Appendices: Chair's Interim Report - Public Interest Investigation into the In-Custody Death of Robert Thurston Knipstrom

Appendix A: Condensed Timeline of Events Related to the Arrest

Appendix B: RCMP Members and Related Persons Involved^{Footnote 1}

Return to footnote 1 referrer Positions and ranks noted as at the time of the events.

Appendix C: Chair's Complaint

Chair-Initiated Complaint

Appendix D: Notice of Public Interest Investigation

January 30, 2009

File No.: PC-2007-2427

Commissioner William J. S. Elliott
Attention: Manager, Public Complaints Unit
Royal Canadian Mounted Police
Coventry Square Building
295 Coventry Square
Ottawa, ON K1K 4M7

Dear Commissioner Elliott:

Re: Chair-Initiated Complaint and Public Interest Investigation (Robert Thurston Knipstrom)

As you know, on November 20, 2007, I initiated a complaint (a copy of which is attached for your ease of reference) under subsection 45.37(1) of the RCMP Act into the circumstances relating to the death of Mr. Knipstrom. At this point, please be advised that I consider it advisable in the public interest to investigate this complaint pursuant to subsection 45.43(1) of the RCMP Act. As a courtesy, I have also notified the Commanding Officer of "E" Division of the public interest investigation.

To expedite the Commission's investigation into this complaint, please instruct your officials to prepare a package of all relevant materials that would include, but not be limited to: copies of the relevant operational file(s); all statements taken from civilian witnesses and members in connection with these events; reports to Crown counsel, all video or audio recordings of the incident; all RCMP and use of force reports; all investigative reports; Coroner's reports; autopsy documents; all notebook entries and continuation reports for the members involved; all applicable national, divisional and detachment policies; and all other materials that your officials think would assist in our investigation.

I would appreciate it if you would advise the members involved, as required by subsection 45.37(3) of the RCMP Act, and provide us with confirmation for our records that the members have been notified of this complaint.

Yours truly,

Paul E. Kennedy

Attach.

