Appendices: Report Following a Public Interest Investigation into a Chair-Initiated Complaint Respecting the Death in RCMP Custody of Mr. Robert Dziekanski

Table of Contents

• A. Chair-Initiated Complaint
• B. Background Information
• C. BCCLA Complaint re Media Issues
• D. RCMP Response to BCCLA Complaint re Media Issues
• E. Braidwood Commissions – Terms of Reference
• F. Independent Observer Program
• G. Chart of YVR International Arrivals Area
• H. Chronology of Events
• I. Actions of Mr. Dziekanski
• J. Pritchard Videos
• K. The Nature of the CEW and the Evolution of CEW Policy
• L. CEW Training
• M. Member Certifications
• N. RCMP Use of Force Options
• O. Use of Force Report
• P. Conduct of RCMP Members in Light of CEW Policy
• Q. Involvement of Staff Relations Representative
• R. Travel to Poland
• S. Media Releases
• T. Medical Assessments
• U. IM/IM Diagram
• V. Investigators' Notebooks
• W. BC Justice Statement
• X. Principles of Sir Robert Peel
• Y. Summary of Findings and Recommendations

Appendix A – Chair-Initiated Complaint

In-custody death of Mr. Robert DZIEKANSKI, October 14, 2007, involving the use of a conducted energy weapon at the Vancouver International Airport

Appendix B – Background Information

The Commission for Public Complaints Against the RCMP is an agency of the federal government and is distinct and independent from the RCMP. When investigating any complaint filed with it, and notwithstanding the fact that the complaint in this matter was initiated by me as the Chair, the Commission is not an advocate for the complainant, the RCMP or its members. As Chair, my role is to reach conclusions after an objective examination of the evidence available. When appropriate, I make findings and/or recommendations as to steps the RCMP may take to improve or correct conduct by RCMP members.

It must be further emphasized that the Commission's mandate does not extend to making findings of criminal or civil liability, but rather is founded in assessing the appropriateness of the conduct of the RCMP members as well as that of the RCMP itself and the procedures in place at the time. Pursuant to the RCMP Act, my recommendations are not binding on the RCMP.

The complaint I filed involves an examination of the conduct of the responding RCMP members, but it also involves an examination of the investigation conducted by the RCMP of the death of Mr. Dziekanski. Increasingly in our society, criticism is levelled against the optics of investigations of police conducted by police. Among my tasks as Chair is to ensure that investigations in which RCMP members investigate other RCMP members are conducted with impartiality and that the investigations are thorough.

On December 11, 2007 the Commission released an interim report listing ten recommendations associated to three broad areas of conclusion (indicated below), and in June 2008 the Commission released a final report, entitled RCMP Use of the Conducted Energy Weapon, concerning the use of CEWs by members of the RCMP.

The three broad areas of conclusion noted in the June 2008 report were that the RCMP should:

• 1) Coordinate and strengthen its efforts related to data collection and analysis of CEW use;
• 2) Empirically justify policy shifts with respect to CEW use, especially when that shift loosens the restrictions of deployment; and
• 3) Clarify to its members and to the public when it is permissible to deploy the weapon.

In a letter to me as Chair of the Commission, dated November 29, 2007, RCMP Commissioner William J.S. Elliott indicated that the RCMP had taken additional steps to study the RCMP's use of the CEW, including:

1. Conducting a preliminary review of the RCMP's national policies and protocols as well as supplementary policy guidelines for RCMP detachments having airports within their jurisdiction, and taking steps to amend those policies to "reflect the requirement to have appropriate medical assistance on hand, whenever possible, when responding to reports of violent individuals and there is a heightened potential for the deployment of a conducted energy weapon."
2. Appointing a senior RCMP Officer to review RCMP policy and training with respect to CEWs.

On January 27, 2009 the RCMP issued an amended Operational Manual policy on the use of CEWs. The key points noted in the amended policy are that:

• 1) The RCMP now recognizes that a risk of death is associated with the deployment of the CEW;
• 2) The CEW may now be used only in circumstances in which the RCMP member, after considering the totality of the circumstances, perceives a threat to his or her safety or the safety of a member of the public;
• 3) RCMP members must now be re-certified annually in the use of the CEW;^{Footnote 105} and
• 4) The term excited delirium was removed from all RCMP policy and was replaced with the phrase agitated or delirious persons.

In addition, subsequent to the death of Mr. Dziekanski the RCMP opted to:

1. Restrict the use of the weapons to situations involving threats to officer or public safety;
2. Test a sample of CEWs to ensure adequate operation (following a Canadian Broadcast Corporation report calling into question the reliability of the output of some CEWs). On June 1, 2009, the RCMP removed from service approximately 1,600 Model M26 CEWs (the older model used by the RCMP) following testing by the Government of British Columbia which indicated that ...80% of the devices failed to operate within the manufacturers specifications. The results also showed that 90% of these units produced less electrical output than would be expected, potentially presenting both public and officer safety risks.^{Footnote 106} The RCMP will test these units and replace defective CEWs with the newer Model X26;
3. Enhance use of force reporting mechanisms; and
4. Conduct ongoing analysis of reporting on CEW usage.^{Footnote 107}

Appendix C – BCCLA Complaint re Media Issues

The following are the texts of the BCCLA letter of complaint, dated November 13, 2007 pertaining to media issues, as well as the BCCLA letter dated March 19, 2009 requesting that I review the RCMP investigation of the initial media related complaint.

PROTECTED

COMPLAINT

File No. PC-2007-2344

SUBJECT:       Mr. Jason Gratl
British Columbia Civil Liberties Association
Suite 550, 1188 West Georgia Street
Vancouver BC V6E 4A2
Telephone No: (604) 687-2919

On November 13, 2007, the Commission received the attached complaint from Mr. Gratl concerning the conduct of Sergeant Pierre Lemaitre of the Richmond, British Columbia RCMP Detachment and Corporal Dale Carr of the Integrated Homicide Investigation Team. Mr. Gratl writes:

"Dear Mr. Kennedy,

Re: Complaint against the RCMP over public statements and actions in the investigation of the in-custody death of Robert Dziekanski

I am writing on behalf of the BC Civil Liberties Association (BCCLA) to initiate a complaint under the Royal Canadian Mounted Police Act against the relevant member(s) of the Richmond RCMP detachment and Integrated Homicide Investigation Team that made public statements regarding the in-custody death of Robert Dziekanski and the seizure of Paul Pritchard's video recording of Mr. Dziekanski's death. Mr. Pritchard loaned his recording to the RCMP with a promise it would be returned within 48 hours, but later had to launch a civil suit against the RCMP to retrieve his property.

Please note that this complaint is distinct from our prior complaint dated October 24, 2007 against the RCMP member who sought to detain Mr. Dziekanski.

Mr. Dziekanski died October 14, 2007 shortly after receiving two taser pulses from an RCMP officer at the Vancouver International Airport. Shortly after the incident, Sgt. Pierre Lemaitre publicly stated that the officers present at the incident attempted to calm Mr. Dziekanski down verbally and with hand gestures. It was stated that Mr. Dziekanski ignored the officers, prompting them to use the taser. Information gleaned from eyewitness accounts contradicts this official position.

Walter Kosteckyj, counsel for Mr. Dziekanski's mother Sofia Cisowski, has stated that he has viewed video of the incident and 24 seconds elapsed between officers arriving on the scene and the use of the taser. Mr. Dziekanski was isolated and reportedly presented no danger to the public or responding officers. In an international airport, it is commonplace for people to have limited understanding of English and it was obvious that Mr. Dziekanski spoke a language other than English and was not understanding the officers. Any statement that the officers made an honest attempt at establishing communications constitutes misrepresentation given the circumstances.

Paul Pritchard, who witnessed and recorded the incident, has publicly stated that he heard an RCMP officer ask for and receive permission to use a taser before the officers confronted Mr. Dziekanski. Any statement that explicitly or implicitly leads the public to believe that the taser was used as a last resort contradicts the statement of Mr. Pritchard. Mr. Pritchard's statement is supported by the rapid deployment of the taser. There appears to be no evidence that supports the position that the taser as used as a last resort. Evidence that is publicly available in fact contradicts this representation. The evidence publicly available indicates that the officers in question did not pursue less intrusive methods, and any statement made otherwise constitutes misrepresentation given the circumstances.

I am also concerned about statements that misled the public as to Mr. Dziekanski's character. Sgt. Lemaitre repeatedly made statements implying if not alleging that Mr. Dziekanski was under the influence of alcohol or drugs or had a medical condition that caused his death. Examples of such statements are as follows:

"The man was sweating profusely and violent which could indicate either drug use or a medical condition." ("RCMP methods under scrutiny after airport Taser death." CanWestNews Service, National Post, 15 October 2007)

[On the RCMP interest in obtaining toxicology results] "There was obviously something very different that was going on inside him." ("Mother questions Taser death." Chantal Eustace, Vancouver Sun, 18 October 2007)

Sgt. Lemaitre also publicly questioned whether Mr. Dziekanski's identification was genuine. ("Witness says she tried to calm victim." Ian Bailey, Globe & Mail, 16 October 2007, S1)

Sgt. Lemaitre spoke without specific evidence to support his position. Mr. Dziekanski's autopsy and toxicology results refute Sgt. Lemaitre's position. While drugs, alcohol or a medical condition are possible contributors to Taser deaths, Sgt. Lemaitre appeared not to be explaining this possibility, but instead framed it as near certainty without alternative explanations. For example, Mr. Dziekanski's physical exertion was the obvious cause of profuse sweating, not drug use. Sgt. Lemaitre's assertion of something being "obviously" wrong was incorrect and inappropriate. Sgt. Lemaitre appears to have misled the public while casting aspersion on the character of Mr. Dziekanski. Either the intent or effect of the characterizations of the events and of Mr. Dziekanski appear designed to provide a favourable account of the RCMP's role in this death. This is inappropriate especially given the fact that the RCMP members are under in investigation and the RCMP has a lead role in undertaking that investigation.

With respect to the video, an unnamed officer spoke with Paul Pritchard and obtained his recording of the incident under the promise it would be returned immediately. The officer quickly informed Mr. Pritchard that the available equipment would not allow a copy to be made, and an agreement was reached to return the recording within 48 hours. Once in possession of the recording, the RCMP first informed Mr. Pritchard that previous agreements would have to be retracted and the recording would not be returned until a coroner's inquest concluded, some 1.5 to 2.5 years in the future.

According to public statements by Cpl. Dale Carr of the Integrated Homicide Investigation Team, the video had to be withheld because it would contaminate witnesses' memories. Yet, by the time these statements were made, the RCMP had already established and publicized their version of the story in great detail. If there were witnesses that had not been interviewed, contamination had already occurred. If the release of the video was inappropriate because of fear of contamination, the previous release of information by the RCMP should be equally viewed as contamination by the RCMP.

Cpl. Carr also publicly attacked Mr. Pritchard's desire to release the video on the grounds that it would upset Mr. Dziekanski's mother, Zofia Cisowski ("Police say they will return Taser video soon." n Fowlie and Chantal Eustace, Vancouver Sun, 2 November 2007, AI). This unfounded statement appears to be made for the purpose of discrediting Mr. Pritchard's intentions, as the public statement by Ms. Cisowski and her lawyer, Walter Kosteckyj, seem only to support the publication of the video.

As of the date of this complaint, the video has been returned to Mr. Pritchard clearly repudiating the RCMP's original justification for withholding the video.

Thus, without legal right, the RCMP effectively seized this video recording and suppressed it in a manner that was, either in intent or effect, to advantage the RCMP's reputation.

In sum, the BCCLA is concerned that the relevant RCMP member(s) misrepresented themselves to the public on various occasions and that they failed to return the video to Mr. Pritchard in a timely manner without grounds for doing so.

Given the serious nature of our complaints, and 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."

This complaint was received by Lorraine Blommaert, Team Lead for the Commission for Public Complaints Against the RCMP. The information contained in this complaint was provided to and received by the Commission pursuant to paragraph 45.35(1)(a) of the RCMP Act. This complaint is forwarded to the RCMP as the notification required to be given to the Commissioner pursuant to subsection 45.35(3) of the Act.

Attachment: 4 pages

March 19, 2009

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

Dear Mr. Kennedy,

Re: Request for review of complaint PC-2007-2344 (2007-30019) regarding public statements and actions by the RCMP in the investigation of the in-custody death of Robert Dziekanski

I am writing on behalf of the BC Civil Liberties Association (BCCLA) to request a review of our complaint PC-2007-2344. This complaint alleges that public statements and actions by the RCMP during the investigation of the in-custody death of Robert Dziekanski violate RCMP policy and amount to professional misconduct.

This complaint was made only a few weeks after Mr. Dziekanski died in police custody. The BCCLA attempted to provide several examples of misrepresentation for the investigator and cited our sources. The assigned investigator requested that the BCCLA provide copies of the articles. The BCCLA denied this request for several reasons.

First, the BCCLA monitors only a limited number of media sources due to our limited capacity as a small, non-profit organization. The BCCLA explicitly noted that the articles we cited were examples, and we believe that a thorough and adequate investigation ought to examine other news sources and relevant RCMP internal records such as press releases and interview tapes in order to effectively investigate our complaint.

Second, the investigator was made aware that the cited articles were available in the public domain. The Vancouver Sun and the National Post allow unrestricted public access to news articles for quite some time. The Globe and Mail restricts access after an article has been posted for seven days, but provides articles for a small fee thereafter. The public library may also have the news articles archived. The BCCLA submits that all articles cited were readily available to the investigator, and in point of fact, are still available.

"RCMP methods under scrutiny after airport Taser death." CanWest News Service, National Post, 15 October 2007.

"Airport death raises questions." Jonathan Woodward, Vancouver Sun, 15 October 2007.

"Mother questions Taser death." Chantal Eustace, Vancouver Sun, 18 October 2007.

"Witness says she tried to calm victim." Ian Bailey, Globe & Mail, 16 October 2007, S1.

"Police say they will return Taser video soon." Jonathan Fowlie and Chantal Eustace, Vancouver Sun, 2 November 2007, A1.

Third, the BCCLA submitted a complaint with clear citations and it is not the responsibility of the BCCLA to undertake investigative duties after filing a complaint. The RCMP has legal duties to a complainant outlined by the RCMP Act, and the clearly cited news articles can be obtained without impact on the limited resources of the BCCLA. The RCMP is obligated to obtain evidence in order to conduct a thorough and adequate investigation and the BCCLA made every effort to facilitate that process. Quite simply, the request was deemed inappropriate.

Furthermore, the investigator states that he was unable to acquire news articles because media outlets referred him to "their legal department and did not cooperate by providing the requested information". The report does not state which media organizations did not cooperate, what noncooperation entailed, and the reasons for not cooperating. As well, the report does not address whether the investigator made any attempts to address this lack of cooperation in order to pursue the RCMP's legal obligations to investigate the BCCLA's complaint appropriately.

Unless the RCMP can provide evidence that they were legitimately refused access to relevant news articles they could otherwise not obtain through other sources, including the internet or library archives, the BCCLA contends that the RCMP has not fulfilled its statutory obligations.

The BCCLA submits that the investigation is inadequate and asks that the complaint be reviewed by the Commission for Public Complaints against the RCMP and investigated further by the RCMP. Due to the gross inadequacy of the RCMP investigation, the BCCLA requests that the Commission monitor future investigation of this complaint in order to ensure the RCMP fulfils its statutory obligations to the BCCLA.

In order to facilitate reinvestigation of the BCCLA's complaint, the BCCLA's allegations and the conclusions of the report are examined in detail below. Please note that the allegations below have been numbered according to the original complaint and that that numbering does not match the investigation report. This was done because the report does not capture all of the allegations made in the original complaint.

Allegation 1

"...24 seconds elapsed between officers arriving on the scene and the use of the taser. Mr. Dziekanski was isolated and reportedly presented no danger to the public or responding officers. In an international airport, it is commonplace for people to have limited understanding of English and it was obvious that Mr. Dziekanski spoke a language other than English and was not understanding the officers. Any statement that the officers made an honest attempt at establishing communications constitutes misrepresentation given the circumstances."

Allegation 2

"Paul Pritchard, who witnessed and recorded the incident, has publicly stated that he heard an RCMP officer ask for and receive permission to use a taser before the officers confronted Mr. Dziekanski. Any statement that explicitly or implicitly leads the public to believe that the taser was used as a last resort contradicts the statement of Mr. Pritchard. Mr. Pritchard's statement is supported by the rapid deployment of the taser. There is no evidence that supports the position that the taser was used as a last resort. The officers did not honestly pursue less intrusive methods, and any statement made otherwise constitutes misrepresentation given the circumstances."

Allegations 1 and 2 seem to have been conflated in the investigation report into a single allegation "that Sergeant Lemaitre stated the attending police officers attempted to calm Dziekanski and as a last resort, used the taser."

Although the articles that supported the BCCLA's allegations were not examined, Tom Forster did report on a CBC interview of which the BCCLA was not aware that resulted in the following statement:

"Sergeant Lemaitre in an interview with the CBC on. October 16, 2007 defended the actions of the members by telling the reporter how various use of force options were not ideal during the altercation with Dziekanski. At this point in time, no opinion from a use of force expert had been received by IHIT indicating whether the use of the CEW or the use of force generally was appropriate or not. Such a report was not requested by IHIT until early November 2007."

The BCCLA made its complaint due to concerns that the investigation of Mr. Dziekanski's in-custody death was biased, and that the primary concerns of the RCMP were the defence of its members and its public image. Canadians expect the RCMP to investigate crimes in a manner that ensures no Canadian is above the law. Nevertheless, Sergeant Lemaitre, a spokesman for the RCMP, defended the actions of officers who were the subjects of an open criminal investigation. Furthermore, Sergeant Lemaitre defended the officers' deadly use of force even though an internal review as to the appropriateness of the degree of force used had not been completed. Despite the investigator's conclusion that the allegations are not supported, it is difficult to see how Sergeant Lemaitre's actions do not indicate professional misconduct and biased reporting of the RCMP's investigation of this in-custody death.

Given the information supplied in the investigation report, that Sergeant Lemaitre actively defended the actions of officers involved in an in-custody death without reference to an internal investigation, any assertion by Sergeant Lemaitre that the attending members used an appropriate degree of force appears inappropriate, unfounded, and biased.

Allegation 3

"Sgt. Lemaitre repeatedly made statements implying if not alleging that Mr. Dziekanski was under the influence of alcohol or drugs or had a medical condition that caused his death."

Allegation 4

"Sgt. Lemaitre also publicly questioned whether Mr. Dziekanski's identification was genuine."

Allegation 3 was expanded into two allegations in the investigation report that addressed the three examples the BCCLA provided in order to support its allegations, "that Sergeant Lemaitre may have been under the influence of alcohol, drugs, or had a medical condition that caused his death," and "that Sergeant Lemaitre stated that Dziekanski was sweating profusely and was violent which could indicate either drug use or a medical condition and that there was obviously something very different going on inside him."

Allegation 4 was not investigated.

Allegations 3 and 4 are based on the appropriateness of certain statements Sergeant Lemaitre made to the media. The BCCLA cited articles that contained unfounded assertions that appeared only to serve as a character attack on Mr. Dziekanski. Unless the RCMP claims that Sergeant Lemaitre was misquoted, it is difficult to see how the investigation report can claim that the statements were not made.

Although the articles that supported the BCCLA's allegations were not examined, Tom Forster notes the following:

"The Pritchard video confirms that Dziekanski was sweating profusely. While it could indicate drug use, or a medical condition or that something was going on inside him, or something else altogether, at the time the comment was said, the autopsy report had not confirmed, eliminated or otherwise provided information about the cause of Dziekanski's sweating or his overall behaviour. As well, the toxicology report had not yet been received and therefore, these comments could amount to speculation which would be contrary to RCMP policy."

Sergeant Lemaitre is clearly speculating in some of his statements, such as when giving weight to a toxicology report not yet received or when questioning the authenticity of identification without cause. Allegations 3 and 4 need to be investigated further, as the report ignores the supporting evidence supplied by the BCCLA and ignores an allegation in its entirety.

The investigation report clearly focuses on the fact that Sergeant Lemaitre did not have investigational details to support his statements. In Allegations l and 2, the BCCLA contends that Sergeant Lemaitre made statements in defence of the members involved and the public image of the RCMP. In Allegations 3 and 4, Sergeant Lemaitre makes statements that consistently create suspicion about Mr. Dziekanski. Defending those that are the subject of an active homicide investigation and casting suspicion on the role of the victim is extremely inappropriate. The BCCLA alleges that Sergeant Lemaitre was not only involved in speculation, but that that speculation served a purpose: to shift blame from the involved officers and the RCMP to Mr. Dziekanski. It is difficult to posit any other reasonable explanation for Sergeant Lemaitre's conduct. It is noteworthy that Sergeant Lemaitre releases many details of the investigation that could contaminate the investigation by altering the accounts of witnesses.

Allegation 5

"An unnamed officer spoke with Paul Pritchard and obtained his recording of the incident under the promise it would be returned immediately. The officer quickly informed Mr. Pritchard that the available equipment would not allow a copy to be made, and an agreement was reached to return the recording within 48 hours. Once in possession of the recording, the RCMP informed Mr. Pritchard that previous agreements would have to be retracted and the recording would not be returned until a coroner's inquest concluded, some 1.5 to 2.5 years in the future.

Without legal right, the RCMP seized this video recording and suppressed it."

Allegation 5 was not investigated but a statement was made that there was no suppression.

The BCCLA submitted in our original complaint that the RCMP had no right to seize Paul Pritchard's property, and that they actively tried to suppress the video by claiming it would not be released until after a coroner's inquest. The investigation report makes a passing reference to this allegation by noting "there is no evidence that there was any attempt to suppress the video as it was presented to the BC Coroner immediately and in fact was viewed by Mrs. Cisowski's lawyer [Walter Kosteckyj] shortly thereafter." The BCCLA does not question whether the BC Coroner's Office had the videotape in question and is aware that Mr. Kosteckyj viewed the tape, but the tape was not returned to Mr. Pritchard until after be launched a lawsuit. The BCCLA alleges that the RCMP did not have the legal authority to maintain possession of the tape and that telling Mr. Pritchard he would not have his property returned to him until after a coroner's inquest amounts to suppression.

While the report does not investigate the allegation it concludes that there is no evidence of suppression. Paul Pritchard's statement, as reported by the Vancouver Sun and other media outlets, contradict this:

"Pritchard said he gave the videos to police right after the incident on the understanding they would be returned within 48 hours. He said police have held onto the videos ever since, telling him he may not see the footage again for up to 2 1/2 years."^{Footnote 112}

The Canadian Press reported that Mr. Pritchard launched his law suit precisely because he was told the video might be withheld for years.

"[Pritchard] turned over the video to police investigators on a promise it would be returned within 48 hours but went public with a lawsuit after being told RCMP might keep it for years."^{Footnote 113}

Documentation of Mr. Pritchard's lawsuit was not examined as part of this complaint, and Paul Pritchard was not contacted as a witness. There appears to be no basis to claim that "there is no evidence that there was any attempt to suppress the video". The BCCLA contends that there is evidence of attempted suppression and that evidence has not been examined.

Allegation 6

"According to Cpl. Dale Carr of the Integrated Homicide Investigation Team, the video had to be withheld because it would contaminate witnesses' memories. By this time the RCMP had already established and publicised their version of the story in great detail. If there were witnesses that had not been interviewed, contamination had already occurred. If the release of the video was inappropriate because of fear of contamination, the previous release of information by the RCMP should be equally viewed as contamination by your office."

