Broken Trust Recommendations Tracker

Recommendation: Nine of the TBPS sudden death investigations that the OIPRD reviewed are so problematic that the Director recommends these cases be reinvestigated.

Status: The re-investigation of the nine deaths was completed, and a confidential report was provided to the families of the deceased, the TBPS, TBPSB, and the OIPRD on March 3, 2022.

Deficiencies in the original investigations were noted in each of the nine deaths, and a change in the cause of death was made in one case.

Recommendation: A multi-discipline investigation team should be established to undertake, at a minimum, the reinvestigation of the deaths of the nine Indigenous people identified.

Status: See Recommendation 01.

Recommendation: The multi-discipline investigative team should establish a protocol for determining whether other TBPS sudden death investigations should be reinvestigated.

Status: The multi-discipline investigative team did not establish a protocol. However, it identified additional TBPS sudden death investigations for potential reinvestigation, and the Officer of the Chief Coroner is undertaking a systemic review of the Broken Trust Re-Investigation of Indigenous deaths in Thunder Bay.

Update as of June 2023: OPP is reinvestigating 13 sudden deaths originally investigated by TBPS between 2006-2019.

Recommendation: The multi-discipline investigation team should also reassess whether the death of Stacy DeBungee should be reinvestigated, based on our investigative report and the Ontario Provincial Police review of the TBPS investigation. The team should also assess when and how the investigation should take place, without prejudicing ongoing Police Services Act proceedings.

Status: The OPP is reinvestigating the death of Stacy DeBungee.

Recommendation: TBPS should initiate an external peer-review process for at least three years following the release of this report.

Status: The TBPS has advised that the multi-discipline investigation team did not provide a document detailing best practices for a peer-review process. Accordingly, the TBPS advises that it continues to revise how it conducts sudden death reviews to reflect best practices.

Update as of December 2023: Extensive and positive progress has been made resulting in a new Sudden Death Policy which the Service is still reviewing. Once the Service finalizes a draft of the new policy, the OIPRD could review it prior to its presentation to the Board.

Update as of April 2024: Following consultation with LECA (formerly known as OIPRD), this recommendation was incorporated and addressed in the Sudden Death Policy adopted by the TBPSB.

Recommendation: TBPS should immediately ensure sufficient staffing in its General Investigation Unit in the Criminal Investigations Branch. Adequate resources must be mad available to enable this recommendation to be implemented on an urgent basis.

Status: The TBPS implementation report to the TBPSB in January 2022 indicates this recommendation is complete, and the January 2023 report indicates further progress.

Recommendation: TBPS should establish a Major Crimes Unit – within the Criminal Investigations Branch – that complies with provincial standards and best practices in how it investigates serious cases, including homicide, sudden deaths, and complex cases.

Status: The TBPS implementation report to the TBPSB in January 2022 indicates this recommendation is complete, and the January 2023 report indicates further progress.

Recommendation: TBPS should provide officers who have taken appropriate training with opportunities to be assigned to work with the Criminal Investigations Branch and the Major Crimes Unit investigators to gain experience.

Status: The TBPS implementation report to the TBPSB in January 2022 indicates this recommendation is complete, and the January 2023 report indicates further progress.

Recommendation: TBPS should develop a formalized plan or protocol for training and mentoring officers assigned to the Criminal Investigations Branch and the Major Crimes Unit.

Status: The TBPS implementation report to the TBPSB in January 2022 and January 2023 indicates implementation of this recommendation is ongoing.

Update as of June 2023: Pending further review.

Update as of December 2023: Positive progress has been made in the TBPS’s Major Crimes Unit, with all members fully trained and meeting key standards, satisfying this recommendation.

Recommendation: TBPS should develop a strategic human resources succession plan to ensure the General Investigations Unit, Criminal Investigations Branch and the Major Crime Unit is never without officers who are experienced in investigations.

Status: The TBPS implementation report to the TBPSB in January 2022 and January 2023 indicates implementation of this recommendation is ongoing.