Appendix E: Summary of Findings and Recommendations

• Finding: Constables Mufford, Labbe and Kardos had current RCMP certified training in the use of force options available to members in the performance of their duties.
• Finding: The members entered into their interactions with Mr. Knipstrom lawfully and were duty-bound to do so.
• Finding: It was not unreasonable for the members to use OC spray and a baton in the manner that they did, and it was in compliance with RCMP use of force policy.
• Finding: It was reasonable for the members to use the CEW when other use of force options (empty hand techniques, OC spray, baton) appeared to have no effect on Mr. Knipstrom.
• Finding: Constable Mufford's deployment of the CEW was reasonable in the circumstances.
• Finding: Constable Labbe's decision to deploy her CEW following Constable Mufford's deployment was reasonable in the circumstances.
• Finding: Constable Kardos' deployments of the CEW were reasonable in the circumstances
• Finding: It was reasonable for the members to conclude that Mr. Knipstrom was not receiving the full effects of the CEW deployments, if any from some deployments.
• Finding: Constable Labbe's decision to recycle her CEW, and to attempt to use a second cartridge when the recycling appeared to have little to no effect, was reasonable in the circumstances.
• Finding: Constables Mufford, Labbe and Kardos exercised their use of force options in a manner consistent with the law and RCMP policy.
• Finding: To the extent that the subject members were involved in the decision to maintain Mr. Knipstrom in the prone position after his arrest, it was reasonable for them to do so in the circumstances.
• Finding: The members appropriately sought and obtained medical treatment for Mr. Knipstrom.
• Finding: The RCMP members involved in the events involving Mr. Knipstrom on November 19, 2007, from the moment of initial contact until transfer to the care of emergency health personnel, complied with all appropriate policies, procedures, guidelines and statutory requirements for the arrest and treatment of persons taken into custody.
• Finding: The scene was properly secured.
• Finding: The appropriate personnel were dispatched to the scene at the appropriate times.
• Finding: An "independent" investigation team was assembled in a timely manner, in accordance with RCMP policy.
• Finding: The investigation was managed in accordance with the Major Case Management principles.
• Finding: All of the relevant witnesses were interviewed.
• Finding: The investigators acted reasonably in their efforts to interview and take statements from the involved members.
• Finding: An SRR should not have been allowed to meet alone with Constable Mufford prior to him completing his duty to account statement, or with either Constable Mufford or Constable Labbe prior to the arrival of the investigation team.
• Recommendation: If the protocol of SRR attendance is to continue, the RCMP should formalize the attendance of the SRR to provide clear policy and guidance to ensure that the SRR knows the bounds of his or her involvement and the required protocols with respect to such attendance.
• Recommendation: I reiterate my recommendation in the Ian Bush decision (November 2007) and St. Arnaud decision (March 2009) that"[t]he RCMP develop a policy that dictates the requirement, timeliness and use of the duty to account that members are obliged to provide."
• Finding: It is inappropriate for subject members to be interviewed by members of the same or lower rank in cases where the MCM model has not been employed.
• Recommendation: All interviews of members involved in serious incidents should be conducted by members of a higher rank in cases where the MCM model has not been employed.
• Recommendation: All witness interviews in serious incidents should be conducted by a two-member team.
• Finding: It was inappropriate for Constable Kardos to be assigned to interview the two main civilian witnesses, as he was involved in the incident and was in a conflict of interest situation.
• Finding: The RCMP policy regarding the testing of CEWs that was in place at the time of the incident was inadequate. However, I am satisfied that the change in RCMP policy has clarified when the testing should be done where a CEW has been involved in an in-custody death situation.
• Finding: The extent to which the investigators looked into Mr. Knipstrom's background and used that information was reasonable and appropriate in the circumstances.
• Finding: The extent to which the investigators explored the role of excited delirium in the death of Mr. Knipstrom was not unreasonable in the circumstances.
• Finding: The RCMP's communications with the coroner's office prior to Mr. Knipstrom's death were not unreasonable or inappropriate in the circumstances.
• Finding: There was no evidence to support a prosecution and it was reasonable not to submit a Report to Crown Counsel for review.
• Finding: There was no unreasonable delay in the RCMP's investigation of Mr. Knipstrom's death and the investigation was completed in a timely manner.

Appendix F: BCCLA Complaint

November 27, 2007

Paul Kennedy, Chair
Commission for Public Complaints Against the RCMP
PO Box 3423, Station 'D'
Ottawa, Ontario
KIP6L4

Dear Mr. Kennedy:

RE: RCMP Complaint into the in-custody death of a man at the Chilliwack

I am writing on behalf of the B.C. Civil Liberties Association (BCCLA) to initiate a complaint under the Royal Canadian Mounted Police Act against the members of the relevant member(s) of the Chilliwack RCMP detachment involved in the handling of
36-year-old Robert Knipstrom, who died on November 24, 2007 while in the custody of the RCMP.

Based on media reports, it is my understanding that the police were called to the store at about 3:30 pm at a business in the 45800 block of Airport Road in Chilliwack. He was arrested Monday at a Chilliwack equipment rental store after a prolonged struggle with RCMP. The attending officers reportedly tried pepper spray, a Taser and batons after being unable to control the man with physical force, but the officers were unable to subdue Mr. Knipstrom quickly with any of these methods. He was finally subdued after the officers called for backup, but not before the man suffered serious injures. He was listed in extremely critical condition, eventually passing away early Saturday in Surrey Memorial Hospital.

The BCCLA is concerned that the RCMP members failed to meet appropriate professional standards in discharging their duty of care towards him. A transparent and independent investigation is warranted in this case in the public interest.

If the RCMP is found to have acted within the guidelines of existing policy and conduct standard we ask that you undertake a review to assess whether such policies are adequate.

To maintain and enhance the public's confidence in the RCMP, we request that your office rather than the RCMP conduct this investigation.

I look forward to your response.