Allegation 6 is examined as an allegation "that Corporal Carr stated the Pritchard video recording was being withheld from the public to prevent witness account contamination but that the RCMP was continuing to publicly espouse subjective information about the incident thereby contaminating potential witness accounts to the detriment of Dziekanski and to the benefit of the RCMP."

The report concludes that Corporal Carr did not release information about the investigation after being assigned to the case. The statements made by Sergeant Lemaitre were not considered. Sergeant Lemaitre, as outlined above, clearly speculated about Mr. Dziekanski's mental state, his mental health, drug use, and the authenticity of Mr. Dziekanski's identification. Sergeant Lemaitre also made several statements as to the appropriateness of the involved officers' conduct. These are clearly details of the investigation that could impact the integrity and content of witnesses' statements. The investigation report implicitly supports a claim that Sergeant Lemaitre released details of the investigation by noting that Sergeant Lemaitre's statements "were contrasted against details depicted in the video". The original complaint made by the BCCLA does not limit its allegation to Corporal Carr, and the statements of Sergeant Lemaitre were not addressed in the investigation report.

That Corporal Carr or other RCMP members did not release details of the investigation after October 16th has not been established. At no time does the report state that RCMP media releases and press conferences were examined; instead, the investigator claims to have examined that which was in the public domain. The BCCLA believes it is appropriate to examine all RCMP press releases and all tapes held by the RCMP of its own interviews. If the RCMP is to make the claim that it does not retain records of its own press releases or record (or keep recordings of) their own press conferences, the BCCLA also believes that some of this information can be obtained from media outlets.

Allegation 7

"Cpl. Carr publicly attacked Mr. Pritchard's desire to release the video on the grounds that it would upset Mr. Dziekanski's mother, Zofia Cisowski." This unfounded statement appears to be made for the purpose of discrediting Mr. Pritchard's intentions, as the public statements of Ms. Cisowski and her lawyer, Walter Kosteckyj, seem only to support the publication of the video."

Allegation 7 was not investigated on the excuse that there was no video of Corporal Carr's statements. The BCCLA cited its source in making the allegation.^{Footnote 114}

The report concludes that Corporal Carr spoke as a parent and projected that no parent would want to see video of their child's death. This is not supported by Corporal Carr's statements to the media. To be clear, the cited article states the following:

"Carr said he expects Pritchard will release the video to the media as soon as he is able. He added, however, that doing so is likely to upset Dziekanski's mother, Zofia Cisowski. 'She is beside herself. This has been extremely traumatic for her and this is what, are we 10 or 15 days later? And it's going to be dredged up again,' he said.

‘Probably, I can pretty much imagine the clips that are going to be shown if it's given, and I think it's terrible,' he added.
...
Pritchard added he is determined to let the public see the video so the full story can get out, but he said he would speak with Cisowski before making any final decisions.

'I will first talk to. Mr. Dziekanski's family and their lawyer to make sure it is okay and then just get it out to the media,' he said.

'I want the public to see this.'"^{Footnote 115}

Corporal Carr clearly states that the release of the video will further traumatize Ms. Cisowski's. Corporal Carr cannot speak for Ms. Cisowski and clearly Mr. Pritchard intended to confer with Ms. Cisowski before he released the tape to the public. The BCCLA contends that it is inappropriate of Corporal Carr, acting as a representative of the RCMP, to state any opinion or judgement on the broadcasting of this video. Corporal Carr's statement serves no purpose other than to shed negative light on the video's release. Corporal Carr did not express any sympathy based on his status as a parent, as claimed in the investigation report.

As the BCCLA's complaint was made shortly after the in-custody death of Robert Dziekanski, certain details of the incident bad not come to light. It is now clear from the Braidwood Inquiry that the taser was discharged five times. The RCMP initially reported that Mr. Dziekanski was tasered twice and expressly denied claims that Mr. Dziekanski was tasered four or five times.^{Footnote 116} Furthermore, it is now clear from the Braidwood Inquiry that four RCMP officers attended the scene. The RCMP initially reported that three officers attended.^{Footnote 117} The BCCLA believes that it is not unreasonable for these instances of apparent misrepresentation also be examined when this complaint is reviewed.

The BCCLA requests that its complaint be reviewed by the Commission. Assuming the Commission accepts our request for review, given the serious charges we bring to your attention, the inadequacy of the ensuing investigation, and to maintain and enhance the public's confidence in the RCMP, we request that your office monitor the reinvestigation of this complaint to ensure that a thorough and unbiased investigation takes place.

I look forward to your response.

Yours sincerely,

Rob Holmes,
President

November 13, 2007

Paul Kennedy, Chair
Commission for Public Complaints Against RCMP
'PO Box 3423, Station 'D'
Ottawa, Ontario K1P 6L4

Fax: 613 952 8045

Dear Mr. Kennedy,

Re: Complaint against the RCMP over public statements and actions in the investigation of the in-custody death of Robert Dziekanski

I am writing on behalf of the BC Civil Liberties Association (BCCLA) to initiate a complaint under the Royal Canadian Mounted Police Act against the relevant member(s) of the Richmond RCMP detachment and Integrated Homicide Investigation Team that made public statements regarding the in-custody death of Robert Dziekanski and the seizure of Paul Pritchard's video recording of Mr. Dziekanski's death. Mr. Pritchard loaned his recording to the RCMP with a promise it would be returned within 48 hours, but later had to launch a civil suit against the RCMP to retrieve his property.

Please note that this complaint is distinct from our prior complaint dated October 24, 2007 against the RCMP members who sought to detain Mr. Dziekanski.

Mr. Dziekanski died October 14, 2007 shortly after receiving two taser pulses from an RCMP officer at the Vancouver International Airport. Shortly after the incident, Sgt. Pierre Lemaitre publicly stated that the officers present at the incident attempted to calm Mr. Dziekanski down verbally and with hand gestures. It was stated that Mr. Dziekanski ignored the officers, prompting them to use the taser. Information gleaned from eyewitness accounts contradicts this official position.

Walter Kosteckyj, counsel for Mr. Dziekanski's mother Zofia Cisowski, has stated that he has viewed video of the incident and 24 seconds elapsed between officers arriving on the scene and the use of the taser. Mr. Dziekanski was isolated and reportedly presented no danger to the public or responding officers. In an international airport, it is commonplace for people to have limited understanding of English and it was obvious that Mr. Dziekanski spoke a language other than English and was not understanding the officers. Any statement that the officers made an honest attempt at establishing communications constitutes misrepresentation given the circumstances.

Paul Pritchard, who witnessed and recorded the incident, has publicly stated that he heard an RCMP officer ask for and receive permission to use a taser before the officers confronted Mr. Dziekanski. Any statement that explicitly or implicitly leads the public to believe that the taser was used as a last resort contradicts the statement of Mr. Pritchard. Mr. Pritchard's statement is supported by the rapid deployment of the taser. There appears to be no evidence that supports the position that the taser was used as a last resort. Evidence that is publicly available in fact contradicts this representation. The evidence publicly available indicates that the officers in question did not pursue less intrusive methods, and any statement made otherwise constitutes misrepresentation given the circumstances.

I am also concerned about statements that misled the public as to Mr. Dziekanski's character. Sgt. Lemaitre repeatedly made statements implying if not alleging that Mr. Dziekanski was under the influence of alcohol or drugs or had a medical condition that caused his death. Examples of such a statement are as follows:

"He may have ingested drugs, or may have a medical condition." ("Airport death raises questions." Jonathan Woodward, Vancouver Sun, 15 October 2007)

"The man was sweating profusely and violent which could indicate either drug use or a medical condition."("RCMP methods under scrutiny after airport Taser death." CanWest News Service, National Post, 15 October 2007)

[On the RCMP interest in obtaining toxicology results] "There was obviously something very different that was going on inside him." ("Mother questions Taser death." Chantal Eustace, Vancouver Sun, 18 October 2007)

Sgt. Lemaitre also publicly questioned whether Mr. Dziekanski's identification was genuine. ("Witness says she tried to calm victim." Ian Bailey, Globe & Mail, 16 October 2007, S1)

Sgt. Lemaitre spoke without specific evidence to support his position. Mr. Dziekanski's autopsy and toxicology results refute Sgt. Lemaitre's position. While drugs, alcohol or a medical condition are possible contributors to Taser deaths, Sgt. Lemaitre appeared not to be explaining this possibility, but instead framed it as near certainty without alternative explanations. For example, Mr. Dziekanski's physical exertion was the obvious cause of profuse sweating, not drug use. Sgt. Lemaitre's assertion of something being "obviously" wrong was incorrect and inappropriate. Sgt. Lemaitre appears to have misled the public while casting aspersion on the character of Mr. Dziekanski. Either the intent or effect of the characterizations of the events and of Mr. Dziekanski appear designed to provide a favourable account of the RCMP's role in this death. This is inappropriate especially given the fact that the RCMP members are under investigation and the RCMP has a lead role in undertaking that investigation.

With respect to the video, an unnamed officer spoke with Paul Pritchard and obtained his recording of the incident under the promise it would be returned immediately. The officer quickly informed Mr. Pritchard that the available equipment would not allow a copy to be made, and an agreement was reached to return the recording within 48 hours. Once in possession of the recording, the RCMP first informed Mr. Pritchard that previous agreements would have to be retracted and the recording would not be returned until a coroner's inquest concluded, some 1.5 to 2.5 years in the future.

According to public statements by Cpl. Dale Carr of the Integrated Homicide Investigation Team, the video had to be withheld because it would contaminate witnesses' memories. Yet, by the time these statements were made, the RCMP had already established and publicized their version of the story in great detail. If there were witnesses that had not been interviewed, contamination had already occurred. If the release of the video was inappropriate because of fear of contamination, the previous release of information by the RCMP should be equally viewed as contamination by the RCMP.

Cpl. Carr also publicly attacked Mr. Pritchard's desire to release the video on the grounds that it would upset Mr. Dziekanski's mother, Zofia Cisowski ("Police say they will return Taser video soon." Jonathan Fowlie and Chantal Eustace, Vancouver Sun, 2 November 2007, A1). This unfounded statement appears to be made for the purpose of discrediting Mr. Pritchard's intentions, as the public statements of Ms. Cisowski and her lawyer, Walter Kosteckyj, seem only to support the publication of the video.

As of the date of this complaint, the video has been returned to Mr. Pritchard clearly repudiating the RCMP's original justification for withholding the video.

Thus, without legal right, the RCMP effectively seized this video recording and suppressed it in a manner that was, either in intent or effect, to advantage the RCMP's reputation.

In sum, the BCCLA is concerned that the relevant RCMP member(s) misrepresented themselves to the public on various occasions and that they failed to return the video to Mr. Pritchard in a timely manner without grounds for doing so.

Given the serious nature of our complaints, and 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,

Jason Gratl,
President

Appendix D – RCMP Response to BCCLA Complaint re Media Issues

Attached below is the letter (the RCMP's Final Report) sent by Chief Superintendent Rob Morrison to the BCCLA with respect to the RCMP investigation of the BCCLA complaint pertaining to media issues.

"E" Division
Operations Strategy Branch
Your File - Votre référence
PC-2007-2344

Our File – Notre référence
2007-30019

Date
December 23 2008

Mr. Jason Gratl
c/o BC Civil Liberties Association
Suite #550- 1188 West Georgia Street
Vancouver, BC
V6E 4A2

Dear Mr. Gratl:

This letter is in reference to the public complaint you lodged with the Commission for Public Complaints against the RCMP (CPC) on November 13, 2007.

A thorough investigation has been conducted and I am now in a position to address your concerns.

Background Information:

On October 14, 2007, Richmond Detachment members were called to Vancouver International Airport following a report of a disturbance in the International Arrivals secure area. Initially, airport security officers attended but were unable to communicate with a 40 year old agitated male who apparently could not respond to English language. This male was sweating profusely and was acting out by shouting. He picked up a small folding table and threw it against a glass wall and then attempted to throw a computer that was still tethered to a counter. As a result, airport security contacted the RCMP. RCMP officers arrived on scene and within a short time, a member activated a Conducted Energy Weapon (CEW). The male, later identified as Robert Dziekanski, fell to the floor and was restrained with the use of handcuffs.

The male fell unconscious and subsequently died at the scene. The Integrated Homicide Investigation Team (IHIT) and BC Coroner's service were called to the scene to Investigate. Initial Media briefings were conducted by Sergeant Lemaitre and Corporal Carr.

An unrelated traveler by the name of Paul Pritchard, used his own digital camera to record continuous footage of the encounter between Mr. Dziekanski and airport security, as well as the arrival and interactions of RCMP officers.

Summary of Complaint:

You allege that there are several misleading statements and misrepresentations made by RCMP media relations officers (MRO's) during the first few days following the police custody death of Robert Dziekanski on October 14, 2007. You also allege that the RCMP had no legal right to seize the video recording from Pritchard and suppress it in a manner that was, either in intent or effect, to advantage the RCMP's reputation or project a more favorable account of the RCMP's role during the encounter with Dziekanski.

You quoted newspaper articles when outlining your allegations: specifically:

1. That Sergeant Lemaitre stated the attending police officers attempted to calm Dziekanski and as a last resort, used the taser.

2. That Sergeant Lemaitre stated Dziekanski may have been under the influence of alcohol, drugs or had a medical condition that caused his death.

3. That Sergeant Lemaitre stated that Dziekanski was sweating profusely and was violent which could indicate either drug use or a medical condition and that there was obviously something very different going on inside of him.

4. That Corporal Carr stated the Pritchard video recording was being withheld from the public to prevent witness account contamination but that the RCMP was continuing to publicly espouse subjective information about the incident thereby contaminating potential witness accounts to the detriment of Dziekanski and to the benefit of the RCMP.

5. That Corporal Carr stated the Pritchard video recording was being withheld from the public to prevent upsetting Mrs. Cisowski (the decedent's mother), even though she and her lawyer wanted it released.

6. That Corporal Carr publicly attacked Paul Pritchard's motive for release of the video.

There have been numerous public complaints lodged relating to this incident, specifically there has been a public complaint lodged relating to the seizure and retention of the video recording taken by Mr. Paul Pritchard. Section 45.36 of the RCMP Act allows for the disposition of complaints should other avenues of investigation be continuing, in this case a Criminal Investigation into the Police Custody Death of Mr. Dziekanski. As such any allegations relating to the seizure and retention of the video recording taken by Mr. Paul Pritchard will be addressed in relation to the MRO's conduct only.

Staff Sergeant Tom Forster was assigned to the investigation of your public complaint.

Findings of Investigation:

In December 2007, the RCMP investigator, Staff Sergeant Forster met with you to determine whether there was any specific evidence to support your allegations and to complete the public complaint form. You did not provide Staff Sergeant Forster with any further documentation or evidence. You did cite newspaper articles and advised that much of the information was held in the public domain. In the course of this interview it was also discussed that you had a reasonable expectation that during the course of this public complaint Investigation, if other non-specified inaccuracies surfaced regarding the release of information to the media by the RCMP in relation to Mr. Dziekanski (decedent), that those issues should be investigated.

Staff Sergeant Forster reviewed information found in the public domain and attempted to obtain information from sources that you cited in your public complaint. The media sources cited in your public complaint referred Staff Sergeant Forster to their legal department and did not cooperate by providing the requested information. As a result, Staff Sergeant Forster relied on media interviews as located in the public domain, as a result the examination of video footage of news segments could only be placed in context if either the preamble and/or postscript was included in the clipping. Interviews were also conducted with members related to the concerns of this public complaint, including the subject members.

Allegation #1: That Sergeant Lemaitre stated the attending police officers attempted to calm Dziekanski and as a last resort, used the taser.

As noted in the Pritchard video, the CEW was utilized approximately 25 seconds after members arrived at the scene. Sergeant Lemaitre in an interview with the CBC on October 16, 2007 defended the actions of the members by telling the reporter how various use of force options were not ideal during the altercation with Dziekanski. At this point in time, no opinion from a use of force expert had been received by IHIT indicating whether the use of the CEW or the use of force generally was appropriate or not. Such a report was not requested by IHIT until early November 2007.

There are several media video clips in the public domain which show Sergeant Lemaitre reporting that members tried to calm Dziekanski down, all to no avail and that a CEW was deployed. Members of the RCMP are familiar with use of force options included in the Incident Management Intervention Model and when interviewed about his comments to the CBC, Sergeant Lemaitre stated he barely recalled doing that interview. He believed his motivation for explaining the various options was to try to help a lay person understand what process the members would have been going through before the CEW was employed. Sergeant Lemaitre when interviewed advised that he was not misrepresenting information.

As such, the allegation that Sergeant Lemaitre misrepresented this information is not supported.

Allegation #2 That Sergeant Lemaitre stated Dziekanski mayhave been under the influence of alcohol, drugs or had a medical condition that caused his death.

No video recording shows that Sergeant Lemaitre asserted this information as fact. Sergeant Lemaitre when interviewed on this stated that he would have said that IHIT were investigating to see if alcohol, drugs or a medical condition existed which is that the investigation would try to determine. Further, in reviewing the IHIT file, it was noted that several eyewitnesses who were interviewed at the airport provided statements to police where they believed alcohol was involved as DZIEKANSKI was acting erratically like a person might under the influence of alcohol or a drug.

This allegation is not supported by any evidence uncovered in this investigation.

Allegation #3: That Sergeant Lemaitre stated that Dziekanski was sweating profusely and was violent which could indicate either drug use or a medical condition and that there was obviously something very different going on inside him.

The Pritchard video confirms that Dziekanski was sweating profusely. While it could indicate drug use, or a medical condition or that something was going on inside him, or something else altogether, at the time this comment was said, the autopsy report had not confirmed, eliminated or otherwise provided information about the cause of Dziekanski's sweating or his overall behavior. As well, the toxicology report had not yet been received and therefore, these comments could amount to speculation which would be contrary to RCMP policy.

There is no video of this particular comment and the newspaper sources cited by the BCCLA did not cooperate. There is no direct evidence relating to this allegation and your office was unable to provide any further Information. As such, this allegation is not supported.

Allegation #4: That Corporal Carr stated the Pritchard video recording was being withheld from the public to prevent witness account contamination but that the RCMP was continuing to publicly espouse subjective information about the incident thereby contaminating potential witness accounts to the detriment of Dziekanski and to the benefit of the RCMP.

The Pritchard video is very graphic and an excellent piece of evidence in factually depicting what happened. As is prudent in any investigation, capturing what an independent witness observed before being able to be influenced by talking with other witnesses or seeing material that could influence their recollection is crucial. Corporal Carr's comments were authorized by Superintendent Rideout, an experienced homicide investigator and a police subject matter expert in investigating deaths. Withholding the video from the public and from potential witnesses until statements were obtained is a tried and true process.

Once all witnesses were interviewed, the Pritchard video was released. There is no evidence that there was any attempt to suppress the video as it was presented to the BC Coroner immediately and in fact was viewed by Mrs. Cisowski's lawyer shortly thereafter.

Once Corporal Carr was assigned to be the spokesperson for the Dziekanski investigation on October 16, 2007, there were no further releases made about details form any witnesses or involved members. However, media outlets were continuing to run footage from Sergeant Lemaitre's early interview releases in anticipation of the public release of the Pritchard video on November 14, 2007. At the time, the early release by Sergeant Lemaitre were contrasted against details depleted in the video.
I cannot support this allegation as it is not supported by any evidence uncovered in this investigation.

Allegation #5: That Corporal Carr stated the Pritchard video recording was being withheld from the public to prevent upsetting Mr. Cisowski (the decedent's mother), even though she and her lawyer wanted it released.

When Corporal Carr was interviewed he stated that while he did not speak to Mrs. Cisowski, he as a parent, projected how any parent would feel about seeing a video where their child dies, nobody would want to see such a thing and especially not on national television. As mentioned earlier, the Pritchard video was withheld for sound Investigational reasons. Of note, the day before the Pritchard video was released, Pritchard himself (in an interview with CTV and Global TV) forewarned the public of the graphic nature of the depictions that he didn't think Mrs. Cisowski would want to see the video.

This allegation is not supported by any evidence uncovered in this investigation or provided to the RCMP investigator.

Allegation #6: That Corporal Carr publicly attacked Paul Pritchard's motive for release of the video.

The Investigator could not locate any video that contained comments which could amount to an attack upon the character of Mr. Pritchard. You could not provide evidence of this allegation when interviewed by the investigator and the newspaper sources cited in your complaint did not cooperate in this investigation.

This investigation is not supported by any evidence uncovered in this investigation.

* Of note is that this investigation recognized that Sergeant Lemaitre did not maintain notes as expected of all RCMP members. I have personally provided Sergeant Lemaitre with operational guidance regarding both the RCMP's expectation and my own, of the importance of keeping adequate notes when involved in any file.

Conclusion:

Media Relations Officers find themselves in demanding situations when responding to incidents of a sensitive nature involving a death in custody. Attempting to release information as expeditious as the public and media desires, puts police investigations at risk. Historically, the RCMP have released little information prior to the conclusion of the investigation. Striking this balance of how much information to release can be difficult. Too much or too little may be misconstrued or put the ability to bring the investigation to a conclusion into jeopardy.

Please be advised that, pursuant to Section 45.4 of the RCMP Act, I am notifying you that the investigation into your complaint has now been concluded. If you are not satisfied with the manner in which your complaint has been addressed by the RCMP, you may request a review by the Commission for Public Complaints Against the RCMP by corresponding with them at the following address:

Commission for Public Complaints Against the RCMP
Canada Post: Bag Service 1722
Ottawa, ON
K1P 083
Tel: 1-800-267-6637
Fax: 1-613-952-8045

Yours truly,

Rob Morrison, Chief Superintendent
Officer in Charge
Operations Strategy Branch
"E" Division

cc: Commission for Public Complaints Against the RCMP, File PC-2007-2344

Appendix E – Braidwood Commissions – Terms of Reference

The Province of British Columbia has initiated two Commissions of Inquiry, each headed by Commissioner Thomas R. Braidwood, Q.C., and known as the Thomas R. Braidwood, Q.C., Hearing and Study Commission, the mandate of each is as follows:^{Footnote 118}

4(1) The terms of reference of the inquiries to be conducted by the study commission ... are as follows:

• a) to review current rules, policies and procedures applicable to constables, sheriffs and authorized persons ... in respect of their use of conducted energy weapons and their training and re-training in that use;
• b) to review research, studies, reports and evaluations respecting the safety and effectiveness of conducted energy weapons when used in policing and law enforcement in British Columbia and in other jurisdictions;
• c) to make recommendations respecting
  1. the appropriate use of conducted energy weapons by constables, sheriffs and authorized persons ... in the performance of their duties and the exercise of their powers, and
  2. the appropriate training or re-training of those constables, sheriffs and authorized persons in that use of conducted energy weapons;
• d) to submit a report to the Attorney General on or before June 30, 2008 (Amended by OIC 882 to June 30, 2009).

(2) The terms of reference of the inquiries to be conducted by the hearing and study commission ... are as follows:

• a) to conduct hearings, in or near the City of Vancouver, into the circumstances of and relating to Mr. Dziekanski's death;
• b) to make a complete report of the events and circumstances of and relating to Mr. Dziekanski's death, not limited to the actual cause of death;
• c) to make recommendations the commissioner considers necessary and appropriate;
• d) to submit a report to the Attorney General on or before a date to be determined by the Attorney General in consultation with the Commissioner.

The second Braidwood Commission, sitting in Vancouver, BC, began to hear witnesses on January 19, 2009.

