachment – Custody Area (Times Denoted in ET)

On September 11, 2024, starting at about 4:44:03 p.m., the Complainant walked into the booking room with WO #2. The Complainant was not handcuffed. He sat on a bench beside the booking desk.

Starting at about 4:44:46 p.m., the Complainant removed his jacket by pulling it over his head and placed it into a property bin on the floor. The Complainant wore jeans, a T-shirt, running shoes and a belt. The Complainant removed all the items and placed them in the property bin himself.

Starting at about 4:46:01 p.m., the Complainant stood up, walked to a wall, and placed his hands on it. The Complainant was searched by WO #2 and a second male officer. The Complainant walked from the booking area through the doorway that led to cells.

Starting at about 4:47:00 p.m., the Complainant walked into the cell. There were no beds in the cell. The Complainant gently laid down onto the floor on his left side. He moved from his left side to his back, and then onto his sides several times.

Starting at about 5:07:27 p.m., the SEW brought a blanket to the cell and left it between the bars. The Complainant continued to roll from his side to his back.

Starting at about 10:08:18 p.m., CW #3 was escorted to the cell by a male officer. He was provided a blanket and laid on the floor opposite the Complainant.

Starting at about 1:24:57 a.m., September 12, 2024, SO #1 carried a property bin and entered the cell. SO #1 touched the Complainant’s right shoulder, followed by his neck and right shoulder. The Complainant rolled onto his back from his left side. SO #1 appeared to do sternum rubs on the Complainant. The SEW stood at the cell door and appeared to speak to SO #1, who continued to perform sternum rubs on the Complainant.

Starting at about 1:26:34 a.m., SO #1 left the cell.

Starting at about 1:28:02 a.m., CW #3 walked to the Complainant and appeared to try and wake him. CW #3 walked to a sink, then back to the Complainant and checked his left wrist. CW #3 then went back to laying on the floor as the Complainant remained on his back.

Checks of the cell were conducted periodically by the SEW.

Starting at about 3:36:40 a.m., the SEW was at the door to the cell.

Starting at about 3:39:03 a.m., SO #1 was in the cell and walked to the Complainant. She conducted sternum rubs and rolled the Complainant onto his left side into the recovery position.

Starting at about 3:39:54 a.m., SO #1 left the cell with the door open.

Starting at about 3:40:54 a.m., SO #1 returned to the cell. She again rolled the Complainant onto his left side. WO #3 arrived and put a blanket under the Complainant’s head.

Starting at about 3:46:19 a.m., SO #1 left the cell while WO #3 held the Complainant in the recovery position.

Starting at about 3:52:48 a.m., SO #1 returned to the cell, woke CW #3 and removed him from the cell.

Starting at about 3:58:27 a.m., a female paramedic arrived in the cell with SO #1. The Complainant was tended to by the paramedic with the assistance of a male in civilian clothes. A stretcher was brought to the cell.

Starting at about 4:22:30 a.m., the Complainant was placed onto the stretcher by the paramedic and the officers and was subsequently removed from the cell.

OPP Communications Recordings (Times Denoted in ET)

On September 11, 2024, between about 4:15 p.m. and 4:27 p.m., WO #2 broadcast that there was a male passed out in front of the Northern Store on Koval Street and an ambulance was required. WO #1 later reported an ambulance being on scene. WO #1 later broadcast that he was heading to the detachment with two males. An OPP communicator called for an ambulance to attend Koval Street for someone passed out. OPP officers were on scene.

On September 12, 2024, starting at about 3:40:13 a.m., SO #1 advised the dispatcher that she needed an ambulance to attend the detachment for the Complainant. The Complainant was in a very deep sleep and gasping for air, and she was having difficulty waking him.

Starting at about 3:41:03 a.m., OPP called EMS and requested an ambulance to the Pickle Lake OPP cells for a 59-year-old male who was having trouble waking up. The male was not fully awake, conscious, and gasping for air.

Starting at about 3:42:02 a.m., a sergeant from the Provincial Communications Centre spoke to SO #1. SO #1 said that a 59-year-old male, the Complainant, had been brought in for public intoxication. Prior to coming into the detachment, he had fallen at the Northern Store. Paramedics were called and cleared him. He was put into a cell at the Pickle Lake Detachment. At 12:20 a.m., SO #1 went to release him. She tried to wake him, but he was in a super deep sleep. She tried a sternum rub on him. He was in a deep sleep, so she decided to let him sleep for a couple more hours. A guard subsequently indicated the Complainant was shallow breathing and gasping for air. SO #1 went to the Complainant. The Complainant was gasping for air, so she put him on his side, and he started to breath easier. EMS attended and put a tube in him. SO #1 went in the ambulance to assist the single paramedic. The Complainant was said to be at the clinic and unconscious. Nothing had happened in the cells; the Complainant had not fallen.

Materials Obtained from Police Service

Upon request, the SIU obtained the following records from the OPP between September 17, 2024, and October 7, 2024:

• Arrest / General / Supplementary / Custody Reports
• Communications recordings
• Event Details Report
• ICC footage
• Custody area footage
• Forensic photographs taken at TBRHSC
• Notes - WO #1, WO #2, WO #3 and WO #4
• Prisoner Care Workbook
• Prisoner Care Manual

Materials Obtained from Other Sources

The SIU obtained records from the following other sources between October 9, 2024, and November 7, 2025.