Yours sincerely,

[Signed] Murray Mollard
Executive Director

Appendix G: Independent Observer Program

The CPC Independent Observer Program assesses the impartiality but not the adequacy of RCMP investigations in these cases using the following criteria:^{Footnote 2}

1. Line Management: Assess whether there are any actual or perceived conflicts of interests in terms of the members of the investigative team and those who are the subject of the investigations. Determine the appropriateness of the management structure and reporting relationships.
2. Appropriate Level of Response: Assess whether the RCMP investigative team response to the incident is appropriate and proportionate to the gravity of the incident. Has the RCMP assigned the appropriately qualified investigators to the investigative team? Are the team leader(s) and the lead investigator(s) Major Case Management accredited?
3. Timeliness of the Response: Assess whether members of the RCMP investigative team responded in a timely fashion to the incident.
4. Conduct: Assess whether the conduct of members of the RCMP investigative team is consistent with section 37 of the RCMP Act.

The Independent Observer completed an assessment as to the impartiality of the integrated investigative team and identified no issues with respect to the impartiality of the investigation. More specifically, with respect to the criteria enumerated above, his observations were:

1. Line Management
   The Observer found that the Team Commander and an RCMP "E" Division Inspector had previously met the member in charge of the Chilliwack General Investigation Section who was one of the members who responded to the call for assistance, but who was not involved in any physical confrontation with the male. Neither had a close relationship with that member. With the exception of some loose connections with the member in charge and one other member, there were no connections of concern. The Major Crime Unit addressed who would participate on the team to avoid any connections with the members involved in the incident.
2. Appropriate Level of Response
   The Investigation Team Commander was accredited (in Major Case Management). The investigators were from the "E" Division Major Crime Unit, the E Division Major Crime – Criminal Investigation Unit (a Major Crime assist unit), the Surrey IHIT and two members from the Abbotsford Police Department. The Vancouver Island Integrated Major Crime Unit was involved to investigate the potential charges against Mr. Knipstrom; however, their involvement ceased upon his death.
3. Timeliness of Response
   The altercation concluded at approximately 3:38 p.m. on November 19, 2007. The integrated MCU was notified at approximately 5:50 p.m. Members of the investigation team arrived in Chilliwack at approximately 9 p.m.
4. Conduct
   The Independent Observer noted no obvious signs of bias or partiality on the part of the investigators.

Return to footnote 2 referrer All information in this section is located on the CPC website: Independent Observer Program.

Appendix H: Scene Diagram and Photographs

Appendix I: Canada Criminal Code Provisions

25. (1) Every one who is required or authorized by law to do anything in the administration or enforcement of the law

• (a) as a private person,
• (b) as a peace officer or public officer,
• (c) in aid of a peace officer or public officer, or
• (d) by virtue of his office,

is, if he acts on reasonable grounds, justified in doing what he is required or authorized to do and in using as much force as is necessary for that purpose.

27. Every one is justified in using as much force as is reasonably necessary

• (a) to prevent the commission of an offence
  • (i) for which, if it were committed, the person who committed it might be arrested without warrant, and
  • (ii) that would be likely to cause immediate and serious injury to the person or property of anyone; or
• (b) to prevent anything being done that, on reasonable grounds, he believes would, if it were done, be an offence mentioned in paragraph (a).

270. (1) Every one commits an offence who

• (a) assaults a public officer or peace officer engaged in the execution of his duty or a person acting in aid of such an officer;
• (b) assaults a person with intent to resist or prevent the lawful arrest or detention of himself or another person; or
• (c) assaults a person
  • (i) who is engaged in the lawful execution of a process against lands or goods or in making a lawful distress or seizure, or
  • (ii) with intent to rescue anything taken under lawful process, distress or seizure.

Appendix J: Incident Management/Intervention Model

Incident Management/Intervention Model - Graphic -Description

Appendix K: Categories of Resistance of Individuals

In the inner portion of the Incident Management/Intervention Model, potential levels of resistance of suspects are noted. The following defines the expected behaviours of individuals displaying each of the levels of resistance included.

1. Cooperative:
There is no resistance. The person responds positively to verbal requests, commands or activation of a police vehicle's emergency equipment. The person willingly complies.