Update as of December 2023: Positive progress has been made through the implementing of a strategic human resources succession plan, satisfying this recommendation.

Recommendation: TBPS should establish procedures to ensure occurrence or supplementary reports relevant to an investigation are brought to the attention of the lead investigator or case manager. This must take place regardless of whether a case has been earmarked for Major Case Management.

Status: The TBPS implementation report to the TBPSB in January 2022 and January 2023 indicates this recommendation is complete. In particular, the TBPS shared a letter dated September 15, 2022, from the Director of Ontario Major Case Management stating, among other things, that all areas arising from the 2018 inspection have been addressed and, overall, the TBPS annual report submissions and major case entries indicate effective use of major case management.

Recommendation: TBPS should develop procedures to ensure forensic identification officers are provided with the information necessary to do their work effectively.

Status: All members of the criminal investigation bureau have received training, and a protocol is in place with the coroner to ensure open communication and formal case conferences have taken place since October 2021.

After TBPS initially reported that this recommendation as complete, the OIPRD requested clarification, and TBPS responded with reference to its sudden death policy. However, upon review, this policy does not include an express directive ensuring initial or ongoing communication between lead investigators, case managers, and forensic officers.

Update as of December 2023: Positive progress has been made through directives, which are already in effect, and draft policy. Once the Service finalizes a draft of the new policy, the OIPRD could review it prior to its presentation to the Board.

Update as of January 2024: The Director commends the service’s extensive efforts and dedication in finalizing the draft of the Sudden Death Policy. This draft will now be brought forward to the TBPSB for review.

Update as of April 2024: The TBPSB has adopted the Sudden Death Policy, and the directives have been implemented. To maintain and enhance this progress, the chief and the board should conduct an annual review.

Recommendation: TBPS should immediately improve how it employs, structures, and integrates its investigation file management system, Major Case Management system and its Niche database.

Status: The TBPS implementation reports to the TBPSB indicate that the new system was fully operational as of July 2022.

Recommendation: TBPS should, on a priority basis, establish protocols with other police services in the region, including Nishnawbe Aski Police Service and Anishinabek Police Service to enhance information-sharing.

Status: TBPS has indicated that both formal and informal protocols exist in relation to communications and information sharing with these police services and the Ontario Provincial Police. TBPS and Nishnawbe Aski Police Service now have a formal protocol to enhance their relationship and share resources to better deliver police services to the community.

The OIPRD notes that external police services are in the best position to review and advise if TBPS’ existing protocols for sharing information are effective. However, the new systems noted above address concerns about the TBPS’ capacity to share information quickly and effectively with regional police services.

Update as of June 2023: On June 6, 2023, Nishnawbe Aski Police Service (NAPS) Chief Roland Morrison and Thunder Bay Police Service (TBPS) Chief Darcy Fleury signed a historic Framework Agreement of Partnership between their respective police services.

Recommendation: TBPS should fully integrate the Aboriginal Liaison Unit’s role into additional areas of the police service. This would help to promote respectful relationships between TBPS and the Indigenous people it serves.

Status: TBPS has replaced the ALU with the Community Inclusion Team (CIT), which includes two Indigenous Liaison Officers trained by the Ontario Provincial Police and a civilian coordinator who are available to assist all areas of the service. The CIT will be evaluated on effectiveness through quarterly and annual reports.

Update as of December 2023: Positive progress has been made to fully integrate the Aboriginal Liaison Unit’s role into more areas of the police service, thus satisfying this recommendation.

Recommendation: TBPS should increase the number of officers in the Aboriginal Liaison Unit by at least three additional officers.

Status: ALU has been replaced by the CIT with two Indigenous Liaison Officers and a civilian coordinator. TBPS reports no plans to increase the number of officers at this time.

Update as of June 2023: TBPS has proposed an increase in the number of members in the CIT Unit with an additional CIT Liaison Officer and a dedicated Sergeant. A long-term business plan has been submitted through the budget planning process.

Update as of December 2023: Positive progress has been made to expand the Aboriginal Liaison Unit, thus satisfying this recommendation.

