In the writing of this report, many individuals contributed their time, expertise, and guidance, and we wish to acknowledge their invaluable support. We extend our sincere gratitude to all staff in our office who have assisted along the many stages of this process. In particular, Julie Erbland helped with the development of our process, participated in several of the initial interviews and provided assistance that was significant and impactful.

This report would not have been possible without all the individuals who participated in the review. This includes all the professionals, friends and family members and others who generously shared their insights, experiences, and wisdom to enhance our understanding and inform the development of the recommendations. It is only through your commitment and dedication to CSE that this report could have been completed. It must be stated that the effort and commitment of all those involved served as the driving force and energy of this review. Thank you all.

It is also important to recognize all the individuals who work in this field for their dedication to a society that cares for all its citizens while also fulfilling a mandate to protect, preserve the life of, and serve all those same citizens.

Finally, it must be acknowledged that it was the unfortunate death of each of the 34 individuals that resulted in the need for this review to occur. These lives, full of promise and potential, were lost too soon and they continue to be missed by those who mourn them. We, as a society, also mourn these losses and are thankful for their commitment and contributions to a more just, safe and humane society.