Introduction
[1] Susan Butlin, a 58-year-old woman, lived alone, next door to Ernie Ross "Junior" Duggan and his spouse, in the community of Bayhead, Nova Scotia. Ms. Butlin and the Duggan family had been neighbours for nearly two decades, forging a good friendship.
[2] On September 17, 2017, Mr. Duggan murdered Ms. Butlin in her home.
[3] Six weeks before, Ms. Butlin had called 911 to report that Mr. Duggan had sexually assaulted her. RCMP members from the Bible Hill RCMP Detachment took a statement from Ms. Butlin, but did not pursue charges, believing that her complaint was unfounded.
[4] In the weeks leading up to the murder, Ms. Butlin and others contacted the RCMP to report concerns about the escalating situation with Mr. Duggan, but to no avail.
[5] The Civilian Review and Complaints Commission for the RCMP (the Commission) conducted an in-depth investigation into the RCMP's response to the complaints and concerns related to Ms. Butlin, and reviewed the processes in place for the investigation of sexual assault cases by the RCMP. Following its investigation, the Commission made 72 findings and 79 recommendations in an interim report it provided to the RCMP.
[6] The Commission found serious deficiencies in the handling of every aspect of Ms. Butlin's case.
[7] The Commission found that the initial investigation into Ms. Butlin's sexual assault complaint was grossly inadequate. The RCMP members failed to recognize that the facts reported by Ms. Butlin provided ample grounds to lay charges of sexual assault against the neighbour. Their initial assessment of the matter was overly hasty and tainted by discredited myths and stereotypes about sexual assault and the expected behaviours of sexual assault victims. Ultimately, their knowledge of sexual assault law was not sufficient to allow them to recognize that the facts reported met the legal requirements for the offence.
[8] This initial, incorrect assessment would go on to taint the RCMP's approach to all other incidents.
[9] From the beginning, there was information pointing to various attempts by Mr. Duggan to threaten and intimidate Ms. Butlin, including by vandalizing her property. Yet, the incidents were not documented or investigated.
[10] On August 21, 2017, Mr. Duggan's spouse called 911 to report that she was afraid her husband would kill Ms. Butlin, and that she thought he might have a firearm. Mr. Duggan had retrieved firearms and ammunition from a hiding place and told his spouse he was showing them to her so she would know this was "real." He had also told his spouse that Ms. Butlin would "have to die" if she did not abandon her court application against him. Mr. Duggan had kicked in the door of his home when he realized his spouse was calling 911. She had fled the home barefoot. She told the RCMP that her husband had been spiralling down and that she was afraid he would use a firearm against himself and others.
[11] RCMP members attended and spoke with all parties involved. They eventually arrested Mr. Duggan for impaired driving. He was released the next day.
[12] The Commission found that the RCMP members failed to appreciate the seriousness of the matters reported. They did not question Mr. Duggan's spouse further about the firearm or the threat to Ms. Butlin. They did not attempt to search for the firearm. They did not arrest Mr. Duggan for having uttered a threat or for having kicked in the door. They failed to take measures to protect Ms. Butlin's safety, and they failed to warn Ms. Butlin about the danger she was in.
[13] The Commission noted that it is impossible to know whether a different response by the RCMP could have prevented Ms. Butlin's murder. The RCMP members involved in the events could not have known what would unfold in the future. That said, even considering only what the RCMP members knew at the time, the Commission found their actions or lack thereof unreasonable and, at times, difficult to explain.
[14] The police file for the 911 call was classified as an impaired driving occurrence. This meant that, going forward, no RCMP member was able to access a complete picture of the information in the RCMP's possession about the threat posed to Ms. Butlin by her neighbour.
[15] Five days after the 911 call by Mr. Duggan's spouse, on August 26, 2017, Ms. Butlin contacted the RCMP to report that Mr. Duggan was sending her harassing messages and seeking to intimidate her. The RCMP member who took the call determined that the messages were not criminal in nature. The Commission found that this response was largely due to the lack of access to complete information about Mr. Duggan's threatening behaviour, but also to the RCMP member's failure to conduct the necessary verifications and make sufficient inquiries.
[16] On August 30, 2017, Ms. Butlin appeared in court as part of an application to prevent Mr. Duggan from further contacting her (a peace bond application). The RCMP members who had received her sexual assault complaint had encouraged Ms. Butlin to pursue this process. In the days leading up to and following the court appearance, Ms. Butlin became increasingly fearful. She slept with a baseball bat next to her bed. She told several friends and family members that she believed Mr. Duggan was going to kill her, and confided in a friend that she did not expect to survive until her next court date.
[17] Upon seeing the allegations in Ms. Butlin's peace bond application, the judge became concerned that they were criminal in nature. He adjourned the hearing to allow the police to investigate. Members from the Bible Hill detachment then reviewed the sexual assault investigation.
[18] Instead of using this opportunity to identify and correct the serious deficiencies in the sexual assault investigation, the RCMP supervisors concurred with the conclusions initially reached, and continued to fail to appreciate the level of threat Ms. Butlin was facing. The RCMP members not only persisted in the original, faulty assessment of Ms. Butlin's complaint, but they became convinced that she had provided inconsistent information in her peace bond application. The original investigator for the sexual assault complaint went so far as to state that Ms. Butlin's application was "borderline perjury."
[19] The Commission found that this belief was entirely baseless. In fact, Ms. Butlin's court application was consistent with her earlier statement to the RCMP on every point. The only reason the RCMP members believed it was not, was because they did not review her statement, they relied on reports that did not fully capture the statement's contents, or they failed to review the materials with sufficient attention.
[20] Worse, when faced with what they believed was new information indicating that Ms. Butlin might in fact have been sexually assaulted, the RCMP members did not consider investigating this information. They focused instead on the concerns they thought it raised about Ms. Butlin's credibility. Only one RCMP Constable suggested that the original statement should be carefully reviewed and the Crown should be consulted about obtaining another statement. Her suggestions were ignored.
[21] Three days before the murder, Ms. Butlin was officially informed, during a meeting at the detachment, that the investigation into her sexual assault complaint was closed. Ms. Butlin was questioned about the alleged inconsistencies in her peace bond application. She was told that police need to consider the offence of public mischief when faced with "conflicting stories" from a party. Ms. Butlin learned after the meeting that public mischief is the offence of falsely accusing a person of a crime. She was devastated.
[22] The Commission found that Ms. Butlin was not treated with the respect, compassion, or sensitivity she deserved. It was unreasonable and inappropriate to question her credibility based on inconsistencies that did not exist. The Commission also observed that almost all of the RCMP members involved in the matter lacked a basic understanding of the law of sexual assault.
[23] In February 2017, just six months before Ms. Butlin reported her sexual assault, the Globe and Mail had published an investigative series, which revealed that police were closing a disproportionate number of sexual assault investigations as "unfounded." The RCMP, like many other Canadian police forces, promised to take action to address the situation. Over the next months and years, the RCMP conducted reviews of its past sexual assault cases and announced a number of initiatives to improve sexual assault investigations, including new training, improved supervision, and external review of sexual assault cases. The Commission reviewed the implementation of these measures to assess whether they address the deficiencies observed in Ms. Butlin's case.
[24] The Commission found that, despite much work done by dedicated individuals within the RCMP, the measures implemented were insufficient. Many of the measures fell far short of the level of change required. Notably, no meaningful changes were made to the supervision structure for sexual assault investigations.
[25] The Commission noted that sexual assault investigations require specialized investigative knowledge and skills, and that RCMP members and supervisors cannot be expected to gain the necessary knowledge and expertise if they are required to conduct these investigations along with high‑volume general policing duties. The Commission concluded that specialized units are needed to ensure that sexual assault complaints are investigated and supervised adequately, and recommended the creation of specialized units in each RCMP division. The Commission also made recommendations to strengthen the other initiatives implemented by the RCMP, and to address the specific deficiencies observed in the handling of Ms. Butlin's case.
[26] In his response to the Commission's interim report, the RCMP Commissioner agreed with almost all of the Commission's findings, and supported the vast majority of the Commission's recommendations. Of note, the RCMP Commissioner supported the recommendation to create specialized units to investigate sexual assault cases, and agreed to implement many of the changes recommended by the Commission to improve these investigations.
[27] The Commission recognizes that achieving the deeper change required to ensure that sexual assault cases are approached adequately will take time and resources. The Commission is encouraged by the RCMP's commitment to implementing meaningful changes, and hopes that the recommended measures will contribute to ensuring that other sexual assault victims do not have to experience treatment like that received by Ms. Butlin.
[28] The Commission extends its sincere condolences to Ms. Butlin's family and friends for their tragic loss.
Overview of the Commission's Investigation
[29] The Commission is an independent agency that investigates and reviews complaints made by the public about RCMP member conduct. It is not part of the RCMP.
[30] On September 27, 2021, the Commission received a written complaint from Cathy Mansley, a retired RCMP member with over 24 years of service. She wrote that she had recently learned about Ms. Butlin's death, and the events leading up to it, through media reports that discussed the case in the wake of the Portapique mass killing.
[31] Ms. Butlin's longtime friend, S. D., had contacted the media to make Ms. Butlin's story known, and had expressed her anger towards the RCMP for allegedly disregarding Ms. Butlin's repeated calls for help and reports detailing the threats she received from her neighbour.Footnote 1 A subsequent media article discussed victim impact statements from Mr. Duggan's prosecution and quoted S. D.'s statement:Footnote 2
I will always believe the system let my Susie down. I know how terrified she was. This is something I will never forget. I can still hear her words, "I won't make the next court date. He will kill me before then." These words of hers haunt me every day.
[32] In her complaint, Ms. Mansley asked the Commission to investigate Ms. Butlin's case, as she believed that the RCMP had not handled the matter appropriately. Ms. Butlin's three sons authorized Ms. Mansley to launch the public complaint and subsequently participated in the Commission's investigation.
[33] On June 2, 2022, pursuant to section 45.59(1) of the RCMP Act, the Commission's Chairperson initiated a complaint into the RCMP's investigation of and response to Ms. Butlin's complaints and concerns about her safety.Footnote 3 The Chairperson also determined that, pursuant to section 45.66(1) of the RCMP Act, it was in the public interest for the Commission to conduct the investigation.Footnote 4
[34] The Commission's investigation examined both the conduct of the RCMP members involved in the three investigations conducted in Ms. Butlin's case, and the broader systemic issues that may have contributed to the deficiencies identified, particularly in relation to the conduct and supervision of sexual assault investigations.
[35] In the course of its investigation, the Commission reviewed over 20,000 pages of police records, documentary evidence, and other relevant information, as well as approximately 25 hours of audio recordings of police interviews. Commission investigators conducted interviews with 36 witnesses, 23 of whom were specifically interviewed regarding the handling of Ms. Butlin's case. These interviews included Ms. Butlin's friends and family, as well as RCMP subject members. Commission investigators also conducted interviews with RCMP members involved in the implementation of various initiatives related to the conduct of sexual assault investigations, as well as victim advocates and other civilian witnesses with expertise in sexual assault investigations.
[36] Of the eleven RCMP members identified as subject members for the investigation, three voluntarily attended interviews with Commission investigators, and one agreed to provide responses to written questions. The seven remaining subject members declined to provide statements or failed to respond to correspondence from the Commission. The Commission exercised its power under section 45.65(1) of the RCMP Act to summon the attendance of those members and compel them to provide evidence.
[37] Throughout its investigation, the Commission made many requests to the RCMP for relevant materials, and asked numerous follow-up questions. The RCMP cooperated and responded to requests in a timely manner. Relevant materials and responses were provided on an ongoing basis between June 2022 and February 2024.
[38] The Commission cautions that its role is not that of a criminal investigator. Rather, its role in this case was to assess the investigations and decisions made by the RCMP members and, where appropriate, to make recommendations focused on measures to remedy the deficiencies identified. Where there were conflicting accounts or gaps in the evidence reviewed, the Commission sought to determine what was more likely than not to have occurred. This legal standard—commonly known as the "balance of probabilities"—was applied by the Commission to reach all of its conclusions in this case.
[39] On June 19, 2024, the Commission completed a 238-page interim report (Appendix A) detailing its findings and recommendations about the case. In accordance with the RCMP Act, the Commission sent its report to the RCMP Commissioner.
[40] On July 10, 2024, the RCMP Commissioner informed the Commission that, due to the number of recommendations and the complexity of the issues, he would require more time than the usual six-month period to provide a response to the Commission's interim report.
[41] On April 24, 2025, the Commission received a response from the RCMP Commissioner (Appendix B), in accordance with section 45.76(2) of the RCMP Act. The RCMP Commissioner agreed with 69 of the Commission's findings, agreed in part with one, and disagreed with two. The RCMP Commissioner supported 77 of the Commission's recommendations (59 were supported in full and 18 in part) and did not support two of the recommendations. Throughout the following year, the RCMP provided periodic updates to the Commission about actions taken to implement the recommendations related to policies and processes.
[42] After considering the RCMP Commissioner's response, the Commission has prepared this Final Report, pursuant to section 45.76(3) of the RCMP Act.
Overview of the Commission's Findings and Recommendations
[43] The death of Ms. Butlin was a devastating loss. Her family and friends described her as a caring and resilient woman. The Commission heard firsthand about the fear Ms. Butlin experienced in the days leading up to her death, and the deep pain and frustration felt by those close to her. Ms. Butlin's story is one of courage, but also one that highlights troubling gaps in the handling of her case by the RCMP.
[44] In the following pages, the Commission provides an overview of its main findings and recommendations. This is not meant as an exhaustive review or summary of all of the Commission's findings and recommendations. For a complete account of the issues examined by the Commission, the evidence reviewed, the Commission's analysis of the evidence, and the conclusions reached, the Commission's interim report should be reviewed in its entirety.
[45] The RCMP's response to the Commission's findings and recommendations is also briefly discussed in the following pages, particularly where the RCMP Commissioner provided additional commentary or information. The few cases where the RCMP Commissioner disagreed with the Commission's findings or recommendations are discussed separately. A table outlining the Commission's final findings and recommendations is included at the end of this report.