Recommendation: With Indigenous engagement and advice, TBPS should take measures to acknowledge Indigenous culture inside headquarters or immediately outside it.

Status: The OIPRD notes that it is up to the TBPS Chief and TBPSB to engage with Indigenous leaders and communities to determine if this recommendation has been fully implemented. In the Fall 2022, TBPS senior leadership held its first in-person meeting with the Elders Advisory Group to obtain their input on activities.

Update as of April 2024: Extensive and positive progress has been made to meet this recommendation. The service is working diligently to create and display the Seven Grandfather Teachings on their bank windows facing Balmoral.

Recommendation: TBPS should make wearing name tags on the front of uniforms mandatory for all officers in the service.

Status: TBPS reported that in August 2020, an internal directive was sent to all officers stating that a name tag was now a mandatory and permanent part of their uniform.

Recommendation: TBPS should implement the use of in-car cameras and body-worn cameras.

Status: TBPS reported that body-worn cameras were deployed for all front-line officers in the uniform and traffic units, and in-car cameras were installed and operational in thirty primary response vehicles by July 2021.

Recommendation: TBPS should, through policy, impose and reinforce a positive duty on all officers to disclose potential evidence of police misconduct.

Status: As noted in One Year After Broken Trust: Report on Implementation, this recommendation was fully implemented.

Recommendation: The Director urges the Ontario government to bring into force Schedule 7, the Missing Persons Act, 2018, as soon as possible.

Recommendation: TBPS and the Board should re-evaluate their missing persons policies, procedures, and practices upon review of the report of the National Inquiry into Missing and Murdered Indigenous Women and Girls, due to be released on or before April 30, 2019.

Status: TBPS reports that it is developing and implementing policies and procedures, on an ongoing basis, in line with the MMIWG report.

The OIPRD continues to review new iterations of the TBPS missing persons policies, procedures, and practices to ensure that they specifically address Indigenous persons reported missing in Thunder Bay.

Update as of January 2024: OIPRD reviewed the Missing Persons Policy prior to its approval by the TBPSB, provided extensive feedback, which was reflected in the final policy. The Director commends the Chief and TBPSB for finalizing this policy and pursuing feedback from the community through a public consultation process.

Recommendation: TBPS and the Board should re-evaluate their missing persons policies, procedures, and practices upon review of the Honorable Gloria Epstein’s report on Toronto Police Service’s missing persons investigations due to be released in April 2020.

Status: TBPS reports that it is developing and implementing policies and procedures, on an ongoing basis, in line with the Honorable Gloria Epstein’s report.

The OIPRD continues to review new iterations of the TBPS missing persons policies, procedures, and practices to ensure that they specifically address Indigenous persons reported missing in Thunder Bay.

Update as of January 2024: OIPRD reviewed the Missing Persons Policy prior to its approval by the TBPSB, provided extensive feedback, which was reflected in the final policy. The Director commends the Chief and TBPSB for finalizing this policy and pursuing feedback from the community through a public consultation process.

Recommendation: The Office of the Chief Coroner, Ontario’s Chief Forensic Pathologist, the Regional Coroner, and TBPS should implement the Thunder Bay Death Investigations Framework on a priority basis and should evaluate and modify it as required, with the input of the parties, annually.

Status: TBPS reports that it has concluded in-house training on the framework with all officers addressing the relationship between the police and the coroner.

The OIPRD notes that the Office of the Chief Coroner is conducting a Systemic Review of the Broken Trust Re-investigation of Indigenous deaths in Thunder Bay, which could impact the full implementation of recommendations 24-31.

Recommendation: The Office of the Chief Coroner should ensure police officers and coroners are trained on the framework to promote its effective implementation.

Status: The OIPRD notes that the Office of the Chief Coroner is conducting a Systemic Review of the Broken Trust Re-investigation of Indigenous deaths in Thunder Bay, which could impact the full implementation of recommendations 24-31.

Recommendation: The Office of the Chief Coroner and TBPS should publicly report on the ongoing implementation on the framework in a way that does not prejudice ongoing investigations or prosecutions.

