Mandate of the SIU

The Special Investigations Unit is a civilian law enforcement agency that investigates incidents involving police officers where there has been death, serious injury or allegations of sexual assault. The Unit’s jurisdiction covers more than 50 municipal, regional and provincial police services across Ontario.

Under the Police Services Act, the Director of the SIU must determine based on the evidence gathered in an investigation whether an officer has committed a criminal offence in connection with the incident under investigation. If, after an investigation, there are reasonable grounds to believe that an offence was committed, the Director has the authority to lay a criminal charge against the officer. Alternatively, in all cases where no reasonable grounds exist, the Director does not lay criminal charges but files a report with the Attorney General communicating the results of an investigation.

Information restrictions

Freedom of Information and Protection of Personal Privacy Act (“FIPPA”)

Pursuant to section 14 of FIPPA (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 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.

Pursuant to section 21 of FIPPA (i.e., personal privacy), protected personal information is not included in this document. 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
  • 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 (“PHIPA”)

Pursuant to PHIPA, any information related to the personal health of identifiable individuals is not included.

Other proceedings, processes, and investigations

Information may have also 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.

Mandate engaged

The Unit’s investigative jurisdiction is limited to those incidents where there is a serious injury (including sexual assault allegations) or death in cases involving the police.

“Serious injuries” shall include those that are likely to interfere with the health or comfort of the victim and are more than merely transient or trifling in nature and will include serious injury resulting from sexual assault. “Serious Injury” shall initially be presumed when the victim is admitted to hospital, suffers a fracture to a limb, rib or vertebrae or to the skull, suffers burns to a major portion of the body or loses any portion of the body or suffers loss of vision or hearing, or alleges sexual assault. Where a prolonged delay is likely before the seriousness of the injury can be assessed, the Unit should be notified so that it can monitor the situation and decide on the extent of its involvement.

This report relates to the SIU’s investigation into the death of a 50-year-old man following his interaction with police on July 20th, 2017.

The investigation

Notification of the SIU

At approximately 2:00 a.m. on Thursday, July 20th, 2017, the Thunder Bay Police Service (TBPS) notified the SIU of the death of the 50-year-old Complainant while in police custody.

The TBPS reported that on Wednesday, July 19th, 2017, at approximately 7:51 p.m., TBPS police officers responded to a call for an intoxicated person, at the rear of an address in the City of Thunder Bay. Superior North Emergency Medical Services (SNEMS) paramedics were also present and examined the Complainant and medically cleared him.

Witness Officer (WO) #1 and WO #2 drove the Complainant to his residence but the occupant would not allow the Complainant entry because of his state of intoxication. WO #1 and WO #2 then checked with the local detox centre, but there were no beds available. As a result, the Complainant was arrested for public intoxication and transported to the TBPS police station at 8:12 p.m. where he was lodged in a cell. Shortly after midnight on July 20th, 2017, during a physical check of prisoners, it was found that the Complainant was not breathing and cardio pulmonary resuscitation (CPR) was performed on him by WO #1 and WO #4. The SNEMS was contacted and the Complainant was transported to hospital, where he was pronounced dead at 1:34 a.m.

The Team

Number of SIU Investigators assigned: 4

Number of SIU Forensic Investigators assigned: 1


50-year-old male, deceased

Civilian Witnesses

CW #1 Interviewed

CW #2 Interviewed

CW #3 Interviewed

CW #4 Interviewed

CW #5 Interviewed

CW #6 Interviewed

CW #7 Interviewed

Witness Officers

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

Subject Officers

SO #1 Declined interview and to provide notes, as is the subject officer’s legal right

Incident narrative

On July 19th, 2017, at approximately 7:51 p.m., police and SNEMS responded to a 911 call to the Victoriaville Mall in the City of Thunder Bay to assist the Complainant. Upon the arrival of WO #1 and WO #2, the paramedics were already present and speaking with the Complainant, who was obviously intoxicated. Once the Complainant was medically cleared by paramedics, police escorted him to their police cruiser and made attempts to find him a place to stay. When that was unsuccessful, he was arrested for being intoxicated in a public place, contrary to the Liquor Licence Act, and transported to the police station to be lodged in a cell until he sobered up and could be released.