2. Non-Cooperative:
There is little or no physical resistance. The person does not comply to the officer's request. This can be done through verbal defiance with little or no physical response or failing to pull their vehicle over and stop when an officer activates the police vehicle's emergency equipment. This may include: refusal to leave the scene, failure to follow directions, taunting officers, and advising others to disregard officer's lawful requests.

3. Resistant:
The person demonstrates resistance to control by the police officer through behaviours such as pulling away, pushing away or running away. This can include a situation where a police officer activates a police vehicle's emergency equipment and the suspect fails to stop and attempts to evade apprehension by driving evasively.

4. Combative:
The person attempts or threatens to apply force to anyone, e.g. punching, kicking, clenching fists with intent to hurt or resists, threats of an assault. In the case of a person operating a vehicle, they attempt to collide with the police vehicle, another vehicle or a pedestrian.

5. Person who shows the potential to cause grievous bodily harm or death:
The person acts in a way which would lead the police officer to believe could result in grievous bodily harm or death to the public or the police:

• knife attack
• baseball bat
• use of firearm

In the case of a person operating a vehicle, they collide with the police vehicle, another vehicle or a pedestrian.

Appendix L: RCMP Policy: Major Case Management

1. General

1. 1. Major cases are cases/investigations that are serious in nature and because of their complexity, risk, and resources require the application of the principles of Major Case Management (MCM).

1. 2. Major case management is a methodology for managing major cases that provides accountability, clear goals and objectives, planning, allocation of resources and control over the direction, speed and flow of the investigation.

1. 3. Major case management is not a computer software operating system (electronic data processing system) however MCM may use an RCMP approved data base management system, such as PROS, SUPERText, or E & R.

1. 4. Major case management is used to conduct significant investigations regardless of business lines (Contract or Federal). Major RCMP cases will be conducted in accordance with the principles of MCM. The methodology of MCM encompasses nine essential elements:

• 1. 4. 1. the command triangle,
• 1. 4. 2. management,
• 1. 4. 3. crime-solving strategies,
• 1. 4. 4. leadership and team-building,
• 1. 4. 5. legal implications,
• 1. 4. 6. ethics,
• 1. 4. 7. accountability,
• 1. 4. 8. communication, and
• 1. 4. 9. partnerships.

NOTE: Guiding principles, additional duties, qualifications and accountability frameworks for all aspects of MCM are outlined in the Major Case Management Manual.

2. Team Roles/Functions

2. 1. Major Case Management Team

2. 1. 1. Major case management is managed by the Major Case Management Team (MCMT). The MCMT is illustrated by the command triangle. The key roles in this model are the Team Commander, Primary Investigator and the File Coordinator. Although each role has clear accountability paths they maintain a collaborative relationship while maintaining independence in their respective roles.

2. 2. Team Commander

2. 2. 1. The Team Commander (TC) is an accredited individual who has ultimate authority, responsibility/ accountability for the MCMT, its resources (human and physical) and its mandate. Accreditation includes successful completion of the Canadian Police College sponsored Major Case Management course.

2. 2. 2. Divisions must maintain pools of accredited TCs with current CVs outlining their experience and training in major cases focusing on leadership/managerial accomplishments.

2. 2. 3. The TC will ensure qualified File Coordinators (FC) and Primary Investigators (PI) are selected. Although the TC assumes overall control, responsibility and accountability for the direction, speed and flow of the case, he/she may perform other roles subject to the risk and nature of the investigation.

2. 3. Primary Investigator

2. 3. 1. The Primary Investigator (PI) controls the direction, speed and flow of the overall investigative process.

2. 3. 2. A key role of the PI is to macro-manage, not perform, all aspects related to the investigation and the PI must be prepared to restrict personal participation to the extent necessary to command the overall operation.

2. 3. 3. The PI is accountable to the TC and must work in collaboration with the File Coordinator (FC).

2. 3. 4. The PI will be an experienced investigator with proven ability to coordinate, organize and control a complex, multi-faceted investigation.

2. 4. File Coordinator

2. 4. 1. The FC is responsible for the control, supervision, organization and disclosure of the file documentation. See sec. 8.1.

