Explanatory note

The Ontario Government is releasing past SIU Director Reports (submitted to the Attorney General prior to May 2017) that include fatalities involving a firearm, physical altercation, and/or use of conducted energy weapon, or other extensive police interaction that did not result in a criminal charge.

Justice Michael H. Tulloch made recommendations about the release of past SIU Director Reports in the Report of the Independent Police Oversight Review, released on April 6, 2017.

Justice Tulloch explained that since past reports were not originally drafted for public release they may have to be edited substantially to protect sensitive information. He took into account that confidentiality assurances were given to various witnesses during the course of SIU investigations, and recommended that some information be redacted in the interests of privacy, safety, and security.

As recommended by Justice Tulloch, this explanatory note is being provided to assist the reader’s understanding of why certain information is redacted in these reports. Notes have also been inserted throughout the reports to help describe the nature of the information that was redacted and why it was redacted.

Law enforcement and personal privacy information considerations

Consistent with Justice Tulloch’s recommendations and guided by section 14 of the Freedom of Information and Protection to Privacy Act (FIPPA) (relating to law enforcement information), portions of these reports have been removed to protect:

  • confidential investigative techniques and procedures used by the SIU
  • information whose release could reasonably be expected to interfere with a law enforcement matter or an investigation undertaken with a view to a law enforcement proceeding
  • witness statements and evidence gathered in the course of the investigation, provided to the SIU in confidence

Consistent with Justice Tulloch’s recommendations and guided by section 21 of FIPPA (relating to personal privacy information), personal information, including sensitive personal information, has also been redacted, except that which is necessary to explain the rationale for the Director’s decision. This information may include, but is not limited to, the following:

  • subject officer name(s)
  • witness officer name(s)
  • civilian witness name(s)
  • location information
  • other identifiers which are likely to reveal personal information about individuals involved in the investigation, including in relation to children
  • witness statements and evidence gathered in the course of the investigation, provided to the SIU in confidence

Personal health information

Information related to the personal health of individuals that is unrelated to the Director’s decision (taking into consideration the Personal Health Information Protection Act, 2004) has been redacted.

Other proceedings, processes, and investigations

Information may have also been excluded from these reports 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.

Director’s report

Notification of the SIU

On Friday, June 21, 2013, at 2340 hrs, Notifying Officer of the Saugeen Shores Police Service (SSPS) notified the SIU of an incident that had taken place at approximately 2300 hrs that evening. Notifying Officer reported that a man, who was later identified as 47-year-old Port Elgin resident Deceased, had broken into his neighbour’s home and police were called. Responding officers engaged in a struggle with Deceased and he soon became non-responsive. Deceased was transported to the Southampton Hospital. Deceased’s condition was not known to Notifying Officer at the time of the notification. Deceased was pronounced dead at the hospital.

Overview

Sensitive personal information

On Friday, June 21, 2013, at approximately 2243 hrs, Civilian Witness #1 and his family were inside their residence, located at a location in Port Elgin, when there were several booming noises heard at the front door of the residence. As Civilian Witness #1 made his way to the front door, the door suddenly exploded inward and Deceased entered the residence, dressed only in his underwear. Civilian Witness #1 grabbed hold of Deceased and they fell into a sunken living room located just off the front door. Deceased was ranting in an irrational manner as they struggled. One of the other occupants of the residence called 911 to request that police attend. Officers were dispatched and were advised that the intruder was threatening to kill the occupants.

Subject Officer #3 and Subject Officer #2 arrived and they attempted to gain control of Deceased, aided in their efforts by Civilian Witness #1. The officers were able to attach a handcuff to Deceased’s right wrist but were unable to fasten the handcuff to his left wrist. During the struggle, Subject Officer #3 was reportedly bitten twice by Deceased. Subject Officer #1 arrived and he/she immediately involved himself/herself in the struggle to handcuff Deceased. Subject Officer #1 was able to fasten his/her handcuffs to both of Deceased's wrists. Deceased was turned onto his side and it soon became apparent that he had become unresponsive. Subject Officer #1 started to perform chest compressions and the officers requested that an ambulance be dispatched.