At 12:21 a.m., the Complainant was observed, during one of the routine cell checks, not breathing and help was immediately summoned and police officers started CPR. When paramedics arrived, they continued life saving measures and the Complainant was transported to the hospital.

Nature of Injuries / Treatment

The Complainant was assessed as vital signs absent (VSA) in the cell block of a TBPS facility by police officers who began CPR and called paramedics. Paramedics attended and continued the care of the Complainant, until he was transferred to staff at the hospital. Efforts to revive the Complainant were unsuccessful and at 1:34 a.m., he was pronounced dead.

The Complainant’s body was then transported, under seal, to the Office of the Chief Coroner in Toronto where, on Saturday, July 22nd, 2017, a post-mortem examination was conducted. The pathologist’s preliminary autopsy findings listed the Complainant’s cause of death as ‘pending ancillary tests’, specifically the results of histology, toxicology, microbiology, and virology tests to be performed on biological samples submitted to the Centre of Forensic Sciences (CFS).

On Tuesday, January 9th, 2017, a toxicology report was received by the SIU from the CFS, dated September 27th, 2017, along with an Ontario Forensic Pathology Service report, authored by the forensic pathologist and dated December 18th, 2017, from the office of the Regional Supervising Coroner, North Region, in Thunder Bay. The report indicated that given the history, autopsy findings, and ancillary tests, the death of the Complainant was attributed to hypertensive heart disease.


The Scene

The cell block area in the TBPS facility consists of a monitor room, which has monitors that view all cells, a booking area, which has two cameras mounted on the ceiling, and several rooms for Breathalyzer tests, first aid, and fingerprinting. There is a washroom, a custodian’s area, and a doorway to the sally port. Additional doorways, adjacent to the monitor room, lead to the women’s custody area and youth cells. Through a doorway, on the south wall from the booking room, is a long hallway that contains two large rooms that house a number of cells in each along with a video remand area and a shower area. That hallway has two cameras mounted on the ceiling, one at the north end and one at the south end.

The Complainant had been in the first large room off the east side of that long hallway in cell 12. There are a total of ten cells in the room. Each cell contains a concrete bench and a toilet. There is a camera above each cell that points at the cell across the small hallway space. In addition, there is a camera located on the farthest east wall that points toward the entrance door from the hallway. There are a total of 11 cameras in the room.

Photo of Cell 12

Photo of Cell 12

Photos of Cell 12 and Hallway

Photos of Cell 12 and Hallway

Photos of Cell 12 and Hallway

Scene Diagram

A total station drawing of the cell area was created by SIU forensic investigators.

Forensic Evidence

Post-Mortem biological samples of the Complainant’s femoral blood, heart blood, and urine were submitted to the CFS for analysis.

Video/Audio/Photographic Evidence

TBPS Cell Block Video July 19, 2017

The cell block video was comprised of five video files labelled as follows:

[157] Cell 12, [182] Sally Port, [192] Booking Room, [223] Cells 06-15, and [167] Male Cells North

At 8:11:32.51 p.m., [182] Sally Port : A dark haired male police officer [now known to be WO #2], exited the front passenger door of the police vehicle and a bald male police officer [now known to be WO #1] exited the driver’s door of the police cruiser. At 8:12:22.48 p.m., the Complainant exited the cruiser by the rear driver’s side door. WO #2 entered the sally port by the door to the right of the screen. The Complainant was not handcuffed and he had a brace on his right wrist. He wore a brown T-shirt and blue jeans and walked on his own. WO #1 held the Complainant’s left bicep with his right hand and guided him. The Complainant walked through the door to the right of the screen with the two police officers and entered the booking room.

At 8:12:52.82 p.m., [192] Booking Room: the Complainant was walked to the centre of the booking area outlined with a yellow rectangle on the floor. The Complainant was told to stand and face the wall with the desk. WO #1 was on the left side of the Complainant and held the Complainant’s upper left arm with his right hand. WO #2 was on the right side of the Complainant and held the Complainant’s upper right arm with his left hand.