Appendix F – 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 119}

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 IHIT investigative team and identified no issues with respect to the impartiality of the IHIT investigation. More specifically, with respect to the criteria enumerated above, his observations were:

1. Line Management
   The Observer found that no IHIT investigators had any association with any of the responding members. He noted that the girlfriend of an IHIT investigator was acquainted with the girlfriend of Constable Millington. As a result, the team commander unilaterally assigned the IHIT investigator to the role of file coordinator, with the result that the investigator did not participate in conducting the investigation itself. This action was taken with no prompting from the Independent Observer.
2. Appropriate Level of Response
   The investigation team commander was accredited (in Major Case Management). Each of the investigators was assigned full time to the IHIT team, meaning that each worked solely on the investigation of homicides.
3. Timeliness of Response
   The incident occurred at approximately 1:30 a.m. on Sunday, October 14, 2007. IHIT was advised of the death of Mr. Dziekanski at 2:28 a.m. and arrived at YVR to begin the investigation at 3:45 a.m.
4. Conduct
   The Independent Observer noted no obvious signs of bias or partiality on the part of the IHIT investigators. On October 29, 2007, the Independent Observer received a CD containing witness statements taken to that date. In his update of November 1, 2007, the Independent Observer noted no concerns with respect to impartiality or leading the witnesses. As part of my Chair-initiated complaint, I have identified issues with respect to the conduct of the IHIT investigation (which arose subsequent to the update), which are discussed in the body of this report and related appendices.

Appendix G – Chart of YVR International Arrivals Area

The chart below is Exhibit 2 filed during the Braidwood Inquiry.

Appendix H – Chronology of Events

3:12 p.m. Saturday, October 13, 2007 – Mr. Dziekanski arrived at YVR via Condor Air flight 6070. He passed through the CBSA Primary Inspection Line and remained in the secure area of the international arrivals area.

10:30 p.m. October 13, 2007 – Mr.  Dziekanski approached the CBSA Secondary Inspection point and was processed by both Customs and Immigration.

12:45 a.m. Sunday, October 14, 2007 – Mr. Dziekanski completed CBSA processing and was free to enter Canada.

1:24 a.m. October 14, 2007 – The first of a series of 911 calls was received by RCMP Richmond Detachment operators indicating that a man (known later to be Mr. Dziekanski), who was reported as likely intoxicated (later found not to be true), was acting erratically, breaking windows and furniture (later found not to be true) and was obstructing the exit from the secure international arrivals area to the public greeting area.

RCMP members who are dispatched do not receive calls from, nor do they speak directly with, persons calling 911. The information is taken by operators and relayed to the member(s) assigned. Because of the nature of radio transmissions, all other members using the same radio frequency, in this case all members assigned to the Richmond Detachment, are able to hear all dispatched transmissions.

The Report to Crown Counsel compiled by IHIT investigators indicates that the time presented on the RCMP dispatch time logs is out of sync with actual time by approximately one minute and 30 seconds. No specific reason for this delay is known, nor are IHIT investigators aware whether this situation has been rectified.

In addition, the internal clock as indicated in the CEW download report does not synch with the timelines. The CEW download indicates that the cycling of the weapon occurred between 01:23:43 and 01:24:32.^{Footnote 120}

01:24:46 – The first 911 call from the YVR Operations Centre was received by RCMP operators. The call lasted approximately one minute and 32 seconds. The caller from YVR indicated that an unknown female had just called her to state that a male in his 50s was presently located in the international arrivals reception lobby, and stated that the male was throwing suitcases and chairs. The caller informed the YVR Operations Centre that the male appeared intoxicated, that he had dark hair and was wearing a white coat. The caller was concerned that someone would be hurt.

At approximately 1:26 a.m., in an exchange lasting approximately 27 seconds, the dispatcher requested via the Richmond Detachment radio dispatch channel that a YVR member attend. Constable Millington replied and indicated that he would take the call. The dispatcher informed him that information was limited, and stated that a non-white male of approximately 50 years was throwing luggage around the international arrivals area. The male had dark hair and was wearing a white coat. An Occurrence Event, a written synopsis of the radio call, was transmitted to E – 23 (Constable Millington) by the dispatcher at 1:27 a.m.

1:28 a.m. – The second 911 call from YVR Operations was received by an RCMP operator. The caller indicated that the male was now throwing chairs through the glass windows.

01:28:40 – The dispatcher contacted Constable Millington again, advised that the male was now throwing chairs through the glass at the location and asked if Constable Millington had any other members attending with him. Constable Millington advised that other members were with him.

01:30:52 – The RCMP dispatcher recognized that the microphone of one of the members attending the complaint of the erratic male at YVR was keyed open, i.e. the radio unit used by that member was broadcasting, and at 01:31:13 went on-air to ask about the status of D – 21, Constable Rundel, whom she knew was working in Zone 1 (YVR) of the Richmond Detachment.

01:31:14 – BC Ambulance Service received a call from YVR Operations. The call was logged as a non-alert overdose and was assigned a routine priority for response.

01:31:38 – E – 23 (Constable Millington) advised dispatch that one male was in custody, that all four YVR members had attended the scene. He confirmed that D – 21 (Constable Rundel) was with him.

01:32:13 – BC Ambulance dispatched unit 51A to respond to the call received at 01:31:14.

01:32:25 – E – 24 (Constable Bentley) requested by police radio that Emergency Health Services (EHS) (also referred to as BC Ambulance Service) be dispatched. Constable Bentley requested that EHS use a routine priority for the call. This means that EHS should attend, but there was no urgency to the need for medical personnel.

01:32:49 – Dispatch received a radio call from an unknown member at the scene who requested that the BC Ambulance Service response be upgraded to Code 3 (most urgent). The member said that the male was unconscious but breathing.

01:32:50 – BC Ambulance received an updating call informing that police were on scene, that the patient had a decreased level of consciousness and requesting that the call be upgraded to Code 3.

01:33:00 – The RCMP dispatcher advised BC Ambulance Service that the call should be upgraded to Code 3. BC Ambulance Service dispatch asked if this was the "intoxicated guy" and the RCMP dispatcher confirmed it. She also indicated to BC Ambulance Service that RCMP members were with the male, and that it was safe for EHS personnel to attend.

01:33:16 – E – 23 (Constable Millington) was advised by dispatch that EHS was en route Code 3.

01:33:39 – BC Ambulance received a call to indicate that the patient was now unconscious.

01:33:57 – Another RCMP dispatcher also called EHS to upgrade the response to Code 3.

01:34:00 – The Richmond Fire Department was contacted by RCMP dispatch and asked to attend YVR. A Captain and three firefighters were assigned.

01:34:09 – Unit 51A, the BC Ambulance unit which had initially been assigned, was cancelled by BC Ambulance dispatch because it was too far removed from YVR for the Code 3 call. At that time, the call was assigned to Unit 69A2 (crew members Egli and Maciak).

01:35:06 – BC Ambulance also dispatched unit 69A1 (crew members Randell and Van Houten) for the Code 3 call to YVR.

01:40:00 – Richmond Fire Department personnel arrived at YVR.

01:42:02 – E – 24 (Constable Bentley) requested the file number for the incident from dispatch.

01:46:57 – BC Ambulance Unit 69A2 arrived on scene.

01:47:17 – BC Ambulance Unit 69A1 arrived on scene.

Appendix J – Pritchard Videos

Video 1 – Prior to RCMP Involvement

Mr. Pritchard's video camera records that at 01:17:52 on October 14, 2007 (according to Mr. Pritchard's video time indicator), he saved the first video of Mr. Dziekanski. This video was taken prior to the arrival of the RCMP, but after the interchange between Mr. Dziekanski and Mr. Meltzer.

At various points in the Pritchard video, Mr. Dziekanski can be heard to make statements in Polish. The words spoken by Mr. Dziekanski were translated on October 18, 2007 by Constable Wicik, an RCMP member fluent in the Polish language.

For the purposes of the Braidwood Inquiry, however, Commission counsel had the audio portion of the Pritchard video enhanced and the Polish words spoken by Mr. Dziekanski translated by a professional translator. The translation was entered as evidence on February 2, 2009 at the Braidwood Inquiry by Mr. A. Kris Barski. Because Mr. Barski is a professional translator, his evidence was given under oath and he had the benefit of enhanced audio, I prefer the translation by Mr. Barski over that of Constable Wicik, and it is Mr. Barski's translation to which I will refer. In addition, Mr. Barski's translation was conducted in conjunction with another Polish translator, Ms. Malgorzata Jaszczewska.

Time referenced in this appendix refers to running time of the Pritchard videos, and not time of day.

As the video opens, Mr. Dziekanski can be seen standing a short distance inside the secure area of international arrivals, a short distance from the exit doors. As indicated previously, these doors are activated by motion sensors inside the secure area which cause the double glass doors to swing out so that as persons walk to exit, the doors automatically swing open. As also noted, an electronic pass card is necessary to open the doors from the public waiting area side.

A clear, glass wall separates the secure and public areas. Leading into the public area from the doors is a waist high barrier consisting of a wooden railing with a glass partition to the floor. The barrier provides a pathway for persons exiting the secure arrivals area.

Just inside the doors to the secure area, a counter can be seen stretching to the right of the doors. A sign above the counter indicates it is the "Airport Greeting Centre". On the counter sits a computer and other items, presumably the property of YVR. No YVR or CBSA employees are seen at the counter.

The video shows two green, swivel chairs blocking the point where the doors into the secure area would normally close. The chairs are seen to act as physical barriers to closing the doors, causing the doors to attempt to close, and then immediately open again because of the blockage. Mr. Dziekanski can be seen placing a small wooden table on the floor next to the chairs, presumably to further block them from closing.

Mr. Dziekanski then walks to the counter, picks up a clipboard in his right hand and walks back to the doors. He appears to be quite upset and agitated. The clipboard can be seen shaking as he holds it. He can be heard on the video to be saying some words (translated below) and can be seen and heard to be breathing heavily. He appears to also be perspiring heavily.

• At the 00:30 mark, Mr. Dziekanski says: Rozpierdole to biuro. This was translated as: I will trash this office.
• At the 00:40 mark, Mr. Dziekanski is heard to say: Spierdalajcie. Mr. Barski translated this as Fuck off.
• At the 00:57 mark of Mr. Pritchard's first video, Mr. Dziekanski can be seen to pick up the small wooden table and hold it in front of himself as if to fend off someone or something.
• At the 01:11 mark of the video Mr. Dziekanski, still holding the table in front of him, steps into the public area and speaks, apparently to the people assembled in the public waiting area. Conversation can be heard between a male and female in the public area speculating as to the language spoken by Mr. Dziekanski. They assume it to be possibly Russian and the male can be heard to say that a Russian interpreter is needed.
• Also at the 01:11 mark of the video, Mr. Dziekanski says: Rozpierdole szyby. Rozpierdole tutaj szyby. Zobaczysz. This was translated as I will smash the glass, and I will smash the glass here. And you will see.
• At the 01:34 mark, Mr. Dziekanski says: Co powiedziałaś? Ty mnie nie pozwolisz which means What did you say? You will not let me?
• At the 01:39 mark, Mr. Dziekanski says: Ty mnie nie pozwolisz?, which means You will not let me?
• At the 01:43 mark, Mr. Dziekanski says: Kurwa go mać. Oskarżę Ciebie I wszystkich, which is translated as For fuck's sake. I will sue you and everybody else.
• At 01:56 of the video, Mr. Dziekanski says: Dobra, dobra. [Nie do odszyfrowania] jesteśmy w innym kraju [Nie do odszyfrowania]. This was translated as Fine, fine [Indecipherable] we are in a different country so [Indecipherable].
• At the 02:08 mark, a woman, later identified as Ms. Sima Ashrafinia, enters the frame and, from the waiting area of the exit barrier, speaks to and attempts to calm Mr. Dziekanski. Mr. Dziekanski speaks to her, and at the 02:34 mark he moves back inside the secure area and holds the table higher, as if in a defensive posture.
• Between the 02:13 and 02:16 marks, Mr. Dziekanski says: Rozpierdolę całą szafkę. Rozpierdolę całą szafkę. [Nie do odszyfrowania] kłopotu. Which means: I will smash the entire desk. I will smash the entire desk. [Indecipherable] trouble.
• At 02:22, Mr. Dziekanski says: Dajcie mnie świety spokój. Odejdźcie mówię. This was translated as Leave me alone everybody. Go away I said.
• At 02:32 of the video, Mr. Dziekanski says: Kurwa mać." This was translated as For fuck's sake.

The video ends at the 02:56 mark.

Video 2 – Deployment of CEW

At the beginning of the second video, Mr. Dziekanski can be seen through the glass wall standing on the secure side of the international arrivals area near the computer sitting on the counter. Ms. Ashrafinia is also in frame, still attempting to calm Mr. Dziekanski. Mr. Dziekanski's luggage can be seen stacked on the floor at the end of the counter closest to the exit doors.

Mr. Barski was also asked to listen to the enhanced audio from this video and attempt to translate the words spoken by Mr. Dziekanski.

• At the 00:06 mark of the video, Mr. Dziekanski was heard to say: Jak długo już mam czekać. This means How long do I still have to wait? Mr. Barski stated that Mr. Dziekanski also said: Co mnie nie puścicie? Nie dacie mnie stąd wyjść? This was translated as So you will not let me go? You will not let me out of here?
• At the 01:06 mark of the video, Mr. Dziekanski is seen throwing the computer from the counter onto the floor. A male voice is heard to say Oh, right in front of the cops, too.
• At the 01:17 mark, Mr. Dziekanski then picks up the small wooden table and throws it against the glass wall, breaking the table.
• At the 01:25 mark, Mr. Dziekanski picks up the computer from the floor. A different male voice is heard to say: Sir, sir. Put it down... Please put it down. A reflected image in the glass of the wall shows this instruction to be from a YVR security guard (dressed in a reflective yellow jacket and later identified as Lance Rudek), who can also be seen to motion with his hands that Mr. Dziekanski should put the computer down. Mr. Dziekanski complies.
• At the 01:59 mark, a female can be heard to say: He's so scared. Just leave him.
• At the 02:02 mark, Mr. Dziekanski moves one of the two green swivel chairs from blocking the doors and takes it back to the counter area.
• At the 02:10 mark, a male voice says: Why are the police not here? We called Security and we called the police.
• At the 02:56 mark, Mr. Dziekanski approaches the exit doors (still in the secure area) causing them to open. He moves the remaining green swivel chair to his right (toward the wall) and out of the way of the doors.
• At the 03:00 mark, the camera swings almost 180 degrees from Mr. Dziekanski to the uniformed RCMP members arriving. Mr. Dziekanski can be heard to yell Policja! (the Polish word for police) twice.
• At the 03:04 mark, an unidentified male (later identified as Constable Bentley) is heard to say Got your Taser? A response of "Yup" is heard. Constable Millington later confirmed that the response came from him. Constable Millington was the only responding RCMP member equipped with a CEW that night.

As the camera pans back to Mr. Dziekanski, a brief exchange between an unidentified male and the arriving members (who continue to move toward Mr. Dziekanski) can be heard. A member says: "Where is he?" The unidentified male (later learned to be Mr. Meltzer, the limo driver) replies: "He's right inside there. He speaks Russian."

Constables Millington and Bentley were the first two to hop over the barrier wall leading to the doors to the secure area at approximately the 03:23 mark. As the members enter the secure area, a voice can be heard to say: How are you, Sir?, then: How's it going, bud?

In evidence during the Braidwood Inquiry, Constable Bentley stated that he spoke these words. Constable Rundel closely followed the first two members, but at the time Constable Bentley's comments were made he had not yet completed crossing the barrier.

At this point, the members were just inside the doors. Mr. Dziekanski was approximately one to one and a half metres inside the secure area facing the members. He appears to be speaking to the members (in Polish) and gestures with his arms. Mr. Dziekanski's comments are inaudible because of the glass wall blocking his voice and because of ambient sound in the public waiting area.

Corporal Robinson can be seen to remain on the waiting area side of the barrier for several more seconds. At the 03:31 mark, he also crosses the barrier and enters the secure area.

At that point the camera begins to swing as Mr. Pritchard moves to another vantage point, causing an obstructed view of the RCMP members interacting with Mr. Dziekanski inside the secure area. Compounding the obstruction is the reflection of lights in the glass wall.

• At the 03:37 mark, the members can be seen talking with Mr. Dziekanski who is approximately two metres inside the secure area, near his luggage. Mr. Dziekanski's arms are at his sides and his stance does not appear combative.
• At the 03:41 mark, Mr. Dziekanski throws his arms in the air and steps away from the members, toward the counter. The members follow, and use hand gestures to indicate to Mr. Dziekanski where they would like him to stand. At this point, Mr. Dziekanski is standing in front of the counter with his back to the glass wall and to the camera. The view of him and the members facing him is obstructed by the counter, which is approximately just above waist height. The members fan out in a semi-circle in front of him. The video indicates that the members were giving direction to Mr. Dziekanski and that Mr. Dziekanski was speaking to the members. His attention appears to be directed primarily to Corporal Robinson. None of the members spoke Polish and Mr. Dziekanski spoke no English.
• At the 03:43 mark, Mr. Barski testified that Mr. Dziekanski stated: Odczep się. Odczep się. Co wy zdurnieliście? [Nie do rozszyfrowania]. Mr. Barski translated this as Leave me alone. Leave me alone! Did you become stupid? Mr. Barski testified this could also mean Are you out of your mind? Why?

Mr. Barski was not positive about the last word uttered by Mr. Dziekanski, but believes it was stated.

• At the 03:45 mark, Mr. Dziekanski appears to pick something up from the counter (later determined to be a stapler) and at the 03:46 mark, Constable Bentley can be seen to take a step back from Mr. Dziekanski. Simultaneously, the other members appear to take note of something Mr. Dziekanski is holding. Corporal Robinson can be seen to withdraw his ASP baton from his holster, but not deploy it. By the 03:48 mark, the other members have taken up positions as indicated below around Mr. Dziekanski, and are approximately two metres away from him. Mr. Dziekanski can be heard speaking loudly to the members.

The video shows Constable Millington (who was the only member equipped with a CEW that night) in the nine o'clock position to the far left of Mr. Dziekanski. Next, in the 11 o'clock position, was Corporal Robinson. To Mr. Dziekanski's one o'clock position was Constable Rundel. Constable Bentley was to Mr. Dziekanski's three o'clock position.

At that point, Mr. Dziekanski is standing facing the members. His hands cannot be seen. In their statements, members indicated that Mr. Dziekanski grabbed a stapler from the counter and that they believed he was going to use it as a weapon.

• At the 03:49 mark, 26 seconds after the members make first contact with Mr. Dziekanski, the conducted energy weapon (CEW) can be heard to discharge. Constable Millington is out of frame at this time, but at the 03:51 mark he can be seen coming into frame, holding the CEW. In his statement to IHIT, Corporal Robinson said that he gave an instruction to Constable Millington to deploy the CEW simultaneous with Constable Millington deploying it on his own.

In evidence during the Braidwood Inquiry, Constable Millington said that he did not hear Corporal Robinson issue the instruction for the initial deployment. He said that he (Constable Millington) then cycled the CEW for the second time of his own volition and that he cycled the CEW for the third time on Corporal Robinson's instructions (when he heard Corporal Robinson say: Hit him again). Notwithstanding the instruction from Corporal Robinson, Constable Millington accepted that the decision to cycle the weapon was his.

Corporal Robinson testified before the Braidwood Inquiry that he verbally instructed Constable Millington to deploy the CEW initially and that the deployment of the weapon by Constable Millington was almost simultaneous with his instruction.

• At the 03:51 mark, Corporal Robinson can be seen to re-holster his still unextended ASP baton.
• Mr. Dziekanski reacts to the deployment of the CEW immediately. His arms flail up in the air and at the 03:52 mark, an object (later identified as an open stapler) can be seen in Mr. Dziekanski's right hand. Mr. Dziekanski then stumbles several steps to his right and at the 03:55 mark he falls to the floor past the end of the counter. Mr. Dziekanski can be seen through the glass wall writhing on the floor and screaming.
• At the 04:04 mark, Corporal Robinson moves in and begins to subdue Mr. Dziekanski. He is joined at 04:06 by Constable Rundel. At the 04:10 mark, Constable Bentley and Constable Millington join in. Constable Millington still has the CEW in his right hand, and his assistance is to hold Mr. Dziekanski's feet with his free (left) hand. Mr. Dziekanski continues to writhe throughout the attempts to subdue him.^{Footnote 121}
• At the 04:12 mark, Constable Millington stands and directs his attention to the CEW, which he holds facing Mr. Dziekanski. At 04:12/04:13 someone, likely Corporal Robinson, is heard to shout "Hit him again. Hit him again."
• At the 04:13/04:14 mark, someone (likely Constable Millington) is heard to say Got 'im. Got 'im.
• At the 04:19 mark, a YVR security guard begins to block the frame and he is joined at the 04:20 mark by another man. The two fully obscure the view. It is clear, however, that the RCMP members were attempting to restrain Mr. Dziekanski and that Mr. Dziekanski continued to struggle. According to witness statements and statements from the involved RCMP members, Mr. Dziekanski received no blows from fists, feet or batons. Neither the baton nor oleoresin capsicum (OC) spray (also known as pepper spray) was used by the members to subdue Mr. Dziekanski. The rationale behind the force used by the RCMP members against Mr. Dziekanski and its appropriateness is discussed in Appendix O of this report.

Constable Millington indicated in his statement that the contact of the CEW probes with Mr. Dziekanski was intermittent, and as a result, he could at times hear a clacking sound, indicating that electrical current was not flowing into Mr. Dziekanski as the CEW was cycled. Clearly, Mr. Dziekanski had some exposure to the electrical current as demonstrated by his reaction to the deployment of the CEW.

• At approximately the 04:23 mark, Constable Millington is seen to move around Mr. Dziekanski and insert himself with the other members close to Mr. Dziekanski. Constable Millington indicated in his statement that he administered the CEW in push stun mode to Mr. Dziekanski twice during this period. Push stun mode means that the electrodes of the CEW were held to Mr. Dziekanski's body.
• At the 04:32 mark, Corporal Robinson can be seen kneeling^{Footnote 122} on Mr. Dziekanski's upper body. At this same time, a male voice (presumably a YVR employee) can be heard in the public waiting area saying: Greg, Cathay is coming through with 300 plus. What do you want to do? Presumably this is a reference to a Cathay Pacific flight from which passengers were due to exit via these doors shortly. No evidence has been located to indicate that the RCMP members were aware of any such flight, or that the presence of these Cathay Pacific passengers affected how they dealt with Mr. Dziekanski.
• By approximately the 04:55 mark, Mr. Dziekanski's struggles lessen considerably and his moans sound as though he is becoming exhausted. At this point, Constable Bentley is seen straddling and sitting on Mr. Dziekanski's thighs, Constable Rundel is near his waist attempting to handcuff Mr. Dziekanski. Corporal Robinson is hidden behind onlookers, but is believed to be near Mr. Dziekanski's head and shoulder area, controlling his upper body movements.
• At the 05:01 mark, onlookers clear and Corporal Robinson can be seen kneeling on Mr. Dziekanski's upper back/shoulder area. Mr. Dziekanski is lying on his stomach during the struggle.
• At the 05:05 mark, Constable Bentley gets up from Mr. Dziekanski's thighs and walks around to Mr. Dziekanski's head. At 05:10, he picks up his baton which he had deployed during the interaction with Mr. Dziekanski. The baton was not used during the altercation; Constable Bentley had dropped it to the floor while assisting in subduing Mr. Dziekanski.
• At the 05:17 mark, Mr. Dziekanski continues to struggle. Corporal Robinson appears to have placed a considerable amount of his weight on Mr. Dziekanski's upper body.^{Footnote 123} By the 05:19 mark, it appears that Corporal Robinson's right shin and ankle are pressing down on the back of Mr. Dziekanski's neck. He remains in this position until the 05:46 mark of the video.
• At 05:31, Constable Bentley begins to collapse his baton. Corporal Robinson and Constable Rundel remain by Mr. Dziekanski, whose movement has by this time virtually stopped.
• By the 05:53 mark, the members appear to be looking at one another and exchanging words. No one appears to check Mr. Dziekanski or take any specific actions to administer first aid.