Part One: The RCMP's Handling of Ms. Butlin's Case
1. Investigation Into Ms. Butlin's Complaint of Sexual Assault
[46] On the evening of July 2, 2017, Ms. Butlin was babysitting her grandchildren, who were playing at a neighbouring property, where Mr. Duggan was also present. When Ms. Butlin returned home, Mr. Duggan volunteered to transport her grandchildren back to her house on his lawn tractor. Mr. Duggan asked if he could come in for a drink. Ms. Butlin agreed and offered him a glass of wine. Mr. Duggan was already intoxicated at the time. He spent an hour or two in Ms. Butlin's home. At one point, Mr. Duggan initiated unwanted sexual activity.
[47] On July 18, 2017, Ms. Butlin disclosed the incident to Mr. Duggan's spouse, asking that Mr. Duggan acknowledge his actions and offer an apology. Mr. Duggan denied any wrongdoing. On August 7, 2017, Ms. Butlin called 911 and reported that her neighbour had sexually assaulted her on July 2, 2017. She also reported ongoing harassment and stated she suspected that Mr. Duggan had vandalized her pool.
[48] The Commission found that the RCMP conducted a cursory investigation and prematurely concluded that Ms. Butlin's complaint was unfounded. The handling of Ms. Butlin's complaint was wholly inadequate, contributing to the lack of reasonable measures taken to ensure her safety. From the initial intake of Ms. Butlin's complaint to the conclusion of the investigation, there were serious shortcomings—gaps in investigative effort, lack of knowledge and understanding of sexual assault law, poor supervision, and a failure to adequately communicate with Ms. Butlin. These failures significantly affected Ms. Butlin's experience, and contributed to the improper conclusion of the investigation without an adequate assessment of the evidence she provided.
[49] The lead investigator, Constable Patrick Crooks, contacted Ms. Butlin by phone after she called 911 to report the incident. He immediately concluded, on the basis of this 15-minutes telephone conversation which he did not record, that the incident Ms. Butlin reported did not constitute a sexual assault. The Commission found that it was premature and unreasonable for Constable Crooks to determine, on the basis of a brief conversation, that no offence had occurred.
[50] Because Ms. Butlin had originally requested to speak to a female officer, Constable Crooks arranged for Constable Christiana Whalen to take a formal statement from Ms. Butlin. Constable Whalen took a 35-minute audio-recorded statement from Ms. Butlin that evening. This was the only detailed and documented statement the RCMP obtained from Ms. Butlin about her sexual assault complaint. Based on the information obtained, Constable Whalen agreed with Constable Crooks' conclusion that no sexual assault had taken place.
[51] The Commission found that Constable Crooks and Constable Whalen wrongly concluded that Ms. Butlin had consented to the sexual activity due to their lack of sufficient knowledge and understanding of sexual assault law. In her statement, Ms. Butlin had clearly indicated that she did not agree to engage in sexual activity—either initially or at any point. She stated that, when Mr. Duggan [redacted] in the bathroom and asked that Ms. Butlin [redacted], she repeatedly told him no, reminded him he was married, and told him to go home to his wife. She returned to the bathroom because Mr. Duggan was refusing to come out and she wanted him to leave. Ms. Butlin told Constable Whalen that she [redacted], but only out of fear that he might harm her. She stated that Mr. Duggan was drunk and strong, and that she was scared. She also feared escalating the situation with her grandchildren in the home. Ms. Butlin further described Mr. Duggan [redacted] without her consent and grabbing her hand [redacted]. She stated she feared Mr. Duggan was going to rape her. This information was sufficient to give rise to reasonable grounds to believe that a sexual assault had occurred.
[52] The Commission noted that Constable Crooks, Constable Whalen and Constable Crooks' supervisor relied on flawed reasoning rooted in myths and stereotypes about how sexual assault victims should behave. This included questioning Ms. Butlin's credibility because she reported the matter four weeks after the incident, assumptions based on a perception of Ms. Butlin's reasons for refusing to engage in the sexual activity, and an exaggerated focus on a comment that Constable Crooks believed Ms. Butlin had made about [redacted].
[53] The Commission found that, because of their incorrect assessment of the matter, Constables Crooks and Whalen unreasonably failed to conduct further investigation into Ms. Butlin's complaint. No effort was made to gather additional evidence or speak to witnesses. Both Constable Crooks and Constable Whalen overlooked critical details in Ms. Butlin's account, including her repeated refusals, her fear, and her concerns about potential retaliation. The Commission found it unreasonable for Constable Crooks to clear the file as "unfounded" – which reflects cases where it was determined, through a police investigation, that no violation of the law took place – without conducting a sufficient investigation or properly applying the law to the facts reported. The deficiencies in the investigation pointed to both individual and systemic gaps in training, oversight, and understanding of sexual assault within the detachment at the time.
[54] Constable Crooks and Constable Whalen also failed to properly document and review the file. Constable Crooks' notes about his initial conversation with Ms. Butlin were insufficient to provide the full context of what Ms. Butlin was reporting. Constable Whalen's report about Ms. Butlin's statement omitted key information about the incident. It also failed to mention information Ms. Butlin had provided about subsequent threatening interactions involving Mr. Duggan and Ms. Butlin's sons.
[55] Constable Crooks did not listen to the audio-recorded statement provided by Ms. Butlin. He maintained his original assessment of the matter based on a brief conversation with Constable Whalen the next day, where she advised that Ms. Butlin's statement aligned with what Ms. Butlin had told Constable Crooks. Constable Crooks showed little interest in reassessing his decision, and it was unclear whether he even read Constable Whalen's report about Ms. Butlin's statement. The Commission found that Constable Crooks failed to conduct a reasonably thorough investigation, and that it was unreasonable for him to neglect to listen to Ms. Butlin's statement before deciding to conclude the investigation.
[56] The Commission also found that Ms. Butlin was not treated with the respect and care expected in sexual assault investigations. She was not referred to victim support services, and no safety plan was developed despite her clear expression of fear. Rather than properly investigating the complaint, the RCMP members unreasonably encouraged Ms. Butlin to apply for a peace bond without any further risk assessment or support from police. This left Ms. Butlin feeling dismissed and unsupported.
[57] While Constable Whalen conducted her interview with Ms. Butlin in a professional and sensitive manner, there were serious communication gaps from the outset. Constable Crooks was not informed about Ms. Butlin's original request to speak with a female member. When he informed Ms. Butlin of his view that the incident she described did not amount to a sexual assault, he did not explain his reasoning. After Constable Whalen took Ms. Butlin's statement and informed her that she did not believe the account met the definition of sexual assault, neither RCMP member followed up with Ms. Butlin. She was not informed that the investigation had been closed until she contacted the detachment herself a few days before the murder.
[58] The Commission further noted that Ms. Butlin had reported information pointing to a pattern of harassment perpetrated by Mr. Duggan against her and an ongoing fear experienced by Ms. Butlin. Ms. Butlin reported that, when Mr. Duggan finally left her home on the night of the incident, he told her that he might return. After Ms. Butlin disclosed the incident to Mr. Duggan's spouse, she found that her pool had been intentionally damaged. She believed that Mr. Duggan was responsible, and that the vandalism had been perpetrated to intimidate her or retaliate against her for having disclosed the incident. Shortly after Ms. Butlin informed Mr. Duggan's spouse that she intended to report the incident to the RCMP, Mr. Duggan confronted Ms. Butlin's sons. While accompanied by an associate whom Ms. Butlin believed to be involved in criminal activity, Mr. Duggan told Ms. Butlin's sons that they had to convince their mother to stop making these allegations, and that it was not "going to be good for anyone if this goes any further." The Commission found that the RCMP members unreasonably failed to take steps to investigate the ongoing harassment and the specific incidents reported.
[59] The Commission found that the inadequate investigation into the sexual assault contributed to the lack of reasonable measures put in place to ensure Ms. Butlin's safety. The RCMP Commissioner agreed with this finding, but noted that the RCMP can never completely ensure that measures taken will guarantee a person's safety. The Commission acknowledges this reality. As pointed out in the Commission's interim report, the findings made about the RCMP's investigative deficiencies are not intended to imply that the RCMP could have prevented Ms. Butlin's murder. A different handling of the investigations might not have changed the outcome for Ms. Butlin. It is uncertain if any measures could have averted the tragedy.
[60] Nonetheless, Ms. Butlin deserved better treatment and service than she received from the Bible Hill RCMP Detachment. The RCMP Commissioner agreed with the Commission's findings in this respect, and supported all of the recommendations made by the Commission to address the specific deficiencies identified. These recommendations included operational guidance for the involved RCMP members about:
- the law of sexual assault and consent, and the dangers of relying on myths and stereotypes in sexual assault investigations;
- the importance of respectful, trauma-informed communication with complainants, victim support obligations and referrals to Victim Services;
- the importance of safety planning and appropriate guidance regarding peace bond applications; and
- the appropriate use of the unfounded clearance code.
[61] The Commission expressed particular concern about the quality of Constable Crooks' work as it relates to sexual assault investigations. In addition to the serious deficiencies in his investigation of Ms. Butlin's complaint, the Commission noted that Constable Crooks continued to defend his original assessment of the matter and to rely on faulty reasoning and inappropriate myths and stereotypes, even after having received additional training, having had a chance to review Ms. Butlin's recorded statement, and knowing the ultimate consequences suffered by Ms. Butlin. For these reasons, the Commission recommended that Constable Crooks' supervisor conduct a review of his past sexual assault investigations to assess whether similar investigative deficiencies occurred in other cases.
[62] The RCMP Commissioner supported this recommendation, but stated that only those investigations that were not resolved through pleas or convictions would be reviewed, in the interest of efficiency and practicality. The RCMP Commissioner noted that investigative quality is less likely to be served by reviewing files already concluded by plea or conviction. The Commission is satisfied that this approach is consistent with the purpose and intent of its recommendation.
2. Response to 911 Call about Threat to Ms. Butlin's Safety
[63] The Commission found that the RCMP's response to the 911 call made by Mr. Duggan's spouse was wholly inadequate. The call, made on August 21, 2017, followed days of escalating tension. Ms. Butlin had filed for a peace bond against Mr. Duggan, and Mr. Duggan's behaviour had become increasingly erratic and volatile. Mr. Duggan's spouse called 911 to report that she feared her husband was going to kill their neighbour, Ms. Butlin, and that she believed her husband had a gun. From the outset, the RCMP failed to appreciate the seriousness of the situation or take reasonable steps to address the danger Ms. Butlin was facing.
[64] The Commission found that the RCMP's Operational Communications Centre lacked adequate safeguards to ensure the identification and proper handling of high-risk cases. Personnel at the Operational Communications Centre did not obtain sufficient information from Mr. Duggan's spouse, and failed to relay some of the critical information they did receive to the responding RCMP members.
[65] During the 911 call, Mr. Duggan's spouse had stated she thought her husband had "a gun . . . a rifle or something", indicating that he had gone up the road and come back wearing blue gloves. She believed the firearm was located in Mr. Duggan's vehicle. The information about the possible location of the firearm, and the details about how Mr. Duggan would have retrieved it, were not relayed to the RCMP members. They were also not informed that Mr. Duggan had kicked in the door when he found out his spouse was calling 911, and that the first call had ended abruptly with his spouse screaming. As a result, the responding RCMP members, Constable Rodney MacDonald and Corporal Stuart Beselt, could not fully grasp the severity of the risk to Ms. Butlin's safety.
[66] The RCMP members also failed to act on the information they did receive. They were informed that Mr. Duggan had said he was going to kill the neighbour after she had accused him of sexually assaulting her; that Mr. Duggan's spouse thought her husband might have gone to get a gun; that she believed he was going to use the firearm on himself or someone else; and that Mr. Duggan's spouse had fled the house because she feared her husband's behaviour. Despite this alarming sequence of events, and the specific information provided, the RCMP members did not take meaningful steps to assess or address the serious threat to Ms. Butlin's safety. The Commission found that Constable MacDonald's and Corporal Beselt's failure to take action was unacceptable and unreasonable.
[67] The RCMP members' intervention was limited to having a brief visit with Mr. Duggan and later arresting him for impaired operation of a motor vehicle. He was released the following morning without conditions. No arrest was made, and no charges were pursued in relation to the threats or any other potential criminal offences. The RCMP members accepted Mr. Duggan's assurances that he did not have a gun at face value, and did not ask further questions about the reported threat to Ms. Butlin or the possible presence of firearms. They did not attempt to locate or seize the firearm and did not investigate any of the possible criminal offences committed by Mr. Duggan based on his spouse's report to 911. They saw the damage to the door that Mr. Duggan had kicked in, but did not pursue charges or seek more information.
[68] When Constable MacDonald met with Mr. Duggan's spouse at a nearby gas station, he noted that she had "fled her house terrified," barefoot and in her pyjamas, and that she had hidden her cellphone because she was afraid her husband would destroy it. Despite Mr. Duggan's spouse reiterating that her husband might have gone to get a gun and had threatened to hurt Ms. Butlin, Constable MacDonald did not ask follow-up questions or seek to obtain details about the possible location of the firearm or the exact words spoken by Mr. Duggan to threaten Ms. Butlin's life.
[69] Had the RCMP members properly questioned Mr. Duggan's spouse or sought to obtain a formal statement from her, they could have learned that Mr. Duggan had shown her two long guns and ammunition and told her that he could not "handle it anymore." Mr. Duggan had then pressured his spouse to go to Ms. Butlin's house to convince her to drop the peace bond application. When Mr. Duggan's spouse returned and told him that Ms. Butlin refused, Mr. Duggan responded, "Well then she's gonna die. She's gonna have to die."
[70] The Commission found that the RCMP failed to provide Ms. Butlin with adequate information about the threat to her safety. When Corporal Beselt briefly visited Ms. Butlin that evening, he did not inform her of the serious threat that had been reported. Corporal Beselt stated that Ms. Butlin "kind of laughed . . . off" the incident, said that she did not wish to leave her home, and said she understood that Mr. Duggan was not a threat. The Commission noted that the limited and vague information provided to Ms. Butlin may have led her to believe that the situation was not serious. The evidence revealed that Corporal Beselt had told Ms. Butlin that Mr. Duggan "seemed calm" now, and that his spouse was probably overreacting. Ms. Butlin was never warned that Mr. Duggan had allegedly threatened her life, or that he may have been in possession of a firearm. The failure to provide her with more complete information was unreasonable.