Both police officers searched the Complainant’s outer garments and asked the Complainant what happened to his wrist; the Complainant did not respond. The Complainant brought his left hand to his mouth as if he was going to vomit and WO #1 asked him if he was going to be sick; the Complainant made gagging sounds. WO #1 grabbed a garbage can and placed it in front of the Complainant. The Complainant was walked to a metal bench to the left of the yellow rectangle and he sat down with the garbage can placed in front of him by the bald police officer. Both police officers stepped away, while the Complainant bent forward with his head over the garbage can. The Complainant made noises as if he was vomiting, but it was difficult to see if he actually did. The Complainant asked for some juice and was told he could have something to drink once he got into the cell.

WO #3 entered the booking room. It appeared that the Complainant coughed up or vomited something. WO #3 filled out paperwork at the front of the desk. The Complainant made more gagging noises and leaned over the garbage can. WO #2 said, “Sprained right wrist” to WO #3. WO #2 said, “Roland, do you take medication for anything?” and the Complainant barely shook his head no. WO #2 asked the Complainant if he was feeling better. The Complainant was told that the sooner he was searched the sooner he could go to his cell and get a juice.

WO #3 asked the Complainant if he had any health conditions which she needed to know about and WO #2 said no. The Complainant took off his shoes. WO #3 told the Complainant she was going to let him keep the brace on his arm but if he fiddled with it she was going to take it off. The Complainant said he wanted some juice and WO #3 told him he would get some in a minute.

The male police officers searched the pant legs of the Complainant while he was in a seated position. The male police officers stood the Complainant up while they supported his upper arms with their hands. They searched the back of the Complainant’s pants. The Complainant was walked through the doorway to the left of the desk.

At 8:16:49.27 p.m., Cells 06-15: The Complainant was walked down the hallway.

At 8:16:58.40 p.m., [167] Male Cells North: The Complainant was brought into the cell area and walked to cell 12.

At 8:17:14.76 p.m., Cell 12: The Complainant was placed into Cell 12 by WO #2 and WO #1. The Complainant sat down in the middle of the bed with his legs to the left of the bed. WO #1 closed the cell door. A green juice box was on the bed to the left of the Complainant. The cells to the left and right of cell 12 were unoccupied. The Complainant lay down on his right side on the bed with his knees bent and his legs on the bed and he appeared to fall asleep. At 8:30:09.76 p.m., the Complainant shifted position on his right side and both his feet moved off the bed, to the left, briefly, and he resumed his position with his feet on the bed. The Complainant appeared to be rocking forward and back as he breathed in and out. His abdomen moved up and down. The Complainant’s upper body rocked slightly forward and backward as he breathed in and out.

At 8:31:59 p.m., the Complainant rolled to his left and his upper left arm was against the wall beside the bed and the Complainant extended his legs.

At 8:33:02.81 p.m., the complainant’s breathing appeared to be heavy and his chest rocked slightly as he breathed.

At 8:34:04.42 p.m., WO #3 stood in front of cell 12 and watched the Complainant.

At 11:48 p.m., WO #3 entered the cell area and walked down the middle of the row of cells looking left and right then walked back and left via the same door.

At 11:49:41.25 p.m., the Complainant appeared to take shallow breaths and his abdomen raised and lowered less as he breathed.

At 12:06:42.15 a.m., July 20, 2017, the Complainant’s abdomen was still and did not move up and down.

At 12:21:43.99 a.m., WO #4 stopped at Cell 12 and looked inside. WO #4 removed his ASP baton from his belt and extended it. He reached through the cell bars with the baton in his right hand. His back was to the camera and his actions were blocked.

At 12:22:55.01 a.m., WO #4 collapsed his baton by banging it on the floor and he walked towards the cell area door.

At 12:23:05.45 a.m., WO #4 left the area.

At 12:24:04.88 a.m., WO #4 returned to the cell area with the SO. WO #4 entered cell 12 and he used his right hand to shake the Complainant. The SO entered the cell and WO #4 looked like he did something to the Complainant’s face to revive him, while the SO pulled at the Complainant’s left arm to revive him.

At 12:24:40.83 a.m., the SO left cell 12 and WO #4 rolled the Complainant to the left and placed him completely on his back and started to do chest compressions.

At 12:25:47.85 a.m., a voice said “we need an ambulance to the cell block for a guy not breathing.” The SO and a bald male police officer ran into the cell block.

At 12:27:15.87 a.m., the SO entered cell 12 and exited the cell and WO #4 continued with CPR. A repeated broadcast over the paging system said, “Emergency at the north male cells.”