• Video footage from the Northern Store
• Ambulance Call Report from the Northwest EMS
• Toxicology Report from the Centre of Forensic Sciences
• Preliminary Autopsy Findings Report from the Ontario Forensic Pathology Service
• Report of Postmortem Examination from the Coroner’s Office
• Consultation Report relating to the Complainant’s death from the Ontario Forensic Pathology Service

The evidence collected by the SIU, including interviews with police and non-police witnesses, gives rise to the following scenario. As was their legal right, neither subject official agreed an interview with the SIU or the release of their notes. SO #1 did provide the SIU a written statement.

In the afternoon of September 11, 2024, the Complainant was outside the Northern Store, 6 Koval Street, Pickle Lake, when he fell and struck his head on the ground. He had been drinking and was intoxicated. WO #1 and WO #2 were present in the area, dealing with others they had arrested for public intoxication. They heard the Complainant fall and went to render assistance. Concerned that he might have suffered a head injury, the officers arranged to have paramedics attend the scene.

Paramedic CW #4, working alone, arrived at the store and assessed the Complainant for a possible head injury. CW #4 looked for trauma to the body and found none. Concluding there were no immediate health concerns, the paramedic medically cleared the Complainant and then assisted WO #2 in lifting him from the ground.

The Complainant was arrested for public intoxication and transported by WO #2 in his cruiser to the OPP Pickle Lake Detachment. He was searched at the station and lodged in a cell at about 3:47 p.m., and fell asleep. Though unsteady on his feet, he had walked on his own power during the booking procedure. A civilian guard – the SEW – was assigned to monitor the prisoners in the cells.

The Complainant slept in his cell. At about 12:30 a.m., September 12, 2024, SO #1 entered the cell intending to release the Complainant. When the Complainant could not be woken, the officer left the cell intending to release him later that morning.

A couple of hours later, the SEW, concerned with the breathing sounds the Complainant was making, alerted SO #1. The officer entered the cell and heard the Complainant gasping for air. She unsuccessfully attempted to rouse him, including with the use of sternum rubs, and decided to contact paramedics.

A paramedic and a firefighter arrived at the cell at about 3:00 a.m. The Complainant was loaded into an ambulance and taken to the Mishkeegogamang Nursing Station. He was subsequently transported to hospital in Thunder Bay, where he passed away on September 14, 2024.

Cause of Death

The pathologist at autopsy was of the view that the Complainant’s death was attributable to blunt force head trauma. The Complainant had suffered “a linear fracture of the right temporal-parietal bone and subsequent underlying epidural hematoma, brain edema, midline shift, and herniation”.

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.

Section 31, Liquor Licence and Control Act - Intoxication

31 (1) No person shall be in an intoxicated condition in,

(a) a place to which the general public is invited or permitted access; or

(b) any part of a residence that is used in common by persons occupying

more than one dwelling in the residence.

(2) A police officer or conservation officer may arrest without warrant any person who is contravening subsection (1) if, in the opinion of the officer, it is necessary to do so for the safety of any person.

The Complainant lapsed into medical crisis while in the custody of the OPP on September 12, 2024, and subsequently passed away on September 14, 2024. The SIU was notified of the incident and initiated an investigation. Two OPP officers were identified as subject officials: SO #1 (the officer with the most direct and consequential dealings with the Complainant while he was in police cells) and SO #2 (the senior supervisory officer ultimately responsible for prisoner care and control). The investigation is now concluded. On my assessment of the evidence, there are no reasonable grounds to believe that either subject official 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 either SO #1 or SO #2, sufficiently serious to attract criminal sanction, that endangered the Complainant’s life or caused his death. In my view, there was not.

I am satisfied that the Complainant was lawfully in police custody through the events culminating in his medical distress in cells. The Complainant, intoxicated and unsteady on his feet at the Northern Store, had fallen and temporarily passed out. It was apparent that he was subject to arrest under section 31 of the Liquor Licence and Control Act, 2019.

I am also satisfied that the evidence falls short of reasonably establishing that either subject official transgressed the standard of care prescribed by the criminal law in relation to the Complainant. SO #1 should have called for medical care when she was unable to wake the Complainant in his cell at about 12:30 a.m. Indeed, recognizing the particular vulnerability of intoxicated persons, OPP policy requires that emergency medical attention be immediately summoned when an intoxicated person cannot be roused. Instead, SO #1 decided to let him “sleep it off” with the intention of releasing him later that morning when he woke up. On the other hand, if SO #1’s decision was a questionable one, it was not entirely without foundation given her prior experience with the Complainant, which led her to believe that he was simply in a deep sleep because of his intoxication. Moreover, there is no evidence indicating that SO #1 was aware that the Complainant had struck his head in a fall. That information, had she had it, would have made the case for accessing emergency medical care more compelling. Rather, SO #1 had been told that the Complainant was checked by a paramedic at the arrest scene and medically cleared. Lastly, as soon as the officer learned that the Complainant’s breathing had become laboured, she acted with dispatch in rendering care and calling for paramedics. On this record, weighing SO #1’s failure to secure emergency medical care for the Complainant when she first checked on him against the extenuating considerations, I am unable to reasonably conclude that the officer’s omission amounted to a marked departure from a reasonable standard of care, and even less a marked and substantial one.

For the foregoing reasons, there is no basis for proceeding with criminal charges in this case against SO #1. As she was a step removed from the situation and had no direct contact with the Complainant, the same is true of SO #2.

It should be noted that the SIU has referred issues pertaining to the Complainant’s supervision in cells to the OPP’s Commissioner for his service’s review. Further to the SIU’s legal obligation under section 35.1 of the Special Investigations Unit Act, 2019, the matter is also being referring to the Law Enforcement Complaints Agency.

Date: November 28, 2025

Electronically approved by

Joseph Martino

Director

Special Investigations Unit