[71] The Commission noted that, throughout the incident, Constable MacDonald and Corporal Beselt grossly underestimated the risk, possibly based on Mr. Duggan's friendly demeanour, or a perception that Ms. Butlin was not afraid because she was seeking to stand her ground and not let Mr. Duggan intimidate her into leaving her home. There was no justification for the RCMP members' perception that Mr. Duggan's spouse was overreacting. On the contrary, her behaviour—fleeing her home barefoot and in her pyjamas, and hiding her phone—indicated genuine fear. The Commission noted that the information received by the RCMP that night should have triggered a far more serious response.
[72] Further aggravating the issue, the file was ultimately entered into the RCMP system as an impaired driving occurrence, which meant that it would not trigger any alerts for RCMP members responding to subsequent incidents involving Mr. Duggan and Ms. Butlin.
[73] The RCMP Commissioner agreed with all of the Commission's findings about the inadequate response to the 911 call, and supported the recommendations made by the Commission to address the issues identified. These included operational guidance for the involved members on the importance of addressing information indicating a danger to human life or safety and of attempting to locate and seize any weapons, as well as training and direction for Operational Communications Centre personnel to ensure that high-risk matters are identified and assessed by supervisors.
3. Investigation Into Ms. Butlin's Complaint of Harassment
[74] The Commission found that the RCMP's response to Ms. Butlin's complaint of harassment was inadequate and unreasonable. Ms. Butlin made this complaint on August 26, 2017, just five days after the 911 call by Mr. Duggan's spouse. She reported receiving an intimidating text message from Mr. Duggan. The message, which Ms. Butlin read to the responding RCMP member over the phone, was clearly meant to pressure her into abandoning the peace bond proceedings. It included accusatory and shaming statements about Ms. Butlin's personal and professional life, and suggested that she was unfit to host students—particularly boys—in her home.
[75] The Commission found that the RCMP failed to properly evaluate the risk to Ms. Butlin's safety and failed to recognize that the text message was part of a pattern of harassment and escalating behaviour. At this point, Ms. Butlin had been living in fear for weeks. She no longer felt safe in her home, she kept a baseball bat by her bed, and she began spending more time at her cottage to avoid Mr. Duggan. Constable Gregory Wiley, the RCMP member who responded to Ms. Butlin's harassment complaint, did not recognize the seriousness of the situation or the risk to Ms. Butlin's safety. He determined after a brief telephone conversation that Ms. Butlin's complaint was "unfounded", and he submitted the case for early conclusion that same day, without taking any investigative steps.
[76] One of the primary reasons for this was the RCMP's collective failure to properly document and share critical information about the prior complaints and incidents involving Ms. Butlin and Mr. Duggan. Details about the damage to Ms. Butlin's pool, the threatening remarks Mr. Duggan made to her sons and the earlier 911 call by Mr. Duggan's spouse, were either never recorded, or were entered in unrelated files without context. Information that should have raised alarm bells was buried in fragmented records, with no indication that the information related to an ongoing pattern of harassment. This breakdown in documentation and information-sharing was a systemic failure that affected each RCMP response to Ms. Butlin's complaints.
[77] The Commission found that the RCMP failed to conduct a reasonable investigation into the harassment complaint. This included a failure to take steps to obtain a statement from Ms. Butlin and a copy of the text message, a failure to interview relevant witnesses, and a failure to ascertain the number and nature of the communications from Mr. Duggan to Ms. Butlin. A proper investigation should have led, at a minimum, to consultation with Crown counsel to assess possible charges, and to ensuring that safety planning measures were put in place.
[78] The Commission also found that Constable Wiley failed to conduct basic checks in police databases, which means that, even if the information had been properly recorded and identified, he would not have found it. Constable Wiley also failed to follow up on the information that Ms. Butlin did provide about her sexual assault complaint and peace bond application. He did not conduct any investigative steps and did not offer to refer Ms. Butlin to Victim Services. Constable Wiley recorded the complaint in a single-line note. He treated the matter as a low-risk, isolated communication, and relied on the upcoming peace bond hearing to resolve the issue. Even in light of the limited information available to him, these steps were not sufficient.
[79] The RCMP Commissioner agreed with the Commission's findings, and supported the recommendations made to address these issues. These included operational guidance for the involved RCMP members on note-taking, on giving meaningful consideration to victim safety and security, and on properly documenting threats to victims' safety, as well as training on the Canadian Victims Bill of Rights. The Commission also recommended addressing a gap in the RCMP's policy on criminal harassment, which did not require members to conduct police database queries at the outset of investigations.
4. Reviews of the Sexual Assault Investigation
[80] The Commission found that subsequent reviews of the sexual assault investigation by RCMP members and supervisors were unreasonable. Instead of addressing the clear deficiencies in the original investigation, the RCMP members confirmed the incorrect conclusions originally reached and even began to question Ms. Butlin's credibility.
[81] The reviews were prompted by concerns raised by the Provincial Court judge who reviewed Ms. Butlin's peace bond application. Upon reading the application, the judge felt that it disclosed facts that went beyond a peace bond and revealed that the criminal offence of sexual assault had been committed. He contacted Crown counsel and suggested that the matter should be investigated by police. Four RCMP members—Constable Crooks, Constable Thorne, Corporal Naime, and Sergeant Cooper—reviewed the file as a result. A fifth member, Corporal Wentzell, reviewed the file subsequently, after Ms. Butlin requested an update.
[82] The Commission noted with concern that the majority of the RCMP members who reviewed the matter—all but one—did not take the time to listen to Ms. Butlin's recorded statement. The RCMP members all failed to recognize that the facts reported by Ms. Butlin corresponded to the definition of a sexual assault. They relied on each other's assessments and were reluctant to second-guess earlier decisions.
[83] The supervisors and the Non-Commissioned Officer (NCO) in charge of Operations who reviewed the file did not have a sufficient understanding of the law of sexual assault, particularly around the concept of consent. They based their conclusions on flawed reasoning and faulty assumptions rooted in sexual assault myths and stereotypes, similar to what had been observed in the original investigation. Several members—most notably Corporal Naime and Sergeant Cooper—placed inappropriate emphasis on the absence of physical violence or threats, failing to recognize that fear or coercion can vitiate consent. Many of the RCMP members wrongly believed that Ms. Butlin's allegations lacked evidence of fear or coercion, both because they did not properly review the information she had provided and because they did not understand what evidence was relevant to meet the elements of the offence of sexual assault.
[84] Worse, the RCMP members developed a mistaken belief that there were significant inconsistencies between what Ms. Butlin had told the police and what she had written in her peace bond application. Constable Crooks told Sergeant Cooper that he believed Ms. Butlin's peace bond allegations were "borderline perjury." He claimed that what she wrote was completely different from what she had told him and Constable Whalen, even though most of the details he considered "new" were documented in Ms. Butlin's statement to Constable Whalen. Constable Crooks never listened to that statement before making this serious accusation. The other RCMP members who reviewed the matter all appeared to adopt Constable Crooks' views without questioning them, becoming convinced that there were serious inconsistencies in Ms. Butlin's information and serious issues with her credibility.
[85] In reality, there were no such inconsistencies. Ms. Butlin's recorded statement aligned with her written application for a peace bond. The belief that it was inconsistent was entirely baseless. During their interviews with Commission investigators, none of the RCMP members were able to point to any actual inconsistencies in Ms. Butlin's information, and they had difficulty explaining how they had come to develop this belief. The Commission found that it was unreasonable for Constable Crooks, Corporal Naime, Corporal Wentzell, and Sergeant Cooper to have questioned Ms. Butlin's credibility on the basis of perceived inconsistencies that did not in fact exist, and that it was inappropriate for Constable Crooks to suggest that Ms. Butlin had been untruthful in her peace bond application.
[86] Constable Thorne, who was the Court Liaison Officer, had recommended a more detailed review of the statements on file, pointing out that, while the police reports mentioned inconsistencies, there was no indication that Ms. Butlin had been asked to clarify her statements or explain her thought process, including her reasons for fearing Mr. Duggan. She recommended that the matter should be submitted to Crown counsel for a decision on whether to conduct another interview with Ms. Butlin. Yet, none of the RCMP members attempted to speak to Ms. Butlin again or to seek advice from Crown counsel on whether a new statement should be taken.
[87] Of great concern, none of the RCMP members involved in reviewing the matter (aside from Constable Thorne) ever considered investigating the information in Ms. Butlin's peace bond application, even if they believed this information had not been previously provided to police and recounted a more serious incident that did involve a sexual assault. The Commission found that it was unreasonable for the RCMP members not to take steps to investigate what they believed to be new information provided in the peace bond application, which revealed a possible sexual assault.
[88] The Commission expressed concern about how Ms. Butlin was treated by the RCMP following the file reviews. First, the RCMP members unreasonably questioned her credibility in communications with Crown counsel, incorrectly informing the Crown that there were inconsistencies between the information in Ms. Butlin's peace bond application and the details she had initially disclosed to the RCMP. Then, after Ms. Butlin requested an update and Corporal Wentzell reviewed the file, he suggested during a meeting with Ms. Butlin that there were inconsistencies in her information, and he mentioned that police must consider the possibility of public mischief when faced with conflicting stories. Public mischief is the offence of intentionally misleading police by making a false statement accusing another person of a crime. Ms. Butlin left the meeting in tears, and was devastated when she later understood the meaning of public mischief, telling friends and family that she felt like a "nuisance", and that the RCMP did not believe her and would not help her.
[89] The Commission found that Corporal Wentzell did not treat Ms. Butlin with sufficient respect, compassion, and sensitivity, and that it was inappropriate for Corporal Wentzell to bring up the offence of public mischief during his meeting with Ms. Butlin.
[90] The Commission concluded that the RCMP failed Ms. Butlin not once, but repeatedly. These cumulative failures contributed to the RCMP's overall inability to protect her from harm. While not all relevant information was properly documented or identified, the RCMP members conducting the reviews had access to information that, if taken seriously and properly assessed, should have prompted further action to investigate her complaints and put measures in place to protect her safety.
[91] The RCMP Commissioner agreed with the Commission's findings, and supported the Commission's recommendations for corrective measures. These included operational guidance for the RCMP members on the law of sexual assault, the importance of verifying facts before questioning a complainant's credibility, and the necessity of investigating all potentially new or relevant information, as well as specific training on the respectful treatment of victims.
[92] Because of its particular concern about Constable Crooks' baseless accusation that Ms. Butlin was being untruthful, and the disproportionate impact that Constable Crooks' original assessment and subsequent review of the investigation had on the handling on Ms. Butlin's sexual assault complaint, the Commission recommended that Constable Crooks not be permitted to respond to, or participate in, any investigation of a sexual offence, until he has received all of the operational guidance recommended in the Commission's report. The RCMP Commissioner supported this recommendation.
5. Recurring Issues
[93] In addition to the persistent failures to properly document, identify and share information, the Commission identified a number of recurring issues that impacted the RCMP's handling of all aspects of Ms. Butlin's case.
Improper reliance on sexual assault myths and stereotypes
[94] The Commission found that faulty assumptions and stereotypical thinking about victims of sexual assault influenced many of the RCMP members involved at all stages of the investigations.
[95] From the outset, the assessment of Ms. Butlin's sexual assault complaint was tainted by an exaggerated focus on a comment Ms. Butlin was believed to have made about [redacted]. In his notes for his unrecorded conversation with Ms. Butlin, Constable Crooks wrote that Ms. Butlin had said that [redacted]. Constable Crooks' belief that Ms. Butlin had consented to the sexual activity was based, in large part, on his interpretation of this comment. The notes provided no context or explanation for the comment, and Ms. Butlin did not mention the comment during her recorded statement. Constable Crooks' understanding was that Ms. Butlin had made the comment to Mr. Duggan during the incident.
[96] In her recorded statement, Ms. Butlin explained that Mr. Duggan had asked her—[redacted] without her prior consent—[redacted]. Ms. Butlin told police that she had been fearful and was trying to appease Mr. Duggan. Under these circumstances, it is likely that, if the alleged comment was made at all, it was made as a result of Ms. Butlin's fear, in an attempt to de-escalate the situation. Constable Crooks did not listen to the recorded statement and did not consider this possibility. Instead, he constantly referred back to the comment, and appeared to believe that, if Ms. Butlin spoke [redacted], it indicated she was a willing participant in the sexual activity. The Commission found that this faulty reasoning was based on stereotypical views of how sexual assault victims should behave.
[97] Corporal Naime, who was Constable Crooks' immediate supervisor at the time of the investigation and was involved in the subsequent review of the file, also relied heavily on the alleged comment. In his written response to the Commission, he stated that Ms. Butlin had been [redacted]. There was no evidence supporting this notion in any of the records. This appears to have been Corporal Naime's own assumption, indicating that his perception of the comment was similar to Constable Crooks', and similarly influenced by stereotypical thinking.
[98] Corporal Naime's subsequent review of the file also relied on myths about how a victim should behave when he wrote that Ms. Butlin "made no attempt to call for help" and did not report the matter until her pool was vandalized. This reflected outdated and harmful assumptions that real victims fight back or immediately report the assault—views that have been clearly rejected by the courts. Corporal Naime further noted in his written response to the Commission that Mr. Duggan had been "drunk from one glass of wine which [Ms. Butlin] provided." This suggested either that Corporal Naime questioned Ms. Butlin's credibility in her description of Mr. Duggan's intoxication level, without any rational basis, or that he wrongly believed that Ms. Butlin bore some responsibility for Mr. Duggan's behaviour because she had provided him alcohol. The evidence demonstrated that Mr. Duggan was already intoxicated when he visited Ms. Butlin's home.
