Missed and Missing - Vol IV

AND SSED
Report of The Independent Civilian

Review into Missing Person
Investigations
The Honourable Gloria J. Epstein

Independent Reviewer
VOLUME I
Executive Summary
and Recommendations
VOLUME II
Investigations
VOLUME Ill
Relationships: The Police
and Communities
VOLUME IV
Recommendations, Conclusion,
and Appendices
Missing and Missed
Report of the Independent Civilian Review
into Missing Person Investigations
The Honourable Gloria J. Epstein

Independent Reviewer
Volume I – Executive Summary and Recommendations

Volume II – Investigations
Volume III – Relationships: The Police and Communities
Volume IV – Recommendations, Conclusion, and Appendices
The Independent Civilian Review into Missing Person
Investigations respectfully acknowledges that our work took
place in Toronto on the traditional territory of many nations
including the Mississaugas of the Credit, the Anishnabeg,
the Chippewa, the Haudenosaunee and the Wendat peoples.
We also acknowledge that Toronto is covered by Treaty 13
signed with the Mississaugas of the Credit, and the Williams
Treaties signed with multiple Mississaugas and
Chippewa bands. Toronto is now home to many diverse
First Nations, Inuit and Métis peoples, to whom we are
grateful for the opportunity to meet, to work and to feel safe
together.
Statement for cover design:

This is a thoughtful moment in time, silhouetted against a
spectrum of colours that layer, blend, and contrast to create
beauty. Inclusive, intersective beauty. The duality of looking
both forward and backwards carries that weighted emotion
where sadness gives way to hope. The design incorporates
the 2018 Progress Pride Flag design of Daniel Quasar. His
rendition combines the Transgender Pride Flag created by
Monica Helms and the original Pride Flag created by artist
Gilbert Baker. Designs have undergone revisions since its
debut in 1978.
~ Sarah Currie
Copyright © Toronto Police Services Board 2021

Contents
15 RECOMMENDATIONS 719
Civilian Oversight (Chapter 3) 722
Toronto Police Services Board Policies 727
Major Case Management and Technology (Chapter 4) 727
Changes to the Ontario Major Case Management Manual 732
Records Management Systems 733
ViCLAS Reporting 733
The Serial Predator Criminal Investigations Coordinator 734
Missing Person Investigations (Chapters 5–9, 12) 736
The Components of a Missing Person Strategic Plan 736
Priority of Missing Person Investigations 739
The Mid-Term Missing Person Model 740
Changes to the Missing Persons Unit and Divisional Staffing 744
Support for Those Directly Affected by Someone Missing 747
The Role of Not-for-Profit Organizations or Charities 754
Risk Assessments 755
The Major Case Designation in Missing Person Cases 765
Criminal Investigation Management Plan 770
Assignments and Continuity of Investigation and Supervision 772
Assignment of Specific Investigators 774
Community Partnership and Engagement 775
Active Involvement of Communities in Advancing Missing Person Investigations 777
Information Sharing by the Police 778
Accessibility of Information 782
Public Warnings 786
Partnerships with Group Homes and Youth-Related Institutions 786
Use of Liaison and Neighbourhood Community Officers 788
Prevention Strategies 789
Missing Person Awareness Days 791
Specific Investigative Issues (Chapters 5–13) 792
Electronic and Internet Searches 792
The Use of Analysts 793
Communication with Another Service 794
i Contents
v
Templates or Checklists for Missing Person Investigations 795

Interviewing 797
300 Metre Searches and Ground Searches 798
Video Footage 800
Access to Hospital-Related Information 801
Memobooks (Chapters 5–9) 802
Unidentified Remains (Chapters 9, 13) 803
Notifications to the Homicide Unit 805
Internal Review of Investigations and Supervision (Chapters 5–9, 13) 806
Reviews of Investigations 806
The Approach to Supervision Generally 807
Removing Barriers (Chapters 5–9, 12–14) 808
Acknowledgements of Deficiencies (Chapters 7, 12, 14) 811
Training, Education, and Professional Development (Chapters 4–14) 814
Minimum Educational Requirements for Recruits 816
Training and Education of Cadets and the Service’s Members 817
The Current Regime 817
Training and Education Based on the Review’s Findings 818
Specialized Training and Education 820
Critical Thinking and Social Context Education 821
Professional Development and Promotion 825
A Centre for Policing Excellence 825
Research and Academic Institutions (Chapter 13-14) 829
Bias and Discrimination (Chapters 12 and 14) 829
Psychological Testing 831
An Equity Plan and Framework 832
Equity Audits 834
Discipline and Discrimination 836
Relationship Building (Chapter 14) 840
Community Consultative Committees 842
Broader Community Engagement 848
Liaison Officers 850
Part-Time Liaison Officers at the Divisional Level 853
The Neighbourhood Community Officer Program 855
Internal Support Networks 856
Need to Involve Other Community Safety Partners 858
Records
in the
Pride (Chapter 14) Possessio
Implementation
Contents v
n of the Toronto Police Service Resources
860
16 CONCLUSION
861
Appendices 868
Appendix A: Terms of Reference 868
Appendix B: Community Advisory Group
Appendix C: Participants in the Policy Roundtable 871
Appendix D: Organizations and Community
Groups
875
884
888
895
Appendix E: Community Engagement Survey 897
Recommendations 719
Chapter 15
RECOMMENDATIONS
There is nothing we can do to change the past but we can still

attempt to correct those mistakes before they become the focus of an
inquiry, media exposure or civil liability.
– Detective Constable Joel Manherz, 2017
Organizationally, we continue to work on our relationship with the

police because we do believe it is a very important one. I think that the
police are under a tremendous amount of pressure. But there needs
to be a seismic shift and demonstrable change in the culture, the
organization, and I think too the leadership of the police for our
community to even begin to reach out a hand to say we’re even open
to a conversation. I think people have just felt abused for decades.
– Community stakeholder, 2020
This Report is titled Missing and Missed. Missing refers to those who have
gone missing and whose disappearances must be addressed in bold new ways.
Missed refers both to those individuals whose memories we honour, and to the
missed opportunities in the investigations under review and past missed
opportunities for change. Given the circumstances that prompted this Review,
and the importance of recent events, the opportunity presented now cannot be
squandered.
In the previous chapters, I find serious deficiencies in how the Toronto
Police Service (the Service) has conducted missing person investigations.
These deficiencies were manifested in a number of the investigations1 into the
disappearances of Bruce McArthur’s victims, as well as in the investigations
relating to Tess Richey, Alloura Wells, and others. Although overt or
intentional discrimination does not explain those deficiencies, I conclude that
1
As I explain in Chapter 7, Project Prism was, in large measure, effective in the investigation of several of
McArthur’s victims, and ultimately in identifying him as the person responsible for eight murders.
systemic differential treatment contributed to them. I document recent,
significant improvements in how missing person investigations are being
conducted – most notably in the creation of a centralized Missing Persons Unit
– but much remains to be done:
 in giving these cases the priority they deserve;

 in creating a new model that gives civilians within the Service and social
service, public health, and community agencies critical responsibilities for
responding to disappearances;
 in ensuring that those disappearances requiring a law enforcement
response be investigated in an effective, timely, and discrimination-free
way;
 in redefining the relationship between the Service and the LGBTQ2S+ and
marginalized and vulnerable communities and addressing, head-on,
systemic discrimination; and
 in ensuring effective civilian oversight, accountability, and transparency in
relation to what the police do.
The Review has been successful in engaging on a broad basis with

many members of diverse communities and groups, many past and current
police officers in and outside Toronto, as well as experts from around the
world. No one who sought to speak to me was turned down. At the Review’s
initiative, I and other members of the team spoke to many others. We also
received written submissions from a number of organizations. Many were
posted on the Review’s website.
My mandate was undoubtedly complicated – and often complemented –
by the wealth of new ideas. These ideas came from initiatives, legislation,
policies, procedures, and practices introduced or discussed during the Review,
including those that arose in the summer of 2020 with renewed demands to
defund or de-task the police after the police killing of George Floyd that May.
In drafting my recommendations, I have also considered the findings
and recommendations made in earlier reports, which I have summarized in
Chapter 11. For example, in many ways, the investigations into the
disappearances of Robert Pickton’s victims in British Columbia were
strikingly similar to those I have identified in this Report. In Chapter 12, I
refer to Judge Wally Oppal’s findings of systemic discrimination in the
investigation of marginalized women in Vancouver’s Downtown Eastside,
many of whom were Indigenous. He also found that the police did not
respond urgently to reports of these women’s disappearances and did not
conduct some key interviews for months and others not at all. The
police did not share
investigative steps taken with those close to the missing women and, at times,
dismissed the families’ belief that something was wrong with their loved ones.
There was no consistency in the investigative avenues taken or in their follow-
up. The police reliance on the “no body, no crime” theory contributed to
inaccurate risk assessments. In their public communications, the police
took the position that there was no evidence of a serial killer. The police
interviews of Pickton were completely unplanned. The police ignored
crucial evidence about a female survivor’s horrifying encounter with
Pickton. Judge Oppal placed heavy emphasis on the ineffectiveness of the
investigations because of the failure of the police to actively seek out the
assistance of community leaders to advance their investigations.
It is troubling that every one of these findings can equally be said about
a number of the Service’s investigations that I evaluate in this Report. I point
out that the Oppal Report was publicly released in 2012 – during Project
Houston. Even a superficial review of the Oppal Report’s findings and
recommendations should have prompted the Service to evaluate its own
investigations or at least question whether these investigations could be flawed
in the same ways. This lack of introspection explains, in part, why my
recommendations on implementation are pointed and detailed.
The missed learning opportunities were not limited to the Oppal Report.
Closer to home, the Toronto police seemed to have not learned the lessons of
the 1981 bathhouse raids when, in 2016, a few months after Chief Mark
Saunders apologized for them, the Service conducted Project Marie.
Project Marie resulted in the ticketing of gay men in the Marie Curtis Park that
further strained relationships with the LGBTQ2S+ communities. This was
especially true because, as many officers within the Service recognized,
Project Marie could have been avoided altogether through community
dialogue and solutions, rather than resorting to the law enforcement
measures taken. In 2000, the Service, including male officers, raided a
lesbian bathhouse. Despite a 2004 settlement of a human rights complaint
about this raid, the Service subsequently faced another human rights
complaint relating to its failure to respect the gender identity and expression
of trans women, resulting in a settlement in 2016 that is only now being
implemented. These events all took place in the context of the Service’s
legacy and ongoing issues in its relationships with Black, LGBTQ2S+,
South Asian, Indigenous, and other marginalized and vulnerable
communities.
However, I would be remiss in failing to mention that I met with many
officers and many civilian members of the Service whose commitment to
equity, diversity, and high-quality policing was nothing less than outstanding.
My recommendations follow. They are designed to address the systemic
issues identified during the Review and provide a plan for their
implementation in a way that ensures transparency and accountability. They
are accompanied by commentary, some of which has been taken from
earlier chapters, that explains their rationale.
The recommendations are divided into categories that correspond with
the topics the Report addresses. It is important to bear in mind that many of
my recommendations pertaining to missing person investigations and to bias
or discrimination are also designed to enable the Service to build and improve
its relationships with marginalized and vulnerable communities. Nonetheless,
I also outline additional measures to meaningfully improve those relationships
that apply to all the Service’s work.
Civilian Oversight (Chapter 3)
The importance of effective civilian oversight of the police cannot be

overemphasized. As I explain in Chapter 3, effective civilian oversight
promotes public respect for the police through a model that involves both
governance and accountability. It can also serve as a means to ensure that
special attention is given to the oversight of policing that affects communities
with a troubled relationship with the police, including racialized, LGBTQ2S+,
Indigenous, homeless or underhoused, and others this Report identifies.
The evidence discloses that the Service failed to share with the
Board operational matters that potentially impacted on the Service’s
reputation, its relationship with diverse communities, and on potential Board
policies as well as appropriate advice or direction to the chief of police. For
example, I was quite troubled to learn that the Board and its chair were
never advised that Project Houston was taking place or had taken place. It is
beyond doubt that Project Houston was precisely the type of operation,
especially once it wound down its operations, that passed the “critical point”
Judge John W. Morden described during the Independent Civilian Review into
Matters Relating to the G20 Summit. During the period I examined, there
continued to be a misunderstanding about information that must be shared
with the Board. As a result, important information was not shared. For
example, reports from the Service’s Audit and Quality Assurance Unit that
raised reputational or systemic concerns were not shared with the Board,
despite their obvious relevance to policy-making, establishing priorities
for the Service, and appropriate direction to the chief of police. (See Chapter
3).
A police services board cannot fulfill its statutory oversight
responsibilities if it is not informed about “critical points” in policing or is
overly deferential to its chief or its police service. Equally, a board oversteps
its statutory responsibilities if it attempts to usurp the chief’s role or to
interfere with the service’s protected core of independence around specific
investigations.
My recommendations build upon Judge Morden’s important work. They
provide clarity on what constitutes “critical points.” They are designed to
promote greater oversight of the Service in a way that is consistent with the
Board’s responsibilities and the relevant sections of the current Police Services
Act and the as yet unproclaimed Community Safety and Policing Act, 2019.
When proclaimed, that new legislation will reinforce the Board’s important
role in police governance and the need for the Board to be responsive to
diverse communities.
RECOMMENDATIONS
1 The Toronto Police Services Board and any future chief of police
should publicly commit to the robust oversight by the Board
recommended in the Independent Civilian Review into Matters
Relating to the G20 Summit, conducted by the Hon. John W. Morden
(June 2012), as explained and amplified in this Report.
2 The Toronto Police Services Board should adopt a policy clearly
defining the types of information that the chief of police should share
with the Board, including what constitutes a “critical point.” The
policy should specify when and how those types of information
should be shared. This policy should be prepared by the Board in
consultation with the Toronto Police Service, and as originally
recommended in the Independent Civilian Review into Matters
Relating to the G20 Summit.
3 The policy outlined in Recommendation 2 should identify criteria that
must be applied in determining when a “critical point” has been
reached. At a minimum, such criteria should include:
(a) a policing operation, event, or organizationally significant issue

requiring command level approval (i.e., by the chief of police or
deputy chief of police) or command level advance planning,
(b) operations that may have a material impact on the Toronto
Police Service’s relationship with, and servicing of, marginalized
and vulnerable communities, including those communities in
which significant numbers of community members mistrust the
police. These include racialized, Indigenous, LGBTQ2S+,
homeless or underhoused, and others identified in this Report,
as well as the intersection of these communities. Included here
are operational decisions that may have a material impact on
future relationships with these communities;
(c) operations that may impact, in a material way, on the Service’s
reputation or its effectiveness;
(d) operational matters, even ones involving an individual case, if
they raise questions of public policy;
(e) internal audits or analogous documents that identify systemic
issues within the Service; and
(f) complaints against individual officers and the Service and
findings about discrimination by other tribunals that raise
systemic issues.
A concrete example of an operational matter that raised questions of public

policy and had a significant impact on the Service’s reputation and relationship
with the LGBTQ2S+ communities was Project Marie, the undercover
operation in Marie Curtis Park in 2016 referred to in Chapters 3 and 14.
4 The Toronto Police Service Board’s “critical point” policy should also
consider the non-exhaustive list Judge Sidney Linden set out in the
2007 Ipperwash Report of operational decisions that might require
policy intervention by government. According to this list, an
operational decision is one that may require some kind of policy
intervention if it:
 requires unexpected financial or other resources

 could affect third parties or issues not directly involved in the
situation / issues
 is necessary to vindicate or balance legal / democratic principles
or rights with policing priorities and practices
 raises interjurisdictional issues
 could set a precedent for similar operational situations in the
future
 requires intervention of higher levels of authority to resolve the
operational issue
 must be made in a police or operational vacuum, where
operational decision-makers do not have existing policies or
protocols to guide them.2
5 The Toronto chief of police should establish corresponding

procedures to the policies outlined in Recommendations 2 and 3 for
sharing information with the Toronto Police Services Board.
6 The Toronto Police Services Board should ensure that initial and
ongoing training and education of its current and future members
should include mandatory continual education not only on the role of
the Board but on how it can be effective in its governance and
oversight role. Emphasis should be on topics such as the sharing of
information (including “critical points”), constructive dialogue with
the chief of police, systemic issues to be explored, and the scope of
and limitations to “directions” to the chief of police.
7 The Toronto Police Services Board and the Toronto Police Service
should ensure that initial and continual training and education of
current and future chiefs of police, deputy chiefs, and senior officers
should include what information should be provided to the chief of
police and deputy chiefs to enable them to fulfill their responsibilities,
including sharing information on “critical points,” with the Board.
As explained in Chapter 14, the latter point is part of a larger, important

conversation about cultivating a more open culture throughout the Service by
sharing more information and removing barriers to raising systemic issues with
superiors.
8 The Toronto chief of police should establish procedures specifying

what types of projects or operations have to be approved by senior
2
Ontario, Report of the Ipperwash Inquiry Volume 2: Policy Analysis (4 vols., Toronto: Ministry of the
Attorney General, 2007) (Commissioner Sidney B. Linden) 328.
command (see Recommendation 3(a)).
9 As explained in Chapter 3, a regulation permitting a chief of police to
decline to provide information in accordance with a direction from a
police services board is unnecessary, given the statutory prohibitions
that already exist against inappropriate intervention by a board. The
Toronto Police Services Board should urge the Ministry of the Solicitor
General not to create such a regulation in the circumstances. If such a
regulation is created, the scope for denying a board information
about operations should be restricted, as it is, for example, in Victoria,
Australia, to information whose disclosure would prejudice an
investigation or prosecution or endanger the life or safety of a
person.3
I have compared the Board’s limited budget to the Service’s large budget.
I recognize that the Service’s budget will continue to undergo close
scrutiny, based both on existing resources and on the movement to reallocate
funds to community agencies. However, the Board cannot begin to
exercise the substantial civilian oversight necessary if its budget is not
commensurate with its responsibilities.
10 The Toronto Police Services Board should be allocated sufficient

funding to ensure it can perform its extensive governance and
oversight responsibilities under the Police Services Act and the new
Community Safety and Policing Act, 2019.
The above recommendations do not merely impact missing person

investigations. They are intended to redefine the Board’s relationship with the
Service. This redefinition is of critical importance at this moment in time. It
comes in the aftermath of George Floyd’s death as well as other highly
publicized disturbing interactions with police in Canada and the United States.
Public discussions around the role of the police and their relationship with the
communities they serve – discussions that are long overdue – have been
dramatically heightened. Systemic racism figures prominently in them.
Questions are raised about whether police services should be “defunded,” “de-
tasked,” or “re-allocated,” as the issue has been variously framed. These
questions involve considering whether the police should continue to perform
3
Victoria Police Act 2013 (Vic), Act 81 of 2013, s. 11(3).
some of their current functions, not merely in relation to missing person
investigations, but with respect to a range of functions, such as responding to
people in crisis.
Whatever terms are used to describe the movement in support of re
allocating police responsibility, I see the Board being of critical importance in
ensuring and overseeing needed changes.
Toronto Police Services Board Policies