The video ends at the 05:56 mark.

Video 3 – Post-Incident

A third video was shot by Mr. Pritchard. The date stamp on the video camera indicates that it was saved at 01:31:06 on October 14, 2007.

As the video begins, Corporal Robinson and Constable Bentley can be seen kneeling beside Mr. Dziekanski, who does not move. At various points, Corporal Robinson leans over Mr. Dziekanski, as if to check for breathing. Constable Millington is rolling up electrical wires, presumably from the CEW probes. Constable Rundel is not seen in this video.

At the 00:43 mark, a male wearing a suit comes into frame and kneels to check Mr. Dziekanski's carotid pulse. The male was later determined to be Mr. Trevor Enchelmaier, YVR Aviation Security Supervisor with the private firm Securigard.

At 00:53, Mr. Dziekanski can be seen to remain handcuffed, although he appears to be unconscious. Other than monitoring Mr. Dziekanski, no identifiable first aid appears to be rendered by the RCMP members in attendance. Corporal Robinson is seen to lean over close to Mr. Dziekanski a number of times prior to the arrival of emergency medical personnel.

Subsequent to his arrest, Mr. Dziekanski appears to be lying in a prone position, but rolled somewhat onto his right side. Each of the RCMP members was wearing gloves. Corporal Robinson can be observed to remove his gloves on at least one occasion, apparently to check Mr. Dziekanski's vital signs.

The video ends at the 01:07 mark.

Appendix K – The Nature of the CEW and the Evolution of CEW Policy

The CEW was first approved for RCMP use in 2001. It is a prohibited firearm pursuant to the Criminal Code ^{Footnote 124}> as indicated in the RCMP Operational Manual,^{Footnote 125} which advises members of that fact. A report completed for the RCMP by an external consultant has identified an issue with respect to the designation of the weapon as approved for use by the RCMP, in that the regulatory amendments necessary to possess the weapons have not been enacted. It is to be borne in mind that notwithstanding the RCMP Operational Manual categorization of the CEW as an intervention option to control individuals and avert injury to members and the public,^{Footnote 126} and the IM/IM categorization of the CEW as an intermediate device, the CEW is, as noted, a prohibited firearm and must be treated as such.

The CEW may be deployed in two modes; probe mode and push stun mode. In probe mode, the function of the CEW is to incapacitate the neuromuscular system of the recipient of the discharge. Compliance may be achieved in a clinical sense by incapacitating muscle groups but the reality, although collateral to the means of incapacitation, is the infliction of severe pain on the recipient.

In push stun mode, i.e. with the electrodes of the CEW being placed directly against the subject, the RCMP Operational policy in force at the time of the YVR incident stipulated that in this mode, the CEW is primarily a pain compliance device. This stipulation has been removed from the most recent iteration of CEW policy.^{Footnote 127} I noted in my March 2009 report that statistics now indicate a reduction of approximately 30% in CEW usage in push stun mode.^{Footnote 128}

Following the RCMP providing the Commission with data concerning CEW deployments during the period October 1, 2007 to December 31, 2007, I expressed my concern to RCMP Commissioner Elliott with respect to the characterization of injuries sustained by recipients of CEW deployments. Specifically, I expressed concern that characterization of injuries ranging from "no injury" to "death proximal to CEW usage" do not appropriately capture the degree of harm the CEW is capable of causing. In the category "no injury", the RCMP includes the immediate effect of CEW usage (slight burns/probe marks). By repeatedly categorizing minor primary injuries as "no injury" the RCMP is, in effect, minimizing the consequences of the CEW and potentially desensitizing RCMP members and the public to the effects of the CEW.

It is of interest to note that in a news interview, Mr. Ujjal Dosanjh, Attorney General of British Columbia at the time when CEWs were first introduced into the province by the RCMP in 2001, indicated that he was advised that the CEW was intended to be used only in situations in which it could be used as an alternative to lethal force.^{Footnote 129}

The concept of less lethal force was reviewed by the RCMP in a 2000 position paper, and a CEW Evaluation Project was conducted by the RCMP. It was recommended that:^{Footnote 130}

1. The M26 Advanced TASER® be adopted as a less lethal response option by the RCMP.
2. Those operational units which already have the M26 Advanced TASER® and trained operators be authorized to continue operational deployment until such time as a final decision has been made.
3. A three-year plan be adopted to assure a timely "roll out" of this less lethal technology to front lines of service delivery.
4. An individual be identified and tasked with the responsibility of implementing this process.

The CEW was marketed as a viable less lethal force option. In a 2007 internal report,^{Footnote 131} the RCMP expanded on the criteria for assessing less lethal devices, as outlined in the 1998 report titled Less Lethal Force Technology. These criteria were:

1. temporary effect;
2. minimal medical implications;
3. high probability of instantaneous control;
4. effective on the highly motivated;
5. observable effects;
6. ideally only affect the intended.

As noted previously, the CEWs used by the RCMP are manufactured by TASER International. In its training sessions,^{Footnote 132} TASER International teaches that the CEW in probe mode incapacitates the central nervous system which in turn incapacitates muscle groups to achieve its goal of incapacitating the subject. The manufacturer indicates that the CEW in probe mode does not rely on pain to achieve compliance. It overwhelms the central nervous system and achieves incapacitation.

TASER International training indicates that although voltage is high (50,000 volts) the amperage of the unit is lower than that of a heart defibrillator and is therefore safe. TASER International also indicates that officer safety is a prime factor in deploying the CEW and cites various examples of jurisdictions where injuries to officers declined significantly after the CEW was implemented.

In order to assess the actions of the RCMP members involved, it is instructive to canvass the evolution of CEW policy within the RCMP. The following is a non-exhaustive listing of policy amendments as they relate to the CEW; included are those amendments I believe are relevant to the discussion at hand. Other amendments, such as the type of approved holster, have not been highlighted here.

Initially, policy on the CEW was part of RCMP Operational Manual Chapter III.2 (Arrest); however, in 2005 the CEW policy was moved to Chapter 17.7, which became a separate chapter dealing with the CEW.

2001

In 2001, RCMP policy^{Footnote 133} with respect to the CEW was that the CEW was viewed as:

... a less lethal means for controlling suspects and averting injury to members, suspects and the public.

Members were required to record details of CEW usage in their police notebooks, and were required to report usage to their supervisors, but were not required to record or report CEW usage further.^{Footnote 134} The Senior Armourer was responsible to maintain a Quality Assurance program for the testing and evaluation of CEWs.^{Footnote 135}

2002

A number of policy revisions were issued in 2002. The first stipulated the types of batteries authorized to be used in the CEW.^{Footnote 136} An amendment issued in May 2002 clarified that the CEW was not to be used for crowd dispersal.^{Footnote 137} An amendment issued in June 2002 required members to also complete and submit a reporting form to Headquarters, Ottawa each time a CEW was used on a suspect.^{Footnote 138}

A September 2002 amendment indicated inter alia that:^{Footnote 139}

1. Members must qualify annually to operate the CEW; and
2. The CEW may only be used to subdue individual suspects who resist arrest, are combative or suicidal.

Finally, an amendment issued in October altered the location of reporting CEW usage form to Headquarters, Ottawa.^{Footnote 140} The requirement for annual CEW recertification was subsequently changed to three years, but annual recertification has now been reinstated-please see below.

2004

One amendment was issued in 2004 which effectively rewrote policy on the CEW and significantly enhanced the content of the Operational Manual with respect to the CEW. Highlights are provided here:

1. Only the Taser® M26, described as an intervention device to control individuals and avert injury to members and the public, is approved for RCMP use;
   1. Use of the term "less lethal" was removed from the description of the CEW as was the term "suspects". Suspects was replaced by the term "individuals";^{Footnote 141}
2. Members were required to re-qualify for CEW use every three years (instead of annually as required in September 2002);^{Footnote 142}
3. Definitions of Stun Mode, Probe Mode, Use of the CEW, and Operational Cartridge were added;^{Footnote 143}
4. Use of the CEW must be in accordance with the principles of the IM/IM;^{Footnote 144}
5. The requirements for medical intervention post-CEW became more stringent;^{Footnote 145}
6. Reporting requirements were altered such that reporting to Headquarters (including whether the CEW was used in stun or probe mode) was required only when:
   1. Medical issues were involved,
   2. A civil claim was anticipated,
   3. Drug or alcohol abuse is anticipated or "difficulties" encountered (difficulties were not defined),
   4. Circumstances were such that the event should be reported,^{Footnote 146}
7. The unit commander became responsible to ensure that all members under his or her command were aware of the policy directive concerning the CEW.^{Footnote 147}

2005

In June 2005 the RCMP Operational policy on the CEW moved from Operational Manual III.2 (Arrest) to Chapter 17.7 (Conducted Energy Weapon).

Added to the definition of Use of CEW were the words:

... when the presence of the CEW assists in taking control of a situation whether the CEW Challenge is given or not.^{Footnote 148}

The requirement issued in the June 23, 2004 amendment that the Headquarters reporting form was required only in certain circumstances was repealed and replaced with a requirement that a report was to be provided within 15 days to Headquarters every time the CEW was used.^{Footnote 149}

An amendment in September 2005 (preceded by an operational bulletin issued in July 2005) recognized for the first time the potential for danger to the subject if the CEW is cycled multiple times or for periods exceeding 15-20 seconds.^{Footnote 150} The caveat with respect to the danger of multiple cycling has been retained in policy since that time. This point was confirmed by comments of Commissioner Elliott before the Standing Committee on Public Safety and National Security on February 12, 2009.

This amendment included a requirement for a battery cool-down period of ten minutes if the CEW was cycled more than ten times consecutively.^{Footnote 151}

Bulletin OM-465 (Operational Manual), issued in July 2005, referred to a report issued by the Victoria (BC) Police Service and indicated that continuous cycling of the CEW for more than 15-20 seconds may increase the risk to the subject and should be avoided where practical.^{Footnote 152} This caveat was included in subsequent versions of CEW policy.^{Footnote 153}

In August 2005, a technical report on CEWs (or Conducted Energy Devices – CEDs as they are also known) was issued by the Canadian Police Research Centre (CPRC), in Ottawa, Ontario. The CPRC report indicated that the work was conducted in close collaboration with a Victoria (BC) Police Service study.

The CPRC's review of CEWs focused on three areas: the medical safety of CEWs, the policy considerations for police CEW operations and the analysis of the medical condition known as excited delirium. As noted, the term "excited delirium" has now been expunged from RCMP policy.

The RCMP no longer uses CPRC to conduct assessments of CEWs. As of November 2008, MPB Technologies Inc. became the approved testing facility for RCMP CEWs.^{Footnote 154} Accordingly, I have not relied at all on any CPRC documentation in my investigation.

An amendment issued in September 2005 altered the wording of the policy on considering other possible intervention options by adding the words to control a subject.^{Footnote 155}

2007

The CEW policy in effect at the time of the death of Mr. Dziekanski (October 2007) was issued in August 2007. This policy required members to take control of the subject as soon as possible during a CEW probe-mode deployment.^{Footnote 156} The version added the concept of excited delirium^{Footnote 157} (which was removed from RCMP documentation as of January 2009) and informed members that:

If you suspect that an individual is experiencing an excited delirium medical emergency, when possible create a response strategy before deploying the CEW and include Emergency Medical Services (EMS) attendance in your strategy.^{Footnote 158}

Excited delirium was explained as a medical emergency which may be brought on by stimulant use, psychiatric illness or a combination of both.^{Footnote 159} It then went on to list symptoms or behaviour typical of excited delirium, which in my view could also include behaviour demonstrated by a person in a state of high agitation. These included:^{Footnote 160}

1. Removal of clothing,
2. Bizarre and violent behaviour,
3. Running in heavy street traffic,
4. Hyperactivity,
5. Aggression,
6. Smashing objects, particularly windows and glass,
7. Non-responsive to police presence or verbal intervention,
8. Extreme paranoia,
9. Incoherent shouting,
10. Flight behaviour,
11. Lid lift (eyes open so wide the whites are completely visible),
12. Impervious to pain,
13. Ability to resist numerous police officers over an extended period,
14. Overheating, or
15. Profuse sweating or no sweating at all.

The policy advises members that a person experiencing a state of excited delirium requires medical treatment following restraint, and suggests that use of the CEW in probe mode may be the most effective response to establish control.^{Footnote 161} The policy also indicated that with respect to excited delirium:

1. Enough members should be on hand for quick and effective control of the individual to minimize the incidence of physical confrontation,
2. One member should be on the CEW,
3. Effectively control the arms and legs during CEW deployment cycles,
4. Apply approved restraints,
5. Remove the subject from the prone position as soon as it may safely be accomplished after control is established,
6. In the event the subject suddenly becomes quiet and stops resisting, summon EMS and prepare to administer CPR, and
7. Subjects experiencing excited delirium should be transported to Health Services by EMS when possible.^{Footnote 162}

I have chosen to equate this state with that of a person who is highly agitated because I believe that the same criteria and response should be provided no matter the underlying cause of the behaviour.

The policy confirmed that a member certified in first aid may remove the probes from an individual after deployment of the CEW.^{Footnote 163}

The requirement to report is modified in that the reporting form must be completed before the end of a shift every time the CEW is used^{Footnote 164} (this includes withdrawing the unit from its holster as a means to gain control, not necessarily deploying it).^{Footnote 165}

2009

The current CEW policy as captured by the RCMP Operational Manual was amended in January 2009.^{Footnote 166} The policy now requires that RCMP members qualified on the CEW must re-certify annually (which, as noted above, was the policy in 2002). Previous policy (2004 to 2009) required a three-year recertification.

The policy as amended takes into consideration the risks inherent in using the CEW and stresses that deploying the CEW is only an option in response to a threat to officer or public safety as determined by the Member's assessment of the totality of the circumstances being encountered.^{Footnote 167} The Manual goes on to note that the member's response must be reasonable and the force used must be necessary in the circumstances.

The policy restraints under which use of the CEW was authorized were relaxed over time. Initially, the CEW was to be used to subdue suspects who resist arrest, are combative or suicidal.^{Footnote 168}

Wording varied slightly, but from 2001 until 2007, RCMP policy stipulated that before resorting to the CEW, members were to consider other possible intervention options to control a subject.^{Footnote 169} The version of the RCMP's CEW policy issued in August 2007^{Footnote 170} (the version in effect at the time of the Dziekanski incident) removed that requirement.

In past reviews, I have expressed concern about the positioning of the CEW within the IM/IM. Most recently, in my report to the Minister of Public Safety, I called for a restriction on the use of the CEW to respond to subject behaviour that is characterized at the combative stage or higher. The Commission has undertaken a broader review of the adequacy of RCMP CEW policies in the form of a public interest investigation into in-custody deaths proximal to CEW use.^{Footnote 171}

As noted above, in January 2009 the RCMP amended its policy stipulating that the CEW may only be used in circumstances in which the RCMP member, after considering the totality of the circumstances, perceives a threat to his or her safety or the safety of a member of the public. However, it is not clear how members will interpret the reference to "threats". This change, which results in less clarity in delineating the appropriate use of police weapons, leaves the Commission unable to determine whether this amendment will raise the bar to the level contemplated in the Commission's recommendation made in its earlier reports to the RCMP. Rather, it relies too heavily on a member's subjective appreciation of events without laying the objective policy-based foundation for which to assess the conduct. The Commission's concern with this is that the lack of clear guidelines may well continue to contribute to "usage creep" institutionally and to the individual cases of inappropriate CEW use that have been reviewed and commented upon by the Commission, including this incident.

Compounding this issue is the recent pronouncements by the Provinces of British Columbia and Alberta regarding their respective positions on the threat threshold to be adhered to by police officers that must be present before a CEW can be deployed. Particularly, it is unclear whether the RCMP's new policy on this threshold can, or will be reconciled with these provincial standards. Additionally, Commissioner Braidwood was unequivocal by stating that a clear and imminent threat of bodily harm must be present before a CEW is deployed. This appears to be a significantly higher threshold that the RCMP's current policy contemplates. It is unclear what amendments to the applicable RCMP policy will be required in order to adhere to these provincial policies while at the same time maintaining a national standard consistent for all members across the RCMP.

General CEW Policy

The content of the police warning to be issued prior to the deployment of the CEW has been changed over the intervening time. Initially, the warning to be delivered was:

Stand still or you will be hit with 50,000 volts of electricity!^{Footnote 172}

The warning was altered in the 2004 amendment to:

Stop or you will be hit with 50,000 volts of electricity!^{Footnote 173}

Subsequent to the incident involving Mr. Dziekanski, the RCMP issued Bulletin OM-478 on January 7, 2008. The Bulletin stipulates that members may use the CEW, whether in probe or push-stun mode, on persons who are displaying Active Resistant Behaviour and higher categories of behaviour.^{Footnote 174} The Bulletin differentiates between active resistant behaviour and passive resistant behaviour. Active resistant behaviour includes behaviour during which a person is physically resisting attempts at control by the police officer. Passive resistant behaviour is behaviour in which a person resists control through passive physical actions or verbal refusal in response to lawful commands.

The Bulletin created two subdivisions in the IM/IM category of Resistant Behaviour. Prior to the issuance of Bulletin OM-478, the behavioural category was indicated solely as Resistant, and was defined as:

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.

Prior to Bulletin OM-478, the IM/IM did not recognize passive resistance as a separate level of resistance for which the use of the CEW was deemed not to be warranted.

The RCMP Operational Manual was amended on January 27, 2009^{Footnote 175} to reflect changes to CEW policy.

On November 20, 2008, the RCMP engaged MPB Technologies Inc. to begin testing of a selection of its CEWs, particularly those manufactured prior to 2006. From across Canada, 30 CEWs were selected and tested using the 2005 TASER International protocol. Following consultation with both TASER International and the CPRC the protocol was amended to obtain a more accurate result. Test results have not yet been received.

At the time, the RCMP was aware that a study^{Footnote 176} commissioned by the Canadian Broadcasting Corporation (CBC) was to be released. That study found variances in the voltage outputs of a number of CEWs tested.

On June 1, 2009, the RCMP removed from service approximately 1,600 Model M26 CEWs (the older model used by the RCMP) following testing by the Government of British Columbia which indicated that ... 80% of the devices failed to operate within the manufacturers [sic] specifications. The results also showed that 90% of these units produced less electrical output than would be expected, potentially presenting both public and officer safety risks.^{Footnote 177} The RCMP will test these units and replace defective CEWs with the newer Model X26.

RCMP Comments on CEW Training

On May 6, 2009 Inspector Troy Lightfoot, the Officer in Charge of Use of Force and Operations Programs appeared before the Braidwood Inquiry. He indicated in his evidence that reporting requirements with respect to the CEW have been altered by the RCMP subsequent to October 2007, and stated that current policy requires that CEW usage reports be reviewed at a divisional and national level to assess whether such usage was within the scope of policy. Added to policy is the category of "acutely agitated or delirious persons" as being at higher risk of harm if exposed to a CEW deployment.

Inspector Lightfoot confirmed that CEW recertification is required annually (as noted above) and stated that ensuring continued CEW certification is a responsibility of each division. He stipulated that the RCMP has not imposed any requirement that members complete a minimum number of years of service prior to becoming CEW certified.

Inspector Lightfoot also discussed amendments to the IM/IM which were approved in May 2008. He said that the IM/IM no longer includes a category of weapons known as "Impact Weapons", and said that the language associated with some subject behaviours has been changed. By way of example, he indicated that:

• Non-cooperative is now called passive resistant behaviour.
• Resistant behaviour is now called active resistant behaviour.
• Combative behaviour is now called assaultive behaviour.
• Death or grievous bodily harm is now called grievous bodily harm or death.

He said that, in addition, a ring has been added to the IM/IM. The intent of this ring is to represent a filter between behaviour and potential intervention responses. The term communication has replaced the former verbal intervention.

Inspector Lightfoot indicated that amendments to RCMP policy subsequent to the death of Mr. Dziekanski stipulate that the CEW may only be deployed in circumstances involving a risk to officer or public safety.

I note that the language used in the amended RCMP policy does not line up with the categories of behaviour currently described in the IM/IM. It is not known how the members will be expected to reconcile the two.

Appendix L – CEW Training

De-escalation Techniques

Prior to discussing CEW training, it is informative to briefly canvass RCMP training with respect to the de-escalation of situations in order to avoid the use of force altogether. At various levels of training at Depot Division, cadets are taught the gradations of the officer interventions as found in the IM/IM, beginning with officer presence and communication, as well as CAPRA-based skills in problem solving. These aspects of training are focussed on developing the necessary verbal skills which police officers rely on when confronting potentially volatile situations. In addition, cadets receive training on negotiation and mediation skills and at the mid-point of their Depot training they begin to make use of these skills in role play scenario-based interactions with actors posing as members of the public.

Cadets are assessed on their ability to apply the appropriate level of response/force in these scenario situations as gauged against the IM/IM. The overall goal of the RCMP in providing such training is to ensure that members respond appropriately to the varied situations they will encounter in the field as police officers.

Although cadets receive such training, I am not aware of ongoing in-service training for RCMP members to reinforce the training received at Depot with respect to de-escalation tactics.

CEW Training

The Course Training Standard (CTS) for the CEW User Course was created in July 2001 and amended in May 2002 and September 2005. The RCMP CEW User Course is 16 hours in length. The CTS indicates that this amount of time allows instructors to teach the necessary material and provides time for practice and scenario based training.

The CTS stipulates that to successfully complete the course, each candidate must pass a written examination and achieve a score of 80%. In addition, each candidate must participate in role play exercises to demonstrate understanding of the weapon. According to the CTS:

Candidates will be given a skill display test and use role playing to ensure they can properly utilise the CEW in an effective and proficient manner. Candidates will be required to demonstrate proper use of the CEW and to explain and provide legal articulation of their actions to the instructor.

Upon completion of the course, each candidate is evaluated by the instructor and is rated either Competent or Unacceptable in each component of the course. A rating of Unacceptable in any course component means that the candidate does not receive credit for the course and is therefore not certified to operate the CEW.

Notwithstanding the requirement to be rated either Competent or Unacceptable, the CTS provides instructors with other assessment categories. In addition to the two noted above (Competent or Unacceptable), instructors may also rate candidates as Needs Improvement or, in the event a skill was not tested during a session, that aspect may be marked as Not Applicable.