2. 4. 2. The FC must identify human and physical resources required to fulfill the role of file coordination. The FC is accountable to the team commander and must work in collaboration with the PI.

2. 4. 3. The FC will be a capable, competent investigator with familiarity in the use of both electronically and manually coordinated, organized and controlled data.

2. 5. Major Case Investigative Team

2. 5. 1. The Major Case Investigative Team (MCIT) is formed with the exclusive purpose of investigating a major case.

2. 5. 2. The MCIT is comprised of investigators (who may be seconded from their primary duties), support staff, and other employees attached to but not part of the major case management team. The MCIT may be comprised of multi-agency personnel.

2. 6. Exhibit Custodian

2. 6. 1. The Exhibit Custodian will be selected by and report directly to the Primary Investigator.

2. 6. 2. The Exhibit Custodian must coordinate and track the movement of each piece of evidence as prescribed by law.

2. 7. Interviewer

2. 7. 1. The PI will select the interviewer or interview team based on the investigative and evidentiary requirements of the case and the individual to be interviewed. The interviewer or interview team reports directly to the PI.

2. 7. 2. An interviewer must have the necessary knowledge, skill and ability to perform the required interviewing functions.

3. Division Responsibility

3. 1. The Cr. Ops. Officer is responsible to ensure that all of the principles of MCM are used in the conduct of major cases in their divisions.

4. Front-End Loading

4. 1. The initial phase of a major case investigation (usually the first 72 hours) is critical.

4. 2. Limiting human or material resources in the early stages of a major case investigation may jeopardize the case so every consideration must be given to the front-end loading, i.e. committing the maximum of available resources to a major case investigation.

5. MCM Software

5. 1. Using a data base management system is critical to major case management.

5. 2. A data base management system ensures the basic objectives of major case investigations (documentation and preservation) are met. A system enhances managerial accountability, proper delegation of responsibilities, efficient/effective use of resources, auditable/consistent standards, efficient disclosure and current procedure in the seizure and preservation of evidence.

5. 3. Once an investigation is identified as a major case, an RCMP approved data base management system will be adopted where applicable and available. See sec. 1.3.

6. Critical Incident

6. 1. A critical incident is an event or series of events that by its scope and nature requires a specialized and coordinated response. Critical incidents include, but are not limited to civil unrest, disasters, hostage/barricaded persons, terrorist attacks.

6. 2. During a critical incident, the incident commander has overall responsibility for the critical incident.

6. 3. The MCMT team must be involved as soon as possible and consulted during the decision making processes. The Incident Commander and the MCMT must work together while the incident is ongoing, including sharing all information and intelligence.

6. 4. An Incident Commander should be trained in both incident command and MCM.

6. 5. The CO or Cr. Ops. Officer will determine when a critical incident is concluded and the MCM TC will then assume responsibility. A documented "hand over" of command must be prepared.

7. Media

7. 1. Media Liaison will report directly to the TC and liaise directly with the TC on media enquiries, problems involving media personnel or procedures and developing an evolving media strategy. See OM Part 27.

7. 2. All media releases must be approved by the MCMT prior to release.

7. 3. The Media Liaison will ensure a Briefing Note (BN) is submitted to National HQ prior to issuing any significant media release.

8. Disclosure

8. 1. Organization of the file must be implemented early to ensure a thorough and efficient disclosure process. The disclosure process is a critical task and Crown Counsel should be consulted during its preparation.

8. 2. The management of disclosure is the responsibility of the FC. Crown Counsel has the responsibility to ensure proper disclosure to both the Court and Defence Counsel.

8. 3. The FC must ensure the appropriate number of resources are assigned to disclosure. When appropriate, the FC will appoint dedicated disclosure officers or disclosure teams. A disclosure officer or disclosure team will report directly to the File Coordinator.

9. Decision Making Process

9. 1. Increasingly, lines of authority are being compelled to account for the management process of the investigation of major cases, in both court and/or other judicial hearings.

9. 2. The decision-making processes within MCM must be preserved. Individual managers, supervisors and investigators must make complete notes documenting their participation, rationale, time, direction and decisions.