[99] Constable Crooks, Constable Whalen and Corporal Naime also improperly took into account the fact that Ms. Butlin waited four weeks before reporting the sexual assault to police and only reported it after she believed Mr. Duggan had vandalized her pool. It is well established that there are many reasons for not reporting a sexual assault immediately, or at all. Courts have ruled that a delay in disclosure should never, on its own, give rise to an adverse inference against the credibility of a sexual assault victim. In Ms. Butlin's case, there was clear evidence that she had disclosed the assault to others before reporting it to police and before she discovered the damage to her pool. The RCMP did not investigate these prior disclosures, and failed to adequately consider or investigate Ms. Butlin's reasons for not reporting the assault earlier. The Commission found that it was unreasonable for the RCMP members to assess Ms. Butlin's credibility based on the timing of her complaint without properly investigating the prior disclosures or the reasons she provided for not reporting the matter earlier.
[100] Constable Whalen displayed stereotypical reasoning of a different nature. Her perception was that Ms. Butlin felt "flattered" by Mr. Duggan's advances because of their age difference. As a result, Constable Whalen believed that Ms. Butlin was saying "no" only because Mr. Duggan was married, and not because she did not want to engage in the sexual activity. This incorrectly introduced an assessment of the validity of a victim's reasons for not consenting to the sexual activity, which is not relevant to the definition of sexual assault.
[101] The RCMP members who subsequently reviewed the sexual assault file also appeared to be influenced by the improper assumption that women frequently lie and make up stories about being sexually assaulted. They immediately became convinced that Ms. Butlin was not telling the truth because of the perceived inconsistencies in her peace bond application, and never considered investigating the information in the application.
[102] Corporal Wentzell, for his part, incorrectly concluded that Ms. Butlin had not feared Mr. Duggan because she smiled when commenting that Mr. Duggan was "much bigger" than Corporal Wentzell. Corporal Wentzell was "troubled" by Ms. Butlin's response, because it did not fit with how a fearful victim "typically" behaves. He did not ask Ms. Butlin whether she was afraid. Corporal Wentzell also told Ms. Butlin to be careful who she allowed into her home—a statement that wrongly implied that victims of sexual assault are responsible for the actions of the perpetrator when they agree to interact with them or invite them into their home.
[103] The RCMP Commissioner agreed with the Commission's findings about the improper reliance on myths and stereotypes, and supported the Commission's recommendations for operational guidance and training to address this issue.
Inadequate Supervision
[104] The Commission found that "H" Division provided inadequate supervision for all three investigations involving Ms. Butlin. The supervision model in place greatly contributed to this serious deficiency. When files were submitted for "early conclusion," as was the case for all three investigations in this case, they were reviewed only by a Case Manager who worked in a different location and was responsible for reviewing 50 to 150 files daily. This did not permit the necessary in-depth review that might have allowed the RCMP to identify the deficiencies in the investigations, and it effectively removed frontline supervisors from the investigative oversight process. The Commission also found that the Case Manager who reviewed the three investigations, Sergeant Robert Leger, did not provide appropriate supervisory review, and unreasonably approved the early conclusion of the files without identifying significant gaps or directing further investigative steps.
[105] Instead of having one senior member in charge of the detachment, the Bible Hill detachment fell under the responsibility of a District Commander who was in charge of three detachments and apparently did not become aware of Ms. Butlin's case until after her murder. The Operations NCO, Sergeant Cooper, sought to provide oversight by reviewing the files, but he was responsible for three detachments in an extremely busy district. He also did not have the authority to make the structural changes required to put in place an appropriate system to quickly identify links between files, to ensure that immediate supervisors reviewed all files, and to ensure that file occurrence types were accurately identified.
[106] The Commission noted that, despite the small size of the Bible Hill RCMP Detachment, there was a disconnect in communication between investigating RCMP members and supervisors. This contributed to the failure to recognize links between the different investigations involving Ms. Butlin, which in turn significantly impaired the RCMP's ability to assess the risks to Ms. Butlin's safety. This stemmed from a combination of broader issues, including poor documentation, fragmented communication, and the heavy workload of supervisory staff. Because the Bible Hill detachment did not have a Detachment Commander, no one was specifically in charge of identifying and correcting these issues.
[107] The Commission found that the supervision model in place for the Bible Hill detachment failed to ensure that major issues in sexual assault investigations would be identified and addressed. Supervisors and senior officers also lacked specialized training and sufficient knowledge of sexual assault law.
[108] The RCMP Commissioner agreed with the Commission's findings about the inadequate supervision, and supported the Commission's recommendations to address this issue. These included recommendations that the RCMP implement a supervisory structure in each detachment that ensures proper documentation, adequate file review, accurate file classification, and timely identification of links between related investigations, and that the RCMP ensure that immediate supervisors retain primary responsibility for overseeing investigations, regardless of the supervision model in place, and that reviews by case managers or risk managers not replace this responsibility.
[109] The RCMP Commissioner recognized the general reasonableness of the Commission's recommendation to implement measures ensuring that, where a supervisor becomes directly involved in an investigation, another supervisor is assigned to monitor and review the file. However, the RCMP Commissioner noted that, as RCMP operations are conducted in over 700 detachments across Canada, some flexibility must be retained to accommodate the particularities of different staffing levels and situations, particularly in small detachments or specialized units. The RCMP Commissioner indicated that he supported the recommendation wherever staffing levels permit. The Commission is satisfied that this is sufficient to implement the intent of its recommendation.
Insufficient Resources
[110] The Commission found that persistent staffing shortages and the resulting heavy caseloads contributed to the RCMP's inadequate response in Ms. Butlin's case.
[111] Despite high call volumes, the Bible Hill detachment and other detachments in the District were often staffed with only 50 percent of the members that were supposed to work on each shift. One of the supervisors told Commission investigators that, often times, staffing shifts at 50 percent was the goal they were expected to reach. There were few specialized units available to take over investigations, so the general duty RCMP members were responsible to complete the investigations for each call for service they responded to.
[112] These resource constraints placed significant pressure on frontline RCMP members. Members described having to rush through investigations, or close files without completing a proper investigation due to the sheer volume of work. Important documentation was often delayed or completed hastily, and there was little time to complete thorough investigations, as was observed in Ms. Butlin's case. The staffing shortages also impacted the supervision of the files. Supervisors were often required to personally respond to calls for service, and had little time to review files or support their teams.
[113] The Commission noted that it is unrealistic to expect even committed and experienced RCMP members to provide high-quality service when they are consistently overwhelmed by competing demands and insufficient resources.
[114] The RCMP Commissioner agreed with the Commission's finding, and supported the recommendation that senior management in "H" Division be directed to review the current allocation of police resources in Colchester County to ensure that proper resourcing is in place in each detachment.
6. Actions Taken by the RCMP in Response to Ms. Butlin's Case
[115] Following Ms. Butlin's murder, the RCMP conducted an Independent Officer Review (IOR) of its members' actions during the events leading up to Ms. Butlin's death. The review identified many of the same serious shortcomings in the RCMP's response to Ms. Butlin's sexual assault complaint as were identified by the Commission. However, the RCMP did not inform the involved members of the deficiencies identified in their work and did not take steps to ensure they would not repeat the same failures again. Most of the RCMP members were not aware that a review had been conducted.
[116] The Commission found that the RCMP did not take sufficient action to review Ms. Butlin's case and to identify and remedy deficiencies. The failure to ensure individual-level accountability for the members and supervisors involved was inconsistent with the RCMP's core value of taking responsibility.
[117] The Commission also found that, although the IOR made helpful recommendations about sexual assault investigations, it did not adequately address the RCMP members' failure to recognize the overall threat to Ms. Butlin's safety or to take steps to protect her.
[118] The RCMP Commissioner agreed with the Commission's findings, and supported the recommendations made to address these issues. These included recommendations that "H" Division share the IOR report with the involved members and amend policies to ensure that internal review reports are shared with the RCMP members whose performance is assessed or that these members are at least informed of the deficiencies identified in their work.
Part Two: Steps to Improve Sexual Assault Investigations
[119] In early 2017, the Globe and Mail published the Unfounded investigative series after gathering data from police forces across the country. The series revealed that one in five sexual assault reports were classified as unfounded by police, and that this unfounded rate was nearly twice as high as the rate for physical assault reports and substantially higher than for other types of crime. The unfounded clearance code meant that police did not believe that a criminal offence had occurred.
[120] The RCMP's overall sexual assault unfounded rate was slightly lower than the national average, but some of the jurisdictions with the highest unfounded rates were policed by the RCMP. This included the Bible Hill detachment, which had a sexual assault unfounded rate of 54%—the second highest in Canada.
[121] The RCMP created a team to review its unfounded sexual assault files and published an action plan committing to implement initiatives to address the concerns raised as a result of the Unfounded series. These included the creation of a national unit to provide guidance and oversight for sexual assault investigations, the development of processes to ensure appropriate supervisory oversight, the creation of external review committees, the development of a sexual assault training curriculum, and the creation of a best practice guide.
[122] The Commission reviewed the measures implemented and found that they were insufficient to remedy the deficiencies identified in the response to Ms. Butlin's sexual assault complaint. The initiatives were often not implemented with sufficient urgency, and they fell short of addressing many of the issues. The Commission highlighted that this was not due to any lack of effort or dedication on the part of the individual RCMP members assigned to work on these issues. Rather, these individuals often lacked the resources or authority to make needed changes because the issue was not sufficiently prioritized and the processes put in place were not sufficiently robust.
[123] The RCMP Commissioner agreed with the Commission's finding, and supported the vast majority of the recommendations made by the Commission to address the most pressing issues.
1. Supervisory Oversight and the Need for Specialized Units
[124] The Commission noted that the RCMP had not made significant changes to the supervision model in place for sexual assault investigations, despite inadequate supervision having been identified as a major deficiency in Ms. Butlin's case. Sexual assault files continued to be supervised in the same manner as other investigations, as they had been in Ms. Butlin's case. This means that RCMP members with no specific expertise in sexual assault investigations supervised general duty RCMP members who were tasked with conducting these investigations along with their other duties, and who similarly had no particular expertise in the matter.
[125] While policy requirements were added mandating reviews of sexual offence files at specific intervals, the Commission observed that, in practice, the mandated supervisory reviews did not always occur within the prescribed timeframes. Some divisions created a process involving review by a Case Manager or other member appointed to conduct reviews of sexual assault investigations. However, these reviews were often done ad hoc, without a formalized process to identify issues to look for or files to review, and without any requirement that recommendations made by case managers or other specialized reviewer be implemented. The level of depth of the reviews also varied greatly between divisions.
[126] The Commission concluded that creating specialized units tasked with conducting and overseeing sexual assault investigations is necessary to effect the change and improvements required in this area. Having general duty RCMP members who lack the specialized training, knowledge and skills conduct sexual assault investigations, while facing continuous pressure to respond to a high volume of calls for service, is not a viable model. In fact, one of the RCMP members involved in Ms. Butlin's case stated she felt it was a disservice to victims of sexual assault to have general duty members handle their complaints, indicating that she handled many such cases and felt she was not able to investigate them the way they should be.
[127] The Commission noted that many other police forces have created specialized units, and that academic research supports the need for specialized response units to address sexual offences, and documents many benefits from implementing such units. The Commission recommended that the RCMP work in collaboration with provincial and territorial authorities to create specialized units to investigate sexual offences in each division, and that the members of such units receive advanced training to ensure they have the required knowledge and skills to adequately handle these files. The specialized units should take over sexual assault investigations in more complex cases, and provide oversight for general duty RCMP members in less complex cases by actively monitoring the investigations and providing guidance. To achieve this, the Commission recommended that RCMP members be directed to report all sexual offence complaints to their division's specialized unit, once created, and that the units should have the authority to take over or monitor investigations as required.
[128] The RCMP Commissioner supported these recommendations, but noted that the criteria for notification of and intervention by the specialized units would require input from the divisions. The Commission welcomes the RCMP Commissioner's support for the creation of the specialized units and for the requirement to report sexual offence complaints to such units. The Commission is satisfied that the requirement to consult with the divisions does not detract from the intent of its recommendation. However, the Commission stresses the importance of ensuring that the specialized units have the authority to determine which investigations they take over, as the members of these units will have the necessary knowledge and experience to determine which investigations require their active involvement.
[129] The Commission also made recommendations to bolster the Case Manager review process pending the creation of the specialized units, including recommendations to ensure that all sexual assault files are reviewed, and that, in cases where investigators decide not to follow a recommendation from the Case Manager, they be required to notify the Case Manager and their own supervisor, and to explain their reasons. The RCMP Commissioner supported the spirit of these recommendations, but noted that only two divisions currently have a Case Manager program, and that the recommendations were supported to the extent that these divisions could accommodate the additional workload.
[130] The Commission acknowledges that the limited availability of resources can pose challenges in implementing these recommendations. However, the Commission stresses the importance of ensuring that additional supervisory oversight is provided while the specialized units are being created, given the potential serious consequences of inadequate supervision, as observed in Ms. Butlin's case. While the RCMP Commissioner indicated in his response that only two divisions currently have a formal Case Manager program, the evidence before the Commission indicated that other divisions also had a process for additional review of sexual assault files outside of the regular supervisory chain. Until such time that the specialized units are operational, divisions should ensure that these reviews cover as many sexual assault investigation files as possible. Divisions should also ensure that there is sufficient accountability in place by requiring additional steps in cases where recommendations from case managers or other RCMP members tasked with the reviews are not followed.
2. National Unit and External Review
[131] The Commission examined the measures put in place by the RCMP to review sexual assault investigations after-the-fact to identify deficiencies and correct errors. Two types of review processes were implemented. First, reviews were conducted by a national unit, the Sexual Assault Review Team (SART), later renamed the National Office of Sexual Offence Investigational Standards (NOSOIS). The SART was originally tasked to conduct reviews of all 2016 sexual assault files cleared as unfounded. Its mandate was soon expanded to reviewing all sexual assault files that did not result in charges for the years 2015 to 2017. It now continues to review a sample of sexual assault files not cleared by a charge.
[132] Beginning in 2019, the RCMP also started establishing external review committees, the SAIRCs, in the divisions. Comprised mostly of individuals who work with community-based organizations that provide frontline services to victims of sexual violence, these committees are tasked with reviewing a sample of RCMP sexual assault investigations that do not result in charges.