At this point, I will comment more generally on the Board’s policies. A police
services board is responsible for establishing policies for the effective
management of its police service. The chief of police creates procedures or
practices to implement those policies. However, in practice, a police services
board’s policies will often do no more than state that the chief or its
service shall create procedures on a certain matter, leaving it entirely to the
chief or the service to give content to the procedures. I observed a number of
instances in which the Toronto Police Service Board’s policies were exactly as
described here, providing no direction or guidance as to what the Toronto
Police Service’s procedures should look like, other than as mandated by
provincial adequacy standards. Board policies that merely direct the
creation of procedures may technically comply with existing legislation
but do not represent true policy-making. More recently, the Board has
developed policies in several matters, such as race-based data collection, that
place its imprimatur on the Service’s procedures.
RECOMMENDATION
11 The Toronto Police Services Board should re-examine all its existing
policies, as they pertain to the matters addressed in this Report, and
ensure that they provide meaningful policy direction to the chief of
police and the Toronto Police Service, consistent with the
recommendations made in this Report.
Major Case Management and Technology (Chapter 4)
In Chapter 4, I outline provincial adequacy standards pertaining to major case

management and the mandated case management software, PowerCase. I also
describe some of the technological tools available to the Service to conduct its
investigations.
The evidence disclosed that, in many ways, the Bruce McArthur–related
investigations did not comply with provincial adequacy standards respecting
major case management or in relation to the use of PowerCase. For example,
officers before and during Project Houston were apparently unaware that
provincial adequacy standards mandated that Mr. Skandaraj Navaratnam’s
case be treated as a major case given he had been missing for more than 30
days. During Project Houston (and to a lesser extent during Project Prism), a
great deal of information collected was never uploaded into PowerCase.
McArthur’s name was not entered into PowerCase during Project Houston,
even after he was interviewed. Similarly, many officer assignments or
“actions” were not recorded or tracked in PowerCase, impeding
supervision and follow-up. This non-compliance represents a longstanding
systemic issue within the Service. Non-compliance does not merely reflect
some “technical” deficiency – it affects the quality of the Service’s
investigations, sometimes in critical ways this Report identifies (see Chapter
4). Moreover, as I state in Chapter 4, the Service is undeniably pouring
substantial human and financial resources into uploading data, however
imperfectly, into PowerCase. This expenditure makes no sense if the
program is not being used appropriately, as often happens. I reject the
proposition that, unlike other large police services, the Toronto Police
Service cannot effectively use PowerCase. It is hardly surprising that
officers express dissatisfaction with PowerCase when it is misused or
underused or its limitations exaggerated.
In the light of the findings contained in this Report, the Service must
take appropriate steps to become compliant with provincial adequacy
standards respecting major case management and the use of PowerCase in
ways that promote effective, efficient, and timely investigations. My
recommendations are designed to ensure that the Service does precisely that.
RECOMMENDATIONS
12 The Toronto Police Service should commit itself, through concrete
measurable outcomes, to complying with existing provincial adequacy
standards respecting major case management and the use of
PowerCase, the mandated case management software, for its
intended purpose. Senior command must support and drive this
commitment.
13 To promote compliance with existing provincial adequacy standards
and establish best practices respecting major case management and
the use of PowerCase, the Toronto Police Service should:
 ensure that those who work on major cases and their
supervisors are properly trained on major case management
and on the use of PowerCase;
 ensure that such training addresses the deficits in knowledge
this Report identifies, including existing misconceptions about
what PowerCase can and cannot do. Training is inadequate if it
merely provides officers with what they must do to comply with
adequacy standards. The training should also explain how
PowerCase can meaningfully advance investigations;
 ensure that those who work on major cases receive periodic
refresher training on major case management and the use of
PowerCase. Refresher training is of particular importance as
PowerCase continues to be upgraded;
 ensure, to the extent possible, that officers trained in major
case management have at least some opportunity to develop
their skills through involvement in major cases so that their
training is not forgotten through not being used;
 establish best practices in its procedures that support the
appropriate use of major case management and the use of
PowerCase;
 improve existing tracking mechanisms to enable the Service’s
Major Case Management Unit to ensure investigations are
appropriately categorized as major cases; work with the
Ministry of the Solicitor General to ensure there is a match
between the number of cases annually reported as open major
threshold cases and the number of open cases utilizing
PowerCase;4
 ensure that, on a regular basis until compliance is the norm, the
Service’s Audit and Quality Assurance Unit evaluates the extent
to which the Service has become compliant with provincial
adequacy standards. This means, among other things, that the
unit’s evaluation should extend beyond the scope of its earlier,
important work, and
4
At the time of writing, there was a disconnect between these numbers, although they need not perfectly
match since provincial adequacy standards permit the use of PowerCase for non-major ca ses in some
circumstances.
 ensure that the Audit and Quality Assurance Unit’s reports on
compliance be provided to the Toronto Police Services Board.
I refer in this recommendation and others to “best practices.” I use the term
with some reticence. “Best practices” is a term used to reflect the highest
or high performance standards. However, best practices are always evolving,
as we learn more through research and experience. As a result, I recognize that
the “best practices” identified in this Report will change through time.
14 The Toronto Police Service and the Toronto Police Services Board
should work in partnership with the Ministry of the Solicitor General
and the Office of the Inspector General of Policing (once Part VII of
the Community Safety and Policing Act, 2019, is proclaimed) to
support periodic independent monitoring of the Service’s compliance
with the provincial adequacy standards respecting major case
management and the use of PowerCase.
I recommend independent monitoring of the Service’s compliance with

provincial adequacy standards in a number of areas. Such independent
monitoring is necessary to restore confidence in the Service and the
Board. Frankly, the need for independent monitoring also reflects the
inability or unwillingness of the Service, to date, to rectify these non-
compliance issues, despite their being identified in the Audit and Quality
Assurance Unit’s reports or in reports generated by previous external
reviews. However, the current need for independent monitoring does not
relieve the Board of its own responsibility to ensure that the Service
complies with provincial adequacy standards. We have to be careful to
recognize that the Board is best situated, if it performs the important role I (and
the applicable legislation) contemplate, to provide long-term sustainable
oversight of the Service.
15 The Toronto Police Service, in consultation with the Ministry of the

Solicitor General, the Major Case Management Unit, and PowerCase’s
designer, Xanalys, should enhance the effective and cost-efficient use
of PowerCase in a variety of ways, including:
(a) addressing the inefficiencies, associated with the number of

steps and the resources engaged, in transferring data from
Versadex to a P Drive to PowerCase. The solution might involve
discontinuation of the P Drive or mechanisms for greater
automatized transmittal of information from one system to
another,
(b) embedding PowerCase indexers into investigations to ensure
they can categorize incoming information meaningfully and to
reduce information silos. This change may also mean that a
PowerCase indexer should be assigned to each Homicide Unit
team (along with a file coordinator) and/or that a PowerCase
indexer be assigned to each division, depending on need and
available resources. Major case management is hampered by
the absence of a full-time file coordinator within each division,
(c) ensuring information is uploaded into PowerCase in a timely
way to enable its use as a case management and analytic tool,
(d) introducing enhancements to PowerCase to address the
concerns expressed by users and summarized in this Report, to
the extent to which those concerns reflect existing
shortcomings, rather than misconceptions, of PowerCase,
(e) moving toward making PowerCase entirely web-based, enabling
it to be accessed from any computer, and
(f) specifically addressing how information not easily uploaded
into PowerCase should be dealt with to maximize its
effectiveness.5
16 The Toronto Police Service, in consultation with its own Missing

Persons Unit, should also work with PowerCase’s developer to
automate predetermined action lists for particular types of
investigations, including missing person and unidentified remains
investigations.
17 The Toronto Police Service’s chief information officer is currently
reviewing the “interoperability of systems” and the software being
used by the Service. Through expert assistance and having regard to
the issues identified in this Report, this review should consider
5
This point can be addressed, in large part, through training, rather than software improvements since the
evidence revealed that other services regularly and successfully upload massive amounts of data that the
Toronto Police Service does not upload.
whether data must be loaded onto three separate systems (Versadex,
a P Drive and PowerCase) in major cases and, in any event, whether
data can be uploaded in ways that reduce the time expended in this
uploading. The review should also consider whether some of the
current functions can be performed automatically.
Changes to the Ontario Major Case Management Manual

The evidence disclosed that Service members have, at times, misinterpreted
the provincial adequacy standards contained in Ontario Regulation 354/04 and
the Ontario Major Case Management Manual. For example, senior
officers have interpreted the definition of “linked cases” in the manual so
narrowly as to severely limit the situations in which the serial predator
criminal investigations coordinator is notified of cases. In some instances, the
evidence also supported some minor refinements to the manual. For
example, the manual is currently unclear on where evidentiary emails (as
opposed to emails generated during an investigation) 6 should be filed.
Inconsistent practices exist inside and outside the Service about where such
emails should be filed.
RECOMMENDATIONS
should request that the Ministry of the Solicitor General consider the
issues identified during this Review in clarifying components of the
Ontario Major Case Management Manual and Ontario Regulation
354/04.
19 More specifically, the Ontario Major Case Management Manual
should be revised
 to elaborate on the definition of “linked cases,” in the light of

the issues identified during this Review and reinforce how the
definition impacts the requirement to notify the serial predator
criminal investigations coordinator of cases;
 to specify where emails extracted from devices during an
investigation should be filed.
6
Ema ils generated during an investigation would include emails between investigators or between
investigators and civilians on non-evidentiary matters.
Consideration should also be given to adding a forensic computer
examiner, IT expert, and/or analyst to the functions and responsibilities
defined in the manual.
Records Management Systems

Ontario police services continue to operate within an environment in which
their records management systems often do not speak to each other. As a
result, information is often siloed between police services.
RECOMMENDATIONS
should request that the Ministry of the Solicitor General revisit the
need for province-wide compatible records management systems.
In Chapter 7, I identify the systemic issue arising from the fact that
McArthur’s interview with the police during Project Houston was not
entered into Versadex. Accordingly, in 2016, when McArthur was
investigated for choking a man, the investigating officer had no indication that
McArthur had previously been interviewed, during Project Houston. As a
result, the investigating officer in 2016 had no opportunity to ascertain
whether Project Houston had information about McArthur relevant to his
investigation. Of course, such an inquiry might have prompted the former
Project Houston officers to scrutinize McArthur closely.
21 The Toronto Police Service should ensure, through its procedures,

that information collected during a major case is available on its
records management system to other officers. This availability is
subject to categories of information (such as that pertaining to
confidential informants) that must or should be restricted.
ViCLAS Reporting
The evidence disclosed that the Service was often not in compliance with
provincial adequacy standards respecting the mandatory submission of
ViCLAS Crime Analysis Reports to the Ontario Provincial Police (OPP)
ViCLAS Unit when the criteria have been met. At times, these failures were
based on misconceptions about when the criteria have been met; at times,
these failures took place despite the beliefs of Toronto investigators
(sometimes
expressed in court documents) that obviously met – indeed, surpassed -- the
reporting criteria. These failures were aggravated during Project Houston
because the Toronto police chose not to submit booklets even in the face of the
OPP ViCLAS Unit’s request that they do so. To the detriment of the
public, the Service’s approach undermined the ability of the OPP ViCLAS
Unit to assist in the identification of victims, in its analysis of unsolved
missing persons, or its analysis of unidentified bodies cases.
This non-compliance is troubling. Over 20 years ago, the “Review of
the Investigation of Sexual Assaults, Toronto Police Service,” by Toronto
Auditor Jeffrey Griffiths, identified related issues. These issues included the
Sexual Assault Unit’s failure to use management information to its full
potential to link connected cases, non-compliance with ViCLAS provincial
adequacy standards, inconsistency and uncertainty among officers about
ViCLAS submission requirements, and a lack of commitment to ViCLAS
training.
RECOMMENDATIONS
22 The Toronto Police Service should commit itself, through concrete
measurable outcomes, to comply with existing provincial adequacy
standards respecting ViCLAS submissions.
23 The Toronto Police Service should ensure that its Audit and Quality
Assurance Unit evaluates, on a regular basis until compliance is the
norm, the extent to which the Service has become compliant with
provincial adequacy standards respecting ViCLAS submissions.
Assurance Unit’s reports on ViCLAS compliance are provided to the
Toronto Police Services Board.
support independent monitoring of the Service’s compliance with the
provincial adequacy standards respecting ViCLAS submissions.
The Serial P re dator Criminal Investigations Coordinator

The evidence disclosed that the Service does not notify the serial predator
criminal investigations coordinator when mandated to do so under existing
provincial adequacy standards. This failure is based on misconceptions as to
when the criteria for notification have been met, as well as attitudinal issues
around the need or desirability for such notification. In this regard, the Service
does not compare favourably to a number of other Ontario police services (see
Chapter 4).
RECOMMENDATIONS
26 The Toronto Police Service must commit, through concrete
measurable outcomes, to complying with provincial adequacy
standards respecting notification of the serial predator criminal
investigations coordinator and to participating in multi-jurisdictional
joint investigations in appropriate cases.
27 The Toronto Police Service should amend its existing procedures
and/or issue a Routine Order to clarify those circumstances in which
the serial predator criminal investigations coordinator must be
notified. Such procedures and/or the Routine Order should identify
the misconceptions around notifications revealed during this Review.
Officers must acquire a robust understanding of why the serial
predator criminal investigations coordinator is to be notified, when
the criteria have been met, and the Service’s commitment to multi-
jurisdictional joint investigations in appropriate cases.
Assurance Unit evaluates, on a regular basis until compliance is the
norm, the extent to which the Service is compliant with provincial
adequacy standards respecting notifications to the serial predator
criminal investigations coordinator.
Assurance Unit’s reports on compliance respecting notification to the
serial predator criminal investigations coordinator are provided to the
Toronto Police Services Board.
support independent monitoring of the Service’s compliance with the
provincial adequacy standards respecting notification to the serial
predator criminal investigations coordinator.
31 The Toronto Police Service should utilize the serial predator criminal
investigations coordinator in training and educating officers on major
case management and the role he or she performs.
Missing Person Investigations (Chapters 5–9, 12)
To begin this section, I set out the components of a missing person strategic
plan and then go on to address many of those components with greater
specificity. I also outline a mid-term and a long-term model for future missing
person investigations.
The Components of a Missing Person Strategic Plan