10. Intelligence Processing/Analysis

10. 1. MCMT should ensure that early consideration is given to intelligence processing and analysis during the course of a major case investigation, in accordance with the Ops. Model.

10. 2. MCMT should consider early assignment of the required resources, in support of the intelligence process.

11. Reporting

11. 1. Regular reporting is a critical component of MCM.

11. 2. The development and monitoring of a reporting system is a division responsibility. Divisions must establish an acceptable reporting structure and frequency schedule.

11. 3. The MCMT must submit timely, regular and comprehensive Briefing Notes (BN) to National HQ in significant/high profile or high-risk incidents.

11. 4. In a JFO, the participating agencies must be included in the reporting structure.

12. Independent Review

12. 1. For quality control purposes divisions must submit major cases to an independent review if an investigation is prolonged, difficult or stalled.

12. 2. An independent review should be conducted by an experienced and accredited major case investigator, not involved in the investigation. The results of the review will be documented and reported to the Cr. Ops. Officer.

12. 3. An independent review will examine:

• 12. 3. 1. implementation of the MCM principles;
• 12. 3. 2. viability of investigative strategy/original operational plan;
• 12. 3. 3. availability of alternative investigative avenues;
• 12. 3. 4. thoroughness of elimination strategy;
• 12. 3. 5. compliance with reporting requirements; and,
• 12. 3. 6. observations and concerns of Critical Incident team members.

12. 4. An MCMT will cooperate with and assist in the independent review process.

13. Critical Debriefs

13. 1. All Major Cases should be critically debriefed at the conclusion of the case.

NOTE: If a critical debriefing is conducted while the investigation is ongoing, disclosure must be considered.

13. 2. The resulting analysis of "best practices" and "lessons learned" should be preserved and made available.

14. Canada Labour Code

14. 1. The TC, PI and the FC must be familiar with and comply with their duties as prescribed by Part II of the Canada Labour Code (CLC).

14. 2. The TC must successfully complete the Occupational Health and Safety Course "Managing Safely" available on the Human Resources Sector website or on CD.

14. 3. Work-related injuries must be reported immediately. Form 3414 will be completed by the individual and submitted to the respective supervisor. The supervisor will complete the form and forward it according to the distribution list. Depending on the severity of the injuries this report must be submitted to Human Resources Development Canada within regulated time limits. Refer to Canada Occupational Health and Safety Regulations, Part XV.

Appendix M: Impartiality Questionnaire

You have been assigned to a high profile sensitive investigation and as such it is imperative that the investigators be viewed as impartial and unbiased. This questionnaire was developed jointly with the RCMP and the Commission for Public Complaints Against the RCMP. The purpose of this questionnaire is to insure that any associations, whether they be professional or social, are disclosed at the onset of the investigation to the Team Commander. The mere acknowledgment of a professional or social association would not preclude a member from participating in the investigative team. If an association exists it is imperative that the member articulate and expound on the nature of the relationship so that an assessment can be made by the Team Commander. It should be noted that investigative team members are not considered "persons involved in this investigation" in the context of this document. In the event that you require clarification on issues contained in this form, please direct them to the Investigative Standards and Practices member on scene or the Team Commander.

Member's Name:

Regimental Number:

Present Posting:

1) Have you ever worked with or been stationed at the same detachment with any persons involved in this investigation?

Yes___ No___

If so please explain.

2) Do you or have you had a social relationship with persons involved in this investigation?

Yes___ No___

If so please explain.

3) Did you attend training at Depot (troopmate) during the same period of time with anyone involved in this investigation?

Yes___ No___

If so please explain.

4) Have you ever been stationed or worked at the detachment in which this investigation is taking place?

Yes___ No___

If so please explain.

5) Are there any issues that would affect the perception of impartiality as it relates to your participation in this investigation?

Yes___ No___

If so please explain.

6) Please provide a synopsis of your investigative experience (point form).

Signature of Member ______________________ Date______________________

7) Team Commander Section

Date and Time Impartiality Questionnaire Reviewed: ___________________________

Comments and Recommendations:

Team Commander Signature: _____________________________