Status: The OIPRD notes that the Office of the Chief Coroner is conducting a Systemic Review of the Broken Trust Re-investigation of Indigenous deaths in Thunder Bay, which could impact the full implementation of recommendations 24-31.

Recommendation: The Ontario Forensic Pathology Service (OFPS) should train all pathologists on the Intersection of Police and Coroners for Thunder Bay Death Investigations as set out in the framework.

Status: As noted in One Year After Broken Trust, the OFPS shared a document entitled the Intersection of Police and Coroners for Thunder Bay Death Investigations that addresses high quality death investigations on the registry.

The OIPRD notes that the Office of the Chief Coroner is conducting a Systemic Review of the Broken Trust Re-investigation of Indigenous deaths in Thunder Bay, which could impact the full implementation of recommendations 24-31.

Recommendation: TBPS should reflect, in its procedures and training, fundamental principles to define the relationship between investigators and pathologists.

Status: As noted in One Year After Broken Trust, the TBPS revised its sudden death policy to reflect the above and training has been provided to all officers. TBPS also reports that it completes an Ontario Forensic Pathology Service “Preliminary Police Report” form.

The OIPRD notes that the Office of the Chief Coroner is conducting a Systemic Review of the Broken Trust Re-investigation of Indigenous deaths in Thunder Bay, which could impact the full implementation of recommendations 24-31.

Update as of December 2023: Positive progress has been made through directives, which are already in effect, and draft policy. Once the Service finalizes a draft of the new policy, the OIPRD could review it prior to its presentation to the Board.

Update as of January 2024: The Director commends the service’s extensive efforts and dedication in finalizing the draft of the Sudden Death Policy. This draft will now be brought forward to the TBPSB for review.

Update as of April 2024: The TBPSB has adopted the Sudden Death Policy, and the directives have been implemented. To maintain and enhance this progress, the chief and the board should conduct an annual review.

Recommendation: The Ontario Forensic Pathology Service should establish a Forensic Pathology Unit in Thunder Bay, ideally housed alongside the Regional Coroner’s Office.

Status: The OIPRD notes that the Office of the Chief Coroner is conducting a Systemic Review of the Broken Trust Re-investigation of Indigenous deaths in Thunder Bay, which could impact the full implementation of recommendations 24-31.

Recommendation: If a Forensic Pathology Until cannot be located in Thunder Bay, TBPS and the Ontario Forensic Pathology Service should establish, on a priority basis, procedures to ensure timely and accurate exchange of information on sudden death and homicide investigations and regular case-conferencing on such cases.

Status: The TBPS has entered into a memorandum of understanding with the Toronto Police Service for their assistance in ensuring the continuity of evidence and reducing delays and travel costs.

The OIPRD notes that the Office of the Chief Coroner is conducting a Systemic Review of the Broken Trust Re-investigation of Indigenous deaths in Thunder Bay, which could impact the full implementation of recommendations 24-31.

Update as of June 2023: TBPS completes an Ontario Forensic Pathology Service “Preliminary Police Report” form for everybody sent to Toronto for post-mortem. This form includes the name, rank, and badge number of the Major Crimes Unit Investigator and Forensic Identification Unit Investigator, as well as a brief description of the scene and the circumstances surrounding the death. (Pending Coroner’s systemic review report).

Recommendation: The Ontario Forensic Pathology Service should provide autopsy services compatible with cultural norms in Indigenous communities

Status: The OIPRD notes that the Office of the Chief Coroner is conducting a Systemic Review of the Broken Trust Re-investigation of Indigenous deaths in Thunder Bay, which could impact the full implementation of recommendations 24-31.

Recommendation: TBPS should focus proactively on actions to eliminate systemic racism, including removing systemic barriers and the root causes of racial inequities in the service. TBPS should undertake a human rights organizational changes strategy and action plan as recommended by the Ontario Human Rights Commission in October 2016.

Status: TBPS reports that the service is undergoing an organizational change project led by the Chief that started in April 2018, which led to the change from the Aboriginal Liaison Unit to the Community Inclusion Team and an internal Equity, Diversity, and Inclusion Committee, including training sessions for all service members.