At 12:27:42.28 a.m., the SO left cell 12 and at 12:28:00.49 a.m., the SO returned to cell 12 followed by two bald male police officers. One of the police officers opened a black bag, while WO #1 took over from WO #4 and did chest compressions. At 12:28:48.10 a.m., WO #1 continued to give the Complainant chest compressions.

At 12:30:44.33 a.m., an ambulance entered the sally port, and at 12:31:55.35 a.m., the paramedics entered cell 12 and assumed the care of the Complainant. At 12:34:22.39 a.m., the Complainant was placed on the stretcher with the assistance of WO #1. The Complainant was wheeled out of cell 12, through the booking room, and into the sally port. The video finished.

Communications Recordings

Both police and SNEMS transmissions recordings were obtained and reviewed.

Materials obtained from Police Service

Upon request, the SIU obtained and reviewed the following materials and documents from the TBPS

  • Complainant’s Charge Report
  • Arrest Report
  • Documentation for TBPS Cruiser involved
  • Duty Roster
  • Event Chronologies
  • Incident Report-Thunder Bay EMS
  • TBPS Email re: COMM-2017-07-20
  • List of Previous Occurrences
  • Medical Records with Release of Body Form
  • Notes of WO #s 1-4
  • Occurrence (Involvements Liquor License Act)
  • Procedure: Prisoner Transportation
  • Procedure: Care and Handling of Prisoners
  • Copy of Names of Other Prisoners
  • Complainant Profile
  • TBFR Witness Report (x5)
  • Photos of Cell Block taken by TBPS:
  • Communications Recordings of Police and EMS transmissions
  • TBPS Initial Information and Hand Written Notes
  • Cell, booking room, sally port, and cell block videos
  • TBPS Letter to Thunder Bay EMS re Communication, and
  • TBPS Provincial Offences Notice

The following materials and documents were obtained from other sources:

  • Post Mortem Report
  • Toxicology Report, and
  • Photograph taken by CW #7, of the unconscious Complainant at the location where he was later found by police and paramedics

Relevant legislation

Sections 219 and 220, Criminal Code - Criminal negligence Causing Death

219 (1) Every one is criminally negligent who

  1. in doing anything, or
  2. 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

  1. 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
  2. in any other case, to imprisonment for life

Section 31(4), Liquor Licence Act – Intoxicated in a public place

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

  1. In a place to which the general public is invited or permitted access; or
  2. In any part of a residence that is used in common by persons occupying more than one dwelling in the residence

Analysis and director’s decision

On July 19th, 2017, at approximately 7:47 p.m., a 911 call was received by the Thunder Bay Police Service (TBPS) reporting that a male in his 50’s was unconscious behind the Investor’s Group building at 959 Fort William Road in the City of Thunder Bay and police and ambulance were dispatched.

Upon police arrival, the paramedics were already on the scene and were speaking with the Complainant. Police and paramedics both observed that the Complainant was obviously intoxicated, noting that his speech was slurred, he had an odour of alcohol on his breath, his eyes were red and glossy, and he kept falling asleep while paramedics were speaking with him. Finding no medical complaint, and that his vital signs were not alarming, paramedics medically cleared the Complainant and left the scene.

Witness Officer (WO) #2 and WO #1 then escorted the Complainant to their police cruiser, while assisting him to walk.

At 7:47 p.m., the police radio transmissions recording reveals a call from one of the two officers stating that they were driving the Complainant home to his stated address in the City of Thunder Bay. This is the only point wherein there is some disagreement between two of the civilian witnesses (CWs) and WO #1.

WO #1 stated that he attended at the residence and spoke to CW #3. While WO #1 indicated that he asked if the Complainant was able to stay at the residence, and that CW #3 stated that he could not as long as he was intoxicated, CW #3 contends that he was never asked to take in the Complainant, but that the officer merely asked if another person was at home and told him that the Complainant was in the police cruiser. While this discrepancy in the evidence is not overly relevant to the investigation, as nothing really turns on it, I accept, as confirmed by the radio transmissions recording, that it was the intention of the police to take the Complainant home, if he was allowed to stay there.

Shortly thereafter, at 8:04:01 p.m., the police transmission recording indicates that an officer called in and requested the dispatcher check if there were any male beds available at the detox centre. Upon calling, the dispatcher was told that all beds were full.