RECOMMENDATIONS
32 The Toronto Police Services Board should prepare and adopt a new
strategic plan for the provision of policing that addresses missing
person and unidentified remains investigations. That strategic plan
should be consistent with this Report’s findings and recommendations
and should meet the following objectives:
(a) recognize the heightened priority that needs to be given to

missing person cases and the cultural change associated with
this heightened priority;
(b) recognize that many missing person cases raise social issues
rather than law enforcement issues or a combination of the
two;
(c) ensure that all missing person cases are triaged, based on risk
assessments, to determine the appropriate response to a
person’s disappearance, including whether that response
should involve a combination of the police and other agencies
and/or a multidisciplinary response, such as a referral to a
FOCUS table7;
7
Currently, there are four FOCUS (Furthering Our Community by Uniting Services) or situation tables in
Toronto. They are co-led by the City of Toronto, United Way Toronto and the Service. They identify
(d) ensure that all missing person and unidentified remains
investigations are conducted in a manner that is non-
discriminatory;
(e) recognize groups and individuals who have been overpoliced
and underprotected and ensure that such recognition is
reflected in the Service’s missing person, unidentified remains,
and associated practices and procedures, in ways to eliminate
disadvantage and adverse differential treatment;
(f) ensure that the police work in true partnerships with diverse
communities in implementing changes to existing practices and
procedures and in drawing on those partnerships in specific
missing person and unidentified remains investigations;
(g) promote the use of civilian Service members, rather than sworn
officers, for suitable responsibilities, including as missing person
coordinators and missing person support workers;
(h) promote the use of civilian Service members and greater use of
special constables for some basic tasks associated with missing
person and unidentified remains investigations;
(i) collaborate with appropriate social service, public health, and
community agencies and not-for-profit organizations to
promote a range of prevention and intervention strategies to
reduce the likelihood that individuals, particularly those who
repeatedly disappear, will choose to go missing or to ensure
they are safe, even when missing;
(j) ensure that members of the public have clear, easily accessible
information about how to report a person missing and that they
are never prevented from doing so for any reason, including the
jurisdiction where they seek to file a report or the time that has
passed since the person went missing;
(k) ensure that barriers to reporting persons missing or to
providing information about missing persons or unidentified
remains are eliminated or reduced in a variety of ways,
including ensuring that there are clear procedures that reduce
fear of law enforcement action against missing persons or those
individuals, groups, and places that have an extremely high probability of harm or victimization and adopt a
multi-a gency response or intervention to address high-risk situations.
who report or provide information about missing persons or
unidentified remains;
(l) ensure, as part of a victim-centred approach to missing person
cases, that those directly affected by a person’s disappearance
are informed of the ongoing missing person investigation,
allowed, where appropriate, to contribute to such
investigations, and are provided with appropriate support,
based on need;
(m) ensure that missing person occurrences are addressed in a
timely way;
(n) ensure that risk assessments are made by those with
specialized training and education, such as missing person
coordinators, and that risk assessments are based on evidence-
based criteria, accurate to the extent possible in individual
cases, updated regularly, and that they are used in deciding
how each missing person investigation is conducted:
(o) ensure that risk assessments address the types of risk involved
and the suggested response to a person’s disappearance,
including whether that response should involve the police,
social service / public health / or community agencies, and/or a
multidisciplinary response;
(p) ensure that risk assessments take into consideration the
appropriate factors, including the elevated risks that are often
associated with marginalized and vulnerable or disadvantaged
community members, and avoid irrelevant considerations and
stereotypical assumptions and misconceptions;
(q) ensure that missing person cases are treated presumptively as
high risk unless and until a risk assessment or available
information reasonably supports a different approach;
(r) recognize and respect the privacy and liberty interests of those
who freely and voluntarily choose to disappear; and
(s) ensure that missing person cases that raise concerns about foul
play, including but not limited to potential serial killings, are
both recognized as such and promptly and thoroughly
investigated, regardless of the personal identifiers and
circumstances of the missing persons.
In my recommendations on implementation, I explain how proposed
changes should take place through a process that involves community
partnership.
Priority of Missing Person Investigations

In Chapter 5, I summarize evidence that low priority is generally given to
cases of missing adults. As I reflect in Chapter 13, this approach represents
a systemic issue – one that has not been given the attention it deserves.
The low priority the Service often gives to missing person investigations
manifested itself in a number of ways, including missing person investigations
having access only to limited resources, delayed assignments, a lack of
ongoing communication with those directly affected when a loved one goes
missing, and no continuity when assigned officers go off-shift. It is hardly
surprising that those affected by a disappearance often feel unheard and
sometimes regard the Service and its officers as dismissive or inattentive.
In future, missing person investigations must consistently be given
higher priority both generally and in individual cases (see Chapter 13). I
recognize that the police response to some missing person cases, such as those
that generate an Amber Alert, is already one of high priority. My focus here is
on the balance of such cases. The low priority given to many of these cases in
Toronto, and indeed in a number of jurisdictions nationally, compares
unfavourably to the approach taken in the United Kingdom and Australia and
in some Canadian jurisdictions.
The Service’s current approach devotes inadequate resources, human
and financial, to missing person investigations. Even after the welcome
creation of the Missing Persons Unit (MPU), the inadequate resources devoted
to the unit generally, and to these investigations specifically, stands in contrast
to other jurisdictions. At present, the MPU is not sufficiently staffed even to
oversee such investigations across the Service, let alone conduct its own
investigations as it often should.
I am well aware of the challenges created by limited financial resources.
However, these challenges offer little mitigation for the low priority these
cases are given. The problems associated with inadequate resources must
be considered in the light of the following issues:
 the number of such cases;

 the proportion that legitimately raises safety concerns about marginalized
and vulnerable individuals, even when foul play is not involved;
 how resources devoted to prevention strategies can reduce the number of
missing person cases;
 the importance of such investigations to affected communities; and
 the disproportionate number of marginalized and vulnerable individuals
who go missing and the impact of poorly conducted missing person
investigations on those most mistrustful of the police.
I specifically address the issue around financial resources at the end of this
chapter.
I acknowledge that the most recent amendments to the Service’s
Missing Persons Procedure recognize, for the first time, that missing person
occurrences are a high-risk area of policing and, from the outset, must be
given appropriate levels of priority and resources. The challenge is to convert
that recognition to tangible action.
RECOMMENDATIONS
33 Missing person investigations deserve heightened priority, consistent
with this Report’s findings and the priority given to these cases in a
number of comparable jurisdictions.
should ensure that the change in culture respecting the heightened
priority of missing person investigations – as well as the reasons for
this priority – is widely communicated within the Service. The change
of culture should make the safety and well-being of missing persons a
greater priority while recognizing the important role of social service,
public health, and community agencies in these cases. The creation of
a Missing Persons Unit represents only one step in recognizing a new
priority for these cases, especially when the current unit is
inadequately resourced.
The Mid-Term Missing Person Model

As I state earlier, the approach to missing person investigations I am proposing
includes a mid-term model and a long-term model. Both preserve a centralized
MPU, with early, and ongoing triaging of missing person cases by expert risk
assessors to determine the appropriate response. This triaging, in partnership
with social service, public health, and community agencies, recognizes the fact
that many of these cases are rooted in social issues rather than in law
enforcement. At the same time, the model recognizes that some missing
person
cases require criminal investigation. The model introduces civilians from both
inside and outside the Service to these investigations to serve as coordinators
and as support providers for those directly affected by the missing as well as
the missing themselves. A long-term model would, in many of these
investigations, move further along the continuum of reducing the involvement
of sworn officers in favour of social service, public health, and community
agencies.
In Chapter 13, I describe the approach largely adopted in the United
Kingdom respecting missing person investigations. The United Kingdom is
working toward a broader, more inclusive approach in which the police
continue to assume primary responsibility for missing person investigations
but, in which the police force’s civilian missing person coordinators together
with social service agencies and not-for-profit organizations are best suited to
support a victim-centred, holistic response to these cases. The theory is based
on government support for a police culture that attaches high priority to the
missing, a priority that attracts commensurate police resources coupled with
collaboration with external agencies and organizations.
The proposed mid-term model is also informed by elements of how
missing person investigations are now conducted in other jurisdictions,
including Vancouver, Calgary, Saskatoon, Edmonton, and Winnipeg, and by
the OPP. In Chapter 13 and throughout this chapter, I outline some key
components of how investigations are conducted in those jurisdictions.
However, I regard my proposed model to be ground-breaking and
consistent with “reimaging” the role of sworn officers to focus on the type of
police work they do best (and, often, prefer), to introduce civilian Service
members where appropriate, and to recognize the critical role of social service,
public health, and community agencies and not-for-profit organizations in
addressing social issues.
I recognize that my proposed models for missing person cases will
require a significant amount of work to transition from the current regime in
which the Service assumes responsibility for such cases, with limited
involvement of other agencies and organizations. It will be necessary for other
agencies to build capacity for assuming significant responsibilities in these
cases and for participating in the triaging that allows cases to be diverted from
a policing response to a response by outside agencies or a multi-disciplinary
response involving the police and such agencies and organizations. However,
my recommended models are consistent with the momentum to approach
community safety and well-being in a holistic way, as contemplated by
both the Police Services Act and the Community Policing and Safety Act,
2019.
They are also consistent with the creation by the City of Toronto of the
Alternative Community Safety Response Accountability Table and the
Community Crisis Support Service Pilot to address people in crisis (both
described in Chapter 13). As well, they are consistent with the successes
of FOCUS tables in Toronto and their equivalents in other jurisdictions.
Several chiefs of police and a large number of Toronto officers of all ranks
expressed the willingness and desire to dramatically reduce policing
involvement in missing person cases that do not require a criminal
investigative response. All this to say, Toronto now has the opportunity to lead
the way on missing person cases.
RECOMMENDATIONS
should adopt the mid-term model for missing person investigations
outlined in this Report. The model preserves a centralized Missing
Persons Unit, but with significant enhancements. It is predicated on
early and ongoing risk assessment and triaging which recognizes that
some of these cases are best addressed by social service, public
health, and community agencies; other cases through a
multidisciplinary approach; and the balance of cases primarily through
police-led criminal investigations.
should work with the City of Toronto, provincial and federal
governments, and social service, public health, and community
agencies and not-for-profit organizations to build capacity for non-
policing agencies and organizations to assume responsibilities
consistent with the proposed mid-term and long-term models.
There was significant support for the proposed mid-term model among police
officers and others who the Review met with and consulted. I acknowledge
that some community members advocated removing all missing person
investigations from the Service. They raised concerns that the police are
primarily interested in missing persons “as a vector of crime” and that civilian
investigators would be better suited to missing person investigations. There
was a sense that many officers are ill-suited, unskilled, untrained, or
unmotivated to find missing persons and are more likely to be dismissive or
discriminatory in dealing with missing persons reports. There was also a sense
that officers in uniform are intimidating, feared, and less likely to be trusted.
Their involvement in criminal law and immigration law enforcement created
barriers to reporting and information sharing. I accept the existence of these
perceptions and that they raise important issues, even while I recognize that
many officers are highly motivated to find missing persons and embrace
change to reduce existing barriers and to generally improve missing person
investigations.
I also fully understand the deep, legitimate concerns that many in the
LGBTQ2S+ and marginalized and vulnerable groups have about the police in
general. Indeed, many of these concerns have influenced both the long-
term model I outline here as well as the mid-term model. Both models
recognize that community agencies and organizations can play a critical role in
missing person investigations, though they need assistance in building
capacity. At the same time, I cannot accept that the police can or should play
no role whatsoever in missing person investigations. As I reflect
throughout this Report, a significant percentage of missing persons are
exposed to the risk that they will become victims of foul play or of other
crimes or criminal exploitation. McArthur’s horrendous crime spree
reinforces the need for effective, timely, and discrimination-free professional
criminal investigations when warranted. Although suggestions that the
police be removed from all missing person investigations informed my
thinking, I am not convinced that the creation of a new agency, as some
proposed, would ultimately lead to a better result. The creation of a new
agency would require buy-in and significant legislative changes initiated
by the provincial government. I prefer to test a model that incorporates
involvement of external agencies but does not require legislative change. In
my view, as long as the Service continues to perform law enforcement
functions, it would be counterproductive to create a model that attempts to
avoid any interaction between the police and disadvantaged
communities. It is essential that the Service build positive relationships
with all the communities it must serve regardless of the extent to which its
role is
reduced in matters better addressed by other agencies.
The differences can be exaggerated between the community
stakeholders who advocate for new civilian agencies and those within the
Service and others who believe that the police must have a continuing role in
missing person investigations. Many in the Service recognize that using more
civilian employees within the Service and referring more cases to external
agencies could alleviate the crushing workloads experienced by sworn
officers. Some in the Service also recognize that barriers between the police
and some community members may be reduced through the use of civilians.
The Toronto
Police Association also supports the increased use of civilians, under some
circumstances. For a variety of reasons, then, there was broad consensus that
civilians, both civilian members of the Service and members of external
agencies, should play an enhanced role in missing person investigations.
The enhanced role of both civilian employees of the Service and
external agencies is central to my proposed models for mid-term and long-
term implementation. In the recommendations that follow, I explain how
civilian missing person coordinators and missing person support workers
within the Service would promote high-quality responses to missing person
occurrences and greater confidence in the processes by marginalized and
vulnerable communities. I also explain how the enhanced role of social
service, public health, and community agencies can similarly promote
appropriate, non- policing responses to missing person occurrences.
The mid-term model I propose emerged from the Review’s
extensive outreach and engagement, and I elaborate on that model in this
chapter. I say much less about the long-term model for two reasons. First, in
my view, the long-term model should be crafted in partnership with a
community implementation committee, discussed later in this chapter. Neither
I nor the Service should impose on the communities a detailed blueprint for
the long- term model. Second, I believe in decision making rooted in
evidence and measurable outcomes. An independent evaluation of the
implementation of the mid-term model should inform the precise contours
of the long-term model. Nonetheless, it was important to articulate a long-
term vision for missing person investigations that involves a move along a
continuum to ever increasing involvement of agencies other than the
police, as circumstances permit.
Changes to the Missing Persons Unit and Divisional Staffing

RECOMMENDATIONS
37 The Missing Persons Unit should include a permanent analyst position
as well as a permanent administrator position.
38 The Missing Persons Unit, each of Toronto’s four quadrants, and,
based on analysis and research, some if not all divisions should have a
missing person coordinator. Unless the missing person investigation
workload in a particular division or quadrant is limited, the
coordinators should work exclusively on missing person and
unidentified remains investigations.
39 Missing person coordinators should
 receive specialized training and education in missing person

investigations;
 include civilian employees;
 perform risk assessments when individuals first go missing and
regularly thereafter;
 triage missing person cases for a policing v a non-policing or
multidisciplinary response;
 meet regularly to ensure consistency in approach to risk
assessments and triaging;
 participate monthly in strategic meetings with social service,
public health, and community agencies and not-for-profit
organizations to discuss trends, patterns, and themes around
the missing and to identify what can be done differently or
proactively;
 provide expertise to divisional officers conducting missing
person investigations, including familiarizing them with existing
community resources to assist investigations;
 monitor case continuity and ensure that an assigned
investigator is on duty for each active divisional missing person
investigation;
 liaise, as needed, with the Office of the Chief Coroner / Ontario
Forensic Pathology Service on issues relating to bodily remains;
 liaise, as needed, with independent researchers conducting
much needed research into missing persons, including testing
and refinement of risk assessment instruments; and
 assist the unit’s support worker, as needed, in ongoing
communication with those directly affected by someone having
gone missing and in developing a communication plan with
them.
In one United Kingdom jurisdiction, all risk assessments are reviewed by a