Paramedics arrived and found Deceased to be vital signs absent (VSA). Deceased was transported to the Southampton Hospital, where he was pronounced dead.

The investigation

The SIU dispatched four investigators and two forensic identification investigators. The first SIU investigator arrived at the scene at 0256 hrs. The scene was photographed and measurements were recorded to be used in the preparation of a scale drawing.

On June 22, 2013, at 0622 hrs, the following officer designations were issued:

  • Subject Officer #1 subject officer
  • Subject Officer #2 subject officer
  • Subject Officer #3 subject officer
  • Witness Officer #1 witness officer
  • Witness Officer #2 witness officer

The use of force equipment worn by the subject officers was secured by the SSPS, for examination by the SIU forensic investigators. SIU forensic investigators removed the officers’ batons from their duty belts and secured the batons in sealed bags. The remaining equipment within the duty belts was photographed and returned to the police service. Handcuffs were missing from the duty belts of Subject Officer #3 and Subject Officer #1.

The SIU requested that the injuries suffered by Subject Officer #3 be photographed by the SSPS.

On June 22, 2013, SIU investigators conducted interviews with the following officers:

  • Subject Officer #1
  • Witness Officer #2
  • Witness Officer #1

Subject Officer #3 and Subject Officer #2 declined several requests for interviews.

SIU investigators interviewed the following civilian witnesses, on the dates noted:

  • Civilian Witness #1 (June 22, 2013)
  • Civilian Witness #2 (June 22, 2013)
  • Civilian Witness #3 (June 22, 2013)
  • Civilian Witness #4 (June 22, 2013)
  • Civilian Witness #5 (June 22, 2013)
  • Civilian Witness #6 (June 22, 2013)
  • Civilian Witness #7 (June 25, 2013)
  • Civilian Witness #8 (June 25, 2013)
  • Emergency Medical Personnel #1 (June 25, 2013)
  • Emergency Medical Personnel #2 (June 25, 2013)

On June 23, 2013, a post-mortem examination was conducted by Dr. Doctor, at the London Health Sciences Centre (University Hospital) in London.

Sensitive Personal Information

In the course of this investigation, the SIU requested, obtained and reviewed the following materials:

  • the Ambulance Call Report
  • the SSPS computer aided dispatch (CAD) report
  • the SSPS Occurrence Report
  • the SSPS Event Chronology
  • the SSPS Use of Force policy
  • SSPS use of force training records for the subject officers
  • Sensitive personal information
  • a SSPS transcript of the dispatch recordings
  • SSPS photographs of injuries suffered by Subject Officer #3
  • a list of civilian witnesses
  • the duty notes of all the witness officers and Subject Officer #1
  • the toxicology report from the Centre of Forensic Sciences (CFS), and
  • a copy of the Report of Post-Mortem Examination

The conclusion of this investigation was significantly delayed while the SIU awaited receipt of the post-mortem examination report, which was received by the SIU on December 2, 2013.

Confidential witness statements and evidence gathered in the course of the investigation provided to the SIU in confidence (Law Enforcement and Privacy Considerations)

Director’s Decision Under s. 113(7) of the Police Services Act

There are no reasonable grounds, in my view, to believe that any of the three subject officers - Subject Officer #1, and Subject Officer #2 and Subject Officer #3- committed a criminal offence in connection with Deceased's death on June 21, 2013.