[133] In both cases, the reviews seek to identify issues such as incomplete investigation, inadequate supervision, inappropriate clearance codes, incorrect understanding of the law of consent, failure to collect all relevant evidence, improper reliance on sexual assault myths and stereotypes, or failure to use a trauma-informed approach.
[134] The Commission noted that the reviews served an important function, particularly in light of the gaps in knowledge and supervision observed in Ms. Butlin's case. Further, having external reviewers involved is important to ensure that police do not develop tunnel vision in their approach to sexual assault investigations, and that victims' perspectives are properly taken into account.
[135] However, there were several issues identified in the processes that seriously impaired the effectiveness of the reviews.
[136] First, the SART and the external review committees lacked the authority to implement changes. There was no obligation to follow the recommendations made by the reviewers, or even to formally respond to them. The Commission noted that recommendations made by the SART in 2020 to 2022 to consider reopening investigations were followed in less than half of the cases. Similar recommendations made by the SAIRCs in 2022 were followed in only 60 percent of cases. The RCMP Commissioner supported the Commission's recommendations to address this issue by requiring designated officers in each division to provide a formal response to NOSOIS and SAIRC recommendations, indicating any action taken and explaining the reasons for any decision not to follow a recommendation.
[137] Another issue was that both NOSOIS and the SAIRCs were only able to review a small number of cases, mostly due to lack of resources and structure to conduct efficient reviews.
[138] The Commission found that the SAIRCs lack consistency across the RCMP divisions in terms of processes, number of files reviewed and frequence of meetings. In 2022, the SAIRCs had reviewed only seven percent of the sexual assault files not cleared by a charge. The SAIRCs recommended reopening the investigation for 20 percent of the investigations they did review. SAIRC members interviewed by the Commission commented that reviewing more files would allow them to better assess trends and systemic issues, and that there were logistical and resources challenges making the reviews less efficient, including the requirement that the reviews be conducted as a group and, in some cases, the lack of access to sufficient equipment. For example, SAIRC members in one division had to share a single computer to review files and video evidence, or review a single copy of a paper file together.
[139] The Commission recommended that:
- the RCMP direct sufficient resources to the SAIRC reviews to ensure that a substantial number of files is reviewed;
- the RCMP develop a clear guideline for the number of times the SAIRCs meet and the number of files to be reviewed;
- the RCMP take into account the SAIRC members' preferences in determining the most efficient process for the reviews (including individual reviews or reviews in smaller groups);
- the SAIRC members be provided with the equipment and resources they need to efficiently conduct their reviews.
[140] The RCMP Commissioner supported these recommendations.
[141] The SART/NOSOIS was similarly limited in its ability to conduct reviews, having reviewed only 9 percent of sexual assault files not cleared by a charge in 2020 to 2022. The Commission noted that this team of nine individuals was entrusted with an enormous task, given that it is responsible for developing training, updating policy and best practice guides, coordinating the SAIRC reviews process, and conducting outreach and public information, in addition to reviewing sexual assault investigations. The Commission further noted that NOSOIS would have additional tasks to oversee the creation of the specialized units, develop the necessary training, and ensure that sufficient information was shared between the divisions. To ensure that problematic files were identified, particularly during the transition period while the specialized units are being created, the Commission found that NOSOIS would need to review a higher number of files.
[142] The Commission recommended that the RCMP substantially increase the number of full-time members of NOSOIS. The RCMP Commissioner supported this recommendation in part, stating that the possibility of increasing NOSOIS' staffing is under consideration, but is dependent on funding and personnel availability. With respect to the Commission's recommendations that NOSOIS review a substantial number of files, including all unfounded sexual assault files, and have the final authority to determine whether the unfounded clearance code was used appropriately, the RCMP Commissioner stated that he supported the intent of the recommendations, to the extent that operational capacity permits. He noted that the RCMP supports improved outcomes through education and collaboration, and that NOSOIS would continue to provide a secondary review to the extent of its capacity.
[143] The Commission welcomes the RCMP Commissioner's support for the spirit of these recommendations and his willingness to consider increasing NOSOIS' staffing. While the Commission understands that availability of funding and personnel can pose challenges, the Commission stresses the importance of ensuring that sufficient reviews are conducted, particularly during the transition period when the specialized units will not yet be operational. Ms. Butlin's case has shown all too clearly the serious consequences that can result from having RCMP members who are not sufficiently trained and knowledgeable conduct and supervise sexual assault investigations without sufficient time and resources. Reviewing the investigations to ensure that errors are caught and corrected is the best safeguard to avoid a repetition of the deficiencies observed in Ms. Butlin's case, at least until specialized units are created and can provide the necessary investigative capability and support.
3. Training
[144] The Commission noted that it took five years for the RCMP to roll out comprehensive training on the conduct of sexual assault investigations. While other training was developed before, it was not complete or sufficient to address the issues observed in Ms. Butlin's case. This meant that, for most of the period that followed Ms. Butlin's case and the publication of the Unfounded Series, general duty RCMP members continued to conduct sexual assault investigations without sufficient training.
[145] The Commission reviewed the training that was developed and noted the extensive consultations conducted in its preparation. The Commission found that the new training provided a more comprehensive exploration of the law of consent and was adequate to fill most of the gaps left by the earlier training. However, the training was not mandatory. Internal tracking showed that less than 10 percent of RCMP members had completed the course as of October 2023. The RCMP Commissioner accepted the Commission's recommendation to make the course mandatory for all RCMP members who might be involved in supervising, investigating or responding to criminal complaints of sexual assault. The RCMP Commissioner also accepted the recommendation to create advanced training for members of the specialized units.
[146] The Commission highlighted concerns with the self-guided and self-paced format of the training. While offering the training online allowed the RCMP to deliver it to more members, the Commission noted that the self-guided format was not ideally suited to instruct on complex topics such as the law of sexual assault and the law of consent. Given the reality of most RCMP members' fast-paced and high-volume workload, attempting to complete this type of training while also attending to their regular duties would not allow the RCMP members to properly absorb, understand and retain the information. The Commission noted that a more interactive format, even if offered online, could remedy some of these concerns, and allow for a better integration of practical components.
[147] The RCMP Commissioner supported the spirit of the Commission's recommendation to consider converting the sexual assault training to an interactive, instructor-led format, stating that he would encourage interactive training whenever possible. He noted that the training would remain online, and that the RCMP would first focus on improving outcomes through increased participation, but that future updates may consider formatting changes. Given the very real impact of the RCMP members' lack of sufficient knowledge and training that was observed in Ms. Butlin's case, the Commission encourages the RCMP Commissioner to take measures to ensure that the RCMP members who receive the training are able to properly understand the materials. This can be achieved through interactive virtual learning, so long as the RCMP ensures that members do not have to continue carrying out their regular duties while taking the training.
4. Policy and Best Practice Guide
[148] There were several amendments to the RCMP's national policy on sexual offences between 2018 and 2021, and NOSOIS has drafted an updated version that was awaiting approval when the Commission's interim report was issued. The Commission made recommendations about areas not addressed in the policy then in force. These included recommendations that the policy:
- caution investigators about the risk of sexual assault victims not being believed based on inappropriate considerations, and require RCMP members to document a rationale and consult with the specialized unit before questioning the validity of a sexual assault complaint or the credibility of the victim;
- provide additional guidance about the importance of ensuring that a safety plan is in place for the victim;
- require that RCMP members accommodate requests by victims about the gender of the investigator where possible;
- provide guidance for first responders interacting with victims and require that they provide information about the support services available;
- provide guidance on allowing victims to have a support person present during their interview with the RCMP;
- emphasize the requirement to provide regular updates to the victim;
- direct RCMP members to consider the needs of vulnerable victims.
[149] The RCMP Commissioner supported these recommendations.
[150] The RCMP Commissioner supported in part the Commission's recommendation that the policy require the use of a soft interview room that maximizes the safety and comfort of the victim. The RCMP Commissioner noted that he supports mandating RCMP members to consider the use of a soft interview room rather than mandating the use of such a room in all cases, as there might be circumstances where this is not in the best interest of the victim. The RCMP Commissioner noted that the Best Practice Guide has recommended the use of a soft interview room since 2020, but that it is important to allow RCMP members to respond to the unique needs of every victim. The RCMP Commissioner stated that he would direct that the next policy update require members to consider the use of a soft interview room or other venue that maximizes victim safety and comfort. The Commission is satisfied that this is sufficient to implement the intent of its recommendation.
[151] The RCMP Commissioner also supported in part the Commission's recommendations that the policy require first responders to notify the specialized unit for the division and to delay the initial interview with the victim until guidance was received from the specialized unit, unless there was an urgent requirement to conduct the interview. The RCMP Commissioner noted that specialized units do not yet exist in every division, and that there are concerns that declining to hear from victims who are ready to speak based on a policy requirement to consult could harm the relationship with the victim and could result in losing contact with the victim altogether.
[152] The Commission is sensitive to the concerns raised by the RCMP Commissioner, and agrees that building trust and establishing a relationship with the victim is of the highest importance for police conducting sexual assault investigations. The Commission clarifies that the primary intent of this recommendation, as explained in the text of its Interim Report, is to allow sufficient time for the victim to process the events, in light of the effects of trauma on short-term memory, and of the importance of allowing time for the victim to prepare for the ordeal of having to discuss the events in detail. This is in line with the guidance in the Best Practice Guide, which recommends delaying the initial interview by 24 to 48 hours.
[153] First responders should be able to explain to victims the benefits of waiting to provide a statement, including an explanation of the impacts of trauma and how they might impair the victim's ability to immediately recall events, and of the importance of seeking support and psychologically preparing for providing the statement. This waiting period can also be used for first responders to consult with the specialized unit, where it exists, so that they are better prepared to conduct the interview, or that the specialized unit can take over the investigation where appropriate. However, if a victim still wishes to provide an immediate statement after receiving this information, they should not be prevented from doing so. As such, the Commission finds that the RCMP Commissioner's response does not detract from the intent of its recommendation.
[154] The Commission reviewed the Best Practice Guide for the conduct of sexual assault investigations and noted that it was a significant contribution made by the SART, who created and updated the Guide. The Commission made a few recommendations for additions, including specific guidance on the appropriate use of clearance codes, guidance on investigative techniques in cases where the assailant is unknown to the victim or the suspect denies that sexual activity took place, and guidance on the duty to warn the public where an assailant who might target specific victims is at large. The RCMP Commissioner supported these recommendations. The RCMP Commissioner supported in part the Commission's recommendation to incorporate in the Best Practice Guide the guidance contained in the Guide for Contacting Victims of Sexual Assault, stating that he would instead include a reference to this other guide in the Best Practice Guide. The Commission finds that this is consistent with the intent of its recommendation.
5. Information-Sharing, Measuring Progress and Accountability
[155] The Commission noted that, for the measures put in place by the RCMP to be effective in improving sexual assault investigations, the information gathered and the lessons learned through the various processes need to be effectively shared. Conducting reviews of sexual assault investigations will not be useful if the information learned is not transmitted to those investigating cases so that they can adjust their approach accordingly. Similarly, for NOSOIS to provide effective national guidance and to identify necessary adjustments to training, policies or processes, it needs to be aware of what is happening on the front lines and to understand the challenges faced by investigators and any recurring issues still observed in sexual assault investigations.
[156] For this purpose, the Commission made the following recommendations:
- NOSOIS and the specialized units should be informed of the results of the SAIRC reviews and the division's responses;
- divisional coordinators in charge of overseeing SAIRC reviews should be embedded in the specialized units and provide reports to NOSOIS about the activities of the specialized units;
- divisional case managers should provide reports to NOSOIS about their file reviews;
- NOSOIS should be tasked with compiling and providing to the specialized units information about general trends and recurring issues, based on NOSOIS' own reviews, the SAIRC reviews, the specialized units' oversight functions and activities in all divisions, and the divisional Case Manager reviews;
- NOSOIS should be tasked with preparing reports for RCMP senior leadership about this information, including file review recommendations not followed, as well as overall trends observed.
[157] The RCMP Commissioner generally supported these recommendations, but cited resource constraints that prevented the complete implementation of some of the recommendations. In response to the recommendation about the NOSOIS report for senior leadership, the RCMP Commissioner indicated that current staffing levels at NOSOIS do not permit the expansion of the reports they prepare, that specialized units are not in place in every division, and that divisions with case managers have advised that they do not have the capacity to report to NOSOIS. However, the RCMP Commissioner noted that the majority of the information listed in the Commission's recommendation is already reported in the annual NOSOIS reports, and that the reported information would increase with NOSOIS staffing and the implementation of more specialized units. The RCMP Commissioner committed to working towards implementing the Commission's recommendation in full, but stated that he could not fully accommodate it at this time.
[158] The RCMP Commissioner stated that he supported the recommendation that divisional case managers provide reports to NOSOIS about their file reviews, to the extent that divisions with Case Manager programs are able to accommodate the additional workload. The RCMP Commissioner stated that he would direct that divisional coordinators be embedded in the specialized units, but did not comment on whether he would direct that they be required to provide reports to NOSOIS about the activities of the specialized units. However, since the RCMP Commissioner committed to working towards having NOSOIS include information about the activities of the specialized units in its reports to senior leadership, the Commission understands that the RCMP Commissioner intends to put in place a mechanism for this information to be reported to NOSOIS.
[159] The RCMP Commissioner stated that he supports the spirit of the recommendation that NOSOIS compile and provide information to the specialized units "to the extent that much of this information is already exchanged between NOSOIS and the divisions." This response did not indicate whether the RCMP Commissioner intends to increase the information currently shared between NOSOIS and the divisions. However, based on the RCMP Commissioner's commitment to work towards having NOSOIS include this information in reports to senior leadership, the Commission infers that it is the intent of the RCMP Commissioner to increase the amount of information compiled by NOSOIS and that this additional information will also be shared with the specialized units.
