The Office of the Independent Police Review Director issued 44 recommendations to the Thunder Bay Police Service, Ontario Coroner and Pathologist.
1. Nine of the TBPS sudden death investigations that the OIPRD reviewed are so problematic I recommend these cases be reinvestigated.
2. A multi-discipline investigation team should be established to undertake, at a minimum, the reinvestigation of the deaths of the nine Indigenous people identified.
3. The multi-discipline investigative team should establish a protocol for determining whether other TBPS sudden death investigations should be reinvestigated.
4. The multi-discipline investigation team should also assess whether the death of Stacy DeBungee should be reinvestigated, based on our Investigative Report and the Ontario Provincial Police review of the TBPS investigation. The team should also assess when and how the investigation should take place, without prejudicing ongoing Police Services Act proceedings.
5. TBPS should initiate an external peer-review process for at least three years following the release of this report.
Recommendations Regarding TBPS Investigators and the Criminal Investigations Branch.
6. TBPS should immediately ensure sufficient staffing in its General Investigation Unit in the Criminal Investigations Branch. Adequate resources must be made available to enable this recommendation to be implemented on an urgent basis.
7. TBPS should establish a Major Crimes Unit – within the Criminal Investigations Branch – that complies with provincial standards and best practices in how it investigates serious cases, including homicides, sudden deaths and complex cases.
8. TBPS should provide officers, who have taken the appropriate training with opportunities to be assigned to work with Criminal Investigations Branch and the Major Crimes Unit investigators to gain experience.
9. TBPS should develop a formalized plan or protocol for training and mentoring officers assigned to Criminal Investigations Branch and the Major Crimes Unit.
10. TBPS should develop a strategic human resources succession plan to ensure the General Investigations Unit, Criminal Investigations Branch and the Major Crime Unit is never without officers who are experienced in investigations.
11. TBPS should establish procedures to ensure occurrence or supplementary reports relevant to an investigation are brought to the attention of the lead investigator or case manager. This must take place regardless of whether a case has been earmarked for Major Case Management.
12. TBPS should develop procedures to ensure forensic identification officers are provided with the information necessary to do their work effectively.
13. TBPS should immediately improve how it employs, structures and integrates its investigation file management system, Major Case Management system and its Niche database.
14. TBPS should, on a priority basis, establish protocols with other police services in the region, including Nishnawbe-Aski Police Service and Anishinabek Police Service to enhance information-sharing.
Recommendations Regarding Other TBPS Operational Areas
15. TBPS should fully integrate the Aboriginal Liaison Unit’s role into additional areas of the police service. This would help to promote respectful relationships between TBPS and the Indigenous people it serves.
16. TBPS should increase the number of officers in the Aboriginal Liaison Unit by at least three additional officers.
17. With Indigenous engagement and advice, TBPS should take measures to acknowledge Indigenous culture inside headquarters or immediately outside it.
18. Thunder Bay Police Service should make wearing name tags on the front of their uniforms mandatory for all officers in the service.
19. TBPS should implement the use of in-car cameras and body-worn cameras.
20. TBPS should, through policy, impose and reinforce a positive duty on all officer to disclose potential evidence of police misconduct.
Recommendations Regarding Missing Persons Cases
21. I urge the Ontario government to bring into force Schedule 7, the Missing Persons Act, 2018, as soon as possible.
22. TBPS and the Thunder Bay Police Services Board should re-evaluate their missing persons policies, procedures and practices upon review of the report of the National Inquiry into Missing and Murdered Indigenous Women and Girls, due to be released on or before April 30, 2019.
23. TBPS and the Thunder Bay Police Services Board should re-evaluate their missing persons policies, procedures and practices upon review of the Honourable Gloria Epstein’s report on Toronto Police Service’s missing persons investigations due to be released in April 2020.
Recommendations Regarding the Relationship between the Police and the Coroner’s Office.
24. The Office of the Chief Coroner, Ontario’s Chief Forensic Pathologist, the Regional Coroner, and TBPS should implement the Thunder Bay Death Investigations Framework on a priority basis and should evaluate and modify it as required, with the input of the parties, annually.
25. The Office of the Chief Coroner should ensure police officers and coroners are trained on the framework to promote its effective implementation.
26. The Office of the Chief Coroner and TBPS should publicly report on the ongoing implementation of the framework in a way that does not prejudice ongoing investigations or prosecutions.