“risk hub” comprised of civilian missing person coordinators who
independently examine the circumstances surrounding disappearances and
draw on patterns and related research, together with their accumulated
experience and calls to social service agencies to obtain more information
about the missing person. These risk assessments are loaded onto the police
records management system within two hours of the reported disappearances.
My proposed model draws on the United Kingdom experience with
suitable modifications.
40 The Toronto Police Service should double the complement of sworn

officers assigned to the Missing Persons Unit to eight investigators.
The Service should also consider adding a detective sergeant to the
unit, as was originally the case. This additional complement of officers
will lead to several needed results. First, it will enable the unit to
oversee investigations done at the division level while conducting its
own complex investigations, with divisional support if required, where
specialized skills are critical. Second, it will enable the unit’s members
to participate in, and lead, training and education on missing person
and unidentified remains investigations. Third, it will enable the unit
to oversee Missing Person reports from inception, rather than limiting
the ability of its members, owing to its restricted resources, to
monitor the response to such reports within the first eight days of an
individual’s disappearance.
41 The Toronto Police Service should create within the Missing Persons
Unit the position(s) of missing person support worker(s). These
workers are civilians, such as social workers who preferably have
experience, education, and training in victim support and cultural
sensitivity (also referred to in this Report as social context education).
The support workers are to be dedicated exclusively to providing
support for those directly affected by the disappearance of
individuals, whether family members, reporting individuals, other
loved ones, or close friends.
I elaborate on the support to be provided to those directly affected by missing

person cases in Recommendation 43.
42 The Toronto Police Service should also make greater use of civilians
(apart from missing person coordinators and missing person support
workers) and special constables to perform certain necessary basic
work that does not require the skills of sworn officers and/or builds
on the skills of the civilians and special constables. Examples of such
basic work might include obtaining relevant videotapes, canvassing
hospitals and shelters, securing items for DNA analysis, and examining
open source social media sites.
Support for Those Directly Affected by Someone Missing

The Service’s current Missing Persons Procedure identifies the commitment to
a victim-centred approach to all missing person cases as one of the
purposes of the new MPU. This language mirrors the victim-centred approach
proposed by Detective Constable Joel Manherz in December 2017 and
Staff Superintendent Myron Demkiw in March 2018.
In practice, although a number of officers demonstrate compassion and
sensitivity to those affected by someone’s disappearance, the Service’s
approach cannot be said to be victim-centred. In many instances, those directly
affected are not regularly contacted by anyone within the Service with updates
or basic information about the investigations. As time passes, such contact
often becomes even more sporadic. Significant dates, such as the anniversary
of someone’s disappearance, usually go unnoticed by the Service. The Review
was advised by Service members that sometimes those directly affected are not
even advised that the missing person has been found, even when privacy
interests are not of concern.
The Review was also advised that family members contact the MPU
about ongoing divisional investigations because they have little information
from or contact with divisional investigators. The unit is limited in its ability
to respond because it is not privy to the current status of the investigation or to
what information can appropriately be shared. The unit is better able to
respond if the inquiries relate to cold or historical missing person cases
that it has reopened and taken some ownership of.
In Chapter 13, I emphasize that many loved ones and friends are
victimized when someone disappears. Among other things, I refer to the
unimaginable pain arising out of the “ambiguous loss” they suffer and the
stigma they experience, especially when a person is missing for an
extended period. In terms of providing support, the Service’s Missing
Persons Procedure8 requires only that officers “consider” obtaining the
assistance of
8
Procedure 04-31.
Victim Services Toronto.9 The Review was told that, in practice, those
affected by the disappearance of a loved one are regularly referred to Victim
Services Toronto, which in turn provides referrals to additional resources.
In my view, the support the Service provides to those directly affected
by disappearances is often poor, at times non-existent, and at best uneven. As
I explain in Chapter 6, this uneven support stems in part from a variety of
reasons – that, for example, as cases remain unresolved, loved ones and friends
are often not seen as victims; or, in the context of LGBTQ2S+ missing
persons, a failure to recognize who the affected loved ones and family
members are, who need support. The police may fall back on
“heteronormative” concepts of who a missing person’s family is or place
undue emphasis on the missing person’s biological relatives, to the exclusion
of others.
The Service’s approach differs from the greater attention it gives to
victims of demonstrated crimes and their loved ones, and especially from the
support provided by a number of other police services to the families and
loved ones of those who have gone missing – for example, in the United
Kingdom and other jurisdictions in Canada. In Australia, most police
departments have a Families and Friends of Missing Persons Unit. The
Calgary Police Service has a Family Liaison Team. The Saskatoon Police
Service has introduced a civilian missing person liaison officer. The
Winnipeg Police Service has embedded social workers within its Missing
Person Unit to do much of the family liaison work and relies heavily on
civilian missing person coordinators to perform intake and initial
management of the file. The Vancouver Police Department has protocols
for high-risk missing person cases that require it, within two weeks, to develop
a communication plan with affected families and other loved ones which
includes certain components I have adopted in the recommendation that
follows. In Chapter 13, I elaborate on the approaches taken by these
various jurisdictions.
I pause here to observe that some jurisdictions refer to Family Liaison
units embedded within the services and within their missing person units, I
prefer to use language other than “family liaison units” to ensure that those
directly affected are defined in the most inclusive way, consistent with the
diversity of our communities and human rights values.
Heidi Illingworth, the ombudsperson in the Office of the Federal
Ombudsman for Victims of Crime, is familiar with the perspective of those
whose loved ones have gone missing. I can do no better than reproduce part of
9
Victim Services Toronto is a Toronto-based organization with a mandate to provide short-term crisis
response, intervention, and prevention services that respond to the needs of individuals, families, and
communities in the immediate aftermath of crime and sudden tragedy.
her written submission to the Review:
Police services tend to focus their attention on the investigation rather than
on the families and associates of the missing person. This can make missing
person investigations more difficult and frustrating for all concerned.
In its 2005 report, Developing a Strategy to Provide Services and
Support Victims of Unsolved Serious Crimes, the Canadian Resource Centre
for Victims of Crime (CRCVC) summarized the research on victims’ needs
for information about unsolved cases, including missing persons. In its
research for this report the CRCVC surveyed families of unsolved homicide
and missing person cases, and noted that respondents said police were not
immediately responsive when family members reported someone missing.
The Centre also noted that police treated the missing person as a runaway or
someone who had left on their own. This was difficult for families to accept,
and made many feel that they were not important; they could not understand
why police did not believe them.
About two thirds of victims (64 percent) said they were unsatisfied
with the police investigation, and many felt there was lack of timely action,
sensitivity and communication. Seventy-four percent of respondents said
police did not keep them regularly informed about what they were doing.
Victims felt they had to initiate the contact with police in order to stay
informed. One family member said, “nothing to report is something to
report.”
This research demonstrates, as do victim services reports, that police
provide little specialized support to families of missing persons. Although
they have experienced traumatic incidents, families are often not considered
victims of crime. Consequently, they do not qualify for programs or services
designed for crime victims. The report concludes that receiving information
about the status of the investigation is crucial to the state of mind of family
and community members whose loved once has gone missing. Experts in the
field agree that denying victims access to information has a strong negative
effect on their ability to cope with the situation. Conversely, offering regular
updates not only provides victims with available facts about the
investigation, but reassures them that neither they nor their loved one has
been forgotten. While some details may need to be withheld for reasons
relating to an eventual prosecution, other information can be shared freely.
The ombudsperson also pointed out that in missing person cases,

inadequate communication with families represents the number one cause of
dissatisfaction with police services, often accompanied by dissatisfaction with
how police communicate with them. The ombudsperson supported a
multidisciplinary missing persons team, as proposed in my Report,
incorporating non-investigative and civilian personnel including social
workers “to provide a holistic and compassionate response in missing person
cases.” The ombudsperson elaborated as follows:
This team could recognize and navigate the mosaic of contributing factors
that may lead to a person going missing without blaming the victim or
relying on stereotypes or misconceptions. There are many intersecting,
systemic factors that affect people who go missing, such as mental health,
poverty, neglect, substance abuse, domestic violence, prostitution, human
trafficking, historical trauma and victimization, location or jurisdiction. It is
essential to understand the victimology – and the victim’s life and
relationships – as part of the investigation.
I note that the Ontario Major Case Management Manual requires that a victim
liaison officer be assigned in every threshold major case, which includes
certain missing person investigations, to perform various listed functions and
duties (see Chapter 13). Although not all these functions and duties have equal
application to all missing person investigations, this approach truly focuses on
the victims – so long as it is complied with. I further note that no victim
liaison officer was assigned during Project Houston or during any other
missing person investigation I reviewed.10
In my opinion, there is no reason why such support should be available
only when a missing person investigation is designated as a major case.
Indeed, smaller police services elsewhere have recognized the importance of
strong support for all those directly affected by someone’s
disappearance. This support must be integrated in a holistic response to
missing persons, and capacity must be built for the provision of meaningful
and consistent support. As I reflect in the recommendation immediately
below, the support for affected persons should be multifaceted. Not
surprisingly, one component of that support is information sharing. When
police fail to communicate promptly their investigative efforts to those
directly affected by the disappearances of individuals, it is understandable
that those affected believe the police are uninterested and unmotivated.
Prompt and effective communication is one
antidote to such perceptions.
A related component concerns the officers’ actual messaging.
Officers often attempt to minimize the concerns expressed about a missing
person with comments such as “He’s probably just partying with friends” or
“She’ll come
10
Project Houston was characterized as a murder investigation, although the missing men had not been
discovered. In my view, the term “victim” should be interpreted broadly to include those directly affected by
the disappearances of persons in major cases, especially in the context of a murder investigation.
back – she’s young.” These types of comments may be motivated by the desire
to give someone hope, but they can reveal stereotypical notions about certain
missing persons. They feed into a perception that the police are not taking a
Missing Person Report seriously. Similarly, police may make assumptions,
based on lifestyle, that missing persons caused or contributed to their
disappearance. Police will sometimes dismiss the fears and concerns of those
who report someone missing. But in many instances, the reporting individual
is better situated than the police to know whether the disappearance of a loved
one or a friend is of concern.
RECOMMENDATIONS
43 The Toronto Police Service should amend its Missing Persons
procedures and practices, in consultation with its own and external
Victim Services agencies and relevant not-for-profit missing persons
organizations, to ensure that the following points are implemented.
(a) Information about an ongoing investigation is regularly

provided to those directly affected by the disappearances of
missing persons.
(b) The Service does not erect unnecessary barriers to providing
such information based on an overly broad interpretation of
what must be withheld to preserve the integrity of an
investigation.
(c) Absent exceptional circumstances, a communication plan is
created for every missing person investigation, in consultation
with those directly affected, that includes
(i) the name and contact information of the liaison person
assigned to assist those directly affected, whether a
missing person coordinator or a missing person support
worker;
(ii) the names and contact information of persons designated
to be updated on the progress of the investigation;
(iii) the frequency and type of information to be provided to
the persons designated in the communication plan (e.g.,
the affected persons’ wishes and schedule for contact,
updates on the progress of the investigation, significant
developments in the investigation);
(iv) the type of information that is to be provided to the liaison
person by the persons designated in the communication
plan; and
(v) the means by which information is to be provided.
(d) Generally, the directly affected persons are advised of details
pertaining to the investigation that will be released to the
media; they are given an opportunity to review and consent to
any information or photos released to the media, unless these
steps would jeopardize the investigation;
(e) Those interviewing directly affected persons use, where
appropriate, a trauma-informed approach, and are mindful of
the ways in which the disappearance of a loved one may affect
them. Interviewers should also be non-judgmental in their
responses to a Missing Person Report and avoid appearing to
blame the reporting individual for any delay in reporting.
(f) The Service’s members have a clear understanding, based on
human rights principles, of who represents a missing person’s
families, loved ones, or those directly affected and how they
should communicate with them. This understanding means,
among other things, that
(i) the individuals who are to communicate with directly
affected individuals are competent to ascertain those with
whom they should be communicating;
(ii) they do so in a sensitive and appropriate way;
(iii) they are respectful of sexual orientation, gender identity
and expression, and other relevant identifiers of the
missing person and those directly affected; and
(iv) communication takes place, whenever possible, in the
language of choice of those directly affected.
(g) Service members provide emotional or logistical support, as
may be needed, to those directly affected or facilitate their
access to other resources. Such support might include
(i) contacting those directly affected on the anniversary of
someone’s disappearance and/or on other special dates,
such as the missing person’s birthday; such support,
recommended in the National Centre of Missing Persons
and Unidentified Remains Best Practices Guide,11 does a
great deal to reassure those directly affected that the
police have not forgotten about their loved ones; and
(ii) working in partnership with social service, public health,
victim-service, and community agencies and non-profit
organizations, including relevant charities, to facilitate
access to needed resources.
44 The Toronto Police Service should develop, in partnership with diverse

communities, a guide to missing person and unidentified remains
investigations for those directly affected as well as the public at large.
45 The Toronto Police Service should comply with the provincial
adequacy standards respecting the assignment of a victim liaison
officer to major cases, including missing person cases. The Service’s
procedures should be amended and/or a Routine Order issued to
reinforce this requirement. In the context of missing person or bodily
remains investigations, the victim liaison officer will generally be the
missing person support worker or a missing person coordinator.
46 The Toronto Police Service’s Missing Persons Procedure should be
amended to include the following requirement. In every missing
person or unidentified remains case, the lead investigator or, in major
cases, the major case manager should ensure that any support that
has been or is being provided on an ongoing basis to those directly
affected by an individual’s disappearance is documented.
In relation to Recommendation 43(g), I agree with the federal ombudsperson

for victims of crime that police services are not always familiar with the
existing supports available to those directly affected by someone who goes
missing. She provides two examples of programs at the federal level that might
assist – the Family Information Liaison Unit,12 which assists the families of
Indigenous women and girls dealing with the loss of loved ones; and the
Canadian Benefit for Parents of Young Victims of Crime, which provides
11
This best practice has also been adopted by the Seattle Police Department. I was advised that these simple
gestures are tremendously impactful in reassuring those affected by a disappearance and building trust.
12
In my view, the Family Information Lia ison Unit can also play an important role as an agency that might
a ssist as part of a community-based, non-policing response to a missing Indigenous person (see Chapter 14).
federal income support for parents who take time from work to cope with the
death or disappearance of a young person under the age of 25 resulting from a
probable crime. However, it is also important to understand that the eligibility
criteria for these programs exclude most families affected by a missing loved
one from benefiting from them.
The Role of Not-for-Profit Organizations or Charities

Several charitable organizations in Canada and the United States provide
assistance to the public and those directly affected by missing persons.
However, in Canada – particularly in Ontario – their partnerships with the
police and the roles they perform are far less pronounced than in the
United Kingdom. There, the Missing People charity performs a daunting
range of functions that would otherwise be left to the police and/or to far
less well resourced charities or not done at all. The province of Ontario, and
ultimately Canada, would benefit from a vibrant missing person not-for-
profit organization to complement the work of missing person
coordinators and support workers and to provide a system whereby missing
persons themselves who have chosen to go missing can contact someone,
even when their whereabouts remains unknown.
RECOMMENDATION
should support, in partnership with the federal, provincial, and
municipal governments, incentives for not-for-profit organizations,
such as charities, to assist missing persons and those directly affected
by their disappearances. These incentives should include start-up or
shared funding for promising initiatives that might enable a not-for-
profit organization to perform functions similar to those carried out
by the Missing People charity in the United Kingdom. Ideally, such an
organization in Ontario could perform the following roles in
substitution for, or in partnership with, the Service and other
agencies:
 providing 24-hour confidential support to those who have gone