As a result of having nowhere else to take the Complainant, where he would be safe and could sleep off his state of intoxication, it was decided to arrest the Complainant for being intoxicated in a public place and to transport him to the police station where he would be lodged in a cell until sober.

The video footage from the police station reveals the Complainant arriving at the station, being escorted into the booking hall, being booked in by the booking officer, vomiting in a garbage can provided to him, and then placed into a cell where he was provided with a juice box, which he had requested.

The Complainant was lodged in a cell at 8:17:14 p.m., and he lay down on the cement bunk and appeared to fall asleep. The cell video confirms that the Complainant was checked on regularly by a police officer. Additionally, the set up at the police station confirms that even if a police officer did not physically check on the cells, there were monitors by which they were able to keep watch over the prisoners.

The Complainant was last personally checked by the booking officer, WO #3, at 11:48 p.m. The video reveals that the Complainant was breathing at that time, as his abdomen is seen to rise and lower with his breaths. WO #3 then took her lunch break, and she was replaced as booking officer by WO #4, who next checked the Complainant’s cell at 12:21:43 a.m. WO #4 is seen to stop outside of the Complainant’s cell and tries to rouse him and when he is unable to do so, he is seen to leave the area, returning within less than one minute with the SO. Both officers then enter the cell and attempt to rouse the Complainant, following which CPR is initiated by WO #4, while the SO can be heard speaking with the ambulance dispatcher 67 seconds later. A broadcast is then heard over the paging system reporting an emergency in the male cell area.

Having heard the page, WO #2 and WO #1 then attended to cell 12 and assisted WO #4 with performing life saving measures on the Complainant until the paramedics arrived and took over. The Complainant was then put on a stretcher and transported to the hospital where he was pronounced dead at 1:34 a.m. At no time did the Complainant regain consciousness after he was first observed to be unconscious in the cells by WO #4.

The forensic pathologist who performed the post mortem on the Complainant concluded that the cause of death was due to ‘hypertensive heart disease’ (the number 1 cause of death associated with high blood pressure, it includes death due to heart failure, ischemic heart disease and left ventricular hypertrophy (excessive thickening of the heart muscle) according to;; etc.).

During the course of this investigation, seven civilian and four police witnesses were interviewed by investigators, with the subject officer (SO) declining to provide a statement, as was his legal right. Additionally, investigators obtained and reviewed the closed circuit television footage from the police station, the police and ambulance dispatch and transmissions recordings, and the post mortem report and results of testing done on bodily samples taken from the Complainant during his post-mortem examination.

With the exception of the one minor discrepancy, as outlined earlier, there is no dispute as to the facts.

At no time did any witness observe any police officer mistreat or abuse the Complainant, and no such allegation was ever made. On the contrary, on all of the evidence it appears that the police were very patient and considerate of the Complainant, some examples of which include: he was not handcuffed, due to the pre-existing injury to his wrist; the police officers attended both a residence suggested by the Complainant where he could spend the night and contacted the detox centre in an effort to find a place where the Complainant could spend the night where he would be cared for, before they opted, as a last resort, to arrest him for being intoxicated in a public place and to have him sleep off his intoxication in a cell from which he would be released when sober; and, his request for some juice was very accommodated. Additionally, despite his state of intoxication and his vomiting quickly in the booking hall, no police officer is seen at any time to be rude or short with the Complainant; their behaviour, as seen on the video and heard on the transmissions recording, is clearly very accommodating to the Complainant and the situation in which he found himself.

It is further clear, on the evidence, that the police were lawfully acting within their duties when they arrested and transported the Complainant to the police station on a charge of being intoxicated in a public place. Both the paramedics and the police made observations which were consistent as to the Complainant’s state of intoxication. The fact that he had previously been reported in the 911 call as being unconscious, and that he kept falling asleep while paramedics were speaking with him, made it further clear that he was not in a state where he could adequately care for himself. As such, the Complainant’s arrest, transport, and subsequent detention at the police station were lawful and justified in the circumstances.

In the absence of any allegation that the death of the Complainant somehow arose as a result of actions by police, and the post mortem is silent as to any findings which would support that inference, the only question left to be addressed is whether or not police were criminally negligent in their treatment of the Complainant, or in failing to see to the Complainant’s needs, and thereby were criminally responsible for his death.