At about 2245 hrs of the day in question, Deceased broke into the neighbour residence at a location in Port Elgin. Wearing nothing but underwear, Deceased was hysterical, violent and incoherent. He was quickly confronted by Civilian Witness #1, and the two men fell to the floor of the sunken living room to the left of the entranceway as one enters the home. They jostled vigorously with Civilian Witness #1 eventually gaining the upper hand, straddling Deceased from the top as Deceased lay on his back. Deceased continued to struggle to free himself, lapsing in and out of coherence, one moment asking to be let up, the next threatening to kill someone. Persons called the police and pleaded for help. About four- minutes after Deceased entered the home, Subject Officer #3 arrived at the residence, followed in very short order by Subject Officer #2. They quickly engaged Deceased with Civilian Witness #1’s assistance, but were unable to secure him in handcuffs because of Deceased's strenuous resistance. Subject Officer #1 arrived shortly after Subject Officer #2 and joined in the fray. Acting in concert, they were finally able to overpower Deceased, turning his body on its side and then in a prone position, at which point Subject Officer #1 was able to secure Deceased's arms behind his back in handcuffs. At approximately the same instant, Deceased fell into acute medical distress, went limp and stopped breathing. The officers immediately began CPR. Those efforts were picked up by attending paramedics, who arrived at about 2257 hrs. Regrettably, Deceased could not be revived. Regarding the cause of Deceased's death, the pathologist at autopsy concluded that it was a “Sudden death associated with Excited Delirium and Prone Restraint”. According to the pathologist, schizophrenia, coronary atherosclerosis and obesity were also contributing factors in the death.

The officers were clearly in the discharge of their duties when they responded to the neighbour residence and attempted to physically subdue Deceased. Deceased, for reasons beyond his control, was a clear and present danger to the health and safety of the home’s residents. He had barged into the home with extreme violence, assaulted Civilian Witness #1 and threatened one or more of the residents with death. In light of Deceased's aggression and level of resistance, it is apparent to me that the officers used no more force than was reasonably necessary in the circumstances. It is noteworthy that none of the officers, according to the eyewitness evidence, actually struck Deceased or used any of their weapons. Rather, it would appear they relied on their muscular force in what was essentially a wrestling contest to eventually secure Deceased's arms in handcuffs. As soon as it became apparent that Deceased had stopped breathing, they rolled him on his back and quickly applied CPR, continuing in their efforts until the paramedics arrived. I am satisfied in these circumstances that the officers were justified in their use of force. I am further satisfied that the officers were alive to the dangers of positional asphyxia and acted promptly to mitigate those risks as soon as it was reasonably feasible to do so.

A word on the findings of the post-mortem examination is warranted. To reiterate, the report of that examination concludes that Deceased's demise was a “Sudden Death associated with Excited Delirium and Prone Restraint”. The “excited delirium” aspect of that diagnosis is not problematic. It seems obvious that Deceased was in the throes of an acute manic episode brought about by a mental condition that seemed to be rapidly deteriorating in the days and hours preceding his death. With respect to “prone restraint”, it is apparent that the officers positioned Deceased on his front for a short period of time and, therefore, may well have contributed to his death. This too causes me no concern in light of my finding, for the reasons set out above, that the officers were justified in taking the action they did. The more interesting and potentially problematic aspects of the pathologist’s report relate to his/her findings of a broken larynx, petechia in one of Deceased's eyes and a fractured sternum. With respect to the fractured sternum, the pathologist noted that the injury was consistent with having been caused by resuscitation efforts, which we know occurred. At first blush, the broken larynx and petechia are suggestive of neck compressions. Indeed, the pathologist states clearly in his/her report that the fractured larynx “is an indicator of neck compression”. The pathologist also notes, however, that there was no associated skin injury or internal neck trauma, and that “[o]nly a petechia was seen on an eye”. The pathologist further notes that the fractured larynx could have been caused by an impact, such as a fall, and that the petechia “could have arisen from resuscitation”. Its significance in terms of the cause of death, according to the pathologist, was “uncertain”. This evidence raises the spectre of a choke hold applied to Deceased, which would clearly up the ante in terms of the severity of the police force in question and its propriety in the circumstances. On the other hand, Civilian Witness #1 also struggled with Deceased for quite some time. However, in light of the equivocal nature of this evidence, I am of the view that it falls short of establishing that Deceased was likely choked during the incident or that it otherwise tips the scales in favour of a finding that one or more of the officers or anyone else used excessive or unnecessary force.

Date: April 28, 2014

Tony Loparco
Director
Special Investigations Unit

Appendix "A"

There were no issues identified with respect to the officer notes.