missing (that is, whose locations are not known but who wish to
have someone to contact);
 providing support to those at risk of going missing;
 providing support to directly affected loved ones of those who
have gone missing or are at risk of going missing;
 providing information to directly affected loved ones about
missing person investigations;
 without violating confidentiality assurances, providing
information to directly affected loved ones that a missing
person is alive or safe;
 serving as a liaison between affected loved ones and the police,
if needed;
 coordinating a network of people, businesses, community
organizations, and media to contribute to the search for missing
persons;
 providing support for those who have returned, including
reconnection assistance and referrals to social agencies or
FOCUS or situation tables;
 acting as a conduit to the police for those individuals who wish
to assist anonymously in investigations;
 publicizing specific missing person cases;
 assisting in the training and education of those who conduct
missing person investigations or who work with returning
missing persons and their affected loved ones;
 championing the cause of missing persons, including serving as
an advocate for needed changes in the law, procedures, or
practices;
 promoting community strategies to ensure that marginalized
and vulnerable individuals who go missing are noticed; and
 sponsoring or conducting research into issues surrounding
those who go missing.
One important reason why the Missing People charity is so successful in the
United Kingdom is the high priority given to missing person cases there. The
profile and importance given to these cases undoubtedly promote public
support for this charity.
Risk Assessments
In Chapter 13, I make the point that risk assessment is the most important
function in responding to the report of someone’s disappearance. Assessing
the degree and nature of the risk to which a missing person might be exposed
forms the basis for prompt triaging of these cases for the appropriate allocation
of resources inside and outside the Service. Poor or non-existent initial
and ongoing risk assessments have been a major weakness in how the Service
has responded to missing person occurrences, specifically in underestimating
the degree and nature of risk to which a missing person is exposed. In Chapters
5 to 7, I explain how the police often failed to appreciate the level of urgency
that should have accompanied the reported disappearances of McArthur’s
victims. This failure was connected directly to how the police assessed risk,
whether related to possible foul play or other safety concerns. In Chapter 8, I
also identify a series of systemic issues associated with risk assessments
that had particular application to the Tess Richey investigation. The
Search Urgency Chart, in use at the time, did not reflect an evidence-based
approach to risk assessment. The distinction among level 1, 2, and 3 searches
is outdated and prone to inconsistent interpretation or application. As
concerns deepened over Ms. Richey’s disappearance, there did not appear to
be any re-evaluation of whether the search level should be elevated.
In Chapter 9, where I address the Alloura Wells investigations, I observe
there was no correlation between how Search Urgency charts were completed
and how an investigation was conducted. Their contents were not being filled
in across the Service in a consistent way, nor were the somewhat rudimentary
assessments contained in these charts truly evidence based. It was even
difficult to reconcile the high urgency reflected in the Search Urgency Chart
relating to Ms. Wells with the categorization of the required level of search.
Sometimes these forms were not filled in at all or not retained in the
investigative files.
In Chapter 8, I also point out that, apart from assessing the risk
associated with a particular missing person, the urgency associated with a
search should also be connected to the concerns expressed by community
members. Although those concerns may not, in and of themselves, be
determinative of how an investigation is conducted, they should inform the
Service’s approach. For example, during Ms. Richey’s missing person
investigation, local community members were feeling unsafe because of the
number of unexplained disappearances in the Village over the previous few
years. Some believed that Ms. Richey’s disappearance was related to the other
disappearances. This belief turned out to be inaccurate, but the pronounced –
and frankly justified – community fears about safety should have figured
prominently in how urgently the police responded to her disappearance.
With the high numbers of missing person cases in Toronto – and
elsewhere in Canada and around the world – it is remarkable that so little
evidence-based research in Canada has been done on risk assessment in
missing person cases. We know that marginalized and vulnerable community
members go missing in disproportionate numbers, and we know that certain of
these community members, by nature of their personal identifiers or
environmental factors, are at heightened risk of foul play (such as members of
the trans community and sex workers) or other types of serious harm (such as
children, those exposed to extreme weather conditions, and those dealing with
certain mental health issues)13. We also know that certain indicia may raise
serious concerns about foul play (such as leaving valued pets behind).
However, there is much about the assessment of risk that remains unknown.
As I state in Chapter 13, we must approach risk assessment with some level of
humility, erring on the side of assuming higher risk unless and until the
contrary is shown. In the meantime, it is important to constantly re-evaluate,
through a combination of collaboration, training and education, and ongoing
research, how these assessments are done.
Against that background, the Service has introduced new risk
assessment tools designed to assist officers in calibrating the response to
someone’s disappearance. They set out factors, such as personal identifiers and
environmental conditions, that are undoubtedly relevant to risk. However, with
respect to some factors (such as membership in certain communities), it would
not be obvious without further explanation how they affect risk. The Service’s
Missing Persons Procedure now imposes an obligation on supervisors to
review the assessments conducted by responding officers and do their own
assessments, identify situations involving an elevated risk, and, in consultation
with the responding officers, articulate the suggested level of response:
 level 1 search (more investigation required)

 level 1–2 search (expand investigation)
 level 2–3 search (immediate response required)
I acknowledge that the current approach to risk assessment

represents an improvement to the earlier approach. The Search Urgency
charts were confusing and potentially misleading because they favoured a
numerical scoring approach that undervalued the significance of a smaller
number of
13
The Review’s enga gement survey showed a substantial percentage of respondents who reported people
missing identified mental health as a relevant identifier.
high-risk factors.14 Some of the factors were miscategorized as high, medium,
or low factors when they were often equivocal at best or dependent on context.
Critical factors were not included on the Search Urgency Chart. It was
difficult, if not impossible, to correlate the contents of the charts to the three
levels of search described in the Missing Persons Procedure. At least the
current procedure and forms identify a wider range of relevant factors to
the risk assessment process, show greater sensitivity to the importance of
a single elevated risk factor, move away from a numerical scoring system that
was not evidence-based, and reinforce the need for supervisory
involvement and consultation in the process.
However, as I discuss in Chapter 13, significant systemic issues remain,
and I address them in the recommendations that follow.
RECOMMENDATIONS
48 The Toronto Police Service, in partnership with academic institutions
and its own analysts, should continually work on developing the most
sophisticated risk assessment tools. This work must include evaluating
and testing the existing risk assessment tools with measurable
outcomes, to ensure they are evidence based.
49 Risk assessments should be done by those with specialized training
and education in missing person investigations and risk assessment.
Such experts should include, at a minimum, the members of the
Missing Persons Unit and missing person coordinators, whether
civilians or sworn officers.
As I state in detail in Recommendations 117 and 119, more basic training and
education should be provided to all sworn officers and certain civilian
members of the Service. This basic training is important, as well, during any
transition to the proposed mid-term model because, at that time, risk
assessments might still be performed by those without specialized training and
education.
50 The Toronto Police Service should build capacity to have risk

assessments performed in missing person cases 24/7 so they can be
14
In fairness, the Service did recognize that the Search Urgency Chart was only an investigative aid, that the
urgency of the situation maynot be reflected by the column with the most checkmarks, and that the situation
must be treated as most urgent if even one factor is life-threa tening.
done as soon as practicable and promptly reviewed. It should also
ensure that risk assessments are regularly re-evaluated as new
information comes forward.
51 The Toronto Police Service should ensure that the officials who
conduct risk assessments meet regularly with each other and with
non-policing agency partners (see Recommendation 52) to
collaborate on current cases and to promote consistent approaches to
assessments and quality control.
52 The Toronto Police Service should develop, in partnership with social
service, public health, and community agencies, a risk assessment–
based triage protocol that enables appropriate cases to be diverted to
non-policing agencies or addressed through a multidisciplinary
approach, including referral to FOCUS tables.
should work with the City of Toronto, provincial and federal
governments, and public health, social service, and community
agencies to build capacity for non-policing agencies to share or
assume responsibilities for missing person cases in ways consistent
with the proposed mid-term and long-term models outlined in this
Report.
54 Risk assessments should identify and document:
(a) the types of risks, if any, associated with a person’s reported

disappearance;
(b) existing factors that elevate or diminish these risks, while
recognizing that a single factor that elevates risk may determine
the level of response to a person’s disappearance;
(c) the recommended investigative or other response to a person’s
reported disappearance;
(d) whether, and to what extent, the disappearance should be
addressed by the police, social service, public health, or
community agencies or through a multidisciplinary response,
including but not limited to referral to a FOCUS table.
55 In amending the current Risk Assessment forms, the Toronto Police
Service should continue to design them to be user-friendly, so as to
enable types of risk and risk factors to be identified, with the ability to
supplement them as needed.
56 The Toronto Police Services Board and the Toronto Police Service,
with their agency partners and the City of Toronto, should consider
whether to create a dedicated missing person FOCUS table or
dedicated FOCUS tables or to build added capacity more generally for
FOCUS tables to enable them to play a more active role in missing
person–related situations. If such a dedicated missing person FOCUS
table or dedicated FOCUS tables are created, the Service and its
partners should develop different, but analogous criteria for
intervention in missing person-related situations, based in part on the
issues identified during this Review.
57 The Toronto Police Services Board’s policies and the Toronto Police
Service’s Missing Persons Procedure and related Risk Assessment
forms should be re-evaluated and upgraded in the light of the
systemic issues identified by and the lessons learned through this
Report. Explicit reference to the issues and lessons should be
incorporated into these documents and/or into training and
education. The list includes the following issues and lessons.
(a) In accordance with the National Centre of Missing Persons and

Unidentified Remains Best Practices Guide, the need to treat
missing person cases as presumptively high risk, unless and
until a risk assessment or available information reasonably
supports an alternative approach.
(b) In accordance with Recommendation 61, the need to
incorporate a clear definition of the “strong possibility of foul
play,” together with specific direction to address continuing
misconceptions about when the strong possibility of foul play
exists.
(c) The need to provide direction, including lists on potential “red
flags” of foul play or exposure to serious bodily harm, informed
by the deficiencies identified in this Report.
(d) In accordance with Recommendations 61-62, the need to
provide further direction as to when missing person cases
should be treated as major cases, whether or not mandated by
provincial adequacy standards.
(e) The need to provide clear direction and lists on the types of
risks to be considered, apart from foul play, again informed by
the deficiencies identified in this Report.
(f) The need for risk assessments to be informed by the
disproportionate number of marginalized and vulnerable
people who go missing; by how those people are also
disproportionately the victims of violence and criminal
exploitation; and how, as a result, their marginalization and
vulnerabilities may, and often do, elevate the risks associated
with their disappearances; merely directing officers to
determine whether missing persons are members of certain
communities, without more information, is inadequate.
(g) The need to ensure that the fears and concerns of those who
report someone missing or are directly affected by their
disappearances are taken seriously, given their familiarity with
the missing persons, and that their fears and concerns are not
responded to in a dismissive or insensitive way.
(h) The need to ensure that the affected communities’ concerns –
for example, about community safety and perceived patterns of
disappearances or the possibility of a serial killer – are taken
seriously and inform any investigative response.
(i) On a related point, the need specifically to consider patterns of
disappearances, where potentially correlated, as part of a risk
assessment, rather than focusing exclusively on a single
disappearance.
(j) The need to avoid a mind-set that unreasonably discounts the
possibility of foul play or serious bodily harm.
(k) Similarly, the need to ensure that risk assessments are not
based on institutional or systemic reluctance to elevate the risk
assessment because of extraneous concerns about resource
implications.
(l) As partially reflected in the Service’s current Missing Persons
Procedure, the need to ensure that risk assessments are not
based on or influenced by stereotypical assumptions or
misconceptions about missing persons with certain personal
identifiers, such as sexual orientation, gender identity, and
gender expression, or missing persons who have certain
perceived or actual lifestyles. In this regard, examples of such
stereotypical assumptions or misconceptions should be
informed by this Report.
(m) The need to ensure that risk assessors are provided direction or
guidance not only on the questions to be asked but also on how
the answers bear on risk.
(n) Though not currently articulated in the Service’s Missing
Persons Procedure, the need to ensure that the contents of
Missing Person questionnaires are used in making risk
assessments.
(o) The need to ensure that risk assessors are provided examples of
scenarios that elevate or reduce risk.
(p) The need to ensure that clear direction is provided as to the
need constantly to re-evaluate risk as an investigation
progresses. When and if a lead investigator or major case
manager is assigned, this ongoing re-evaluation should take
place collaboratively with these officers.
In relation to item (e), there is a correlation between degree of risk and the
marginalized and vulnerable status of community members who go missing.
As I outline in Chapter 12, we know, for example, that LGBTQ2S+
community members are at greater risk of being the victims of certain crimes.
The statistics on violence against trans individuals are frightening. As well,
the already frayed confidence of these community members in the Service
can only be enhanced through robust investigations when their fellow
community members go missing.
***
The current Missing Persons Procedure provides that a supervisor must review
the Risk Assessment Form immediately when a risk factor is indicated, but, if
no risk factors are indicated, the supervisor need review the form only as soon
as it is practicable. In my view, if responding officers misunderstand what
constitute risk factors or minimize the urgency associated with an individual
case, as I saw repeatedly during this Review, the bifurcated approach to
supervision could result in unacceptable delay in identifying risk. Further, at
present the MPU may not review such risk assessments until a person has gone
missing for eight days. I am concerned about the institutional delay in ensuring
that those with specialized knowledge in risk assessment make or review the
assessment of risk in the early days of someone’s disappearance, especially if
the Service transitions to the mid-term model I propose.
As well, current supervision of risk assessments is problematic because
supervisors are not trained and educated in this area. I address this problem in
my recommendations on training and education.

Procedure to abolish the bifurcated approach to the time within
which a supervisor must review an initial risk assessment (described in
the commentary that precedes this recommendation) that currently
exists.
As I state in Chapter 13, the three levels of search that have been preserved in
the current Missing Persons Procedure are not easily correlated to the risk
assessments. A disappearance may require a response that includes some
components of each of a level 1 search, level 2 search, and level 3 search. The
descriptions “more investigation required,” “expand investigation,” and
“immediate response required” are vague, confusing, and not helpful. Two of
these superficial descriptions straddle multiple levels of search (e.g., expand
investigation applies to both levels 1 and 2 searches), making them even more
difficult to understand or apply in a consistent way.
The procedure states that level 1 will be implemented when “there are
no extenuating circumstances.” The meaning of “extenuating circumstances”
is unclear. The procedure also states that, at level 1, “there are minimal
concerns regarding the issue of foul play or the infirmity or limitations of the
missing person.” However, it is clear that foul play or the infirmity or
limitations of the missing person are not the only criteria for elevated risk. In
addition, the strong possibility of foul play has been frequently misinterpreted
and requires some definition.
Level 2 is to be implemented when a missing person is under 16 and
judged likely to be incapable of self-care, mentally challenged, over 65 years
old or infirm, or where there is evidence of foul play. There are a variety of
circumstances sufficient to elevate the urgency of a search beyond these
criteria. However, such circumstances are unspecified in the procedure. The
procedure does not explain how investigations into those who have gone
missing for over 30 days fit into these levels, other than reflecting that such
investigations are mandatory major cases. Ultimately, it is difficult to see why
these levels of search should be preserved. In identifying an ongoing risk
assessment, the focus should be on the circumstances of each case. These
circumstances should dictate the specific resources that should be devoted to
the case. As well, a number of investigative steps, especially those that
involve community engagement and the use of external supports, Victims
Services, and prevention strategies, are largely framed in discretionary
terms. They should not merely be considered but should be central to every
high-quality investigation.
59 In the light of the concerns and deficiencies identified in this Report,

the Toronto Police Service should re-evaluate the usefulness of the
levels of search currently set out in its Missing Persons Procedure. The
investigative response to a particular disappearance should be based
on the circumstances of the disappearance that exist or as they
evolve. The search response to a missing person should be closely
correlated both to the risk assessment process and to the criteria set
out in the Ontario Major Case Management Manual – or any
additional criteria identified by the Service for determining when a
missing person occurrence constitutes or should be treated as a major
case.
The federal ombudsperson for victims of crime stated, “Despite the fact that
missing persons are a social phenomenon that encompasses vast areas of
interest, relatively little is known about those who go missing, what happens
to them while they are missing, or what can be done to prevent these incidents
from occurring.” There is a need for such research to be done to enhance the
accuracy of risk assessment tools.
During the Review, I also examined the use of artificial intelligence to
potentially enhance risk assessment. A detailed discussion of the use of
artificial intelligence is beyond the scope of this Report, but it is well
recognized that current uses of artificial intelligence by law enforcement,
particularly in the United States, have been problematic and at times, skewed
to perpetuate pre-existing marginalization and to target already discriminated-
against groups and individuals. The use of artificial intelligence must be
approached with appropriate caution. I welcome the research being done
elsewhere on the use of artificial intelligence to assist in risk assessments.
However, I am convinced that even the creation of discrimination-free
algorithms to assist in assessing risk will never obviate the need for skilled
personnel to evaluate risk. As has been recognized in academic papers, the
time may come when the optimal approach to risk assessment may be the
judgment of an experienced detective that takes into account a risk coefficient
that is created by a discrimination-free algorithm.
60 The Toronto Police Services Board and the Toronto Police Service (the
Service) should support continuing research on risk assessment,
including the creation of predictive models, based in part on
disaggregated data collected by the Service and on analytical work.
I return to the topic of research later in this chapter.
The Major Case Designation in Missing Person Cases

Since 2013, the definition of a major case has included cases where a person’s
disappearance remains unsolved for more than 30 days. Although the Service’s
Major Case Management Unit currently tracks the expiry of 30 days in at least
some missing person cases, it is obvious to me that Toronto investigators have
been unaware of or have failed to act on the 2013 change in the definition of a
major case to include missing person cases outstanding for over 30 days. More
generally, apart from whether the definitions are known to officers, I found
that officers failed to recognize when missing person cases must be designated
as major cases based on the strong possibility of foul play. In my view, “foul
play” involves being victimized by crime involving a missing person’s death,
abduction, or serious bodily harm. A “strong possibility” of foul play is a
significantly lower threshold than a “probability,” “reasonable grounds,” or
“reasonable and probable grounds” Unlike the grounds required to exercise
police powers or seek judicial orders, a strong possibility of foul play need not
be based on admissible evidence. Some investigators interpret this provision
so narrowly as to virtually exclude any missing person cases unless there is
indisputable evidence of foul play. No body, no crime. As I state earlier, this
interpretation does a disservice to those missing, and to their families and
friends.
RECOMMENDATIONS
61 The Toronto Police Service should ensure, through a combination of
amended procedures, Routine Orders, and training and education,
that its officers understand when a missing person occurrence must
be designated as a major case. The amended procedures should
(a) dispel misconceptions around the meaning and interpretation

of a “major” missing person case and “the strong possibility of
foul play”;
(b) further draw on and acknowledge the issues identified during
the Review and the lessons to be learned as a result;
(c) specifically indicate that “strong possibility of foul play” does
not require definitive proof of foul play or even the probability
of foul play; in missing person cases, the “strong possibility of
foul play” will be based, almost invariably, on circumstantial
information, such as “red flags” that elevate concerns about the
missing person as a victim;
(d) specifically indicate that the “strong possibility of foul play”
includes the strong possibility of being victimized by crime
involving a missing person’s death, abduction, or serious bodily
harm; and
(e) specifically indicate that any uncertainty about whether “a
strong possibility of foul play” exists should be resolved in
favour of its existence.
Under provincial adequacy standards, the “strong possibility of foul play” and
the passage of 30 days from the date a person is reported missing provide the
criteria for the designation of a missing person occurrence as a major case.
However, the Service is not prohibited by provincial adequacy standards from
treating additional missing person occurrences in the same way as cases
involving these criteria.
62 The Toronto Police Service should amend its procedures to permit or

require lead investigators and their supervisors to treat missing
person occurrences as the functional equivalent of or analogous to
major cases when:
(a) foul play cannot reasonably be excluded; or,