[160] The Commission acknowledges that resource constraints can limit the RCMP's ability to compile and share information about its processes. That said, without this information being shared, the effectiveness of the processes put in place to improve sexual assault investigations could be compromised, as different units and divisions would be deprived of the knowledge gained through the file reviews and experience of other units, and NOSOIS would be more limited in its ability to identify broader corrective measures necessary. The Commission trusts that the RCMP Commissioner's support for the intent of the recommendations and his commitment to work towards more complete implementation is the result of a recognition on the part of RCMP leadership of the importance of information-sharing to achieving the goal of improving sexual assault investigations.
[161] In its interim report, the Commission reviewed evidence and publicly available information in an attempt to ascertain whether the situation has improved since Ms. Butlin's case and the publication of the Unfounded series in 2017. The Commission found that the available information was limited, and that the RCMP lacked adequate processes to measure its own progress. A review of Statistics Canada data for 2019 to 2022 showed that the RCMP's unfounded rate for sexual assaults declined slightly, as did its unfounded rate for all violent crimes. However, due to the uncertainty surrounding RCMP members' understanding of the clearance codes and the fact that many of the measures taken by the RCMP with respect to sexual assault investigations were not implemented until 2022 or later, it was impossible to ascertain whether the decline was the result of any improvement in the conduct of investigations.
[162] Data from the SAIRC reviews appeared to indicate some improvement between 2020 and 2022, but the usefulness of this data was limited, as the overall number of cases reviewed was very small. The SART and SAIRC reviews, as well as the evidence from victim advocates, all showed that there were still significant issues being observed on an ongoing basis. For example, the SAIRC reviews indicated that, in 2022, a lack of adequate supervision and a lack of understanding of the law of consent on the part of the investigator were still observed in a quarter of cases, a third of the investigations lacked completeness or thoroughness, and victims were only referred to Victim Services in a little over half of cases.
[163] The Commission found that the RCMP needed to improve its ability to measure the effectiveness of the processes it was implementing to improve sexual assault investigations. The RCMP Commissioner accepted the Commission's recommendation that the RCMP set up appropriate processes to collect reliable and verified data about sexual assault investigations, including statistics about unfounded cases.
[164] The Commission also highlighted the need for the RCMP to be accountable to the public about its handling of sexual assault investigations. The Commission noted that, in the interest of transparency, the RCMP should be prepared to report to the public on specific steps taken to improve sexual assault investigations, and to provide detailed information about key indicators to measure progress. The Commission recommended that the RCMP publish periodic updates about these issues that would include information about:
- the file reviews and their results;
- the number of recommendations made to reopen investigations and the response to those recommendations;
- the evolution of the unfounded rate;
- action taken to address trends and recurring issues; and
- the activities of the specialized units, once operational.
[165] The RCMP Commissioner generally supported these recommendations. He stated that the current annual reports prepared by NOSOIS have been cleared for publication, although they do not contain all of the items listed in the Commission's recommendations. The RCMP Commissioner noted that the remaining items are reported internally by NOSOIS but have not been cleared for public release. The RCMP Commissioner committed to working towards an annual report that meets the requirements of the Commission's recommendations, with a version that can be publicly posted. The Commission welcomes the RCMP Commissioner's commitment and his recognition of the importance of maintaining accountability and transparency.
Findings and Recommendations not Accepted by the RCMP
Modification of the "Unfounded" clearance code in Ms. Butlin's case
[166] The Commission found that it was inappropriate for the RCMP to change the clearance code for Ms. Butlin's sexual assault file from "Unfounded" to "Hist.-Complete-Unsolved." While Constable Crooks' perception that Ms. Butlin's complaint was unfounded was the result of his lack of understanding of sexual assault law and his failure to conduct an adequate investigation, the evidence before the Commission indicated that Ms. Butlin's complaint was treated as unfounded, and that this was the reason the investigation was concluded. The complaint had been referred to as unfounded in RCMP members' notes and in the police report. Constable Crooks also confirmed in his interview with Commission investigators that he had concluded that the complaint was unfounded, and believed this was the clearance code he had applied. He did not know why the code was changed to "complete-unsolved" and did not recall making the change.
[167] The Commission noted that the change in the clearance code was not based on any new investigative steps or a revised conclusion. The Commission expressed concern that administrative changes of this nature can obscure investigative deficiencies and distort police statistics. The original designation of unfounded accurately reflected how the file was handled, and therefore should not have been changed.
[168] The RCMP Commissioner disagreed with this finding. He stated that, after careful consideration of the material available, he did not find it established that the clearance code was actually changed. He explained that the use of clearance codes is a data-entry process conducted in support of Statistics Canada, and that the only criteria used to assign a code are those provided by Statistics Canada. He noted that the RCMP does not retain discretion in how to apply the codes, and does not select codes to flag files for further review, to reflect investigative approaches, or to avoid contentious labels. The RCMP Commissioner also stated that the prerequisite for secondary review of a sexual assault investigation is that the file has not been cleared by a charge. As such, an inaccurate clearance code would not prevent a file's inclusion in broader review processes.
[169] Aside from referring to his own review of the evidence, the RCMP Commissioner did not provide new facts or analysis in support of his conclusion that the clearance code had not been changed. The evidence before the Commission established that Constable Crooks intended to clear the file as unfounded, and that a different code was ultimately entered. Regardless of whether the clearance code was entered by Constable Crooks and subsequently changed, or whether Constable Crooks instructed that the file be cleared as unfounded and other RCMP personnel entered a different code instead, it remains that the final code assigned to the file did not reflect the reason for concluding the file. Constable Crooks' own description of his decision-making confirms that he treated the complaint as unfounded. While that conclusion was inappropriate for other reasons, the unfounded code accurately reflected the approach taken in the case.
[170] RCMP national policy requires that clearance codes reflect the outcome of the investigation.Footnote 5 The "complete-unsolved" code would be appropriate in a case where the matter could not be solved after a proper investigation was conducted, for example because a suspect could not be identified. This was not the case in Ms. Butlin's file, where the suspect was identified, but the complaint was prematurely dismissed because the RCMP members did not believe that a crime had been committed. Assigning a code that does not align with what actually occurred risks misleading subsequent reviewers and distorting statistical reporting. While there is no evidence indicating that this was the intent in this case, the end result was a clearance code that did not reflect the real reasons for concluding the file.
[171] For these reasons, the Commission reiterates its finding that it was not appropriate for the RCMP to incorrectly record, or change, the clearance code to record an inaccurate outcome of the investigation.
Systemic failures to address information about threats to Ms. Butlin's safety
[172] In reviewing issues with the supervision of the investigations related to Ms. Butlin, the Commission found that the Colchester District's atypical supervisory structure contributed to the Bible Hill detachment's systemic failure to recognize and address the information about the threat Ms. Butlin was facing.
[173] The RCMP Commissioner agreed only in part with this finding. He stated that, while he accepted the finding in general, it was his opinion that the relevant materials demonstrated that this was a situation of "multiple failures," as opposed to a systemic failure.
[174] Based on the evidence reviewed, the Commission cannot agree with this view. While there were numerous individual failures, there were also broader systemic issues that created an environment in which these individual shortcomings could accumulate without being addressed. These included resourcing challenges that led to persistent deficiencies in documentation and file management, inadequate supervision, and a deficient structure for supervisory oversight that allowed files to be concluded without proper review. The absence of a detachment commander compounded these issues, leaving no one in charge of addressing the recurring issues.
[175] For these reasons, the Commission reiterates its finding.
Insufficient action to improve sexual assault investigations
[176] Having reviewed the measures put in place by the RCMP in the aftermath of the Unfounded series, the Commission found that, since 2017, the RCMP has not taken sufficient action to improve the quality of sexual assault investigations.
[177] The RCMP Commissioner disagreed with this finding. He stated that, while he respects and appreciates the Commission's contributions regarding the quality of sexual assault investigations conducted by the RCMP, and believes that the Commission's perspective is invaluable for the continued improvement of the service provided by the RCMP, he could not agree that the RCMP could have done more, faster than it had. He noted that the many initiatives put in place since 2017, the continual monitoring of training and policy, and the engagement with experts within and outside the RCMP are an integral part of the RCMP's modernization and that these efforts continue within, and possibly in spite of, a reality in which the RCMP faces continuous resource pressures. He stated that resourcing is a joint effort between the federal government and the provinces or territories, and that policing priorities are a joint discussion between the RCMP and the jurisdictions it serves.
[178] The RCMP Commissioner added that he was nevertheless encouraged by the considerable overlap between the recommendations made by the Commission and the most recent updates to the RCMP's national policy on sexual offences. He believed that the many parallels demonstrate that the Commission and the RCMP share the same vision for improvement. He stated that the RCMP would continue to strive to serve all, but particularly the vulnerable communities disproportionately impacted by sexual offences.
[179] The Commission acknowledges the resource pressures faced by the RCMP, as well as the RCMP Commissioner's recognition of many of the deficiencies identified in this case. In particular, the RCMP Commissioner did agree in full with the Commission's finding that the RCMP did not implement sufficient measures to remedy the deficiencies identified in the response to Ms. Butlin's sexual assault complaint. The RCMP Commissioner also showed a clear willingness to address the remaining issues by implementing the Commission's recommendations.
[180] Because of the time it took to implement many of the key changes, the failure to make any significant changes to the supervision model, and the failure to implement a sufficiently well-resourced and robust process for file reviews, the Commission must reiterate its finding that the action taken since 2017 was not sufficient. However, the Commission recognizes that this was partly due to factors outside of the RCMP's control. The Commission is encouraged by the commitments provided by the RCMP Commissioner in his response in this matter, and hopes that the further action taken will assist in creating meaningful change.
Process for SAIRC file reviews
[181] During the Commission's investigation, some members of the SAIRCs raised concerns about the role of the RCMP members assigned to coordinate the reviews (the divisional coordinators). They noted that the presence of the coordinator during the review can limit the external committee's ability to speak openly and freely about the cases. The coordinators stated that they only remained present to answer questions and make sure they understood the SAIRC's findings. The Commission had no concerns about the coordinators' intentions, and noted that the relationship with the SAIRCs was generally positive. However, the coordinators' presence during the reviews risked creating a perception that the reviews are not independent or that the RCMP was seeking to control the external review process. The Commission recommended that the divisional coordinators not be present during the reviews and ensure that the SAIRCs are provided a private space to conduct reviews and hold discussions.
[182] The RCMP Commissioner supported this recommendation only in part. He assured the Commission that divisional coordinators are trained to have no influence over the SAIRC and are only present to answer questions. However, he stated that, as the SAIRC reviews are considered an extension of the investigation, the care and control of the files are the RCMP's responsibility. As such, an RCMP member must be present, in accordance with the privacy impact assessment completed as part of the introduction of the SAIRCs. The RCMP Commissioner indicated that he supported the continued provision of private space to conduct the reviews and hold discussions.
[183] The Commission acknowledges the importance for the RCMP of maintaining control over its records and ensuring that privacy is properly safeguarded. The Commission also accepts that the divisional coordinators are not attempting to influence the reviews. That said, SAIRC members have indicated that the coordinators' presence can nevertheless limit their ability to speak freely, even if not as a result of the coordinators' actions. Further, it is important to ensure that the perception that the reviews are fully independent and external is safeguarded. This is difficult to achieve when an RCMP member is present during the discussions leading to the external committees' findings and recommendations. Based on the evidence before the Commission, including the evidence provided by a SAIRC member who also conducted external reviews with another police force, it appears that other police forces in Canada have been able to provide more independent access to records for their external review committees. Indeed, providing privacy to the committees in an RCMP-controlled environment should be sufficient to ensure that privacy is protected and control is maintained over the records. The Commission encourages the RCMP to explore this option and to revisit the original privacy impact assessment as required to ascertain the exact limits imposed by privacy legislation.
[184] For these reasons, the Commission reiterates this recommendation.
Referrals to community-based victim support services
[185] In its interim report, the Commission stressed the importance of providing access for victims of sexual assault to community-based victim services, in addition to police-based or government-run support services. The evidence before the Commission indicated that community-based organizations could often provide more support and a wider range of services. Victim advocates also pointed out that some victims might feel reluctant to receive support from a police-based organization, particularly in instances where the victim is not satisfied with the police response to their complaint. For these reasons, the Commission recommended that the RCMP's national policy be amended to add a requirement that RCMP members offer referrals to community-based victim support services.
[186] The RCMP Commissioner did not support this recommendation. He explained that referrals to victim support services are a joint effort between the RCMP and the justice departments of the respective provinces or territories. As such, he stated that the RCMP cannot unilaterally mandate changes to how referrals are made without the input of its provincial or territorial partners. However, the RCMP Commissioner noted that a September 2024 update to the national policy directs investigators to the 2024 Guide for Investigators: Contacting and Providing Support to Survivors of Sexual Violence, which contains lists of non-police support services for survivors in each division. The updated policy also provides an email link to the Guide. The RCMP Commissioner stated that community-based services are valuable partners in supporting victims, and that the RCMP supports this initiative, short of making the referrals to such organizations a requirement.
[187] The Commission is satisfied that this approach adequately implements the intent of its recommendation.
Dissemination of the Best Practice Guide
[188] The Commission noted there had been concerns in the past about accessing the Sexual Assault Investigations Best Practice Guide. While links had since been added in relevant policies, these links generated a message requesting the Guide, which was then sent in reply. The Commission recommended to make access simpler by sending out the Guide to all RCMP members who might be involved in receiving sexual assault complaints or conducting investigations, as well as integrating the Guide into their mobile workstations.
[189] The RCMP Commissioner did not support this recommendation, indicating that emailing the Guide would be contrary to Government of Canada direction on email management, due to its status as transitory information. The RCMP Commissioner did assure the Commission that the Guide is readily available on the RCMP's Infoweb and linked within the national policy. He also stated that he would direct the divisions to consider making the Guide accessible on mobile workstations to the extent that this practice is technologically feasible. The Commission is satisfied that this approach implements the intent of its recommendation.