The purpose of the CEW course at the time of the YVR incident was set out as:

This course is designed to provide the learner with the techniques, abilities, and knowledge to safely carry and use Conducted Energy Weapons (CEW). Successful candidates will be able to:

• State the philosophy of Less Lethal Interventions;
• Describe where the Conducted Energy Weapon fits into the Incident Management / Intervention Model, in both probe and "Push Stun" deployment;
• State RCMP Policy as it relates to the CEW;
• State the design characteristics of the Conducted Energy Weapon;
• State the relevant technical data for the Air Cartridge and the Conducted Energy Weapon;
• Identify and name the parts of the Conducted Energy Weapon;
• Describe the function of the CEW in the "Push Stun" Mode and the "Probe" Mode;
• Describe the target areas on the body, for "Probe" deployment and state the considerations in determining the point of aim;
• Explain the effectiveness of the CEW as it relates to "Probe" spread;
• Describe the different injuries that can result from the Conducted Energy Weapon and state the physiological and psychological effects of the use of the Conducted Energy Weapon, in both "Probe" mode and "Push Stun" mode;
• Perform the function check for the Conducted Energy Weapon;
• Describe and demonstrate the loading procedure for the Conducted Energy Weapon;
• Explain proper drawing and holstering from a CEW Holster;
• Describe and demonstrate how to aim the Conducted Energy Weapon, with or without the use of the laser sight;
• Describe and demonstrate the failure drills; incorporating transitions from the failed CEW deployment to other mandated levels of intervention;
• Explain approved battery loading and battery recharging considerations;
• Explain the medical care requirements of post CEW deployment, in both the "Probe" mode and "Push Stun" mode;
• Explain and demonstrate the operational considerations for "Probe" deployment;
• Explain and demonstrate the operational considerations for "Push Stun" deployment;
• Understand the CEW reporting procedures;
• Describe and demonstrate how to clean and maintain the Conducted Energy Weapon;
• Demonstrate and explain the proper technique to use when removing probes from a client;
• Identify the groups at risk in experiencing excited delirium;
• Identify the typical development of a person experiencing excited delirium; and
• Have a [sic] understanding of the physiology associated to excited delirium.^{Footnote 178}

The RCMP CEW course is divided into 14 modules as follows:

1. Introduction, Course Orientation

• Opening address
• Mutual introductions
• Course outcomes and purpose (i.e. job relevancy)
• Syllabus
• Course materials
• Assessment procedures and purpose
• General administration
• Accommodation and meals
• Transportation
• Deportment
• Expenses (i.e. financial coding)
• Any other matter of concern to the efficient operation of the course

2. Technology Overview

• Technology
• Central nervous system
• Sensory nervous system
• Motor nervous system
• Stun to NMD

3. Electrical – CEW (TASER®) Characteristics

• Technical data
• Arcing
• Wet environment

4. Medical

• Safe technology
• Physical effects
• Physical injuries
• Common and possible side effects

5. RCMP Policies And Protocol

• Definitions
• Deployment
• Certification
• Medical treatment
• Reporting procedures

6. Why CEW?

• Lower lethality force
• Modes of deployment
• Principles of the IMIM

7. Voluntary Exposure

• Rational
• Safety and guidelines
• Voluntary exposure report

8. CEW (TASER® X/M26)

• Nomenclature
• Weapon safety
• Cartridge safety
• Nomenclature and trigger operation
• Holsters

9. Batteries And Air Cartridges

• Battery removal/insertion
• Power indicator
• Battery testing guidelines
• Air cartridges types and characteristics
• Propulsion system
• Probes, wires and AFID tags
• Maintenance and storage

10. Practical Application

• Loading, unloading, re-loading and aiming
• Preparation for duty
• Firing sequence and verbal commands
• Operational deployment
• Failure drill
• Tactical consideration
• Effects on animals

11. Field Application

• First responder response option
• Drug users
• Preventing suicides
• Emotionally disturbed persons
• Independent conclusions
• In-custody deaths

12. Scenario Based Training

• Objectives
• Officer safety
• Safety rules
• Safety equipment
• Scenario training rules
• Practical scenario based training

13. Excited Delirium

• Typical development
• Physiology
• What officers need to know
• What we don't know
• Case study

14. Dataport Download

• Downloading data
• Download maintenance

15. Course Final Verbal Critiques

• An open discussion with candidates
• Constructive feedback from candidates
• The review of each topic with the purpose of seeking ideas to improve the design, content and delivery of the course
• The review of the content, value and delivery of each scenario
• A discussion on the learning environment and accommodation
• A discussion on the instructors and observers
• A discussion on the course coordinator
• Suggestions from candidates regarding additional content required and redundant content in the current course.

Training of RCMP members and indeed, training of other police forces in Canada is dependent upon the research conducted by various organizations and agencies. Various studies^{Footnote 179} cited in this report inform police officers that the CEW is a viable alternative to lethal force, that it poses a low risk of danger to the responding police officers and to the subject of the CEW and that it is, in effect, a much more humane way of effecting control over an individual who is resistant to arrest or control.

In its report, the Canadian Police Research Centre (CPRC) indicated that various injuries have been observed in police personnel undergoing such voluntary exposure. The Phoenix (Arizona) Police Department reportedly has banned voluntary exposure because of the concern for injuries to police personnel. The report noted that injuries have also been caused to police personnel when training in more traditional arrest and control techniques such as joint control and hand to hand measures.

The CPRC concedes that use of the CEW, initially introduced as an alternative to lethal force, has evolved to the point where it is viewed as being appropriate for use in situations in which what had until May 2008 been known in the RCMP IM/IM lexicon as intermediate weapons (see references to testimony from Inspector Lightfoot, above) may be used.

The concept of Intermediate Weapons was developed in the United States in the 1980s, according to a document entitled Report on Conducted Energy Weapons and Excited Delirium Syndrome issued in November 2007 by the RCMP.^{Footnote 180}

Appendix M – Member Certifications

With respect to CEW and first aid training and certification, the responding members were qualified as follows:

Corporal Robinson

CEW^{Footnote 181} – Taser® Operators Course on April 23, 2003 (Instructor – Constable B. Cassell [since retired]) Expiry – April 23, 2006

First Aid – First Aid recertification – January 14, 2005 Expiry – January 14, 2008

Constable Millington

CEW – Conducted Energy Weapon Users Course completed July 12-13, 2007 (Instructors – Corporal G. Gillis and Constable Dhillon) Expiry – July 13, 2010

First Aid – Basic First Aid completed – June 4, 2007 Expiry – June 8, 2010

Constable Rundel 

CEW – Conducted Energy Weapon Users Course completed July 21-22, 2007 (Instructors – Corporal Sandry and Constable Tarasoff. Course Coordinator – Corporal Gillis^{Footnote 182}) Expiry – July 22, 2010

First Aid – Basic First Aid completed – December 12, 2004 Expiry – December 12, 2007

Constable Bentley

CEW – Conducted Energy Weapon Users Course completed July 21-22, 2007 (Instructors – Corporal Sandry and Constable Tarasoff. Course coordinator – Corporal Gillis) Expiry – July 22, 2010

First Aid – Basic First Aid completed – November 29, 2005 Expiry – November 29, 2008

Appendix N – RCMP Use of Force Options

The RCMP members were required to assess Mr. Dziekanski's behaviour and the attendant level of danger/risk he posed to himself, to the RCMP members and to the public at large, and take steps to manage the risk. To carry out this task, the RCMP members had a number of options available to them pursuant to the IM/IM. These included:

1. Tactical Repositioning

Tactical repositioning refers to a situation in which police refrain from confronting the suspect pending a greater tactical advantage. The IM/IM model provides that tactical repositioning may be used at any point in a situation:

• If doing so reduces the likelihood and extent of harm to the public;
• If fear of death or grievous bodily harm is identified, providing it does not expose others to injury or deadly force;
• If seeking assistance will help to ensure public and police safety;
• If buying time and gaining distance will help to ensure public and police safety; and
• If the member has ensured that the scene has been contained and there is little or no potential for harm.

During the Dziekanski incident, the members had the option of not confronting Mr. Dziekanski until they had all the relevant facts at their disposal. They could, for example, have canvassed the witnesses and YVR security present to determine the level of threat posed by Mr. Dziekanski. Mr. Dziekanski had already demonstrated erratic behaviour as well as a propensity for violence and he had damaged property. The members were unable to communicate with him. Instead of confirming the level of threat posed, the members made a decision to confront Mr. Dziekanski.

This is not to suggest that police officers should ignore an unfolding situation which requires immediate intervention. As I have noted, I do not believe that was the case in this situation and it was therefore open to the responding members not to take immediate action.

Constable Bentley stated that in his mind, Mr. Dziekanski changed from cooperative to combative behaviour when he grabbed the stapler. Although the members involved may have considered the demeanour of Mr. Dziekanski to be combative, they had the option of tactical repositioning to contain Mr. Dziekanski and maintain control, while observing his actions and attempting to find a less violent means of resolving the situation. That option was not exercised.

Appendix O – Use of Force Report

As noted in the body of this report, I have not relied on the Use of Force Report prepared by Sergeant Brad Fawcett in my investigation. My comments and analysis of the Use of Force Report set out the reasons for non-reliance.

On March 3, 2008, a Use of Force Report was provided to IHIT investigators by Sergeant Fawcett, a member of the Vancouver Police Department. Sergeant Fawcett indicated in the document that he was providing an opinion at the request of IHIT, but did not indicate the question on which he was asked to opine.

The involvement of Sergeant Fawcett came about due to a November 23, 2007 letter from Superintendent Wayne Rideout, Officer in Charge of IHIT, to Chief Constable Jim Chiu, Chief of the Vancouver Police Department, requesting Sergeant Fawcett's services to provide an expert opinion on the use of force used by the four involved members. The letter requesting Sergeant Fawcett's assistance did not specify whether Sergeant Fawcett was to gauge the actions of the four RCMP members against RCMP policy, nor did it specify for Sergeant Fawcett the scope of his review.

Sergeant Fawcett stipulated in his report that he is qualified in assessing the adequacy and appropriateness of the force used by police and that he provides:

... expert opinions in the areas of Use of Force, Police Training and Training Standards, Non-Firearms Prohibited Weapons, Street Weapons, and Weapons Concealed by Design.

As will be discussed in more detail below, Sergeant Fawcett made certain assumptions which I did not find to be in evidence. For example, he attributed characteristics such as anger to Mr. Dziekanski, when Mr. Dziekanski's state of mind cannot be known. More importantly, Sergeant Fawcett assessed the actions of the responding RCMP members not by the training received by RCMP members pursuant to the IM/IM, but by what he perceived to be standard police training pursuant to the National Use of Force Framework (NUFF), and by threat cues he assumed or believed to have been perceived by the responding members. Although he may be correct in his assumptions concerning training, no mapping of RCMP training to the NUFF was provided as a concordance to enable the reader to accurately assess the response of the responding members based on the IM/IM. This is a fatal methodological flaw.

In his report, Sergeant Fawcett canvassed the witness statements of persons who observed the actions of Mr. Dziekanski and the interaction with the RCMP members, as well as the statements of the RCMP members, and reviewed video associated with the incident. Sergeant Fawcett then conducted an analysis of the events using the facts as known juxtaposed against the National Use of Force Framework,^{Footnote 186} a document akin to the IM/IM. The NUFF is a document which, at the time of the YVR incident, was not used in RCMP training.

Following the scenario of the incident as visible in the Pritchard video, Sergeant Fawcett noted that the RCMP members, upon initially confronting Mr. Dziekanski, used the force response options of officer presence (four uniformed officers) and communication (informal greeting). He went on to say that the members did not take an aggressive stance and attempted to use hand signals with Mr. Dziekanski as a means of communicating with him and attempting to calm him.

Sergeant Fawcett pointed out that after Mr. Dziekanski put his arms in the air and walked away from them, the RCMP members fanned out around Mr. Dziekanski and maintained what is known as a reactionary gap. He stated that police across North America are trained to make use of such a space and defined the reactionary gap and its rationale as:

... the distance outside the longest technique of the subject, generally four to six feet for an apparently unarmed subject. A reactionary gap is used to provide officers with sufficient time to analyze, evaluate, plan, and initiate a physical response to threat stimulus. The time required is typically ¾ of a second. The reactionary gap concept takes into account the fact that subjects have the benefit of first act and the officers will also be responding to a threat stimulus that happened in the immediate past. It is hoped that maintaining a reactionary gap will provide officers with sufficient time to respond effectively to a spontaneous assault.

Fanning out around Mr. Dziekanski was, in Sergeant Fawcett's opinion, a reasonable approach and one that was tactically called for to avoid a situation in which the suspect could attack all of the police officers at one time.

Sergeant Fawcett stated that police training is to contain the problem in order to mitigate opportunities for the suspect to flee police and resume (the) behaviour elsewhere. He indicated that it also reduces the possibility of other persons unwittingly placing themselves in jeopardy by entering into an uncontrolled area.

Sergeant Fawcett pointed out that the intervention took place in an airport terminal and that it was reasonable for the RCMP members to anticipate that other travellers leaving the international arrivals area could enter into the situation at any time.

At the time Mr. Dziekanski picked up the stapler, the members can be seen on the Pritchard video to appear more concerned and Constable Bentley can be seen to take a step back. In Sergeant Fawcett's opinion, by acquiring the stapler for the purpose of using it as a weapon, Mr. Dziekanski elevated the level of demonstrated behaviour to assaultive. The National Use of Force Framework states that assaultive behaviour occurs when a person:

... attempts to apply, or applies force to any person; attempts or threatens by an act or gesture, to apply force to another person, if he/she has, or causes that other person to believe upon reasonable grounds that he/she has, present ability to effect his/her purpose. Examples include kicking and punching, but also include aggressive body language that signals the intent to assault.

The RCMP trains its members using the Incident Management/Intervention Model (IM/IM). The IM/IM does not recognize a resistance level known as assaultive behaviour, but like the NUFF, the IM/IM does recognize increasing levels of resistance (from cooperative to non-cooperative to resistant to combative to persons who show the potential to cause grievous bodily harm or death).

The lack of mapping between the NUFF, used by Sergeant Fawcett, and the IM/IM, is problematic. Sergeant Fawcett's report did not correlate one use of force measurement to the other; therefore, it cannot be stated with certainty how a term such as "assaultive behaviour" equates to the term "combative behaviour" as used in RCMP training.

The relevant IM/IM resistance levels in terms of the indications provided by the Pritchard video as well as the members' statements and those of other witnesses appear to be resistant leading to combative resistance. The resistant level is defined by the IM/IM as:

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.

Combative, which is how the RCMP members who attended described Mr. Dziekanski, is defined in the IM/IM as:

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.

However it is characterized, the rationale for the increased level of aggression is that by potentially using the stapler as a weapon of opportunity, Mr. Dziekanski increased the level of harm that he was capable of producing. Sergeant Fawcett stated:

A stapler held in a fist maintains the integrity of the fist upon impact, adds weight to a punch, and provides a variety of impact surfaces (a subject can strike with a "loaded fist" or with the top or bottom of the stapler. ... The behaviour demonstrated by the deceased is classified as Assaultive. ... He had the apparent means, ability, intent, and opportunity to assault the officers or anyone else who entered into the immediate area.

Sergeant Fawcett does not explain how an open stapler equates to a "loaded fist." To the uninitiated, an open stapler (as visible in the Pritchard video, half of the stapler unit was moving freely outside of Mr. Dziekanski's fist), used as a means to buttress a punch, would appear to result in potential injury to the hand of the person holding the stapler if it folded on itself.

Sergeant Fawcett stated that the reactionary gap should be increased when a subject is armed or demonstrates what he described as "pre-assault cues." These include the following gestures and actions:

• Clenching fists;
• "Thousand yard" stare;
• Balling of the masseter muscle (jaw clenching);
• Bladed stance relative to the officers;
• Adjusting their positions relative to the officers;
• Target glancing;
• Verbal threats; and
• Depersonalizing officers or others.

Sergeant Fawcett provided the above as examples of such pre-assault cues and stated that police officers are instructed to recognize pre-assault cues in order to defend themselves and/or others from assault they believe to be imminent.

The IM/IM used by the RCMP does not refer to "pre-assault cues." Rather, RCMP training teaches members to analyze "threat cues" through their interaction with an individual. In this regard, the IM/IM states:

Throughout the management of an incident, a police officer should be alert to threat cues such as body tension, tone of voice, body position and facial expression to ready them to use an appropriate response option. These threat cues may indicate the potential for a suspect to display more or less resistant behaviours described under "categories of resistance" that would justify the use of different "response options" ...

Overarching the IM/IM, RCMP members are trained using the CAPRA problem-solving model. CAPRA is an acronym standing for the processes included in the RCMP problem-solving model: Client/Acquiring and Analysing Information/Partnerships/Response/Assessment and Continuous Improvement. Fundamental to the RCMP CAPRA model are the concepts of finding alternative and preventing crime. Practitioners of CAPRA are encouraged to prevent:^{Footnote 187}

... the problem from occurring or from escalating by addressing contributing factors to the broad problem rather than specific incidents or manifestations of the issue.

The impact of the CAPRA model on the IM/IM and use of force options was not discussed by Sergeant Fawcett in his report.

Although Sergeant Fawcett's Use of Force Report does not address the issues from the point of view of RCMP training standards, there may be overlap in the concepts involved. Corporal Gregg Gillis, an RCMP use of force expert, responded as follows to questions from an external agency pertaining to situational factors:

Question 1:

... "situational factors" (within the meaning of the IMIM & Part 17.7[^{Footnote 188}] of the RCMP Operational Manual) include environmental conditions, number of subjects, perceived subjects' abilities, knowledge of subject, time & distance and potential attack signs....

Corporal Gillis confirmed that this is correct from an RCMP perspective.

This position was reiterated in his evidence before the Braidwood Inquiry, when Corporal Gillis said:

... each and every case has to be looked at on its own situational factors, the behaviours of the persons, the perceptions of the officers, and tactical considerations.

Question 2:

Does the term "situational factors" also include subject behaviours/categories of resistance such as combative behaviour or are subject behaviours/categories of resistance regarded as a different category of factors? ...

Corporal Gillis responded:

The behavior of the person or persons an officer is interacting with are [sic] a different category and not included in the Situational Factors[^{Footnote 189}] portion of the IMIM. The behavior of the person, or persons, is [sic] significant factor. The officer's perceptions of that behavior are critical in the risk assessment and related response as such it is a separate category or section of the IMIM and distinct from the "Situational Factors" area.

Corporal Gillis also stated that, in general, response options are aligned to the behaviour being exhibited to the police officer.

In his evidence before the Braidwood Inquiry, Corporal Gillis confirmed that the NUFF and the IM/IM are similar in nature, and provided an overview to the Commissioner of the two.

On July 29, 2009, Deputy Commissioner H.D.M. Madill, responsible for Contract and Aboriginal Policing provided me with a letter in which he provided an update on the status of the 22 recommendations arising from the interim and final reports (issued in December 2007 and June 2008, respectively) of the Commission pertaining to the RCMP's Use of the CEW. With respect to the alignment of the IM/IM and the NUFF, Deputy Commissioner. Madill stated:

On May 29, 2008 the RCMP approved a new Incident Management Intervention Model (IMIM) to align with the existing Canadian Association of Chiefs of Police (CACP) National Use of Force Framework (NUFF). The alignment of the IMIM and the NUFF will ensure commonality of language and terminology between the RCMP and other Canadian law enforcement agencies. The term "impact weapon" is no longer included in the new IMIM.

I was not provided with an RCMP analysis of the process of aligning the IM/IM and the NUFF to be able to comment with any insight on the rationale for the alignment, the process of carrying out the alignment or a means of gauging the appropriateness of the alignment, and more importantly, its outcome.

Use of Force Report and Deployment of the CEW

Within four seconds of Mr. Dziekanski picking up the stapler, Constable Millington discharged the CEW in probe mode. The video does not indicate at what point Constable Millington withdrew the CEW from its holster (because he is out of frame), but it does not appear to be in his hand when Constable Millington was last in frame. It is therefore reasonable to conclude that Constable Millington drew the weapon at the time Mr. Dziekanski picked up the stapler and Constable Millington became concerned that Mr. Dziekanski could use the stapler as a weapon.

Assuming that the time required to draw and point the CEW is approximately two seconds, any assessment carried out by Constable Millington that the stapler in the hands of Mr. Dziekanski constituted a weapon took place in less than the remaining two seconds. Police officers are required to make very quick decisions, often under very trying circumstances. Had Mr. Dziekanski held a more robust weapon, such as a letter opener, a piece of pipe or a chair, for example, the quickness of the decision to deploy the CEW would perhaps have been more articulable and understandable.

Sergeant Fawcett categorized the CEW as an intermediate weapon, in the same category as OC spray and other such weapons. This categorization of the CEW and OC spray is supported by the IM/IM. The police baton, at that time, was considered an impact weapon pursuant to the IM/IM.^{Footnote 190}

As the members entered the scene, and as pointed out by Sergeant Fawcett, at least two of them contemplated the use of the CEW. This is supported by the fact that as they entered the YVR terminal, Constable Bentley asked Constable Millington (the only member in possession of a CEW that night) whether he had the CEW with him. Constable Millington replied in the affirmative.

Sergeant Fawcett believed that consideration of the CEW as an option was reasonable because of the information the RCMP members had received via radio prior to arriving at the scene as well as their observations upon arrival. It will be recalled that the members responding believed that the male could be intoxicated and that he had already demonstrated violent behaviour. It will be recalled as well that Superintendent Rideout indicated to the Commission that IHIT had no knowledge of the responding members' predetermining that the CEW would be deployed against Mr. Dziekanski.

I agree that consideration of the CEW was reasonable. Deployment of the weapon as it actually occurred, however, was not.

Sergeant Fawcett stated that OC spray:

... has been shown to have a significant failure rate when used on subjects intoxicated by drugs and/or alcohol, subjects who are mentally ill, and/or subjects that are goal oriented. Officers had been informed that the deceased appeared to be intoxicated and the officers, based on their observations and information provided to them by police dispatch and witnesses could suspect that he might be suffering from a mental illness.

These statements, written by Sergeant Fawcett in his report dated March 8, 2008, are entirely speculative. Because he referred in the report to injuries received by Mr. Dziekanski which were noted during the autopsy, I assume that Sergeant Fawcett had read the autopsy report prepared by Dr. Lee. Sergeant Fawcett would therefore have known that the autopsy report of Dr. Lee, received by the BC Ministry of the Solicitor General on January 29, 2008, indicated that no drugs or alcohol were found in Mr. Dziekanski's body (although the responding RCMP members would not have know this at the time of the incident).

Further, although the responding members had been informed by radio dispatch that Mr. Dziekanski appeared to be intoxicated, none of the members indicated in their statements that they suspected from their observations at the scene that Mr. Dziekanski was intoxicated or suspected that he suffered from a mental illness. They did note the destruction of property (computer and chair) at the scene.

Sergeant Fawcett postulated that the members responding:

... also have to consider the tactical environment in which the incident was occurring. The use of oleoresin capsicum spray would result in significant contamination in a closed environment. Anyone coming into the area could be impacted.

Some of the responding members did express a concern that OC spray would contaminate the area.

Sergeant Fawcett considered the possibility of the use of the police baton during the incident. His opinion was that using the baton would have required the members to close the reactionary gap between them and Mr. Dziekanski, thereby placing them at greater risk of injury from the weapon of opportunity (the stapler) possessed by Mr. Dziekanski. Further, closing the reactionary gap would have compromised the ability of Constable Millington (the only member equipped with a CEW) to acquire Mr. Dziekanski as a target because the other members would be in the field of view.

Sergeant Fawcett was of the view that the use of the baton was not appropriate because baton blows to Mr. Dziekanski would have caused significant bruising and potentially more serious injuries.

In his Use of Force Report, Sergeant Fawcett considered the possible option of the four members physically controlling Mr. Dziekanski without the aid of any tactical weapons. He formed the opinion that:

Engaging the subject in a physical struggle would have been contrary to training with regards to the One-Plus-Theory. ... The officers could reasonably expect that anyone involved in a physical struggle (themselves, the deceased, or bystanders) may suffer an injury. A concern for the officers when considering the use of Physical Control as a force response option is the fact that they would likely be precluding Constable MILLINGTON from using his conducted energy device should their efforts at establishing physical control fail. The use of physical control tactics is strongly influenced by officer characteristics such as confidence in his or her abilities, previous successes or failures, his or her perception of the subject's ability to resist, and many other variables. Subject characteristics and environmental considerations may also influence an individual officer's decision to preclude the use [of] Physical Control in a given situation. Attempting physical control, while not prohibited, would be contrary to the One-Plus-one Theory.