(b) the missing person’s life or safety may be at serious risk for
reasons unrelated to the strong possibility of foul play.
In addition to the lack of clarity and uncertainty over when a missing person
occurrence should be designated as a major case, there is a lack of clarity over
what that designation means in practice – that is, when it is
operationalized. Such a designation, if made, does not resolve questions over
who or which unit conducts the investigation or whether a command triad is
needed (not all major cases require the assignment of three different
officers to perform the command triad functions in a major case).
63 The Toronto Police Service should outline in its procedures the

operational implications of the designation of a missing person
occurrence as a major case or as analogous to a major case, most
particularly when the designation is based on the strong possibility of
foul play or analogous concerns. Such procedures should specifically
address the following issues:
(a) who decides whether the case involves a strong possibility of

foul play or analogous concern;
(b) how that decision is to be documented;
(c) how the decision is to be effectively and regularly monitored
and updated when appropriate;
(d) how the review of the decision is to be documented;
(e) when a missing person occurrence involves a strong possibility
of foul play or analogous concerns, how the decision will be
made whether the investigation is led by the Homicide Unit, the
Missing Persons Unit, or the relevant division’s Criminal
Investigations Bureau, with or without investigative support
from other units; and
(f) regardless of which unit leads these cases, how the decision will
be made as to whether a command triad will be set up or
whether major case management will be employed without the
assignment of three separate officers.
I stress that this recommendation does not compel the Service to craft
procedures that are so rigid as to prevent the above decisions from being made
case by case. However, the status quo is simply unacceptable. Other than
relying on “limited resources,” officers were often unable to articulate to the
Review a principled basis for any of these decisions. Equally important, my
research disclosed missing person occurrences that unquestionably
deserved heightened attention. But they never got it. The designation of an
occurrence as a major case, if employed properly, makes it more likely that the
ensuing investigation will be given appropriate priority, identify links to other
major cases, and attract additional resources.
64 The Toronto Police Service should recognize that divisional criminal

investigations units may be ill equipped or resourced to conduct
complex, lengthy missing person investigations. In some instances,
giving such investigations to the criminal investigations bureaus sets
them up for failure. These investigations should often be done or led
by the Missing Persons Unit itself, unless the occurrences meet the
criteria for referral to the Homicide Unit for investigation. The Missing
Persons Unit can lead the investigations, with work delegated to the
divisional criminal investigations bureau officers as needed.
Jurisdiction 15
The evidence disclosed several instances in which the choice of jurisdiction
impeded the effectiveness of a missing person investigation. In relation to Tess
Richey’s disappearance in November 2018, the Service’s Missing Persons
Procedure dictated, as it does now, that the division where Ms. Richey resided
should conduct the missing person investigation (see Chapter 8). However, it
made more sense for the investigation to be conducted by the division
where she was last seen. In relation to Abdulbasir Faizi’s disappearance, the
Peel police conducted the missing person investigation because Mr. Faizi
lived within their jurisdiction (see Chapter 5). However, much of the
investigative work was done in Toronto because he was last seen there.
The Service’s Missing Persons Procedure includes a detailed and
complex set of directions for determining which division will assume
jurisdiction over an investigation into a Missing Person Report. The procedure
also provides direction where a Toronto resident is reported missing to another
police service (see Chapter 13 and the Reporting Reference Guide). As I state
in Chapter 13, the Service’s procedure relating to jurisdiction can only be
described as confusing at best and ineffective at its worst. Too much
prominence is given to the place where the missing person resides, even in the
15
Though Toronto police officers have city-wide police powers, I use “jurisdiction” here as a convenient
term to discuss which division assumes carriage of a missing person investigation.
face of obvious evidence that the investigation must primarily be focused on a
different location where the person was last seen. In my view, the time is long
overdue for the Service to re-evaluate jurisdiction when missing person
investigations are to be done at the division level rather than by the centralized
Missing Persons Unit. In my respectful view, the Ministry of the Solicitor
General should consider whether this re-evaluation should form part of a larger
examination of how and when Ontario police services should assume
jurisdiction in cases that have a multi-jurisdictional dimension, although not
necessarily qualifying as major cases.
RECOMMENDATIONS
65 The Toronto Police Service’s procedure that defines which division or
service investigates a missing person case is outdated and, in
partnership with the Ministry of the Solicitor General, should be
revisited. Among other things, revised procedures should be informed
by the following considerations:
(a) Where the police reasonably believe that the focus of the
investigation will largely, although perhaps not exclusively, be
within the jurisdiction where the person was last seen, if
known, and the investigation is not to be conducted by the
Missing Persons Unit, it should generally be conducted by the
division where the person was last seen. This approach is
subject to a determination by the Missing Persons Unit that the
particular circumstances warrant a different approach.
(b) In the above circumstances, where the missing person resides
in the jurisdiction of another police service, the relevant police
services should liaise with each other to determine jointly the
most appropriate service to lead the investigation. That
determination should be documented and should be made
based on where the investigation would most effectively be
conducted, rather than on extraneous considerations.
(c) Where more than one division or service must perform the
actual investigative work, efforts should be made to avoid
duplication and other inefficiencies. There should be clear lines
of reporting and coordination, and, in cases involving more than
one police service, the province should create a process for
facilitating these investigations, even if they do not meet the
criteria for multi-jurisdictional joint investigations.
should urge the Ministry of the Solicitor General to adopt province-
wide guidelines on jurisdiction to be exercised in missing person and
unidentified remains investigations. Consideration should be given to
the National Centre of Missing Persons and Unidentified Remains Best
Practices Guide respecting jurisdiction; the guide treats the place a
missing person is last seen, if known, as the lead criterion for
assuming jurisdiction.
Criminal Investigation Management Plan

The Missing Persons Procedure refers to the Service’s Criminal Investigation
Management Plan as an associated governance document. However, the
procedure fails to incorporate the requirement specific to missing person
investigations that investigations involving a strong possibility of foul play or
level 2 or 3 searches in turn need to be assigned to a specialist criminal
investigator.16 The plan also identifies other types of cases requiring a
specialist criminal investigator.
In relation to missing person investigations, I am of the view that,
properly interpreted, the plan contemplates an investigator with specialty
training, education, and skills. However, it appears the Service does not
interpret the plan in this way because, historically, no specialty training and
education has been available for missing person investigators. As I explain in
Chapter 13, regardless of how the plan is interpreted, I strongly support the
creation of specialty training and education in missing person investigations. I
base my support on the significant number, the importance and the range of
complexity of these investigations, features that distinguish them from general
investigative work, as well as the demonstrable inconsistencies in the quality
of such investigations conducted by officers without specialized knowledge.
In addition, the Policing Standards Manual’s sample police services
policy suggests that every police service should establish a crime management
system that includes, among other elements, a process for supporting a multi-
jurisdictional investigation that is not a major case, including liaising with
other law enforcement agencies. However, the Criminal Investigation
16
A “specialist criminal investigator” is defined as a police officer who has received specialized training in
the area to be investigated and is competent to conduct the investiga tion.
Management Plan does not incorporate this requirement. It should.
RECOMMENDATIONS
Procedure to ensure that it complies with its Criminal Investigation
Management Plan respecting the assignment of specialist
investigators in missing person investigations. The Service may
consider and incorporate within its Missing Persons Procedure and its
Criminal Investigation Management Plan whether there are categories
of such investigations, particularly those of less complexity, that need
not be assigned to a specialist investigator if overseen by the Missing
Persons Unit. The Criminal Investigation Management Plan should
also incorporate a process for supporting a multi-jurisdictional
investigation that is not a major case.
In Chapter 9, I observe that two parallel investigations at two different

divisions took place simultaneously in relation to Ms. Wells’s unidentified
bodily remains and her reported disappearance. At one point, the steps in both
investigations were duplicated – for example, Detective Randy Wynia and
Detective Constable Guy Kama interviewed some of the same witnesses.
Clearly, this duplication does not represent best practice. Rather, it represents
an unnecessary use of police resources even as it imposes a burden on
witnesses, who must tell their stories twice. I recognize that some duplication
is inevitable when a connection has not been made between two seemingly
unrelated cases. But, in my view, when a tentative connection between
investigations is known, the Service should at the very least take steps to
determine whether the investigations should be merged.
68 The Toronto Police Service should create a process, reflected in its

procedures and its Criminal Investigations Management Plan, for a
decision to be made, where appropriate, to merge investigations
otherwise being conducted in multiple divisions and to avoid
unnecessary duplication of investigative work. Where the decision is
made to maintain separate investigations, the lead investigators
should coordinate their efforts to ensure that they are not duplicating
investigative steps.
Assignments and Continuity of Investigation and Supervision
The evidence disclosed that in many missing person cases, unacceptable
delays occurred in assigning an officer in charge. For example, it took two
days after Tess Richey was reported missing for a lead investigator to be
assigned (see Chapter 8). The absence of a lead investigator made it less likely
that the search would be conducted in a comprehensive coordinated way. In
other instances, investigative work stopped altogether when a lead investigator
went off-shift for a period of time. Similarly, there was an unacceptable delay
in assigning the lead investigator to the unidentified remains investigations
involving Alloura Wells (see Chapter 9). Indeed, in relation to the second
investigation involving Ms. Wells – the missing person investigation – the
identity of the assigned lead investigator remains unclear even today.
Moreover, the records the Review examined were unclear at times as to the
lead investigator in relation to the disappearance of Mr. Navaratnam.
As I explain in Chapters 8 and 9, the delay in the assignments of serious
matters, or uncertainty in relation to the assignment of an investigation, adds
to the unfortunate impression that the police regard these investigations as
unimportant. That in turn undermines the investigation and may adversely
impact supervision and accountability.
The evidence discloses that these assignment issues have been systemic
at the Service insofar as they relate to missing person investigations.
Community members have had difficulty reaching those directly involved in
the investigations, either to make inquiries or contribute information.
Investigations often ground to a halt when the lead investigator went off-shift.
Longstanding or “cold” missing person investigations fell into an abyss as
investigators were reassigned. In some instances, the identity of the assigned
lead investigator was not clear even in the Service’s own records.
The Service’s Missing Persons Procedure does not address the
assignment of officers or the continuity of investigations as officers go
off- shift or are transferred to other responsibilities. In general terms, the
procedure does state that the Missing Persons Unit (MPU) will ensure
“continuity and consistency of file management.” I am pleased that the unit
has taken significant steps, outlined in Chapter 13, to address the systemic
issues surrounding continuity of investigations. I support these initiatives.
My recommendations below supplement them further.
RECOMMENDATIONS
Procedure to ensure full continuity in missing person investigations
when lead investigators go off-shift. Such continuity means
(a) investigations should continue even in the absence of the lead

investigator;
(b) an officer assumes carriage of the investigation in the lead
investigator’s absence; and
(c) changes in the identity of the lead investigator, are documented
in the investigative file and made known to those closely
associated with the missing person’s disappearance.

Procedure to ensure full continuity in missing person investigations
when lead investigators are reassigned or retire. Such continuity
means
(a) the investigation should be reassigned promptly;

(b) the reassignment should be documented in the investigative file
and made known to those closely associated with the missing
person’s disappearance; and
(c) when feasible, the former lead investigator should take steps to
familiarize the new lead investigator with the investigation and
document the fact that this step has been taken.
71 The Missing Persons Unit or, on adoption of the mid-term model

proposed in this Report, missing person coordinators should assume
responsibility for continuity and consistency of file management.
Missing person coordinators should have lines of reporting within
their division or quadrant as well as to the head of the Missing
Persons Unit.
72 The Toronto Police Service should amend its applicable procedures, in
accordance with the recommendation contained in the 2019
Inspection Report of the Ministry of the Solicitor General, to require
(a) the officers assuming the responsibilities of the command triad

in major cases to be clearly identified, and
(b) the assigned officers in missing person and unidentified remains
investigations, or the officers who assume the responsibilities of
the assigned officers in their absence, to be easily accessible to
the public, most particularly those closely associated with the
missing persons or, potentially, to the unidentified remains.
Pursuant to the model contained in this Report, missing person coordinators

and/or missing person support workers may be the ones who most
accessible to the public or to those closely associated with the missing
person or, potentially, to the unidentified remains. The point here is that those
directly affected by a disappearance should never have to struggle to figure out
who, if anyone, has carriage of the missing person investigation or, more
generally, struggle to reach someone who can meaningfully communicate with
them. The National Inquiry into Missing and Murdered Indigenous Women
and Girls 17 also identified this issue as a country-wide problem,
recommending that protocols be developed to recognize that a high
turnover among officers assigned to investigate missing person cases may
negatively affect progress on the investigations and relationships with family
members.
Assignment of Specific Investigators

The Service modified its existing procedures, in the aftermath of the Jane
Doe18 case, to allow complainants in sexual offence cases to choose the gender
of their interviewer. One member of senior command has suggested that, in the
future, an analogous approach should be taken for investigations involving
LGBTQ2S+ community members. The extent to which this analogy applies
may depend on the nature of the investigation; the relevance of
someone’s sexual orientation, gender identity, or gender expression; and
the extent to which this choice will reduce barriers and create a safe and
welcoming environment for community members. I am also mindful of the
desirability that all officers (not just selected officers) treat community
members with respect and dignity and be as exposed as possible to the lived
experiences of our diverse communities.
17
Canada, National Inquiry into Missing and Murdered Indigenous Women and Girls, Reclaiming Power
and Place: The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and
Girls [Ottawa: Privy Council Office, 2019], online resource.
18
In 1986, a woman known as Jane Doe was sexually assaulted in Toronto. When she reported the crime to
the Service, she was advised that the attack fit the pattern of other sexual assaults targeting local women.
Ms. Doe successfully sued the police for failing to warn the community about the serial predator. Toronto
City Council later appointed an independent auditor, Jeffrey Griffiths, to examine the Service’s sexual
assault investigations. His report is summarized in Chapter 11.
RECOMMENDATION
73 The assignment of investigators or interviewers to a missing person
investigation should be informed by their individual skills and
competencies. In making such assignments, supervisors should be
mindful of, and informed by, the dynamics in individual cases. These
dynamics may include
(a) the nature of the investigation; and

(b) the personal identifiers relevant to the missing person, those
who report that person missing, or those being interviewed.
Community Partnership and Engagement