The only criminal charge open for consideration on these facts would be one of criminal negligence causing death contrary to s.220 of the Criminal Code. There is no dispute that the death of the Complainant was not directly attributable to the actions of the SO or any of the officers under his command on the night of the Complainant’s death, the only question being whether or not the SO, who was the officer in charge of the police station on the night of the Complainant’s death, or any of the police officers under him, failed in their duty when they lodged the Complainant in a police cell for the night.

Specifically, the question to be posed is whether the SO, as the officer in charge and therefore specifically tasked with caring and ensuring the safety of those in the police station during his shift, omitted to do anything that it was his duty to do and, in failing to do so, showed a wanton or reckless disregard for the life or safety of the Complainant (s.219 of the Criminal Code: definition of criminal negligence).

There are numerous decisions of the higher courts defining the requirements to prove an offence of criminal negligence; while most relate to offences involving driving, the courts have made it clear that the same principles apply to other behaviour as well.

In order to find reasonable grounds to believe that the SO committed the offence of Criminal Negligence Causing Death, one must first have reasonable grounds to believe that he had a duty toward the Complainant which he omitted to carry out, and that omission, pursuant to the decision of the Supreme Court of Canada in R. v J.F. (2008), 3 S.C.R. 215, represented ‘a marked and substantial departure from the conduct of a reasonably prudent person in circumstances’ where the SO ‘either recognized and ran an obvious and serious risk to the life’ of the Complainant ‘or, alternatively, gave no thought to that risk’. The courts have also made clear that the risk of death to the Complainant must have been foreseeable to the SO (R. v Shilon (2006), 240 C.C.C. (3d) 401 Ont. C.A.)

Clearly, while the Complainant was unable to care for himself due to his state of intoxication, and unable to get help on his own, due to his being incarcerated at the police station, the SO had a duty to ensure that the Complainant was safe and properly cared for, in as much as he was able.

While failing to comply with police policy does not necessarily equate with criminal conduct, it appears clear on the evidence as provided by the cell video, that police policy was being complied with in this instance. I specifically note, as per the policy relating to the ‘Care and Handling of Prisoners’ which required police: to transport the Complainant to a Detox Centre, if a bed was available, before resorting to housing him in a cell at the station; to check prisoners every 30 minutes; to not enter a prisoner’s cell without first obtaining a second officer to attend with him; and that officers should be trained in life saving techniques, that all of these requirements were met by the officers who dealt with the Complainant on the night in question (albeit the last check of the Complainant was 33 minutes, and not 30 minutes, I infer this was due to WO #3 going on lunch and WO #4 having to come in off the road to take over).

I further note, with respect to the foreseeability of the Complainant’s death, or even a possible risk that his life or health might be in danger, that the police officers who were monitoring the Complainant were made aware that he had been medically cleared by paramedics, that no concern had been noted as to any medical condition of the Complainant, and that on all of the evidence, the only issue that police were aware of was that the Complainant was intoxicated.

Based on all of these facts, I cannot find that there is any evidence which should have alerted the police that the Complainant was at high risk for medical complications. Certainly, having been fully assessed by paramedics, who had the medical training that the police did not, and having been advised that there were no medical concerns, police were justified in relying upon that information in formulating their care plan for the Complainant.

In all of these circumstances, I cannot find reasonable grounds to believe that the actions of the SO, or any of the police officers tasked with the care of the Complainant while in police custody, are capable of satisfying any of the elements required in order to pursue a charge under s.220 of the Criminal Code in that they neither omitted to carry out any duty to act, nor did their actions amount to a marked and substantial departure from the conduct of any reasonably prudent person in their circumstances, nor did they show a wanton or reckless disregard for the life or safety of the Complainant, and his subsequent death was totally unforeseeable in the circumstances.

On all of the evidence, it appears that the tragic death of the Complainant was as a result of his lifestyle and possibly other genetic or medical factors which were unknown to police and paramedics and there is no causal connection between the actions or inaction of any police officer or the SO and the death of the Complainant. On this record, I can find no basis for the laying of criminal charges and none shall issue.

Date: May 16, 2018

Original signed by

Tony Loparco
Special Investigations Unit