In my opinion, the decisions taken by the responding members, particularly Constable Millington, were based on more than what Sergeant Fawcett considered to be their perceptions as they responded to Mr. Dziekanski. The training received by these members, coupled with what Sergeant Fawcett described as their past experience with similar situations (to the best of my knowledge, none of the responding members had encountered a situation such as the one involving Mr. Dziekanski previously), and the knowledge that several people were witnessing their actions likely created a mindset within which the members responded to the situation which presented itself that night.

Sergeant Fawcett discussed various use of force options available to the RCMP members who responded. He stated that:

RCMP Officers have been instructed in the area of Force Options Theory contained within the Incident Management and Intervention Model (IMIM) and the One Plus One Theory. Force Options Theory advocates that officers are not required to incrementally escalate through all categories of force options before they determine the appropriate use of force response. There are many circumstances, such as the incident in question, where it is reasonable and appropriate to escalate from Officer Presence to Intermediate Weapons without attempting Physical Control. The decision to escalate their force response option should be based upon preclusion: lower force options would be inappropriate and/or ineffective. The officers involved in the incident had attempted the force response options of Officer Presence and Communications, both of which failed to gain the deceased's voluntary compliance. High-level officer presence (multiple uniformed officers) and Communications had failed to gain the deceased's voluntary compliance.

The One-Plus-One Theory advocates that police offices [sic] respond to subject behaviours with a force response option one "level" greater than that demonstrated by the subject(s). Additionally, should an officer discover one weapon on a subject they are to assume there is a second one they have not yet discovered. In the incident in question the officers were responding to a subject armed with a weapon, albeit one limited to close quarters tactics. The officers responded with a CED, which allowed them to remain outside the effective range of the subject. Doing so was consistent with the One-Plus-One Theory.

Sergeant Fawcett concluded that:

The actions of the officers in this incident represent a reasonable escalation and de-escalation of force based upon the actions of the subject.

From my review of the available video, I noted no de-escalation of force by the responding members. Sergeant Fawcett cited his reasoning as follows:

The officers precluded lower force options, specifically high level Officer Presence in conjunction with Communications, by virtue of the fact that they had been attempted and failed. Once Officer Presence and Tactical Communications fail officers must necessarily escalate to the application of physical force. The officers used an Intermediate Weapon, specifically a conducted energy weapon, in conjunction with Physical Control to gain control of DZIEKANSKI. The officers' actions were consistent with their Common Law duties, various Criminal Code (Canada) provisions and RCMP policy and training.

Sergeant Fawcett did not provide a temporal discussion with respect to the failure of officer presence and communications. He did not suggest how much time is enough time to have attempted a particular tactic in order for officers to determine whether it is successful, nor is there a discussion of what elements constitute failure or how failure is measured.

Sergeant Fawcett stated:

The reasonableness of a particular use of force must be judged from the perspective of a reasonable peace officer on the scene, rather than with 20/20 vision of hindsight. The calculus of reasonableness must embody allowance for the fact that peace officers are often forced to make split second judgements in circumstances that are tense, uncertain, and rapidly evolving. These circumstances inflict neurological and physiological responses of fight, flight, posture, and submit on the officer, and may influence the determination of the level of force considered necessary by the peace officer in a particular situation. The courts have said that the peace officer cannot be expected to measure the force used with exactitude (R. v. Bottrell: 60 C.C.C (2d) 211).

DZIEKANSKI'S intentions when angrily damaging property and grabbing the stapler may have been for innocent purposes however the officers involved had no way of knowing this. There has been an extraordinary media outcry regarding the reasonableness of the use of force decisions made by the officers involved in the incident. It should be noted, however, that media and/or public perception of the incident do not determine the reasonableness of the officers' use of force.

Various media have asserted that DZIEKANSKI needed "help". It must be realized that no other assistance, medical or otherwise, could be provided until control had been established. The many callers to 9-1-1 and airport security called for the police, not Emergency Health Services.

It is responsible to point out that, while the author and reader have had the opportunity to view the videos provided numerous times, in slow motion, and stop action – the officers involved in the incident did not. Their decisions were based upon their perceptions, which evolved from the dispatched information, witnesses statements made to them upon arrival, and their own observations. Their perceptions are influenced by their training, past experience with similar situations, and the knowledge that several people were witnessing their actions.

In my opinion, the decisions taken by the responding members, particularly Constable Millington, were based on more than perceptions. The training received by these members, coupled with what Sergeant Fawcett described as their past experience with similar situations, and the knowledge that several people were witnessing their actions actually created a mindset within which the members responded to the situation which presented itself that night. RCMP CEW training teaches that the CEW is a less lethal intervention to control suspects. The implication, therefore, is that RCMP members are trained to view the CEW as a more humane manner of carrying out an arrest in order to mitigate and minimize potential injuries to the police, to the suspect and to bystanders.

Given that Constable Millington had completed his CEW training in July 2007, only three months prior to the YVR incident, it is foreseeable that Constable Millington's training would have been relatively fresh in his mind and he might well have been more inclined to deploy the CEW.

Sergeant Fawcett cited the 1999 decision of the Honourable Madam Justice Southin of the British Columbia Court of Appeal:^{Footnote 191}

What a judge must not do in a case such as this is take into account in determining the issue of "reasonable grounds" what the person injured was in fact intending to do, nor the actual consequences of the force used, no matter how tragic.

Sergeant Fawcett's analysis, cited above, considered various use of force options and discussed the possibility that RCMP members, civilians or the suspect could be injured in the event that a confrontation took place which involved hand to hand physical force. Although he did consider options ranging from officer presence to use of the baton, his analysis did not take into consideration soft and hard empty hand control techniques as taught to RCMP members as part of the use of force process. Prior to the deployment of the CEW, no soft or hard empty hand control techniques were used in the arrest of Mr. Dziekanski.

The distinction is important in that these options, particularly soft empty hand control techniques, include joint locks. Sergeant Fawcett did briefly discuss the use of superior strength by police officers in effecting an arrest (which he called physical control) and which allows for the use of joint locks. He did not, however, discuss the relative merits of such procedures versus use of the CEW.

In using techniques such as joint locks, the individual officer is able to apply the requisite amount of force to achieve the goal of compliance. The CEW does not allow for such variation in force; when the CEW is deployed, the full voltage is applied to the recipient and the officer deploying the CEW is not able to vary the current to achieve the desired outcome. This issue was not canvassed by Sergeant Fawcett's report.

Consideration of the entire range of use of force options available was a reasonable and necessary step not only for Constable Millington, but for all of the responding members in determining how best to deal with Mr. Dziekanski. Use of the CEW is but one aspect of the range of options. Given the apparent level of threat posed by Mr. Dziekanski as captured on the Pritchard video, resorting to and deploying the CEW in such a short time span is problematic.

I have concerns with respect to the analysis conducted by Sergeant Fawcett because his analysis does not bring the use of force as trained by the RCMP into primary focus. Rather, he uses the National Use of Force Framework as his policy guide. While this document may be relevant for many police forces across Canada, it is not the training standard of the RCMP. Further, he does not directly tie his analysis into specific aspects of even the NUFF.

Although the principles are similar, and although I have no reason to doubt that Sergeant Fawcett's intention was to identify best practices, it is unfortunate that Sergeant Fawcett did not analyze the appropriateness of the RCMP response in light of the training provided to RCMP members.

Discussion in Sergeant Fawcett's report surrounding issues such as the appropriateness of the One Plus One Theory, and the reasonableness of the RCMP members' beliefs concerning the response to Mr. Dziekanski, especially in light of the inability of the RCMP members to recall in their statements the events as depicted in the Pritchard video, would have been helpful.

Further, I take issue with Sergeant Fawcett ascribing a state of mind to Mr. Dziekanski, which may give the appearance that Sergeant Fawcett exhibited bias in his assessment of the situation. For example, Sergeant Fawcett refers to Mr. Dziekanski "angrily" damaging property. Language such as this can only be supposition on Sergeant Fawcett's part; he cannot know what Mr. Dziekanski's state of mind was at the time.

Sergeant Fawcett also addressed media reports that Mr. Dziekanski needed help and pointed out that 911 callers asked for the police and not Emergency Health Services. Sergeant Fawcett was asked to provide his assessment of the reasonableness of the force used by responding RCMP members, not to address extraneous issues. By providing such unsolicited comments, Sergeant Fawcett called into question his objectivity.

I note that Corporal Gregg Gillis, an RCMP member recognized as a use of force expert, is of the view that Sergeant Fawcett's report is not inconsistent with RCMP training. Semantics and descriptors may differ, but Corporal Gillis' view is that the overarching principles enumerated by Sergeant Fawcett are sound. While not in any way undermining Corporal Gillis' reputation, I note as well that it was Corporal Gillis who trained Constable Millington in the use of the CEW. The coordinator for the CEW user courses taken by Constables Bentley and Rundel was also Corporal Gillis. Constable Rundel indicated in his statement that his CEW instructor was Corporal Gillis. As such, any opinion provided by Corporal Gillis would, at the very least, create the perception of bias.

Appendix P – Conduct of RCMP Members in Light of CEW Policy

The following table illustrates the conduct of the responding members as it aligns with policy in existence at that time (October 2007):

Appearances are that prescriptive policy was generally complied with. Those areas in which compliance was not noted deal primarily with aspects of the application of policy involving judgement. In addition, the members appear not to possess an understanding and appreciation for the nature of the CEW as a weapon.

CEW Usage Report – Constable Millington

Constable Millington did file a CEW Usage Report (as noted in the table above) as required by RCMP policy. The report (Form 3996) contained a number of omissions and errors, which are a cause of concern. Specifically, they are as follows:

1. The ostensible reason Constable Millington and the others felt threatened by Mr. Dziekanski was that he had picked up a stapler which they were concerned he would use as a weapon. Constable Millington's CEW Usage Report, however, does not mention the fact that Mr. Dziekanski possessed a weapon. The box labelled Weapons Carried or Immediately Accessible by Subject was left blank. The stapler is mentioned in the Incident Summary box, however.
2. Although the model of the CEW used by Constable Millington is indicated (Taser® X26), the serial number of the weapon is not indicated. The serial number was captured elsewhere, such as in the investigation exhibit report; however, the failure of Constable Millington to include the serial number is significant in that absent the serial number, it is not possible to identify the particular weapon used in order to ensure that the correct unit was tested with respect to its operating properties and parameters of the electrical current produced by it.
3. The narrative provided by Constable Millington does not align with the Pritchard video coverage of the incident. In his report, Constable Millington indicated that:

   When members got closer to the male, he stepped back and away. The male then deliberately knocked items off of a desk nearby and grabbed an office stapler. The male swung the stapler wildly with his arm at the members. Cst. MILLINGTON unholstered the CEW and pointed it at the male subject. The male was not apprehensive upon seeing the CEW. The male raised the stapler in one hand and raised the other fist. The male then aggressively moved towards members on scene. Cst. MILLINGTON recognized the male's behaviour had escalated from resistant to combative, and deployed the CEW. The CEW was cycled once for the full 5 seconds, which stopped the male from moving, but he continued to walk towards members with his arms raised once the cycle was completed. Cst. MILLINGTON cycled the CEW a second time, after which members were able to wrestle the male to the floor. The male was still struggling at this time and Cst. MILLINGTON cycled the CEW again. However, the CEW electrical impulse was audible, which meant that at least one of the probes were [sic] not attached. Cst. MILLINGTON took the cartridge off of the CEW and used the push stun mode on the male's rear deltoid (upper back) area. At this point, members were able to control the male and get him into handcuffs.

The Pritchard video does support Constable Millington's contention that Mr. Dziekanski stepped back and away from the members shortly after they arrived. It does not, however, support Constable Millington's justification for unholstering the CEW when he stated that Mr. Dziekanski swung the stapler wildly with his arm at the members, that Mr. Dziekanski raised the stapler in one hand and raised the other fist, or that Mr. Dziekanski then aggressively moved towards members on scene. The video clearly demonstrated that at the time Constable Millington discharged the CEW, Mr. Dziekanski was standing at the counter with his arms by his sides.

Given that the stapler is clearly visible in his right hand after he was struck by the CEW probes, it is likely that Mr. Dziekanski did pick up the stapler as he approached the counter. However, since his hands were not visible in the video it is not possible to know at what point exactly when.

4. Constable Millington indicated in his Form 3996 that:

Cst. MILLINGTON unholstered the CEW and pointed it at the male subject. The male was not apprehensive upon seeing the CEW.

The Pritchard video suggests that after the responding members fanned out around Mr. Dziekanski (during which time Constable Millington appears to have unholstered the CEW) and prior to the discharge of the CEW, Mr. Dziekanski glanced at Constable Millington (to the far left of Mr. Dziekanski) for at most a second, just as the CEW was fired. In my view, Mr. Dziekanski did not have time to register apprehension or any other emotion prior to the deployment of the CEW.

I do not accept any of the versions of events as presented by the involved members because I note so many discrepancies in the detail and accuracy of the recollections of the members when tracked against video evidence.

All of the foregoing was canvassed and confirmed by evidence given by the responding members during the Braidwood hearings.

Appendix Q – Involvement of Staff Relations Representative

As noted in the body of the report, prior to the commencement of interviews with the involved RCMP members by IHIT investigators, the members met with Staff Sergeant (then Corporal) Mike Ingles, the Staff Relations Representative (SRR) collectively and at least Constable Millington met with him individually.

The issue is not the fact of the meeting, but the perception it conveys. Did the SRR and the member meet alone? For how long? What was discussed? What was the resulting input or influence, if any, of the SRR's involvement? Who called the SRR and why?

The Commission subsequently posed questions to Staff Sergeant Ingles with respect to both the meeting and the nature of the duty to account statements taken from the members. In his response Staff Sergeant Ingles stated that no formalized duty to account requirement exists. Staff Sergeant Ingles stated that:

Specifically there is an "unwritten" acknowledgment that our members should not be withholding any information that would either a) compromise any investigation, or b) place any member of the public or another member in danger. Unless a member has knowingly committed an offence they will almost always want to provide their version of what occurred. When and how that should happen is another, more complex, matter.

He went on to state that:

A member does have a [sic] "Rights" as outlined in the "YOUR RIGHTS AND OBLIGATIONS – A Guide for Members of the RCMP" document that can be found on the SRR website. As even the investigators are often at odds on what a member is "required" to provide our role is to gain a rudimentary understanding of what has occurred and explain to the members what is likely to occur, what their options are, and how they can assist the investigation while ensuring they are not placing themselves in legal peril.

In the case of YVR ... I will note that even the understanding of the investigator(s) of our role and position is unclear. ... Essentially we are free from the constraints of the investigator role, focused on ensuring that the mental and physical health of the member are being addressed, and based on our frequent involvement in such situations being able to provide guidance to a member who in most cases, specifically an in custody death, has not been involved in a similar situation previously. We also understand that there are certain things that an investigator needs to know to allow the investigation to proceed. ... the involved member likely has not experienced this before and to have the guidance of someone who is neither their supervisor nor the investigator is often helpful.

I suppose considering there is no policy that requires a member to provide a statement there is no need to have a policy that directs when the member can consult an SRR. The [sic] are free to contact and consult us on any matter related to their welfare and employment.

I note that RCMP "E" Division guidelines (which are not national in scope) do contemplate the duty to account. The RCMP "E" Division Internal Investigations Guidelines state:

All members are accountable to the RCMP for their actions during the course of their duties. Included in this accountability is an obligation to provide relevant information when requested.

This duty to account should not be confused with providing a voluntary statement to an investigator. The duty to account could simply encompass the completion of standard paperwork such as form 1624 or answering basic questions pertaining to an incident that could be expected from any supervisor or fellow member in other investigations. The request for a voluntary statement made to a member subject of a Part IV investigation should be separate and distinct from an investigator's request for information to satisfy the duty to account or the RCMP's "right to know". The voluntary statement may encompass more detailed questioning by the investigator pertaining to the alleged incident.

The role of the SRR is not to provide legal advice. Since SRRs do not provide legal counsel for members, conversations between the involved member and the SRR are not therefore privileged in the legal sense, although they are confidential.

According to Staff Sergeant Ingles (the SRR), after being called by the Richmond Detachment SRR sub-representative, he arrived at YVR at approximately 3:45 a.m. on October 14, 2007. He spoke with the four involved members and at one point spoke alone for approximately two minutes with Constable Millington to determine the latter's emotional state (he was aware it was Constable Millington who had deployed the CEW). The SRR stated that he did not discuss any details of the incident with the involved members (neither on the night of the incident nor at subsequent meetings with the involved members) and that he was with them at the YVR sub-office until the arrival of Corporal Brassington of IHIT.

Staff Sergeant Ingles wrote that:

We did not have discussions relating to details of the incident. I advised all four members that I didn't want or need to get into any details of the investigation, and that they should not discuss details of what had occurred during the incident with each other until after they had given statements.

He went on to state that he:

... advised the four members of the differences between a "statement" and accounting for their actions in the first instance, often referred to as a "duty to account". I advised them that they were not required to provide statements right now (meaning that morning), simply providing a short outline of their involvement as they would in any file is sufficient at this point. I explained that this was an extremely stressful time for everyone involved and that their recollections would likely be more clear once they had gotten one or more sleep cycles. I was advised by them all, but do not specifically recall the words or gestures in reply from any particular one of them, that the facts were the facts and they didn't have any problem providing a statement to the investigators.

Staff Sergeant Ingles wrote that at approximately 4:40 a.m. Corporal Brassington stated to the four involved members:

You need to do a duty to account. If you are willing to give a statement, I'll take that as well. You guys aren't a suspect or anything like that.

Staff Sergeant Ingles wrote that he:

... commented to the 4 members that I didn't think a statement at that time, following a long shift and a traumatic incident, was a good idea, however they could make their own decisions on if and when they would provide a statement.

I have no knowledge of the content of the conversation between Constable Millington and Staff Sergeant Ingles, other than Staff Sergeant Ingles' comments and Constable Millington's comment in his statement that Staff Sergeant Ingles told him that he had the option to sleep on it and not give a statement right away to ensure that he (Constable Millington) recalled all of the details.

I have received a copy of the notes kept by Staff Sergeant Ingles with respect to the morning of the incident (October 14, 2007) and his meeting with the four involved members at the YVR RCMP sub-detachment office. His notes of that meeting consist of one page and one line on a second page in a small police notebook. He has indicated that he kept no notes of subsequent meetings with the four involved members. As I have indicated in the part of this report addressing what I perceive to be an ongoing lack of quality in police note keeping, I find these notes to be inadequate to properly capture the content of the discussion between Staff Sergeant Ingles and the responding members.

In a response to questions posed by the Commission with respect to the involvement of Staff Sergeant Ingles and the duty to account statement, Staff Sergeant Ingles cited the following RCMP regulations pertaining to the Staff Relations Representative Program as his authority for attending:

RCMP Regulations

Division Staff Relations Representative Program

96. (1) The Force shall have a Division Staff Relations Representative Program to provide for representation of the interests of all members with respect to staff relations matters.

(2) The Division Staff Relations Representative Program shall be carried out by the division staff relations representatives of the members of the divisions and zones who elect them.

In support of his attendance, Staff Sergeant Ingles also cited the SRR Constitution which he said gives us direction on duties. He quoted from Article 13 of the SRR Constitution (emphasis added by Staff Sergeant Ingles):

ARTICLE 13 – DUTIES OF STAFF RELATIONS REPRESENTATIVES

A. The duties of the SRRs are as follows:

(i) Providing information, guidance and support to RCMP members, and in particular:

(a) Providing RCMP members with information on developments nationally, Regionally and in the Division, including but not limited to national policies, SRR Caucus positions, decisions and local developments;

(b) Reporting information of RCMP-wide interest for broader dissemination through the Program Director;

c) Providing advice, guidance and active support to members on the human resources implications and applications of legislation, policies and procedures as they affect them;

(d) Establishing and maintaining processes and mechanisms for effective two-way communication with members and Divisional management for the effective resolution of issues and disputes; and

(e) Arranging or engaging in facilitation and mediation to resolve issues and disputes between members and management.

(ii) Participating in divisional meetings where discussions will directly affect the terms and conditions of employment of members;

(iii) Representing members' interests and ensure their participation in the overall management of the RCMP, including but not limited to the following:

(a) Participating in studies, task forces and committees established by the RCMP where they impact or may potentially impact members, at the national, Regional, Divisional, and other levels;

(b) Participating as a member in one or more of the National Committees;
RCMP Staff Relations Representative Program Constitution (2007-10-04 Final)

I Consulting with members and/or their representatives on issues affecting or potentially affecting them that are the subject of discussion in National Committees, at SRR Caucus and Regional Caucus or as part of studies or reviews; and

(d) Subject to RCMP Policy and guidelines established by the SRR Caucus, represent members' interests with the media and with external stakeholders;

(iv) Supporting the overall effectiveness of the SRR Program, including but not limited to the following:

(a) Supporting the involvement of the Sub-representatives of his/her division, zone or area designated directorate to have the training, information and support they need to be effective;

(b) Participating in meetings of the SRR Caucus unless excused by NE or prevented by any sanction imposed under the SRR Constitution;

I If unable to attend any meeting of the SRR Caucus, appointing a replacement
Sub-Representative to attend; and

(d) Supporting, advancing and carrying out all official policies, goals and objectives of the SRR Program.

It appears to me from the response of Staff Sergeant Ingles that, in his view, the role of the SRR is to filter information as between the involved member and the investigators. I see this as a dangerous and potentially precarious situation. The investigators, particularly in the early stages of an investigation, require facts which are not adulterated or influenced. The investigator should be able to conduct the interview of the involved member without the presence of the SRR.

My concern is that prior to the commencement of taking a statement from the involved member, the investigator could be influenced by information or a version of events provided by the SRR. To paraphrase an old maxim, an impartial investigation must not only be done, it must be seen to be done. This is particularly true when the police are investigating the police.

The protocol of members meeting with an SRR has been noted in previous^{Footnote 192} matters which have been investigated by the Commission. Although such meetings may have legitimacy, the optics are such that members could be coached by the SRR on what to say or how to react during their subsequent statement(s). I stress that I have no evidentiary basis to impute inappropriate motives or conduct to the SRR in this instance.

I recommended in a previous decision^{Footnote 193} that the RCMP should consider implementing policy with respect to the issue of the duty to account statement. Such policy would provide clarity for RCMP members as well as the public in terms of the nature of such a statement, when it is required, what information is required and the use to which it may be put.

Appendix R – Travel to Poland

This issue of the necessity for travel to Poland by investigators was addressed by Superintendent Wayne Rideout, the Officer in Charge of IHIT at a news conference on December 17, 2008.^{Footnote 194} Superintendent Rideout stated:

The reason our investigators traveled to Poland was to obtain witness statements that would be used in any court proceedings, inquests or inquiries in Canada, and to determine Mr. Dziekanski's activities, health and state of mind in the days leading up to his departure for Canada. The team discovered a number of factors, which they passed on to the medical experts to help them render an opinion in relation to cause of death.

...

The trip took place from April 14 to 17, 2008. The investigators were able to observe interviews conducted by the Polish authorities, based on questions that our investigators provided in advance and supplemented by follow up questions through an interpreter. The entire process took place in accordance with Polish law and with the cooperation of Polish prosecutors. A Polish prosecutor oversaw the interviews and heard the evidence, given under oath.

When the investigators returned to Canada, the statements they had obtained were translated and provided to medical experts and to the Provincial Crown as supplementary information to the initial report to Provincial Crown Counsel. Experts used this information in conjunction with all other information to provide their opinions with respect to Mr. Dziekanski's death.

Appendix S – Media Releases

The issue of misstatements and/or the provision of misinformation to the media, and ultimately to the public, by the RCMP have become issues with respect to the investigation into the death of Mr. Dziekanski. As part of my investigation in this matter I identified these issues as being worthy of comment.