Update as of December 2023: Positive progress has been made. To maintain and enhance this progress, the chief and the board should conduct an annual review.

Recommendation: TBPS leadership should publicly and formally acknowledge that racism exists at all levels within the police service, and it will not tolerate racist views or actions. TBPS leadership should engage with Indigenous communities on the form and content of these acknowledgements. This would be an important step in TBPS advancing reconciliation with Indigenous people.

Status: As noted in One Year After Broken Trust, this recommendation was fully implemented.

Recommendation: The Thunder Bay Police Services Board should publicly and formally acknowledge that racism exists within TBPS and take a leadership role in repairing the relationship between the TBPS and Indigenous communities. This, too, would be an important step in TBPS advancing reconciliation with Indigenous people.

Status: As noted in One Year After Broken Trust, the TBPSB publicly acknowledged institutional racism. However, the OIPRD does not consider that the TBPSB has taken a leadership role in repairing the relationship between the TBPS and Indigenous communities.

Recommendation: TBPS leadership should create a permanent advisory group involving the police chief and Indigenous leadership with a defined mandate, regular meetings, and a mechanism for crisis driven meetings to address racism within TBPS and other issues.

Status: TBPS reports that the Executive Committee on Indigenous and Diversity Issues meets quarterly acting as an advisory group to the Chief of Police when major incidents occur that require community input. However, the mandate of this committee is being redefined as part of the service wide organizational change project.

Update as of April 2024: Positive progress has been made in establishing an Indigenous Chief’s Advisory Committee with representatives from First Nations governments and agencies. The service is holding monthly meetings and diligently working with the committee to develop the terms of reference.

Recommendation: TBPS should work with training experts, Indigenous leaders, Elders and the Indigenous Justice Division of the Ministry of the Attorney General to design and implement mandatory Indigenous cultural competency and anti-racism training for all TBPS officers and employees, that:

1. Is ongoing throughout the career of a TBPS officer or employee
2. Involves “experiential training” that includes Indigenous Elders and community
   members who can share their perspective and answer questions based on their own
   lived experiences
3. Is informed by content determined at the local level, and informed by all best practices
4. Is interactive and allows for respectful dialogue involving all participants
5. Reflects the diversity within Indigenous communities, rather than focusing on one
   culture to the exclusion of others
6. Explains how the diversity of Indigenous people and pre and post contact history
   is relevant to the ongoing work of TBPS officers and employees. For example,
   Indigenous culture and practices are highly relevant to how officers should serve
   Indigenous people, conduct missing persons investigations, build trust, accommodate
   practices associated with the deaths of loved ones and avoid micro-aggressions.
   Micro-aggressions are daily verbal or non-verbal slights, snubs, or insults that
   communicate, often inadvertently, derogatory or negative messages to members of
   vulnerable or marginalized communities.

Status: The Chief of Police and the majority of the TBPS senior management team, along with members of the TBPSB and the Thunder Bay Police Association, completed the Bimickaway cultural awareness training provided by the Ministry of the Attorney General’s Indigenous Justice Division.

TBPS reports that the Curriculum Working Group, with expert assistance from Dr. Leisa Desmoulins, are developing a training curriculum in consultation with experts and trainers from across the justice sector. The curriculum was approved in December 2021, and all members are scheduled for training in the next two year.

Update as of December 2023: Positive progress has been made. To maintain and enhance this progress, the chief and the board should conduct an annual review.

Recommendation: TBPS should ensure the Indigenous cultural competency training recommended in this report is accompanied by initiatives in collaboration with First Nations police services that allow TBPS officer to train or work with First Nations police service and visit remote First Nations to provide outreach.

Status: TBPS reports that a community outreach project where TBPS officers visit First Nations communities continues. The OIPRD notes an absence of any formal mechanisms for TBPS officers to train or work with First Nations Police Services.