Commission's Final Findings and Recommendations
| Commission's Findings | RCMP Commissioner's Response | Commission's Analysis of RCMP Commissioner's Response |
|---|---|---|
1) The RCMP's investigation into Ms. Butlin's complaint of sexual assault was wholly inadequate. |
Agree |
|
2) The inadequate investigation into the sexual assault complaint contributed to the lack of reasonable measures put in place to ensure Ms. Butlin's safety. |
Agree |
|
3) Constable Crooks and Constable Whalen did not have a sound understanding of the law of sexual assault during the investigation of Ms. Butlin's complaint. |
Agree |
|
4) Constable Crooks and Constable Whalen wrongly concluded that Ms. Butlin's information did not give rise to reasonable grounds to believe that a sexual assault had been committed. |
Agree |
|
5) It was both premature and unreasonable for Constable Crooks to conclude, solely based on his telephone conversation with Ms. Butlin, that there were no reasonable grounds to believe that an offence had been committed. |
Agree |
|
6) Constable Crooks unreasonably neglected to listen to Ms. Butlin's audio recorded statement prior to deciding to conclude the investigation. |
Agree |
|
7) Constable Crooks did not conduct a reasonably thorough investigation into Ms. Butlin's complaint of sexual assault before concluding that charges were not warranted. |
Agree |
|
8) Constable Whalen did not explore several relevant areas and issues during her interview with Ms. Butlin. |
Agree |
|
9) It was unreasonable for Constable Crooks and Constable Whalen to question Ms. Butlin's credibility based on the timing of her complaint, without considering her explanations and further investigating the reasons for the timing of the complaint. |
Agree |
|
10) Given their reliance on the timing of Ms. Butlin's complaint, it was unreasonable for Constable Crooks and Constable Whalen not to explore whether Ms. Butlin had made any prior disclosures about the assault before reporting it to the police. |
Agree |
|
11) It was unreasonable for Constable Crooks, Constable Whalen and Corporal Naime to rely on faulty assumptions and reasoning based on myths and stereotypes about the expected behaviour of sexual assault victims. |
Agree |
|
12) It was unreasonable for Constable Crooks to have cleared the sexual assault investigation file as "unfounded" without conducting a sufficient investigation and recognizing how the law applied to the events reported by Ms. Butlin. |
Agree |
|
13) It was not appropriate for the RCMP to change the clearance code for the sexual assault file without changing the approach to the investigation or the ultimate conclusion of the file. |
Do Not Agree |
The Commission reiterates its finding that it was not appropriate for the RCMP to incorrectly record, or change, the clearance code. |
14) Constable Crooks did not treat Ms. Butlin with sufficient compassion and respect. He did not adopt a victim-centred approach, and his attitude led to Ms. Butlin not feeling believed. |
Agree |
|
15) Constable Whalen conducted the interview of Ms. Butlin in a professional and sensitive manner. Her interview was guided by consideration for Ms. Butlin. |
Agree |
|
16) Constable Crooks and Constable Whalen did not adequately consider Ms. Butlin's safety, contrary to RCMP policy and the Canadian Victims Bill of Rights. |
Agree |
|
17) Constable Crooks and Constable Whalen neglected to offer victim services to Ms. Butlin, contrary to RCMP policy. |
Agree |
|
18) Constable Crooks did not inform Ms. Butlin of the status and outcome of the investigation into her sexual assault complaint. His failure to do so was contrary to RCMP policy and did not reflect the RCMP's core value of professionalism. |
Agree |
|
19) It was unreasonable for Constable Crooks and Constable Whalen to encourage Ms. Butlin to apply for a peace bond in the circumstances of this case without any further risk assessment or support from police. |
Agree |
|
20) Constable Whalen should have documented the information about the threat made to Ms. Butlin's sons. |
Agree |
|
21) Constable Crooks should have documented and investigated the threat to Ms. Butlin's sons and the damage to Ms. Butlin's pool. |
Agree |
|
22) The RCMP's response to the 911 call was wholly inadequate. |
Agree |
|
23) The Operational Communications Centre lacked adequate safeguards to ensure the identification and proper handling of all high-risk cases. |
Agree |
|
24) Constable MacDonald's and Corporal Beselt's failure to take any action to address the serious threat to Ms. Butlin's safety was unacceptable and unreasonable in the circumstances. |
Agree |
|
25) It was unreasonable for Corporal Beselt not to provide Ms. Butlin with more complete information about the threat to her safety. |
Agree |
|
26) The response to Ms. Butlin's complaint of harassing or intimidating communications was not adequate or reasonable in the circumstances. |
Agree |
|
27) It was unreasonable for Constable Wiley not to conduct basic queries about Ms. Butlin and Mr. Duggan in PROS. |
Agree |
|
28) The guidance provided in the RCMP's national policy on criminal harassment is not sufficient to ensure that RCMP members investigating such offences conduct all necessary inquiries about prior history and allegations. |
Agree |
|
29) The RCMP did not conduct a reasonably thorough investigation into Ms. Butlin's complaint of harassment. |
Agree |
|
30) Constable Wiley should have asked more questions of Ms. Butlin prior to making his determination about the investigative steps required. |
Agree |
|
31) Based on all of the information in its possession, it was unreasonable for the RCMP not to obtain a statement from Ms. Butlin and a copy of the text messages at issue. |
Agree |
|
32) Constable Wiley should have questioned Ms. Butlin further to determine whether she was at risk and whether safety planning was necessary. |
Agree |
|
33) The RCMP did not properly evaluate the risk to Ms. Butlin's safety and did not conduct adequate safety planning, which would have been necessary based on the information in the RCMP's possession. |
Agree |
|
34) Constable Wiley should have informed Ms. Butlin of the services provided by Victim Services and made an offer for referral. |
Agree |
|
35) The RCMP did not properly investigate the criminal offences potentially applicable following Ms. Butlin's complaint of harassing communications and intimidation. |
Agree |
|
36) The RCMP unreasonably failed to interview witnesses and to attempt to speak to Mr. Duggan following Ms. Butlin's complaint of harassing communications and intimidation. |
Agree |
|
37) It was unreasonable for Constable Crooks, Corporal Naime, Corporal Wentzell, and Sergeant Cooper to have questioned Ms. Butlin's credibility on the basis of perceived inconsistencies that did not in fact exist. |
Agree |
|
38) It was unreasonable for Constable Crooks, Corporal Naime, Corporal Wentzell, and Sergeant Cooper not to take steps to investigate the information in the peace bond application, in light of their belief that there were inconsistencies in Ms. Butlin's information and that the information in the peace bond application was new. |
Agree |
|
39) It was unreasonable for Corporal Naime not to review Ms. Butlin's statement when reviewing the file and prior to concluding that there were inconsistencies in the information she provided. |
Agree |
|
40) It was unreasonable for Sergeant Cooper not to review Ms. Butlin's statement or task someone to review the statement before concluding that there were inconsistencies in Ms. Butlin's information and advising the Crown of this. |
Agree |
|
41) Constable Crooks' belief that Ms. Butlin had been untruthful in her peace bond application was unreasonable and inappropriate. |
Agree |
|
42) Sergeant Cooper, Corporal Wentzell, and Corporal Naime did not have a sound understanding of the law of sexual assault when they conducted their review of the sexual assault investigation file. |
Agree |
|
43) It was unreasonable for Sergeant Cooper, Corporal Wentzell, and Corporal Naime not to recognize that the information provided by Ms. Butlin was sufficient to give rise to reasonable grounds to believe that Mr. Duggan had sexually assaulted her. |
Agree |
|
44) It was unreasonable for Corporal Naime and Corporal Wentzell to have questioned Ms. Butlin's credibility based on sexual assault myths and stereotypes. |
Agree |
|
45) Corporal Naime failed to ensure that the issues (such as the timing of the complaint and prior disclosures) were properly investigated before assessing the complaint. |
Agree |
|
46) It was unreasonable and inappropriate for Corporal Wentzell to bring up the offence of public mischief when discussing the case with Ms. Butlin. |
Agree |
|
47) Corporal Wentzell did not treat Ms. Butlin with sufficient respect, compassion, and sensitivity. |
Agree |
|
48) Sergeant Leger's approval of the early conclusion of the sexual assault investigation, the "Impaired Operation" file, and the harassing communications file was unreasonable. |
Agree |
|
49) The RCMP's "H" Division provided inadequate supervision for all three investigations related to Ms. Butlin. |
Agree |
|
50) The supervision model employed in this case was not adequate to ensure that major issues in the investigations would be identified and addressed. It was unreasonable for the RCMP's "H" Division to provide no supervisory oversight for any of the three investigations, aside from the reviews by the Case Manager. |
Agree |
|
51) The Colchester District's atypical supervisory structure contributed to the Bible Hill detachment's systemic failure to recognize and address the information about the threat Ms. Butlin was facing. |
Agree in Part |
The Commission reiterates its finding. |
52) The supervision model in place for the Bible Hill detachment failed to ensure that major issues in sexual assault investigations would be identified and addressed. |
Agree |
|
53) It was unreasonable for Constable Crooks, knowing that Ms. Butlin's complaint involved sexual assault, to obtain an unrecorded statement over the phone. This led to a lack of sufficient information to make a reasonable assessment of the complaint. It also did not comply with RCMP policy concerning interviewing. |
Agree |
|
54) It was unreasonable, and contrary to RCMP policy on note-taking, for Constable Crooks and Constable Whalen not to articulate and document their rationale for concluding that there were no reasonable grounds to believe that a sexual assault had been committed. |
Agree |
|
55) Constable Crooks did not adequately document, in his notes and report, the details of his telephone conversation with Ms. Butlin on August 7, 2017. |
Agree |
|
56) Constable Whalen did not document in her report important information that Ms. Butlin disclosed during her statement and that was critical in assessing the sexual assault complaint. |
Agree |
|
57) Constable MacDonald and Corporal Beselt did not select an occurrence type that reflected the gravity of the situation. |
Agree |
|
58) It was unreasonable, and contrary to RCMP policy on note-taking, for Corporal Beselt not to document the substance of his discussion with Ms. Butlin on August 21, 2017. |
Agree |
|
59) It was unreasonable, and contrary to RCMP policy on note-taking, for Constable MacDonald, as the arresting officer, not to document in his notes and reports the grounds for the arrest. |
Agree |
|
60) It was unreasonable, and contrary to RCMP policy, for Constable Wiley not to properly document his telephone conversation with Ms. Butlin. |
Agree |
|
61) Constable Wiley should have clearly documented in the file the content of the message Ms. Butlin stated was intimidating and threatening. |
Agree |
|
62) It was unreasonable, and contrary to RCMP policy on note-taking, for Sergeant Cooper, Constable Thorne, and Constable Crooks not to document important information pertaining to their review of the investigation into Ms. Butlin's complaint of sexual assault, and her peace bond application. |
Agree |
|
63) Staffing shortages and the resulting heavy caseloads contributed to the inadequate manner in which the RCMP responded to the incidents in Ms. Butlin's case. |
Agree |
|
64) The IOR report made a number of helpful findings identifying significant gaps in the RCMP members' response to Ms. Butlin's complaints. The IOR report also made helpful recommendations to improve sexual assault investigations in "H" Division. |
Agree |
|
65) The RCMP did not take sufficient action to review Ms. Butlin's case and to identify and remedy deficiencies. |
Agree |
|
66) It was unreasonable for "H" Division not to inform the RCMP members involved in Ms. Butlin's case of the shortcomings in their performance that were identified in the IOR report. |
Agree |
|
67) The RCMP's failure to ensure individual-level accountability for the RCMP members and supervisors involved in this matter was inconsistent with the RCMP's core value of taking responsibility. |
Agree |
|
68) Most of the recommendations made in the IOR report have been or are in the process of being implemented, except for the recommendation for advanced investigations training for supervisors. |
Agree |
|
69) The IOR report did not sufficiently address the RCMP members' failure to appreciate the overall threat faced by Ms. Butlin and to take measures to ensure her safety. |
Agree |
|
70) The IOR report did not identify and address issues of staffing shortages and heavy caseloads, which significantly impacted this case. |
Agree |
|
71) The RCMP did not implement sufficient measures to remedy the deficiencies identified in the response to Ms. Butlin's sexual assault complaint. |
Agree |
|
72) Since 2017, the RCMP has not taken sufficient action to improve the quality of sexual assault investigations. |
Do Not Agree |
The Commission reiterates its finding. |
| Commission's Recommendations | RCMP Commissioner's Response | Commission's Analysis of RCMP Commissioner's Response |
|---|---|---|
1) Constable Whalen should be directed to take the RCMP Sexual Offences Investigation course, if she has not already received this training since the latest training records provided to the Commission. |
Supported |
|
2) Constable Crooks should receive operational guidance about the law of sexual assault and the law of consent, and about the specific issues identified in this report in terms of his handling of Ms. Butlin's complaint, particularly with respect to his premature and faulty assessment of the complaint. |
Supported |
|
3) Constable Crooks' supervisor should complete a file review of past sexual assault investigations conducted by Constable Crooks to ensure that other investigations did not suffer from similar deficiencies. |
Supported in Part |
The Commission is satisfied that the measures to be taken by the RCMP are consistent with the purpose and intent of the recommendation. |
4) Constable Crooks and Constable Whalen should receive operational guidance about the dangers associated with adopting reasoning based on rape myths and stereotypes in evaluating sexual assault complaints. |
Supported |
|
5) Constable Crooks and Constable Whalen should receive operational guidance about the appropriate response to delayed reports of sexual assault. |
Supported |
|
6) Constable Crooks should receive operational guidance on the need to conduct a thorough investigation before concluding that a sexual assault complaint is unfounded. |
Supported |
|
7) Constable Crooks should receive operational guidance specific to the importance of treating sexual assault victims with respect and compassion, and ensuring that they do not feel judged or disbelieved, particularly during initial encounters with law enforcement. |
Supported |
|
8) Constable Crooks and Constable Whalen should receive operational guidance on the importance of considering and discussing safety planning with victims, regardless of whether an arrest has been made or a charge has been laid. |
Supported |
|
9) Constable Crooks and Constable Whalen should receive operational guidance on the importance of submitting a referral to Victim Services in all sexual assault cases. |
Supported |
|
10) Constable Crooks and Constable Whalen should be directed to take the Victim Bill of Rights course. |
Supported |
|
11) Constable Crooks should receive operational guidance on the importance of keeping complainants informed of the progress and outcome of investigations into their complaints. |
Supported |
|
12) Constable Crooks and Constable Whalen should receive operational guidance, training or mentoring on the timing and appropriateness of advising complainants to apply for a peace bond. |
Supported |
|
13) Further training and direction should be provided to Operational Communications Centre personnel on the requirement to carefully identify files that contain any high-risk elements so that the files can be assessed by RCMP supervisors and reviewed as necessary. |
Supported |
|
14) Constable MacDonald and Corporal Beselt should receive operational guidance about the importance of addressing information indicating that there is a danger to human life or safety, including by conducting the necessary investigations and attempting to locate and seize any weapons. |
Supported |
|
15) The RCMP should amend its national policy on criminal harassment to require RCMP members to conduct entity queries in police information systems at the outset of an investigation of criminal harassment. |
Supported |
|