In Chapter 9, I examine the investigation into Alloura Wells’s unidentified
remains. Ms. Wells was a member of Toronto’s trans community. She was
also Indigenous, a sex worker, and struggled with drug abuse. As I state
earlier, she was marginalized and vulnerable in several ways that intersected,
though she was also engaged with her communities and well known.
However, the investigator was unaware of the resources available to assist
him – community resources and the Service’s own resources, including the
LGBTQ2S+ liaison officer. With one or two notable exceptions, officers in the
McArthur-related investigations similarly failed to use available resources and
to partner with affected communities to advance their work.
This type of community engagement cannot be regarded as peripheral
or optional as the Service has often regarded it. It is at the core of
effective investigative work, especially for missing person and
unidentified bodily remains cases involving marginalized and vulnerable
individuals. All told, this issue requires a fundamental shift in how the
community becomes engaged in the Service’s work.
In 1999, the Griffiths Report found that Toronto front-line officers had
little experience or understanding of communities of colour, cross-cultural
communities, immigrants and refugees, and communities where language
barriers existed.19 The Report also found, in the context of sexual assault
investigations, that effective co-operation with community service
providers by Toronto police was an issue. Such co-operation was described
as essential to these investigations, not simply a public relations exercise.
More recently, Judge Oppal observed that the steps taken by the police
19
Jeffrey Griffiths, “Review of the Investigation of Sexual Assaults, Toronto Police Service” (Toronto:
Toronto Audit Services, October 1999).
in British Columbia respecting the Pickton-related investigations were largely
ineffective because the police failed to educate themselves about the dynamics
of the Downtown Eastside community and did not actively seek the assistance
of community and Indigenous leaders to build the trust necessary to overcome
barriers to police-community communication. He added that, to investigate
reports of missing women successfully, the police need the assistance of
family members, friends, the community, and the media, especially in
circumstances where foul play cannot be ruled out and where there is no
crime scene. Strategies for proactively involving these external sources of
information are key.
I make similar observations with respect to the Toronto police
investigations relevant to this Review. Investigators should work in partnership
with communities to advance missing person and unidentified remains
investigations. Community members have important information. They have
expert knowledge about their communities that most investigators will not
have and are likely unable to access. However, community members
cannot provide such information if they don’t know an investigation is
taking place. If the police are to act in meaningful partnership with
affected communities, the police must provide those communities with basic
knowledge to enable them to assist. As I state in Chapter 7, the lack of
transparency comes with a price far greater than the risk of jeopardizing an
investigation. If affected communities do not trust the police, in part, because
they feel the police do not trust them, investigations will inevitably suffer,
and public confidence and support for the police will be eroded. A
fundamental shift is required in how the police share information with
communities. With respect to marginalized and vulnerable communities, this
shift is also necessary to overcome barriers of distrust and even fear of the
police.
To its credit, the Service has recently used town halls to provide
communities with an opportunity to be heard regarding their issues and
concerns. What is remarkable is, as one deputy chief acknowledged, that very
little community engagement such as town halls took place afterthe McArthur-
related investigations were over. The deputy chief frankly did not know why.
The Service was, in many ways, tone-deaf about the impact these cases had on
the public and the affected communities.
The evidence disclosed that the police were anxious to keep Project
Houston secret on the theory that transparency would harm the investigation.
However, as I observe in Chapter 6, the secrecy around Project Houston
far exceeded anything needed to preserve the investigation’s integrity.
This extreme secrecy set the Service up for heightened mistrust when
community
members later learned they were misled or, at a minimum, shut out.
The Service must commit itself to a robust communication strategy
in missing person investigations. Distributing posters, issuing press releases,
and holding meetings where virtually nothing is shared with the community do
not represent meaningful and respectful communications. I was told that, at
one point in the McArthur investigation, in order to respond to the criticism
that nothing had been done to investigate the mounting disappearances of
members of the Village communities, the Service created an information
pamphlet that listed what had, in fact, been done. The pamphlet was too
little, too late. It reflects a mind-set where many members of the Service see
communicating as counterproductive to their investigations or as a necessary
evil, rather than a way of enhancing their investigations and building
confidence in their work. Moreover, Corporate Communications, whose
members are responsible for media relations, cannot communicate what
they don’t know or provide effective advice in a vacuum. Virtually every
officer agreed that the Service does a poor job of letting the public know what
is being done behind the scenes or, in fact, much about the Service at all.
In Chapter 13, I discuss five components of effective missing person
investigations under the rubric of community partnership and engagement: (1)
active involvement of communities, including their leaders and organizations,
in advancing missing person investigations; (2) information sharing by the
police with affected communities and the public at large about specific
investigations; (3) accessibility of information about how to report persons
missing and about available resources; (4) provision of public warnings about
potential danger to community members; and (5) partnerships with group
homes and other institutions, particularly residences involving youth, to
address the problem of recurrent missing youth. Here, I add another
component, highlighted in earlier chapters: (6) use of the Service’s liaison and
neighbourhood community officers to facilitate missing person and
unidentified remains investigations. I briefly comment on each before
setting out my recommendations.
Active Involvement of Communities in Advancing Missing Person

Investigations
The Policing Standards Manual recommends that a service’s missing persons
procedure include a “requirement” that officers liaise with voluntary or
community agencies involved in locating those who have gone missing.
The Service’s Missing Persons Procedure currently requires the
supervisory officer in a level 2 search to “consider” obtaining assistance from
the Community Partnerships and Engagement Unit – Auxiliary Program 20 as
well as community organizations. The new Missing Persons Unit (MPU) is
also said to be a “collaboration of all partners to leverage all available
resources that may be utilized as a resource for investigative assistance,
information and community mobilization.”
Community partnership and engagement should be a core component of
how the Service conducts missing person investigations. This component
should involve engagement strategies and the active participation of the
Service’s liaison officers and neighborhood community officers, as well as the
MPU and divisional representatives. Although the MPU is alive to this need,
as are some individual investigators, the reality is that the existing Missing
Persons Procedure does not require community partnership and engagement.
The procedure makes such engagement explicit only for levels 2 and 3
searches. In practice, it is not consistently taking place and, in many cases,
does not take place at all.
RECOMMENDATION
74 The Toronto Police Service should strengthen its existing Missing
Persons Procedure to ensure that the investigators make themselves
aware of existing community resources that can advance their missing
person investigations and fully use those resources as needed. The
Service should work proactively with community groups and leaders
to establish processes for community partnership and engagement in
missing person investigations.
As reflected in Recommendation 83, the Service’s liaison and neighbourhood

community officers can assist investigators (as can missing person
coordinators) in identifying existing community resources.
Information Sharing by the Police

The Missing Persons Act, 2018, provides broad authority for the chief of
police, or individuals the chief designates, to disclose information about
missing person investigations to the public at large. Apart from the legislation,
the police undoubtedly have authority to share information with affected
communities and their members in order to advance investigations and
20
The Community Partnerships and Engagement Unit – Auxiliary Program deploys trained volunteers to
support the Service in various roles, particularly community-oriented policing initia tives.
promote public safety.
The Service’s Missing Persons Procedure is largely silent on the issue
of information sharing with the public. It states that a citizen requesting
information, either electronically or by telephone, about another citizen’s
whereabouts shall be directed to the officer in charge. The officer in charge
shall determine whether it is appropriate to release the requested information.
Aside from this direction, the procedure provides no guidance as to when or
how members of the public should be updated about an ongoing missing
person investigation.
The procedure does require officers to “consider” using a poster or
bulletin to assist in locating the missing person. In the case of a level 2 search,
divisional investigators are also required to “consider” requesting assistance
from the media and to “consider” communicating the relevant information on
social media. There are no suggested timelines for issuing a media release at
the outset of an investigation or on any ongoing basis. However, the procedure
does incorporate the Service’s News Media Procedure as an associated
governance document, and some valuable direction is provided there.
I recognize that procedures cannot contemplate or address every
scenario. However, in my view, the existing procedures can better address
identified systemic flaws. Several of those flaws involve failing to issue timely
media releases in missing person cases and overly restrictive information
sharing with communities generally. As well, those directly affected should
have a greater say in the contents of media releases or social media messaging,
subject to overriding public interest concerns. That greater say reflects the
justifiable concern some family members expressed to me about the missing
persons whose disappearances the Review investigated. In those cases, some
media information, whether coming from the Service or the media, showed a
lack of sensitivity to the missing persons and those closely associated with
them. Although the Service cannot control how the media depict a missing
person, it can at least alert the media to issues of sensitivity and compassion. I
have already addressed the role of those directly affected in media releases in
Recommendation 43(d).
RECOMMENDATIONS
should develop, in partnership with community groups and leaders,
an information-sharing strategy that institutionalizes ongoing
communication with community leaders and groups and with the
public at large about the Service’s missing person investigations. The
information-sharing strategy should draw upon the systemic issues
this Review identifies and the related lessons learned. In particular,
the strategy should promote:
(a) information sharing about specific investigations with affected

communities and the public at large;
(b) community partnership in how and what information is shared,
including use of community resources for messaging;
(c) a process for decision making around public warnings that
includes, to the extent possible, confidential input from
community leaders or groups;
(d) police participation in community meetings, and town halls,
both to inform communities about existing missing person
processes and about specific investigations of concern to those
communities, and to address potential barriers to information -
sharing;
(e) ongoing feedback from communities about the Service’s
successes or failures in its communication strategy and, more
generally, in its ongoing relationships with diverse communities;
(f) consideration of the impact on marginalized and vulnerable or
disadvantaged communities in failing to communicate
information;
(g) the development of a user-friendly missing person and
unidentified remains webpage;
(h) the development of a coherent and comprehensive approach to
the use of posters and both, social and traditional media to
share information;
(i) recognition that not every community member has equal
access to the internet or electronic communication, as well as
the need to address linguistic barriers, and to accommodate
those with disabilities; and
(j) the creation of missing person awareness days (see
Recommendation 87).
76 The Toronto Police Service should incorporate the information-

sharing strategy into the missing person strategic plan described in
Recommendation 32 and in the Toronto Police Service’s Missing
Persons Procedure.
The strategy should also incorporate Recommendation 43(d), which provides

for the input of those directly affected, where feasible, before information
about or photos of the missing person are given to the media.
A senior member of the Service suggested that for major crimes
involving equity-seeking groups, the Service should aim to be “as proactively
transparent as possible with the information provided to the communities
during the investigative stage.” It was suggested that this approach might
mean, for example, that the Service take the initiative in seeking to unseal
information in high-profile criminal cases involving equity-seeking groups,
rather than merely reacting to media requests for unsealing orders. 21 I agree
with this suggestion, which has application, by analogy, to high-profile
missing person investigations.
The proposed communication strategy should ensure that
information sharing does not undermine the integrity of an investigation,
while recognizing that the Toronto Police Service has, at times, unduly
restricted information sharing based on this principle.
Regarding media releases, I observe in Chapter 8 that the police failed
to issue a timely media release in relation to Tess Richey’s disappearance. In
Chapter 9, I find that the police also failed to issue a timely media release with
respect to Ms. Wells’s unidentified remains. Timely media releases are
important, particularly where the missing person is at risk. I recognize there
are circumstances in which a media release may undermine the safety of a
missing person – for example, where a missing person may be the specific
target of a criminal organization. For that reason, I am not recommending that
media releases be issued in every case.
77 The Toronto Police Service should amend its procedures relating to

both missing person and unidentified remains investigations to ensure
that, where appropriate, timely media releases are issued in relation
to such investigations.
78 Where the state of unidentified remains prevents the release of a
photograph or where efforts will be made to reconstruct the facial
21
Courts frequently order that documents be sealed, prohibiting access by the public, including those
suspected of crimes. The media or another party may seek an order unsealing some or all of the documents’
contents.
features of the deceased, a media release should nonetheless be
issued, in the absence of exceptional circumstances. The media
release should provide information about the location where the
remains were found, when they were found, and potential identifiers
such as articles of clothing that were found.
Accessibility of Information
The MPU has improved the public’s access to information about how to report
someone missing. For example, the Missing Persons Unit (MPU) now has a
webpage on the Service’s website: http:www.torontopolice.on.ca.22 The
MPU’s webpage is http://www.torontopolice.on.ca/homicide/missing-
persons-unit.php.23 The webpage is a welcome development, although, as I
reflect below, some significant enhancements should be done to make it more
useful, more user friendly, and more accessible particularly to diverse
communities. As well, from my community outreach and engagement, I
learned that members of the public remain mystified about who they should
speak to, at or outside the Service, about the disappearance of their loved one,
both at the outset and while their loved one remains missing. The current
webpage has not alleviated the public’s confusion. Accordingly, as reflected
in Recommendation 79, the webpage presents a valuable opportunity, one of
many, to share information.
The unit does not currently have the budget or resources to create and
host its own website. The webpage contains information about how to report a
person missing and enables people to fill out a Missing Person Questionnaire
in advance of meeting with a responding officer. It also indicates that there is
no waiting period to report someone missing and contains links to external
organizations and agencies that support missing person investigations and the
loved ones of missing people. However, the number of organizations
listed leaves the reader uncertain as to which organization to contact and what
each one can realistically provide.
Information about individual missing person cases is not published on
the unit’s webpage. Instead, the unit relies on the National Centre for Missing
Persons and Unidentified Remains webpage for publication of eligible cases. 24
A link to this webpage is available on the unit’s webpage.
22
The website contains other useful information, including links to general information about the Service,
links to the Service’s social media profiles (including Twitter, Facebook, and YouTube), and links to assist
the public in finding information or obtaining police assistance.
23
Users can navigate to the Missing Persons Unit webpage by clicking on the “Find a Unit” button in the
“About TPS” drop-down menu on the main page of the Service’s website.
24
https://www.canadasmissing.ca/index-eng.htm
The unit’s webpage may be the first point of contact for many people
looking to report a disappearance. It can and should be improved. In many
ways, the Service is underusing the power and potential of internet and
smartphone technology to improve public interaction with the police and
increase the efficiency of missing person investigations. For example:
 Although the MPU’s webpage is accessible on a cellphone, the Missing

Person Questionnaire cannot be filled out and submitted using a phone.
Given the ubiquity of cellphone usage (and the reality that not all
cellphone users own or have access to a computer), cellphone access to a
workable version of the Missing Person Questionnaire should be
prioritized. The questionnaire could also be more “assistive” with
“explanation” and “help” icons for every question.
 The information on the webpage is only in English. The webpage could
easily include a readily available function that instantly translates the
content of the webpage (and the Missing Person Questionnaire) into
languages commonly spoken in Toronto. Such a function would remove
linguistic barriers in reporting and improve the accuracy and value of
information provided on the Missing Person Questionnaire. The fact that
the questionnaire is in English only was identified in my community
engagement as a barrier to members of the South Asian communities.
 The webpage could direct members of the public to the division closest to
them. On a smartphone and most computers, this task could be
accomplished through the GPS.
 Similarly, accessibility could be increased by linking an explanatory
video with multilingual captioning to outline the missing person reporting
process and the work of the unit. Properly produced, this video too could
assist in calming the reportee and improving the public’s perception that
the unit truly wants to help those in all segments of the city.
 A member of the public accessing the webpage should be assumed to be
in a state of emotional stress. The wording of the webpage should reflect
an understanding of that reality. Changes might include acknowledging
the pain and uncertainty of the situation, affirming the Service’s
commitment to prioritizing missing person cases, and offering an
overview as to what a missing person investigation typically entails.
 The webpage could incorporate a “Frequently Asked Questions” section
to provide answers to common questions. Providing this resource online
may reduce the amount of time officers spend answering basic questions.
 The webpage could offer additional practical tools to empower
individuals to participate in missing person investigations. For example,
the webpage could offer an “auto create missing person poster” link.
Using a photograph and information provided by the reportee, the
webpage could produce a poster and send it back electronically to the
reportee for electronic or hard-copy distribution.
 The webpage could alert members of the public to the Service’s diverse
membership and allow reportees to request that an officer from a given
community (Indigenous, LGBTQ2S+, female-identifying, etc.) respond
to the Missing Person Report, if doing so would facilitate trust between
the reportee and the Service and create a safe environment within which
to engage with the police.
 The webpage could feature profiles of historical or ongoing missing
person cases.25 They could, for example, be posted on the birthday or
anniversary of the disappearance of a missing person. Such exposure
might raise the profile of a given investigation, just as it might also
provide a sense of comfort for the loved ones of the missing person and
enhance confidence in the police investigation. Any posting should be
done, when feasible, with the consent of the family or other loved ones.
 Options could be provided for those within affected communities to
subscribe for regular search updates through text or email.
 The webpage could, after consultation with external organizations and
agencies, provide better guidance as to which ones to contact in which
situations.
 The webpage should also provide accessibility capabilities for the
visually and hearing impaired.
RECOMMENDATIONS
79(a) The Toronto Police Service should improve the webpage relating to
missing persons in ways that might include:
 providing cellphone access to a workable version of the Missing