Recommendations Regarding the Relationship between the Police and Pathologist
27. The Ontario Forensic Pathology Service should train all pathologists on the Intersection of Police and Coroners for Thunder Bay Death Investigations as set out in the framework.
28. TBPS should reflect, in its procedures and training, fundamental principles to define the relationship between investigators and pathologists.
29. The Ontario Forensic Pathology Service should establish a Forensic Pathology Unit in Thunder Bay, ideally housed alongside the Regional Coroner’s Office.
30. If a Forensic Pathology Unit cannot be located in Thunder Bay, TBPS and the Ontario Forensic Pathology Service should establish, on a priority basis, procedures to ensure timely and accurate exchange of information on sudden death and homicide investigations and regular case-conferencing on such cases.
31. The Ontario Forensic Pathology Service should provide autopsy services compatible with cultural norms in Indigenous communities.
Recommendations Regarding Racism in TBPS Policing – General
32. TBPS should focus proactively on actions to eliminate systemic racism, including removing systemic barriers and the root causes of racial inequities in the service. TBPS should undertake a human rights organizational change strategy and action plan as recommended by the Ontario Human Rights Commission in October 2016.
33. TBPS leadership should publicly and formally acknowledge that racism exists at all levels within the police service and it will not tolerate racist views or actions. TBPS leadership should engage with Indigenous communities on the forum for and content of these acknowledgements. This would be an important step in TBPS advancing reconciliation with Indigenous people.
34. The Thunder Bay Police Services Board should publicly and formally acknowledge racism exists within TBPS and take a leadership role in repairing the relationship between TBPS and Indigenous communities. This too, is an important step in TBPS advancing reconciliation with Indigenous people.
35. TBPS leadership should create a permanent advisory group involving the police chief and Indigenous leadership with a defined mandate, regular meetings and a mechanism for crisis-driven meetings to address racism within TBPS and other issues.
Recommendations Regarding Racism in TBPS Policing – Training
36. TBPS should work with training experts, Indigenous leaders, Elders and the Indigenous Justice Division of the Ministry of the Attorney General to design and implement mandatory Indigenous cultural competency and anti-racism training for all TBPS officers and employees, that:
a. Is ongoing throughout the career of a TBPS officer or employee
b. Involves “experiential training” that includes Indigenous Elders and community members who can share their perspective and answer questions based on their own lived experiences.
c. Is informed by content determined at the local level, and informed by all best practices
d. Is interactive and allows for respectful dialogue involving all participants
e. Reflects the diversity within Indigenous communities, rather than focusing on one culture to the exclusion of others.
f. Explains how the diversity of Indigenous people and pre and post contact history is relevant to the ongoing work of TBPS officers and employees. For example, Indigenous culture and practices are highly relevant to how officers should serve Indigenous people, conduct missing persons investigations, build trust, accommodate practices associated with the deaths of loved ones and avoid micro-aggressions. Micro-aggressions are daily verbal or non-verbal slights, snubs, or insults that communicate, often inadvertently, derogatory or negative messages to members of vulnerable or marginalized communities.
37. TBPS should ensure the Indigenous cultural competency training recommended in this report is accompanied by initiatives in collaboration with First Nations police services that allow TBPS officers to train or work with First Nations police services and visit remote First Nations to provide outreach.
38. TBPS leadership should provide greater support for voluntarism by attending relevant sporting or community events.
39. TBPS should develop and enhance additional cultural awareness training programs relating to the diverse community it serves.
Recommendations on Racism in TBPS Policing – Recruitment and Job Promotion
40. TBPS should implement psychological testing designed to eliminate applicants who have or express racist views and attitudes. In Ontario, such specific testing is not done. It can be tailored to the TBPS experience. This testing should be implemented in Thunder Bay on a priority basis.
41. TBPS should, on a priority basis, create and adopt a proactive strategy to increase diversity within the service, with prominence given to Indigenous candidates.
42. TBPS leadership should link job promotion to demonstrated Indigenous cultural competency.
Recommendations for Implementation of Recommendations
43. TBPS should report to the OIPRD on the extent to which the recommendations in this report are implemented. This is imperative given the crisis in confidence described in this report. The OIPRD should, in turn, report publicly on TBPS’s response and the extent to which the recommendations in this report are implemented.
44. On an annual basis, TBPS should provide the public with reports that provide data on sudden death investigations. These reports can provide data, in a disaggregated Indigenous and non-Indigenous manner, detailing the total number of sudden death investigations with a breakdown of investigative outcomes, including homicide, accidental death, suicide, natural death and undetermined.