16) All of the RCMP members involved in investigating Ms. Butlin's complaints or supervising the investigations should receive operational guidance on the importance of giving meaningful consideration to the safety and security of victims, and on the importance of documenting all information about threats to the safety of a victim, regardless of whether an arrest has been made or a charge has been laid. |
Supported |
|
17) All of the RCMP members involved in investigating Ms. Butlin's complaints or supervising the investigations should be directed to take the Victim Bill of Rights course, if they have not already received this training. |
Supported |
|
18) Constable Crooks, Corporal Wentzell, and Sergeant Cooper should receive operational guidance about the importance of verifying all of the facts prior to questioning the credibility of a sexual assault complainant. |
Supported |
|
19) Constable Crooks, Corporal Wentzell, and Sergeant Cooper should receive operational guidance about the necessity of investigating all information believed to be newly received that indicates the possibility that a sexual assault was committed. |
Supported |
|
20) Constable Crooks should not be permitted to respond to any sexual offence complaint, or conduct or participate in any investigation of a sexual offence until he has received all of the operational guidance recommended in this report. |
Supported |
|
21) Sergeant Cooper should receive operational guidance about the law of sexual assault and the law of consent, and about the specific issues identified in this report concerning the investigation and review of the sexual assault complaint. |
Supported |
|
22) Sergeant Cooper should be directed to complete the Sexual Offences Investigation course. |
Supported |
|
23) Corporal Wentzell should receive operational guidance about the law of sexual assault, and about the specific issues identified in this report regarding the handling of Ms. Butlin's complaint. |
Supported |
|
24) Corporal Wentzell should be directed to take the RCMP's Sexual Offences Investigation course, if he has not already received this training. |
Supported |
|
25) Corporal Wentzell should receive operational guidance about the dangers associated with adopting reasoning based on rape myths and stereotypes in evaluating sexual assault complaints. |
Supported |
|
26) Corporal Wentzell should receive operational guidance specific to the importance of treating sexual assault victims with respect and compassion. |
Supported |
|
27) Corporal Wentzell should be directed to take the Victim Bill of Rights course. |
Supported |
|
28) The RCMP should ensure that, regardless of the different supervision models adopted in the divisions, primary responsibility for overseeing general duty members' investigations remains with the investigators' immediate supervisor and their chain of command. |
Supported |
|
29) The RCMP should ensure that reviews conducted by case managers or risk managers are never used to discharge immediate supervisors of their responsibility to review all files for investigations conducted by the members under their supervision. |
Supported |
|
30) The RCMP should implement measures to ensure that, if supervisors become directly involved in an investigation, another supervisor is tasked with monitoring and reviewing the investigation. |
Supported in Part |
The Commission is satisfied that the measures to be taken by the RCMP are consistent with the intent of the recommendation. |
31) The RCMP should ensure that each detachment has an adequate supervision structure sufficient to ensure that investigations are properly documented, that supervisors adequately monitor and review all files, that file types are correctly identified, and that links between different files can be easily recognized and acted upon. |
Supported |
|
32) Constable Crooks should receive operational guidance about the process to follow when initiating contact with sexual offence victims and about the importance of recording statements from sexual assault victims. |
Supported |
|
33) Constable Crooks and Constable Whalen should receive operational guidance on the importance of taking detailed and comprehensive notes. |
Supported |
|
34) Constable MacDonald and Corporal Beselt should receive operational guidance on the importance of identifying accurate occurrence types. |
Supported |
|
35) Corporal Beselt should receive operational guidance regarding the proper documentation of observations made and of police actions. |
Supported |
|
36) Constable MacDonald should receive operational guidance on the proper documentation of observations made and of police actions, as well as on the importance of documenting his grounds for conducting an arrest. |
Supported |
|
37) Constable Wiley should receive operational guidance about completing detailed, accurate, and timely police notes and reports. |
Supported |
|
38) Sergeant Cooper should receive operational guidance on the importance of taking detailed and comprehensive notes in a timely manner. |
Supported |
|
39) Senior management in "H" Division should be directed to review the current allocation of police resources in the Colchester County District to ensure that proper resourcing is in place in each detachment. |
Supported |
|
40) The "H" Division CROPS Officer should be directed to officially share the IOR report with all concerned RCMP members. |
Supported |
|
41) The RCMP "H" Division should amend its policy on audit and evaluation programs to incorporate individual-level accountability measures to ensure that future Incident Review reports identifying performance gaps are shared with the appropriate RCMP senior members, so that action can be taken to address shortcomings, strengthen learning, and improve performance. This might not require sharing the report with all the individuals involved in every case, but would, at a minimum, require informing them of the issues identified with their performance. |
Supported |
|
42) The RCMP should work in collaboration with the provincial and territorial jurisdictions it polices to create specialized units to investigate sexual offences in each division. |
Supported |
|
43) Once the specialized units are created, the RCMP should direct that all RCMP members report all sexual offence complaints to their division's specialized unit. The specialized units should have the authority to take over any sexual offence investigation and to actively monitor the investigations they do not take over. |
Supported in Part |
The Commission reiterates its recommendation. |
44) The successful completion of advanced training should be required for members of specialized sexual offence investigation units, as well as divisional sexual assault coordinators and case managers. This training would preferably be taught in person and give in-depth instruction on all aspects of the law of sexual assault, including the law of consent. Updated or refresher training should be completed by the members as necessary. |
Supported |
|
45) The RCMP should make the Sexual Offences Investigation course mandatory for all RCMP members and supervisors who might be involved in investigating or responding to criminal complaints of sexual assault, or who might be involved in supervising such investigations or responses. Updated or refresher training should be completed by the members as necessary. |
Supported |
|
46) The RCMP should consider converting the Sexual Offences Investigation course and the Using a Trauma-Informed Approach course to an interactive, instructor-led format, whether it is taught online or in person. |
Supported in Part |
The Commission reiterates its recommendation. |
47) Until the specialized sexual offence investigation units are operational, NOSOIS should review all unfounded sexual assault files and should have final authority to determine whether the unfounded clearance code was appropriately used for each of the files reviewed and to change the code as required. |
Supported in Part |
The Commission reiterates its recommendation.
|
48) NOSOIS should ensure that it reviews a substantial number of sexual assault files that did not result in charges in each division. Review of this higher number of files should continue for each division until the specialized unit has been fully operational for several years and the issues observed are less serious or less frequent. |
Supported in Part |
The Commission reiterates its recommendation.
|
49) Following the NOSOIS file reviews and recommendations, a designated officer in each RCMP division should be required to provide a formal report to NOSOIS indicating any action taken and explaining the reasons for any decision not to follow a recommendation. |
Supported |
|
50) Once the specialized sexual offence investigation units are created, divisional coordinators should be embedded in the units and should be required to prepare regular reports to NOSOIS about the activities of the unit. |
Supported in Part |
The Commission reiterates its recommendation.
|
51) The RCMP should task NOSOIS with compiling the information it obtains about general trends and recurring issues of concern from its own reviews, the SAIRC reviews, the specialized units' oversight functions and activities in all divisions, as well as the divisional Case Manager reviews, and to provide regular reports to the specialized units (once established) about the issues observed. |
Supported in Part |
The Commission reiterates its recommendation.
|
52) The RCMP should substantially increase the number of RCMP members assigned to work as full-time members of NOSOIS. |
Supported in Part |
The Commission reiterates its recommendation.
|
53) The RCMP should formally define the mandate of NOSOIS, while maintaining sufficient flexibility to ensure that NOSOIS can address emergent issues. |
Supported |
|
54) Following the SAIRC file reviews and recommendations, a designated officer in each RCMP division should be required to provide a formal report to the SAIRCs, through the divisional Coordinator, indicating what action was taken as a result of each SAIRC recommendation and explaining the reasons for any decision not to follow a recommendation. |
Supported |
|
55) The RCMP should direct sufficient resources to the SAIRC reviews to ensure that a substantial number of randomly selected files not cleared by a charge is reviewed in each division. |
Supported |
|
56) Each division should have a clear guideline outlining the number of times the SAIRCs will meet and the number of files to be reviewed to meet the target number of reviews. The preferences and availability of the SAIRC members should be taken into account in determining the most efficient process for the reviews, which may include individual reviews or reviews in smaller groups. |
Supported |
|
57) The SAIRC members should be provided with the equipment and resources they need to conduct reviews efficiently. |
Supported |
|
58) The divisional coordinators should not be present during the SAIRC reviews. They should ensure that the SAIRCs are provided with a private space to conduct the reviews and hold discussions. |
Supported in Part |
The Commission reiterates its recommendation.
|
59) The divisional Coordinator should inform NOSOIS and the specialized sexual offence investigation unit in their division (once established) of the results of the SAIRC reviews and the division's responses. |
Supported |
|
60) Each RCMP division should ensure that one or more divisional Case Manager reviews all ongoing and recently closed sexual assault files until the specialized sexual offence investigation unit becomes operational. |
Supported in Part |
The Commission reiterates its recommendation.
|
61) The RCMP should require investigators, if they decide not to follow a recommendation by the Case Manager, to inform the Case Manager of their reasons for not following the recommendation, as well as to report the matter to their supervisor. |
Supported in Part |
The Commission reiterates its recommendation.
|
62) Divisional case managers should be required to provide reports to NOSOIS on a monthly basis about their file reviews, including the number of files reviewed, the recommendations made, any recommendations not followed, and the recurring issues noted. |
Supported in Part |
The Commission reiterates its recommendation.
|
63) The RCMP should amend its national policy on sexual offences to incorporate a direction to treat victims with compassion, care and respect throughout the investigative process. |
Supported |
|
64) The RCMP should amend its national policy on sexual offences to add guidance cautioning investigators about the risk of sexual assault victims not being believed based on inappropriate considerations, such as rape myths and stereotypes, or due to a lack of understanding of the impact of trauma. The policy should direct that members must document a rationale and consult with the specialized sexual offence investigation unit (once created) before taking investigative steps to question the validity of a sexual assault complaint or the credibility of the victim. |
Supported |
|
65) The RCMP should amend its national policy on sexual offences to add guidance reminding RCMP members of the importance of ensuring that a safety plan is in place for the victim and that the plan considers all aspects of the victim's safety. |
Supported |
|
66) The RCMP should amend its national policy on sexual offences to add a requirement that RCMP members offer referrals to community-based victim support services. |
Not Supported |
The Commission is satisfied that the measures to be taken by the RCMP adequately implement the intent of the recommendation. |
67) The RCMP should amend its national policy on sexual offences to add a requirement that RCMP members accommodate any request by the victim about the gender of the investigator, wherever possible. |
Supported |
|
68) The RCMP should amend its national policy on sexual offences to provide clear guidance on the role of RCMP members who act as first responders to sexual offences complaints. This guidance should include:
|
Supported in Part |
The Commission reiterates its recommendation, with additional explanations. |
69) The RCMP should amend its national policy on sexual offences to provide guidance on allowing victims to have a support person present during their interview with the RCMP investigator, where possible after considering the impact on the investigation. |
Supported |
|
70) The RCMP should amend its national policy on sexual offences to require the use of a soft interview room that maximizes the safety and comfort of the victim, wherever possible, while allowing for the necessary audio- or video-recording to occur. |
Supported in Part |
The Commission is satisfied that the measures to be taken by the RCMP are sufficient to implement the intent of the recommendation. |
71) The RCMP should amend its national policy on sexual offences to direct that RCMP members prioritize the continuity of the investigator, wherever possible and unless a change is requested by the victim, and to mandate that, if a change of investigator is unavoidable, the victim should be notified as soon as practicable, and the new investigator should make contact with the victim without delay. |
Supported |
|
72) The RCMP should consider including a specific mention in its national policy on sexual offences of the requirement to proactively provide updates to the victim on a regular basis. |
Supported |
|
73) The RCMP should amend its national policy on sexual offences to direct RCMP members to consider the needs of vulnerable victims, and to take appropriate action to address the barriers and issues they face. |
Supported |
|
74) The RCMP should amend the Sexual Assault Investigations: Best Practice Guide to:
|
Supported in Part |
The Commission is satisfied that the measures to be taken by the RCMP are consistent with the intent of the recommendation. |
75) The RCMP should send out the Sexual Assault Investigations: Best Practice Guide to all RCMP members who might be involved in receiving sexual assault complaints or conducting sexual assault investigations, as well as integrate the Guide into their mobile workstations. |
Not Supported |
The Commission is satisfied that the measures to be taken by the RCMP implement the intent of the recommendation. |
76) NOSOIS should be tasked with preparing annual or bi-annual reports for national and divisional RCMP senior leadership. The reports should compile and analyze all of the information NOSOIS receives, including:
|
Supported in Part |
The Commission reiterates its recommendation. |
77) The RCMP should set up appropriate processes to collect reliable and verified data about sexual assault investigations, including statistics about unfounded cases. |
Supported |
|
78) The RCMP should publish periodic updates about steps taken to improve sexual assault investigations and the results achieved. These updates should include:
|
Supported in Part |
The Commission reiterates its recommendation. |
79) Once the specialized units are created, the public updates should also include information about:
|
Supported |
Conclusion
[190] Pursuant to subsection 45.76(3) of the RCMP Act, the Commission has considered the RCMP Commissioner's response and submits this Final Report. The Commission reiterates its findings and recommendations, and its mandate in this matter is ended.
____________________
Brent Cotter, K.C.
Interim Chairperson