On November 13, 2007^{Footnote 195} the British Columbia Civil Liberties Association (BCCLA) initiated a public complaint pursuant to Part VII of the RCMP Act, pertaining to the lack of accuracy of information provided to the media and the failure of the RCMP to return the video taken by Mr. Pritchard in a timely manner. These actions were characterized by the BCCLA as violations of RCMP policy and professional misconduct on the part of the involved RCMP members.

The complaint was investigated by the RCMP as per Part VII of the RCMP Act; however, the BCCLA was not satisfied with the RCMP investigation into its complaint (as per the RCMP letter of disposition to the BCCLA dated December 23, 2008). In a letter I received from the BCCLA dated March 19, 2009, subsequent to my decision to comment in this report on issues involving RCMP media releases, the Commission was requested to review the RCMP investigation into the BCCLA complaint pertaining to RCMP media releases (pursuant to Part VII of the RCMP Act). I will accede to that request.

Because the BCCLA request for review is inextricably linked to the overall investigation into the death of Mr. Dziekanski, it is my intention to deal with the review in the context of this report. The correspondence from the BCCLA as well as the RCMP letter of disposition are appended to this report at Appendix C and Appendix D, respectively.

As noted, the November 13, 2007 complaint by the BCCLA contained a number of issues which may be categorized into several broad areas:

1. The failure to return the Pritchard video in a timely manner
2. Content and accuracy of RCMP media releases
3. The investigation into the BCCLA complaint

The allegation concerning the failure of the RCMP to return the Pritchard video has been addressed elsewhere in this report (see Section titled Pritchard Video). Issues pertaining to RCMP media releases and the nature of the RCMP investigation into the BCCLA complaint are addressed below.

Allegations of inaccuracies in RCMP media releases in the early stages of the investigation into the death of Mr. Dziekanski may be characterized into three principle areas. First are the allegations of factual errors provided by the RCMP media relations officer (MRO), who, in the early days of the investigation was Sergeant Pierre Lemaitre, "E" Division Strategic Communications (Sergeant Lemaitre was replaced as MRO by Corporal Dale Carr, the MRO for IHIT). Second are the allegations of gratuitous comments and apparent hypothesizing engaged in by Sergeant Lemaitre. Third is the failure to correct known factual errors in information provided by the MROs.

The BCCLA complaint identified a number of facts in various media news articles in which the MRO was quoted and which were subsequently shown to be false. The BCCLA complaint indicated that during media interviews Sergeant Lemaitre stated that:

• The attending RCMP members attempted to calm Mr. Dziekanski and used the CEW as a last resort;
• Mr. Dziekanski may have been under the influence of alcohol, drugs or had a medical condition that caused his death;
• Mr. Dziekanski was sweating profusely and was violent which could indicate either drug use or a medical condition and that there was obviously something very different going on inside of him.

Further, the BCCLA complaint stated that when Corporal Carr assumed the responsibility as MRO with respect to the death of Mr. Dziekanski, Corporal Carr:

• Stated that the Pritchard video was being withheld from the public to prevent witnesses account contamination but that the RCMP was continuing to publicly espouse subjective information about the incident thereby contaminating potential witness accounts to the detriment of Dziekanski and to the benefit of the RCMP;
• Stated that the Pritchard video recording was being withheld from the public to prevent upsetting Mrs. Cisowski (the decedent's mother), even though she and her lawyer wanted it released;
• Attacked Paul Pritchard's motive for release of the video.

Although the above are the examples cited in the BCCLA complaint, other misstatements have also been identified and my comments will include them.

The release of information by the RCMP to the media is governed by RCMP policy,^{Footnote 196} which includes the requirement to ensure that information released to the media:

• Does not result in injury, injustice or embarrassment to the victims or the accused;
• Does not result in publicity that could affect the course of a trial;
• Does not contravene the provisions of the RCMP Act, Privacy Act, Access to Information Act, the Canadian Charter of Rights and Freedoms or the Canadian Human Rights Act.

Pursuant to that same policy, RCMP members when speaking with the media are advised not to speculate or offer a personal opinion. They should report only the facts.

Further, RCMP policy is that members are not to release information that would compromise an investigation or individual rights.^{Footnote 197} All information released to the media must present the views of the RCMP and any of its partner stakeholders.^{Footnote 198} I presume this final caveat to be interpreted by the RCMP such that the views of the RCMP and its partner stakeholders, when viewed in the context of the overall RCMP media policy, are that RCMP MROs are expected to provide a factual and non-biased version of events to the media.

According to an internal RCMP report titled A Review of Communications Surrounding the 2007 YVR Incident prepared in May 2008, during the month following the death of Mr. Dziekanski, over 1,000 e-mails were exchanged within the RCMP with respect to the creation of the media strategy to address that incident.^{Footnote 199} The review examined the RCMP's media response to the incident and made recommendations with respect to the process of incident management from a media relations perspective.

Included in the report is a discussion on the effect of apologizing, both from the point of view of the perceived assignment/assuming of blame by the person or agency apologizing, and from a more pragmatic and realistic point of view that an apology statistically lowers legal costs and increases public support.

Overall, the report recognizes organizational and systemic deficiencies in the handling of media issues relating to the death of Mr. Dzierkanski and suggests steps to be taken to address and correct them.

Factual Errors by the MRO

At approximately 7:23 a.m. on October 14, 2007, just hours after the death of Mr. Dziekanski, a briefing was held at the Richmond RCMP Detachment at which IHIT investigators attended along with Sergeant Lemaitre and Corporal Carr. Sergeant Lemaitre was with the RCMP "E" Division Strategic Communications, while Corporal Carr was the MRO for IHIT.

Evidence presented during the Braidwood Inquiry has demonstrated that during the briefing, the Pritchard video was viewed by those in attendance and in addition, Corporal Robinson, one of the RCMP members involved in the interaction with Mr. Dziekanski, also attended to provide investigators with his version of the incident (see the section in the body of the report titled The IHIT Investigation, sub-section titled Presence of Corporal Robinson at Richmond Detachment Briefing). Both Sergeant Lemaitre and Corporal Carr said in evidence before the Braidwood Commission that they viewed the video briefly. Sergeant Lemaitre said that he paid little attention to Corporal Robinson's version of events and said that he was able to tune it out of his mind.

During media interviews in the days immediately following the death of Mr. Dziekanski, Sergeant Lemaitre made a number of statements of fact and provided speculation to the media as to the state of mind of Mr. Dziekanski. He was also critical of the recollection of Ms. Sima Ashrafinia, one of the witnesses to the incident. At various points during those interviews Sergeant Lemaitre used the term "going on the record," apparently to impress upon the media the veracity of the information he was conveying.

Sergeant Lemaitre was the RCMP's MRO with respect to the Ian Bush matter and as such he was criticized for providing too little information to the media in that situation. In his statement to the RCMP Part VII complaint investigator, Sergeant Lemaitre said that he felt pressure because of the criticism from the Ian Bush matter to release more information than he had done in that case.

In the early part of the investigation the team commander, Staff Sergeant (then Sergeant) David Attew, discussed with Sergeant Lemaitre the information to be released to the media. Staff Sergeant Attew later said that he was surprised when he learned of the information Sergeant Lemaitre had released to the media because it was not what had been agreed between them. Staff Sergeant Attew was concerned that the "spin" being placed by Sergeant Lemaitre would be seen as self-serving to the RCMP, appeared to be defensive in tone and contained inaccuracies. This concern came to be shared by Superintendent Rideout, who opted to remove Sergeant Lemaitre and replace him as MRO with Corporal Carr.

Clearly, it was recognized early by IHIT investigators that some of the information imparted by Sergeant Lemaitre was incorrect and/or speculative. As will be discussed below, no steps were taken by IHIT to correct these inaccuracies. Although not exhaustive, this included statements by Sergeant Lemaitre that:

• The CEW had been cycled twice. Sergeant Lemaitre indicated that the source of his information in this regard was IHIT^{Footnote 200} and stated: We know for a fact that there were two pulses.^{Footnote 201} (This was later confirmed by Constable Baltzer's download report to be five cycles);
• Three RCMP members attended the incident involving Mr. Dziekanski (the actual number was four). At the time of making this statement, Sergeant Lemaitre was responding to a question concerning a discrepancy between the number of members reported by a witness (five) and the number actually attending. Sergeant Lemaitre went on to speculate that two YVR security employees dressed in uniforms and bright yellow jackets could have been misinterpreted for RCMP members. Those two plus the three members who he said did attend would account for the five reported by the witness;
• No YVR video of the incident existed. Sergeant Lemaitre stated: I can tell you that there was no video camera in that area at the airport.^{Footnote 202} The tape then stops. It is not known, therefore, whether Sergeant Lemaitre qualified this statement any further. The statement was in response to a media question as to whether there existed video coverage of the international arrivals area at YVR (Sergeant Lemaitre had viewed the Pritchard video when he made this statement). In fact, YVR video of the area did exist. Unfortunately, the quality of the video and the distance of the camera from the events rendered it virtually useless;
• Mr. Dziekanski may have had drugs or alcohol in his system (later shown to be false); and
• Mr. Dziekanski received a second "pulse" from the CEW and there was absolutely no change in disposition. Still erratic, violent.^{Footnote 203} He said that after the three members physically controlled Mr. Dziekanski on the ground, they placed handcuffs on him to stop Mr. Dziekanski from punching and fighting. Mr. Dziekanski slipped into unconsciousness and one member continued to monitor his pulse and vital signs up to the time that EMS took over.

In his statement to Staff Sergeant Forster, Sergeant Lemaitre said that he did attend the Richmond Detachment briefing on the morning of October 14, 2007 and viewed the Pritchard video one time. He recalled the IHIT members present discussing the file and what each witness had said, but said that he shut it out of his mind because he did not need to know that information.

When asked about the statement that there was no video in the area of the incident, Sergeant Lemaitre implied that Corporal Carr told him not to mention the Pritchard video and said that he was responding to a question about the availability of YVR surveillance video. He knew the Pritchard video was a key piece of evidence, and he did not believe that it was up to him to divulge its existence, absent clear direction from IHIT that he could talk about it.

Sergeant Lemaitre stated during his Part VII interview by Staff Sergeant Forster that he said that there were two cycles of the CEW because that was what he had heard at the Richmond Detachment briefing on the morning of October 14, 2007. The same rationale was provided as the reason he indicated that three RCMP members had responded to the incident involving Mr. Dziekanski.

He recalled explaining the IM/IM during a media interview, but believed he was simply providing background and context, as opposed to justifying the actions of the involved RCMP members. With respect to the comments that Mr. Dziekanski may have consumed alcohol or drugs, Sergeant Lemaitre stated that he was simply providing comments based on his experience as a police officer. In his evidence before the Braidwood Inquiry, Sergeant Lemaitre stated that he was clear in the interview that he was speculating and said that he added during the interview that [i]t would be up to a coroner and the toxicology report to give us those answers.

Sergeant Lemaitre did indicate in a French language interview conducted on November 14, 2007 that some of the information he had provided in the hours after the death of Mr. Dziekanski had been incorrect. He did not go into specifics, but indicated that he had been misinformed. The media reported that Sergeant Lemaitre would not make the same statement in English. No such corrections were made by him or any other MRO or IHIT representative in the English media. Sergeant Lemaitre's position was that he made the clarifications he did in the French interview because he was responding to a question from the media. He stated that he did not have the authority to clarify any information for the English media.

Sergeant Lemaitre stated that he challenged Ms. Ashrafinia's version of events in the media interview because, based on the information he had been provided, he believed that she was incorrect. In his statement he recognized that by making such comments he could be perceived as being less than impartial. He stated that he was never notified by Corporal Carr or anyone else at IHIT that there were problems with his media releases, nor was he ever told why he was taken off the file.

Appendix T – Medical Assessments

An autopsy was performed by Dr. Charles Lee on Mr. Dziekanski on October 16, 2007. Dr. Lee stated in his autopsy report that the cause of death cannot be conclusively determined and that a pre-existing heart condition of Mr. Dziekanski combined with chronic alcoholism and being pinned in the prone position as he was being subdued, may have led to a fatal arrhythmia.^{Footnote 209} Dr. Lee indicated as well that although Mr. Dziekanski was agitated, he likely did not suffer from delirium. The autopsy of Mr. Dziekanski found no trace of alcohol or drugs in Mr. Dziekanski's body. Dr. Lee ruled that the death of Mr. Dziekanski was best characterized as sudden death following restraint.

Subsequent to Dr. Lee's autopsy, Dr. Michael Pollanen, the Chief Forensic Pathologist for Ontario, was asked by IHIT investigators to review the autopsy findings of Dr. Lee and provide a second opinion on the findings. After reviewing the autopsy report and supporting medical documentation and evidence collected by Dr. Lee, as well as viewing video and photos, Dr. Pollanen concluded that:

1. Robert Dziekanski did not die of the effects of a physical injury, the toxic effects of a drug, or an acutely fatal natural disease or condition. There are at least four variables that could be co-factors in death: an agitated state, restraint in the prone-position, the effects of a taser discharge and chronic alcoholism.
2. Robert Dziekanski did not die of a taser-induced cardiac arrhythmia.
3. There is competing scientific evidence on the putative adverse non-cardiac effects of a taser discharge in animals and man. If Robert Dziekanski's death was caused, in part, by the adverse effects of an agitated state, then we need to keep an open mind about the putative role that the taser discharge may have played in indirectly contributing to death, since Mr. Dziekanski appears more (dis)stressed and agitated after the deployment of the taser.

Dr. Pollanen encapsulated his conclusions as follows:

In addition to the autopsy reports, IHIT investigators also sought an expert opinion from Dr. Christian M. Sloan of Del Mar, California with respect to the potential effects of alcohol withdrawal, on Mr. Dziekanski. Dr. Sloan is a practicing emergency physician, certified by the American Board of Emergency Physicians. He is employed as an academic attending and assistant clinical professor at the University of California at the San Diego Medical Center. Dr. Sloan indicated in his report that he has taken care of numerous patients in various states related to alcohol, including alcohol intoxication, as well as the complete range of alcohol withdrawal; from mild tremors to fully developed major alcohol withdrawal as well as delirium tremens.

I did not find Dr. Sloan's opinion helpful in analyzing alcohol withdrawal as a contributing factor in Mr. Dziekanski's death.

Dr. Sloan concluded:

From what I have available to me, in my opinion, Mr. Dziekanski's condition on that evening could certainly be consistent with some degree of alcohol withdrawal. I believe that the time frames we are looking at would allow the development of alcohol withdrawal if he was habitually using in at least the week prior to his travel. By adding the condition of alcohol withdrawal to the milieu of agitated delirium that is witnessed on the video and described by those involved, or if it is solely due to alcohol withdrawal, is difficult to definitively determine, but placed him at risk for sudden death.

I note that found in Mr. Dziekanski's effects was an unopened 750-millilitre bottle of Vodka which Mr. Dziekanski could have opened and consumed at any point. He did not do so. As a result, I must question the assumption that alcohol withdrawal was an important contributing factor in Mr. Dziekanski's death.

Appendix U – IM/IM Diagram

The diagram below is the Incident Management/Intervention Model (IM/IM) used by the RCMP at the time of the YVR incident. It has since been amended (May 2008).

Text Version

At the time of the YVR incident (October 14, 2007), the RCMP considered the following to be intermediate devices:

1. OC Spray (oleoresin capsicum)
2. CS gas
3. Conducted Energy Weapon (CEW)
4. Water Projection System

The only intermediate weapons carried by RCMP uniformed members on their duty belts are OC spray and the CEW. As discussed in the body of the report, the CEW is optional and may be carried only by qualified members.

At the time of the YVR incident, the RCMP considered impact weapons to include:

1. Extendable police baton (ASP)
2. Sock rounds

Because of the pain and risk of injury or death to the recipient, the Commission has consistently encouraged the RCMP to consider the CEW to be an impact weapon to underscore in the minds of members the importance of assessing the relevant considerations of its use prior to CEW deployment. Subsequent to the YVR incident the RCMP revisited the nature of intermediate and impact weapons and has since amended various aspects of the IM/IM and revised its listing of such weapons to identify only one category of weapon. The category of impact weapons has been removed as per amendments to the IM/IM in May 2008 and become part of the Intermediate Weapons category, now called Less Lethal Weapons. Less lethal weapons, defined as those whose primary use is not intended to cause serious injury or death consist of kinetic energy weapons, aerosols and conducted energy weapons.

As I have indicated in this report, I have assessed the YVR incident and activities related to it in light of policy as it existed at the time of Mr. Dziekanski's death. As I have noted, the IM/IM was subsequently amended.

The levels of intervention include officer presence, verbal intervention, soft and hard empty hand control, intermediate devices, impact weapons and finally, lethal force, which is only authorized where there is a threat of death or grievous bodily harm. At any given point, members are taught they may tactically reposition to de-escalate a situation or to better assess the risk.

As diagrammed, the IM/IM is not a linear structure such that one response necessarily leads to another. Rather, the IM/IM is intended to train RCMP members with respect to the need to constantly assess the risk and potential for harm and to respond at an appropriate level.

The IM/IM model assists RCMP members to categorize suspects into levels of anticipated levels of resistance based on threat cues such as body tension, tone of voice, body position and facial expression to ready them to use an appropriate response option. These threat cues may indicate the potential for a suspect to display more or less resistant behaviours.

The appropriate level of intervention must be determined by what the RCMP member knew, or should have known, as well as the information available to the member when he or she arrives on scene. RCMP members are trained that this assessment of risk is conducted using the CAPRA problem-solving model. CAPRA is an acronym standing for the stages included in this problem solving model: Client/Acquiring and Analysing Information/Partnerships/Response/Assessment and Continuous Improvement.^{Footnote 210} These factors are the basis upon which a member will make the assessments called for in the IM/IM. Members are required to assess the risk posed by a subject, followed by a determination of the appropriate level of response, which may include the use of force. Fundamental to the RCMP CAPRA model are the concepts of finding alternative means to resolve an issue, and preventing crime. As practitioners of CAPRA, RCMP members are encouraged to prevent:^{Footnote 211}

...the problem from occurring or from escalating by addressing contributing factors to the broad problem rather than specific incidents or manifestations of the issue.

In formulating the course of action to be followed, the members must next consider the behaviour of the subject. The IM/IM lists subject behaviours as ranging from co-operative to non co-operative to resistant to combative to posing the threat of death or grievous bodily harm.

In general, once a member makes a determination as to the behaviour and risk posed by a subject, he or she must then choose an appropriate response. Early intervention options include officer presence, verbal intervention and physical control. As the threat increases, the member may turn to greater levels of physical force, intermediate weapons (such as OC spray^{Footnote 212} or CEW), impact weapons^{Footnote 213} (such as the baton) and finally the application of deadly force.

Verbal interventions and tactical repositioning occur regardless of the level of risk to assist the member in maintaining control of the situation, de-escalating any confrontation, and ensuring maximal safety for all concerned. This is consistent with the underlying principles of the IM/IM, which stress the safety of the public and the member and define the best strategy as the least amount of intervention to manage a risk. Accordingly, the best intervention causes the least amount of harm.

The version of CEW policy in effect at the time of the death of Mr. Dziekanski (October 2007) was issued in August, 2007. This policy required members to take control of the subject as soon as possible during a CEW probe-mode deployment.^{Footnote 214} The version added the concept of excited delirium^{Footnote 215} (which was removed from RCMP documentation as of January 2009) and informed members that:

If you suspect that an individual is experiencing an excited delirium medical emergency, when possible create a response strategy before deploying the CEW and include Emergency Medical Services (EMS) attendance in your strategy.^{Footnote 216}

The RCMP members had a number of response options available to them according to the IM/IM. I have no evidence to suggest that any of these response options, except for the use of the CEW, were seriously considered. Briefly, these included:

1. Tactical Repositioning

Tactical repositioning allows police to remove themselves from confronting the suspect pending a greater tactical advantage or obtaining more complete information. As with verbal intervention (below), tactical repositioning is an ever-present and fluid response option. I note no evidence of the response option of tactical repositioning being utilized during the YVR incident.

2. Officer Presence

The very presence of a uniformed police officer can have the effect of de-escalating or escalating a given situation.

The RCMP members attended the scene of the complaints. Initially, Mr. Dziekanski appeared calm but within seconds, he put his hands in the air and walked away from the police officers. In the Pritchard video, Mr. Dziekanski can be seen looking at his luggage, while Corporal Robinson can be seen directing Mr. Dziekanski to the counter area, which is the direction taken by Mr. Dziekanski. While open to interpretation, the gesture by Mr. Dziekanski of putting his hands in the air and moving to the location as directed by Corporal Robinson may be an act of compliance, and not hostility.

The assumption by the responding members appears to have been that officer presence was not having an effect on Mr. Dziekanski because Mr. Dziekanski walked away from them. Because the situation was immediately escalated it cannot be known whether, given additional time, officer presence would have had the desired effect and defused the situation.

3. Verbal Intervention

The RCMP members attempted to speak to Mr. Dziekanski, and he to them, but since neither spoke the language of the other communication was difficult. Absent a Polish interpreter neither could verbally understand the needs of the other. Given that Mr. Dziekanski shouted Polizia! Several times, it is apparent that he understood them to be police officers.

It is unfortunate that more time was not spent by the members to use gestures and sign language to convey to Mr. Dziekanski that he should remain calm and that they had the situation in hand. Certainly, the police needed to take control of the scene and ensure that Mr. Dziekanski was not able to effect further damage to property or to any person present.

Further efforts by the police to calm Mr. Dziekanski may or may not have had the desired effect, but the fact that they were not attempted helped ensure that the interaction would escalate.

4. Empty Hand Control

Empty hand controls include "soft" empty hand control processes such as joint locks (for example, applying leverage to the suspect's arm or leg joint(s) to create immobility), pain compliance, creating imbalance in the suspect and handcuffing the suspect.

This was an option that could have been used by the members without resorting to any higher level of force. The problem with such empty hand control (soft) is that to wrestle a person of Mr. Dziekanski's size (Mr. Dziekanski was approximately 177 cm tall [5' 11"] and weighed 86 kg [190 lbs]) and subdue and handcuff him, the risk is much greater that either Mr. Dziekanski or one of the RCMP members would have been injured. This risk was not specifically articulated by the members in their statements.

A second level of empty hand control, known as "hard" hand control, was also open to the members. Hard empty hand control processes include punches, kicks and carotid holds. None of these were used against Mr. Dziekanski. In their statements, none of the members discussed in detail the use or lack of use of the empty hand control processes.

The RCMP's IM/IM model continues to describe intermediate devices as including OC spray and the CEW. The model, as it existed at the time of the YVR incident, then moved upwards to impact weapons (such as the baton). For some time now, one of my primary concerns has been the positioning of the CEW on the IM/IM as a (lower range) intermediate device akin to OC spray, as opposed to situating it as an impact weapon (and therefore higher in the range of devices) and taking into account the potential for greater harm to be caused by the CEW. Characterizing the CEW as being higher on the scale of intermediate devices advises RCMP members that the CEW is considered to possess higher potential lethality as a weapon, and therefore is not to be resorted to absent clear justification for its use.

My reasoning for altering the position of the CEW is that police officers do not appear to adequately comprehend the nature of the CEW as a weapon, i.e. the extreme level of pain inflicted nor the possibility that the CEW may have a causal relationship in the death of the recipient of the charge, because the training provided to them does not require them to take such analyses into account at the time of deploying the CEW.