Update as of December 2023: Positive progress has been made through the MOU with NAPS, fostering better collaboration. To maintain and enhance this progress, the chief and the board should conduct an annual review.

Recommendation: TBPS leadership should provide greater support for voluntarism by attending relevant sporting or community events.

Status: When a TBPS member is identified as having demonstrated outstanding commitment to volunteering in the community, they are presented a certificate of recognition by the TBPSB.

Update as of April 2024: Extensive and positive progress has been made by the TBPS leadership to participate and volunteer in community events.

Recommendation: TBPS should develop and enhance additional cultural awareness training programs relating to the diverse community it serves.

Status: TBPS reports that the Community Inclusion Team established FACT Fridays, communicating information to all members of the TBPS on cultural awareness topics to inform and promote understanding.

Update as of December 2023: TBPS should continue its efforts to satisfy this recommendation. The chief and the board should conduct an annual review.

Update as of April 2024: The service plans to form a Chief’s Diversity Committee in 2024 to address this recommendation. To maintain and enhance this progress, the chief and the board should conduct an annual review.

Recommendation: TBPS should implement psychological testing designed to eliminate applicants who have or express racist views and attitudes. In Ontario, such specific testing is not done. It can be tailored to the TBPS experiences. This testing should be implemented in Thunder Bay on a priority basis.

Status: TBPS reports that extensive psychological testing is now done, including testing for potentially racially offensive conduct. Candidates with concerning or inconclusive test results meet with a psychologist. Candidates with concerning test results are screened out of the hiring process.

Recommendation: TBPS should, on a priority basis, create and adopt a proactive strategy to increase diversity within the service, with prominence given to Indigenous candidates.

Status: TBPS reports that the entire recruitment process has been redeveloped with a focus on removing systemic barriers disproportionately encountered by Indigenous candidates. The service is expanding its human resources department and is focusing its recruitment efforts with communities, including First Nations, in Northwestern Ontario and Manitoba.

Update as of December 2023: Positive progress has been made to the recruitment process. To maintain and enhance this progress, the chief and the board should conduct an annual review.

Recommendation: TBPS leadership should link job promotion to demonstrated Indigenous cultural competency.

Status: TBPS reports that its 2020-2023 collective agreement and internal processes now focus less on exam results and more on the experience and diversity of each individual.

Update as of June 2023: In the 2023 promotional process, there is a 30% weight attached to the candidate’s resume and 70% weight placed on the interview portion.

A candidate’s resume is scored using a matrix, which allows for points to be awarded for attending cultural competency training and holding positions that showcase a candidate’s cultural awareness, both within the Service and volunteer work outside of the Service. Additionally, a minimum of one (1) questions during the interview will be based on cultural competency and awareness – representing a total of 11.6 percent of a candidate’s overall score in the process.

A candidate must showcase the requisite knowledge, skills, and appropriate competency to receive a passing mark. As the promotional process is tied to the Collective Agreement, the process can be revisited in 2024 when collective bargaining occurs.

Update as of December 2023: Positive progress has been made. To maintain and enhance this progress, the chief and the board should conduct an annual review.

Recommendation: TBPS should report to the OIPRD on the extent to which the recommendations in this report are implemented. This is imperative, given the crisis of confidence described in this report. The OIPRD should, in turn, report publicly on TBPS’s response and the extent to which the recommendations in this report are implemented.

Status: TBPS publicly reports its progress through frequent reports to the TBPSB, which the OIPRD monitors, and provides an annual report to the OIPRD.

Recommendation: On an annual basis, TBPS should provide public reports that provide data on sudden death investigations. These reports can provide data, in a disaggregated Indigenous and non-Indigenous manner, detailing the total number of sudden death investigations with a breakdown of investigative outcomes, including homicide, accidental death, suicide, natural death, and undetermined.

Status: Based on the most recent TBPS report to the TBPSB, it appears that this recommendation has not been implemented. TBPS maintains that most of the data exists in its annual reporting but will assess a different reporting model to fully implement this recommendation.

Update as of January 2024: The TBPS publishes an annual report that includes number of sudden deaths and homicides investigated.