I note that during the YVR incident, Constable Millington resorted to the CEW (as noted, he was the only member carrying a CEW that evening). Simultaneously, both Corporal Robinson and Constable Bentley drew their ASP batons (Constable Bentley actually extended his baton). Constable Rundel, presented with the same scenario unfolding before him as the other responding members, opted not to resort to any weapon at that point.

It has been demonstrated that use of a CEW as opposed to a firearm, has saved lives. As I have previously stated, the CEW does have a place in the RCMP's arsenal of response options. The exercise of appropriate discretion is crucial in the decision to use the CEW; however, the key is that proper training is necessary to assist police officers in applying judicious discretion in the decision to deploy the CEW.

6. Lethal Force

The IM/IM stipulates that lethal or deadly force is to be used only in the presence of exigent circumstances where the intent of the member is to cause death in order to prevent death or grievous bodily harm to the member or a member of the public. No such threat existed in this situation. I accept that the responding members did not intend to cause the death of Mr.  Dziekanski and that the RCMP does not identify the CEW as a use of force mechanism which may be used in a manner intending to cause death.

In the YVR incident, the members knew from the radio dispatch that a male of approximately 50 years of age was acting in a violent manner by throwing his luggage and throwing chairs through windows (later found not to be true). As the members arrived they were also told that the male did not speak English. They noted as they approached him that he appeared distraught and agitated.

The Commission recognizes that in any confrontation the dynamics of the situation can change very quickly and consequently the police must be prepared to take the actions they believe at that moment are appropriate. Depending on the urgency of the situation and the circumstances involved, the entire assessment, risk identification and characterization, and the decision as to which level of force best suits the situation can take place in the space of mere seconds.

Appendix V – Investigators' Notebooks

RCMP policy speaks to the importance of investigators' notebooks and the need to maintain them in a complete and timely manner:^{Footnote 217}

2. General

2. 1. The member's notebook is a fundamental investigative tool. It is essential that notebooks be properly compiled, complete and accurate in order to support investigations, corroborate evidence and increase the credibility of a member's testimony in court. Properly recorded entries (notes) may also prove to be invaluable in substantiating information years after an investigation.

2. 2. You may use notebook entries to refresh your memory for court if the notes were made at or near the time of the occurrence.

2. 3. If you are performing operational duties, use and maintain an up-to-date notebook. Record the date for any operational assistance in your notebook.

2. 4. To reduce duplication in minor cases, notes may be made directly on the continuation report, form 1624.

3. Types of Entries

3. 1. Take notes as events occur or at the first available opportunity. If possible, make your entries in black or dark ink, neat, legible, concise, informative and well organized. While the specific contents of your notebook will depend on the type and complexity of the investigation, your notes should contain:

3. 1. 1. your observations and actions;

3. 1. 2. the collection, identification and handling of evidence;

3. 1. 3. the grounds to support detention, arrest or search;

3. 1. 4. any cautions or warnings given to persons and details of the circumstances;

3. 1. 5. statements by suspects or witnesses, verbatim if possible;

3. 1. 6. the demeanor and emotional and physical state of persons, particularly when they make statements; and

3. 1. 7. personal information of any person involved in the investigation, excluding confidential sources.

Appendix W – BC Justice Statement

Friday, December 12, 2008

CRIMINAL JUSTICE BRANCH CLEAR STATEMENT

Robert Dziekanski was a 40-year-old Polish man, who was the only child of Zophia Cisowski. Ms. Cisowski had immigrated to Canada from Poland in 1999 and settled in Kamloops. In 2007, arrangements were made for Mr. Dziekanski to immigrate to Canada and reside with his mother in Kamloops.

In the time preceding his departure, friends of Mr. Dziekanski confirmed that he was very apprehensive about leaving Poland to start a new life in Canada. He was also extremely anxious and fearful about the prospect of flying, as he had never been in an airplane before. An earlier flight had to be cancelled and rescheduled as a result of his fear of flying.

On the morning of his departure, October 13, 2007, Mr. Dziekanski was extremely anxious and afraid of the flight. He had not eaten or slept well in the days preceding his flight. When friends arrived at his home at approximately 3:00 a.m. to take him to the airport, he indicated that he was not going to fly. He spoke with his mother by telephone, using the speakerphone function, maintaining that he was not going to fly. He was described to be in a highly fearful and panicked state, bordering on hysterical. One friend described him sitting or lying on the floor physically shaking and becoming physically ill. Another friend also described him hanging on to a radiator on the verge of becoming hysterical. Mr. Dziekanski eventually calmed down approximately 20 minutes prior to his departure to the airport. All the witnesses were consistent in their description of Mr. Dziekanski's emotional state and the fact that he took a small container with him as he rode in the car to the airport, in case he became ill.

At the airport Mr. Dziekanski continually stated that he was afraid of flying; however, he boarded the airplane and departed for Frankfurt at 6:20 a.m. He arrived in Frankfurt at approximately 7:55 a.m. and departed once again at 12:15 p.m. on a flight to Vancouver (YVR). He arrived at YVR at what would have been 12:25 a.m. Polish time the following day, or 3:25 p.m. Vancouver time. His travel time to this point would have been approximately 21 hours. There was no information available to investigators regarding Mr. Dziekanski's emotional state during his flight to Vancouver from Frankfurt.

Video surveillance displayed Mr. Dziekanski passing through the primary checkpoint at 4:05 p.m. Vancouver time and into the baggage carousel area at 4:10 p.m. He had been instructed by his mother in their earlier conversation to wait for her at the baggage carousel; however, she was not aware that this area was not accessible to members of the public.

Mr. Dziekanski was observed by video surveillance briefly at 9:25 p.m. and 9:31 p.m.; it is not known what he did in the Canadian Border Services Agency (CBSA) area in the interim until he presented himself to the CBSA "Point" officer at 10:40 p.m. Mr. Dziekanski was directed to the secondary inspection area where he was processed by staff. Mr. Dziekanski did not speak or understand English, but they were able to ascertain through non-verbal communication that he had been sitting or sleeping on one of the chairs in the luggage carousel area for more than six hours. This may account for the time period between 4:10 p.m. and 9:31 p.m. Staff located his luggage at one of the baggage counters and they were able to process his travel documents.

At 12:45 a.m. on October 14, 2007, CBSA Officers finished processing Mr. Dziekanski and escorted him to the hallway area which leads to the international arrivals area. He exited through the glass doors at 12:53 a.m. and sat down on the chairs on the public side. It would have been over 30 hours since he began his journey to Canada.

To this point, the investigation revealed that Mr. Dziekanski had personal contact with YVR Customer Service Representatives and CBSA Officials. They described him as pale, nervous, confused, frustrated and sweating profusely. One officer believed he was under the influence of alcohol.

Shortly after 1:00 a.m., Mr. Dziekanski began to display bizarre and threatening behaviour. Several civilians in the international arrivals area called 911 and also spoke with YVR security. Mr. Dziekanski was observed to bang on the glass doors in an attempt to re-enter the secured area. He managed to gain entry and placed his baggage and some airport furniture in the exit way keeping the doors open. He then began to throw items around including furniture, a computer, and a wooden chair against a window in an attempt to break it. At times he would calm down for a brief period and then become agitated once again. One civilian began video recording portions of the incident after Mr. Dziekanski had been posturing with furniture and he recorded several, but not all aspects of the incident. There were five civilians, three airline staff, and two YVR security staff in the area observing these events.

All the witnesses were consistent in describing Mr. Dziekanski's emotional state and actions prior to the arrival of police. They used terms such as aggressive, crazy, totally enraged, heightened state of pure panic, really upset to the point of delusional, on drugs and intoxicated. He was observed to be sweating profusely throughout the incident.

At approximately 1:25 a.m., four uniformed Richmond RCMP members, Constable Millington, Constable Bentley, Constable Rundel and Corporal Robinson, responded to the call to the international arrivals area of YVR. They had been advised by dispatch that an intoxicated male was at the international arrivals area of YVR throwing luggage around. Approximately two minutes after the initial call they were further advised by dispatch that the same male was now throwing chairs through glass windows in the same area. When the officers arrived at the reception area witnesses advised them that Mr. Dziekanski was freaking out, drunk and did not speak English.

Constable Millington was asked by another officer if he had his taser. He responded yes. When Constable Millington entered the secured area his taser was still in its holster. This was corroborated by independent evidence.

At this juncture the evidence of independent civilian witnesses, police officers and digital video were materially consistent in relation to the events which followed.

The officers attempted to talk to Mr. Dziekanski and communicate with him with hand signals for several seconds. He momentarily calmed down and dropped his arms to his side.

He then became annoyed or frustrated, threw his arms up and moved off to the right. While doing so, he grabbed a stapler from a counter and held it out in his hand. On the video Constables Bentley and Rundel and Corporal Robinson suddenly and simultaneously moved backwards and away from Mr. Dziekanski when he grabbed the object from the counter. The video shows that he was holding a stapler in his right hand in the open position.

At this point, Mr. Dziekanski was 'tasered' in the probe mode by Constable Millington. Constable Millington deployed the taser two more times in probe mode, as the taser appeared to be malfunctioning. Constable Millington determined that the taser was not functioning properly because of a "clacking" sound indicating that the probes were not making proper contact, resulting in an incomplete electrical circuit. This is referred to as "non-dynamic hits or deployments."

One taser probe was later located in the lower portion of Mr. Dziekanski's shirt, which is indicative that only one of the two probes remained in contact with his body. At autopsy, an abrasion was located on Mr. Dziekanski's central chest area consistent with having been caused by a taser probe; a second electrode mark was not apparent, although other abrasions were present on Mr. Dziekanski's chest and abdomen, one of which may have been an electrode mark.

After Mr. Dziekanski went to the ground he continued to struggle and resist despite the efforts of three officers to bring him under control and handcuff him. Constable Millington manoeuvred himself to the area around Mr. Dziekanski's shoulders and deployed the taser two more times in push stun mode, as Mr. Dziekanski continued to struggle and resist.

It took approximately 30 seconds after the last taser deployment to restrain and handcuff Mr. Dziekanski. The officers applied force to Mr. Dziekanski while he was on the ground in the prone position for at least 45 seconds. The force included Corporal Robinson pushing his knee/shin down in the shoulder/neck area of Mr. Dziekanski. Several independent witnesses commented in statements on how Mr. Dziekanski was able to resist and struggle with police while on the ground.

Once handcuffed behind his back, Mr. Dziekanski appeared to go limp and become unconscious. Mr. Dziekanski's pulse and breathing were periodically checked, and both were normal in the circumstances; however, upon the arrival of firefighters and paramedics, no pulse could be found. Shortly thereafter, Mr. Dziekanski went into cardiac arrest and died.

A use of force expert from a police department outside the RCMP reviewed the police investigation file in this case. In his report the expert concluded that the actions of the officers appeared to be consistent with the Incident Management/Intervention Model used by the RCMP, as they represented a reasonable escalation and de-escalation of force based upon the actions of the subject. This RCMP model defines the appropriate parameters of use of force by police. The expert also concluded that the actions of the officers were consistent with RCMP policy and training.

CAUSE OF DEATH

An autopsy was conducted on Mr. Dziekanski. The forensic pathologist observed the presence and signs of chronic alcohol abuse. However, toxicology tests showed that Mr. Dziekanski did not have any drugs or alcohol in his system at the time of his death. This raised the possibility that alcohol withdrawal may have played a role in his behaviour before and during his dealings with police.

The forensic pathologist concluded that Mr. Dziekanski's death was as a result of Sudden Death Following Restraint. He found no definite cause of death, which is typical of these types of incidents. Sudden death following restraint cases usually involve individuals who exhibit combative and bizarre behaviour. As a result, these cases often involve law enforcement personnel, but some cases include medical personnel and occasionally ordinary citizens. Sudden death following restraint has been associated with virtually all forms of physical restraint, most instances of which did not involve the use of a taser. Before the taser was in use in Canada, sudden deaths following restraint were not uncommon.

In the pathologist's opinion, the use of the taser did not directly cause the cardiac arrest. Two other forensic pathologists concurred with that view. The combined opinions of three pathologists identified several factors which could have contributed to the cardiac arrest causing death; these include heart disease due to chronic alcohol abuse, an agitated state of delirium, the stress of the physical restraint worsened by the deployment of the taser, a decreased ability to breathe as a result of being restrained in the prone position for part of the struggle, and alcohol withdrawal.

Two medical experts in the area of addiction psychiatry and alcohol-related disease also reviewed this case. They identified a number of factors which could explain Mr. Dziekanski's bizarre and aggressive behaviour at YVR. Both experts concluded that Mr. Dziekanski was exhibiting behaviour consistent with the medical syndrome of delirium prior to death. The onset of the delirium could be explained by a number of factors including alcohol withdrawal, lack of sleep; dehydration, and a high degree of anxiety. These factors would have placed Mr. Dziekanski at increased risk for sudden death.

CHARGE ASSESSMENT POLICY

In conducting a charge assessment, Crown counsel must fairly, independently and objectively examine all the available evidence to determine:

1. First, whether there is a substantial likelihood of conviction; and, if so,
2. Whether a prosecution is required in the public interest.

A substantial likelihood of conviction exists where Crown counsel is satisfied there is a strong, solid case of substance to present to the Court. In determining whether this standard is met Crown counsel must determine:

1. What material evidence is likely to be admissible; and
2. The weight likely to be given to the admissible evidence; and the likelihood that viable, not speculative, defences will succeed.

APPLICATION OF THE LAW

The possible offences under the Criminal Code that were reviewed for the purposes of a charge assessment in this case were assault, assault with a weapon, and manslaughter.

Furthermore, the Branch is of the view that the available evidence would support the finding of both factual and legal causation at law. Simply stated, the officers' efforts to restrain and take physical control of Mr. Dziekanski were a contributing cause of his death. What remains is the consideration of the available justifications or defences at law which may absolve the officers from criminal responsibility.

The most relevant sections of the Criminal Code relating to lawful justifications, or defences considered in this assessment were sections 25 and 26 of the Code, which permit a peace officer to use reasonable force in the proper execution of his or her duties. Secondary provisions that were considered were sections 34 and 37, which set out the defences of self-defence and using force to prevent an assault.

According to decided cases, a peace officer is not expected to measure the use of force with exactitude, particularly in circumstances which may result in serious injury to officers or members of the public.

DECISION

The charge assessment in this case was undertaken and reviewed by three levels of Executive Management within the Criminal Justice Branch. The reviews were unanimous in their conclusion.

There is a substantial body of independent evidence which supports that the officers in question were lawfully engaged in their duties when they encountered Mr. Dziekanski, and the force they used to subdue and restrain him was reasonable and necessary in all the circumstances.

In light of this independent evidence, there is not a substantial likelihood of conviction in this case for any of the offences considered; in fact, the available evidence falls markedly short of this standard.

Accordingly, the Criminal Justice Branch will not be approving any charges in relation to this very tragic event.

CRIMINAL CODE OF CANADA PROVISIONS

PROTECTION OF PERSONS ACTING UNDER AUTHORITY

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.

(2) Where a person is required or authorized by law to execute a process or to carry out a sentence, that person or any person who assists him is, if that person acts in good faith, justified in executing the process or in carrying out the sentence notwithstanding that the process or sentence is defective or that it was issued or imposed without jurisdiction or in excess of jurisdiction.

(3) Subject to subsection (4), a person is not justified for the purposes of subsection (1) in using force that is intended or is likely to cause death or grievous bodily harm unless he believes on reasonable grounds that it is necessary for the purpose of preserving himself or any one under his protection from death or grievous bodily harm.

(4) A peace officer who is proceeding lawfully to arrest, with or without warrant, any person for an offence for which that person may be arrested without warrant, and every one lawfully assisting the peace officer, is justified, if the person to be arrested takes flight to avoid arrest, in using as much force as is necessary to prevent the escape by flight, unless the escape can be prevented by reasonable means in a less violent manner. [R.S., c.C-34, s.25.]

EXCESSIVE FORCE

26. Every one who is authorized by law to use force is criminally responsible for any excess thereof according to the nature and quality of the act that constitutes the excess. [R.S., c.C-34, s.26.]

Appendix X – Principles of Sir Robert Peel

The nine principles by Sir Robert Peel:

1. The basic mission for which the police exist is to prevent crime and disorder.
2. The ability of the police to perform their duties is dependent upon public approval of police actions.
3. Police must secure the willing co-operation of the public in voluntary observance of the law to be able to secure and maintain the respect of the public.
4. The degree of co-operation of the public that can be secured diminishes proportionately to the necessity of the use of physical force.
5. Police seek and preserve public favour not by catering to public opinion but by constantly demonstrating absolute impartial service to the law.
6. Police use physical force to the extent necessary to secure observance of the law or to restore order only when the exercise of persuasion, advice and warning is found to be insufficient.
   
7. Police, at all times, should maintain a relationship with the public that gives reality to the historic tradition that the police are the public and the public are the police; the police being only members of the public who are paid to give full-time attention to duties which are incumbent on every citizen in the interests of community welfare and existence.
   
8. Police should always direct their action strictly towards their functions and never appear to usurp the powers of the judiciary.
   
9. The test of police efficiency is the absence of crime and disorder, not the visible evidence of police action in dealing with it.

The nine principles by Sir Richard Mayne:

1. To prevent crime and disorder, as an alternative to their repression by military force and severity of legal punishment.
   
2. To recognize always that the power of the police to fulfill their functions and duties is dependent on public approval of their existence, actions and behaviour and on their ability to secure and maintain public respect.
   
3. To recognize always that to secure and maintain the respect and approval of the public means also the securing of the willing co-operation of the public in the task of securing observance of laws.
   
4. To recognize always that the extent to which the co-operation of the public can be secured diminishes proportionately the necessity of the use of physical force and compulsion for achieving police objectives.
   
5. To seek and preserve public favour, not by pandering to public opinion, but by constantly demonstrating absolutely impartial service to law, in complete independence of policy, and without regard to the justice or injustice of the substance of individual laws, by ready offering of individual service and friendship to all members of the public without regard to their wealth or social standing, by ready exercise of courtesy and friendly good humour, and by ready offering of individual sacrifice in protecting and preserving life.
   
6. To use physical force only when the exercise of persuasion, advice and warning is found to be insufficient to obtain public co-operation to an extent necessary to secure observance of law or to restore order, and to use only the minimum degree of physical force which is necessary on any particular occasion for achieving a police objective.
   
7. To maintain at all times a relationship with the public that gives reality to the historic tradition that the police are the public and that the public are the police, the police being only members of the public who are paid to give full-time attention to duties which are incumbent on every citizen in the interests of community welfare and existence.
   
8. To recognize always the need for strict adherence to police-executive functions, and to refrain from even seeming to usurp the powers of the judiciary of avenging individuals or the State, and of authoritatively judging guilt and punishing the guilty.
9. To recognize always that the test of police efficiency is the absence of crime and disorder, and not the visible evidence of police action in dealing with them.

Appendix Y – Summary of Findings and Recommendations

Findings:

1. Finding
   The RCMP members involved in the arrest of Mr. Dziekanski were in the lawful execution of their respective duties and were acting under appropriate legal authority.
2. Finding
   In light of the information possessed by the RCMP members responding, the decision to approach Mr. Dziekanski to deal with the complaints was not unreasonable. At any point a member of the travelling public or an employee at YVR could have happened upon Mr. Dziekanski. As evidenced by the multiple calls to 911, it was incumbent upon the RCMP members to ensure a safe environment for the public and employees using the airport facility and to halt the disturbance being caused by Mr. Dziekanski.
3. Finding
   To ensure a coordinated approach to Mr. Dziekanski, Corporal Robinson should have taken control and directed the other responding members to ensure that each was aware of the intended response and to ensure that each communicated with the others as the events unfolded.
4. Finding
   Prior to deploying the CEW, Constable Millington should have issued the required warning/challenge to Mr. Dziekanski as required by RCMP policy, notwithstanding the fact that Mr. Dziekanski appeared not to understand the English language.
5. Finding
   Because no significant attempts were made by the RCMP members present to communicate with Mr. Dziekanski, to obtain clarification of information pertaining to Mr. Dziekanski's situation, or to communicate among themselves, deployment of the CEW by Constable Millington was premature and was not appropriate in the circumstances.
6. Finding
   Constable Millington cycled the CEW multiple times against Mr. Dziekanski when those subsequent cycles were not known by him to be necessary for the control of Mr. Dziekanski.
7. Finding
   The multiple cycles of the CEW against Mr. Dziekanski when no significant effort was made to determine the effect of the CEW on Mr. Dziekanski was an inappropriate use of the CEW.
8. Finding
   Corporal Robinson did not adequately monitor Mr. Dziekanski's breathing and heart rate.
9. Finding
   Because Corporal Robinson did not know the qualifications of Mr. Enchelmaier, he should not have allowed him to provide first aid or actively monitor Mr. Dziekanski's condition. That task should have been performed by the RCMP members themselves. Corporal Robinson, therefore, failed to provide adequate medical care to Mr. Dziekanski.
10. Finding
    The handcuffs should have been removed from Mr. Dziekanski when the members recognized that he was unconscious and in distress and no immediate threat to the members was perceived. At a minimum, they should have been removed immediately upon the initial request of medical personnel.
11. Finding
    The failure of Corporal Robinson to take control of the scene, communicate with and direct the more junior and inexperienced members negatively manifested itself throughout the interaction with Mr. Dziekanski.
12. Finding
    I do not accept as accurate any of the versions of events as presented by the involved members because I find considerable and significant discrepancies in the detail and accuracy of the recollections of the members when compared against the otherwise uncontroverted video evidence. In their statements, the members indicated in responses to numerous questions that they could not recall the detail of the events as they unfolded. The fact that the members met together and with the SRR prior to providing statements causes me to question further their versions of events.
13. Finding
    The conduct of the responding members fell short of that expected of members of the RCMP by the Canadian public and by RCMP policies. The members demonstrated no meaningful attempt to de-escalate the situation, nor did they approach the situation with a measured, coordinated and appropriate response.
14. Finding
    The members failed to adequately comply with their training in CAPRA and IM/IM to assess the behaviour of Mr. Dziekanski, and therefore the risk posed by him. As a result, the level of intervention went beyond what was necessary and acceptable, contrary to the RCMP's IM/IM and CAPRA model.
15. Finding
    Because the RCMP positions the CEW as an intermediate weapon and trains its members that it is appropriate to use the CEW in response to low levels of threat because it is a relatively less harmful means of controlling a subject, the responding members did not fully appreciate the nature of the CEW as a weapon and it was resorted to too early.
16. Finding
    Although IHIT did engage the services of a use of force expert, that expert was not provided with adequate direction in terms of the questions to be considered, the scope of his work or the terms of reference he was to consider.
17. Finding
    Corporal Robinson, as an involved member, should not have been allowed to attend the IHIT briefing held at the Richmond Detachment on October 14, 2007. Sergeant Attew failed to ensure that only appropriate RCMP members were present during the briefing.
18. Finding
    The responding RCMP members meeting alone at the YVR sub-detachment office following the death of Mr. Dziekanski was inappropriate.
19. Finding
    An SRR should not have been permitted to meet alone with Constable Millington prior to the IHIT investigator.
20. Finding
    If for no other reason than to be fair to the responding members and give them an opportunity to address the significant and readily apparent discrepancies between their versions of events and the video, it would have been appropriate to provide the responding members with an opportunity to view the Pritchard video prior to taking further statements from them.
21. Finding
    The responding members did not keep adequate notes of the incident involving Mr. Dziekanski.
22. Finding
    No bias or partiality toward the involved RCMP members was present in the IHIT investigation of the death of Mr. Dziekanski.
23. Finding
    The RCMP should have released certain information to the media which would have served to clarify information pertaining to the death of Mr. Dziekanski and correct erroneous information previously provided without compromising the IHIT investigation.