Person Questionnaire,
 creating a more “assistive” questionnaire with “explanation”
and “help” icons for every question,
 introducing measures to overcome linguistic barriers,
 through the GPS, directing members of the public to the
25
The MPU does place some profiles on Facebook.
division closest to them,
 introducing an explanatory video with multilingual captioning to
outline the missing person reporting process and the work of
the unit,
 using more sensitive language, in keeping with the anticipated
state of emotional distress of a member of the public accessing
the webpage,
 offering an overview as to what a missing person investigation
typically entails.
 incorporating a “Frequently Asked Questions” section,
 offering additional practical tools to empower individuals to
participate in missing person investigations, such as an “auto
create missing person poster” link,
 alerting members of the public to the Service’s diverse
membership and allow reportees to request that an officer
from a given community (Indigenous, LGBTQ2S+, female-
identifying, etc.) respond to the Missing Person Report,
 featuring profiles of historical or ongoing missing person cases,
when feasible, with the consent of the family.
 allowing those within affected communities to subscribe for
regular search updates through text or email,
 providing better guidance as to which ones to contact in which
situations, and
 providing accessibility capabilities for the visually and hearing
impaired.
79(b) The Toronto Police Service should evaluate or ensure that an

evaluation is done of the extent to which the online Missing Person
Questionnaire is being used by members of the public, how helpful it
is to investigators, and whether members of the public find it
accessible and user-friendly.
80 The Toronto Police Service should study the feasibility of a dedicated
call-in number for missing person information, which should
ultimately be staffed by civilians with specialized training and
education.
Public Warnings
In Chapter 7, I discuss the Service’s decision in mid-July 2017 that it
should not issue a public safety media release in relation to gay men using
social media dating sites to arrange sexual liaisons. It appears the director
of corporate communications made the decision not to issue that release on the
basis that it could cause the public to connect the disappearances of Mr.
Kinsman or the Project Houston missing persons with their use of social
media, when there was no evidence to establish that connection. The Service
issued a public safety release only in December 2017. As I state in Chapter 7, I
see no impediment to issuing such a warning regardless of whether the
evidence had already established a link between the dating sites and the
disappearances. The language of the alert could clearly make that point, as
well as reinforcing the legitimacy of using dating websites for sexual
encounters. Public safety should trump other considerations. Moreover, such
a release was unlikely to jeopardize the ongoing investigations in any
meaningful way. In my view, the investigators directly involved, rather than
Corporate Communications, should make the decisions around the propriety of
a public warning, mindful of the lessons learned from the Jane Doe case.
RECOMMENDATION
81 The Toronto Police Service should re-evaluate its existing decision-
making processes for issuing public safety warnings. At a minimum, in
relation to major case investigations, the major case manager should
make the ultimate decision, in consultation with the Service’s
Corporate Communications, as to whether a public safety warning is
required. These types of decisions should be made, whenever
possible, in partnership or in consultation with community leaders.
Partnerships with Group Homes and Youth-Related Institutions

Many officers expressed frustration with the time and resources devoted to
habitual runaways, as they are described, from group homes or other youth-
related institutions. In the view of the officers, these young people are not
necessarily “missing” in the sense contemplated by the definition of missing
persons under the legislation, but instead are temporarily absent without
permission and likely to return safely. They are concerned that resources
would be better devoted to cases involving risk of serious harm, and they
question whether institutions unnecessarily report these young people missing
to fulfill their legal obligations or to avoid legal liability. The challenge, of
course, is that young people at large without permission may also be exposed
to a range
of dangerous activities, such as human trafficking and sex work. The other
challenge is that they may be “running away” from abuse or other intolerable
conditions. As well, some youth-related shelters or institutions describe the
complacent attitude of some officers who respond – sometimes slowly – to
missing person calls for service, even when there may be legitimate concern
about the young person’s safety.
To its credit, the Missing Persons Unit (MPU) has tried to develop a
consistent protocol for group homes and shelters to use when a person is
reported missing. As I explain in Chapter 13, to date there has been no success
in achieving a consensus on procedures and information sharing.
I was impressed by the Saskatoon Police Service’s approach to
similar issues. A large percentage of its missing person cases involve
habitual runaways or young people who go absent from these homes and
institutions. Protocols have been developed that, under certain circumstances,
permit such homes andinstitutions to record the absences of young people with
the police without the record immediately generating a missing person
investigation. Such protocols include appropriate follow-up if the person
does not return within a short period of time. I endorse this approach, as
long as it is accompanied by appropriate triaging of cases and prevention
strategies outlined elsewhere in my recommendations. After all, so-called
runaways can also be at high risk depending on the circumstances.
RECOMMENDATION
82 The Toronto Police Service should take steps to introduce a new and
complementary approach to cases involving youth who go missing
from group homes, shelters, and other youth-related institutions. This
approach should be designed to proactively reduce the number of
young people who leave their care homes or institutions; ensure that
issues explaining their departure are addressed by social service,
public health, or community agencies; implement measures to ensure
that such young people are safe when away from their care homes
and institutions; and appropriately triage cases involving young
people who leave care homes or institutions. Such an approach may
involve, as it does in Saskatoon, reporting to the police that a young
person is missing from care without immediately activating a missing
person investigation.
Use of Liaison and Neighbourhood Community Officers
The Service must do a much better job in fully using the skills and knowledge
of its liaison officers and neighborhood community officers in advancing
its missing person and unidentified remains investigations. The role of
such officers in major investigations has been undervalued. They have often
been brought into situations only when damage has already been done, rather
than proactively to ensure that the frayed relationships with community
members and groups are not exacerbated.
As one officer stated to the Review and as discussed in Chapter 14,
a true community policing model means that liaison and neighbourhood
community officers perform core functions. One chief of police shared a
powerful endorsement of these officers. In his view, the relationship the liaison
and neighbourhood officers have with those in the communities with which
they are connected creates trust and gives them access to information. As a
result, such officers become the most important members of a police service
when it comes to any issue that has arisen in the area to which they are
assigned. “If a service has a truly ‘embedded front-line,’ these officers become
a service’s most significant information resource.” At the same time, liaison
officers should not be conscripted to engage in activities that will undermine,
rather than solidify, their relationships with marginalized and vulnerable
communities.
RECOMMENDATIONS
83(a) The Toronto Police Service should fully use its liaison officers and its
neighbourhood community officers to advance missing person and
unidentified remains investigations.
83(b) The Toronto Police Service should revise its Missing Persons
Procedure, as well as relevant job descriptions, to explicitly recognize
that its liaison and neighbourhood community officers may
(a) facilitate information being made available, particularly from

marginalized and vulnerable community members otherwise
reluctant to come forward;
(b) create a safe and welcoming environment for those who want
to report a person missing and for potential witnesses who
want to come forward;
(c) dispel existing mistrust and provide needed assurances;
(d) familiarize investigators with the significance of information
they are being provided;
(e) correct stereotypical assumptions or preconceptions that can
infect investigations;
(f) access street-level community members, otherwise inaccessible
to investigators, who may be well situated to assist an
investigation;
(g) address concerns about the potential misuse of information
provided to police, including privacy issues around sexual
orientation, gender expression, or identity; and
(h) ensure that appropriate language is employed in media releases
and by investigators in their interactions with community
members.
Here I am addressing the important role of liaison officers and

neighborhood community officers in assisting investigators in overcoming
barriers, particularly with marginalized and vulnerable communities, and
thereby enhancing the quality of missing person and unidentified remains
investigations – indeed, investigations generally. In my later
recommendations, I discuss the larger role of these officers unrelated to
specific investigations but in building community relationships.
Prevention Strategies
The Service’s Missing Persons Procedure mandates certain steps for the police
to take when a missing person is located. Unless there are exceptional
circumstances, an officer must personally attend the location where the
missing person is present to verify that the person is safe and to ensure that the
reportee and/or next of kin has been notified. The officer must also “consider”
contacting the divisional community relations officer or the crime prevention
officer for follow-up and prevention strategies to address repeat
occurrences. There is no requirement that a return or prevention interview
be conducted with the person who went missing to discuss any outstanding
issues that might explain the disappearance and prevent reoccurrences in
the future. Such interviews are not routinely done in Toronto. They should
be.
In a number of jurisdictions, return or prevention interviews form a core
component of how police services respond to missing person cases. These
interviews are routinely done in the United Kingdom and in Calgary, as well
as by the Ontario Provincial Police. They are often done by social
workers, social service agencies, or civilians rather than by sworn
officers, for the
obvious reason that sworn officers are associated with law enforcement
activities, sometimes in the missing person’s community. Detective Mary
Vruna, the Missing Persons Unit’s (MPU’s) head, supported the use of return
interviews, particularly those conducted by trained civilians. She felt that,
preferably, the interviews should not involve an officer, because many of these
located individuals are hesitant to interact with the police and may be
unwilling to share sensitive information about their mental health, traumatic
experiences, or personal safety with an officer. To that list, I would add
information about their criminal activities while missing.26 Equally
important, the return interviews are likely to raise social issues best
addressed by non-policing agencies.
There is evidence that such return interviews reduce the number of
missing person cases reported to the police and, going forward, assist
investigators in identifying patterns and predicting the location of those who
have gone missing. This evidence is yet another instance in which the Service
must recognize activities that should be at the core, rather than the periphery,
of missing person responses.
In the United Kingdom, “safe and well” checks, the equivalent of
“return interviews,” are considered to be as important as investigations
themselves. Officers debrief the returned person in a one-to-one conversation
in which the questions are drawn from a template and the discussion is
confidential. The debriefing helps identify why the person went missing and
what underlying problems continue to exist. Consistent with broader
community safety strategies, the debriefing may lead to a referral to a social
agency.
The Calgary Police Service attempts to conduct return interviews to
determine why the located persons went missing, where they have been, who
they were with, what they were doing, and whether they were victimized.
Return or prevention interviews, standard policy for the Ministry of Social
Services, are also a common practice in Saskatoon.
RECOMMENDATION
84 The Toronto Police Service should modify its Missing Persons
Procedure to require, in the absence of exceptional circumstances,
that a “return” interview be sought with a person who chose to go
missing. The return interview should address whether there are
underlying issues, particularly those unrelated to law enforcement,
26
An OPP pilot project involving use of return interviews found that many youth were being exposed to
crimina lity while away.
that explain why the person decided to go missing, and how to avoid
the person repeatedly going missing, thereby reducing the number
and costs of future missing person cases. To the extent possible, these
return interviews should be conducted by non-policing agencies or
civilian missing person support workers. Uniformed sworn officers
should be involved as little as possible. In some instances, return
interviews should result in referrals to multidisciplinary FOCUS tables
to address underlying social issues that explain the person’s
disappearance. The Service and the agencies involved in such
interviews should create a template of questions to assist the process.
The template should merely be a guide or checklist, rather than rigidly adhered
to.
TextSafe is a service in the United Kingdom that engages young people
by text. If someone goes missing, the police will ask the Missing People
charity to send a TextSafe message inviting the young person to text the
organization. This system allows a message to be sent to the missing
person with advice about available support services.
RECOMMENDATIONS
85 The Toronto Police Service, in partnership with community
organizations, should also support a service modelled on the United
Kingdom’s TextSafe program.
86 The Toronto Police Service should support the creation of a diverse
survivor working group, consisting of those who have previously gone
missing or their loved ones. Such a working group can assist in
building community awareness about missing persons and how to
respond when a person goes missing.
Missing Person Awareness Days

RECOMMENDATION
87 At regular intervals, the Toronto Police Service should conduct a
Missing Person Awareness Day in which Service members explain to
the community the approach taken to missing person cases, provide
information on how to report missing persons, what websites to
access for information about missing persons or missing person
investigations, including who to contact with questions about how
missing person investigations have been conducted or how to provide
relevant information. In this regard, the Toronto Police Service should
consider the Ontario Provincial Police’s model, with necessary
modifications.27
Specific Investigative Issues (Chapters 5–13)
Electronic and Internet Searches

Project Houston and other investigations relied heavily on electronic and
internet searches. During Project Houston, the officers spent an extraordinary
number of hours examining James Brunton’s computer, including emails, his
online search history, websites he visited, and his chat messages. Yet, no one
comprehensively examined each missing man’s involvement in social media
and the internet. This was not simply a problem that related to priorities.
Officers in Project Houston and other investigations had varying abilities to
access electronic media. They sometimes sought assistance from the
Technological Crime Unit and, after its inception, the Cyber Crime Unit.
Sometimes they did not. Sometimes the technological support was
available. Sometimes it was delayed.
The Review met with many officers who had an incomplete
understanding of how to obtain a comprehensive internet and social media
profile of missing people. This was the case regardless of whether the task
involved forensic searches of computers, tablets, cellphones, open-source
searches, judicial production orders, Mutual Legal Assistance Treaty requests,
or some combination. Social media and the internet represent critical sources
for investigative information, subject of course to appropriate privacy
boundaries. The evidence disclosed no uniform approach to this work. It also
revealed that officers had varying understandings of technical support or
resources available to assist them in accessing or obtaining electronic
information, including social media and internet use.
RECOMMENDATIONS
88 The Toronto Police Service) should address the systemic issues
associated with how it collects electronic evidence, including the
content of devices and internet and social media use. In particular,
27
The OPP model is described in Chapter 13.
the Service should amend (or improve) its existing internet procedure
and practices to promote:
(a) clarity on what electronic searches should be done by

investigators and what electronic searches should be done
through the Technological Crime Unit and/or the Cyber Crime
Unit;
(b) timely access to technological support when it is needed for
major investigations;
(c) clarity on when and how needed information should be
obtained through Mutual Legal Assistance Treaties, production
orders under the Missing Persons Act, 2018, the Criminal Code,
or other means.
I recognize that investigators have varying skills in collecting electronic

information, and that “one size may not fit all.” This recommendation is to
ensure that electronic information is not left undiscovered either because
officers are unfamiliar with how it can be successfully accessed or because
technological support is unavailable when needed.
Even when it is clear that Mutual Legal Assistance Treaty (MLAT)
applications are required to collect such evidence, the MLAT process is
burdensome and may significantly delay investigations. This is, of course, not
an issue confined to the Service.
should urge the provincial and federal governments to address and
streamline the Mutual Legal Assistance Treaty process for collecting
electronic information. The criteria for obtaining such information
should remain the same, but the bureaucracy associated with this
process needs to be streamlined.
The Use of Analysts

The evidence disclosed that, to the prejudice of the investigation, the civilian
analyst assigned to Project Houston was underutilized. In fairness, it was
apparent that during Project Houston the assignment of an analyst to an
investigation was the exception, rather than the rule. - Frequently analysts are
not fully integrated into major investigations.
RECOMMENDATION
90 The Toronto Police Service should ensure that civilian analysts are
fully integrated into major investigations to which they are assigned.
They should not be treated as secondary participants but ideally have
full access to the information available to the assigned investigators.
***
Some of the Service’s civilian employees described a culture that favours the
views of sworn officers over civilians. Some civilian employees regard
themselves as marginalized within the Service. Without attempting to quantify
the extent to which this represents a larger systemic issue, I wish to stress that
any manifestation of this culture should not only be resisted but also
proactively addressed. There are a number of ways to do this including
through lines of reporting that integrate civilians fully into the Service’s
decision- making and give those who have supervisory responsibilities
equivalent ranks to uniformed officers. I saw examples of that approach
within the Service. Ultimately, it is incumbent on senior command to take
responsibility for supporting and protecting civilian employees when and if
they encounter resistance. As the Service moves away from a paramilitary
culture and embraces a holistic approach to community safety and well-being,
it is more likely that civilians and sworn officers will be valued and treated
equally within the Service.
Communication with Another Service

The evidence disclosed that Peel police unsuccessfully attempted to
interest the Toronto Police Service in the possible connection between the
disappearances of Mr. Faizi and Mr. Navaratnam. The failure of the Service to
identify the potential connection between these two cases – when presented to
them by the Peel police – represented a failure of epic proportions. As I state
in Chapter 5, this failure speaks to systemic deficiencies in how missing
person cases were dealt with, and a failure to learn the lessons from the Paul
Bernardo tragedy when services did not work together to solve his crimes. The
Service’s failure to respond to the Peel police potentially reinforces
community perceptions, whether accurate or not, that the Toronto police
were largely indifferent to the disappearances of gay men of colour. It was
another missed opportunity to solve this case earlier.
RECOMMENDATIONS
91 The Toronto Police Service should amend its procedures, including the
Missing Persons Procedure, and disseminate a Routine Order to
address the systemic issue represented by the Service’s failure to
respond to the attempts of another police service to interest the
Service in a potentially connected investigation. More specifically, the
procedures should require:
 that a Toronto police officer, advised of a potential connection

between a case in Toronto and another jurisdiction, document
the information provided and ensure that it is followed up on,
and that the follow-up is documented in the relevant
investigative file.
92 The Toronto Police Services Board and the Service should request that
the Ministry of the Solicitor General draw the issue of lack of
communication between services to all Ontario police services and
identify a contact person (or position) at the ministry in the event that
any officer or service is concerned about the failure to respond
appropriately to such information being communicated.
Templates or Checklists for Missing Person Investigations

In Chapters 5 to 7, I find significant inconsistencies, among the various
missing person investigations, in the investigative steps that were pursued. A
similar finding prompted the 2019 Report of the National Inquiry into Missing
and Murdered Indigenous Women and Girls to develop a checklist for the
minimum investigative tasks to be considered and undertaken during a missing
person investigation. Other jurisdictions, such as Scotland, have developed
such checklists.
I identify inconsistency as a recurring issue in the missing person
investigations this Review examined. Some officers were diligent and
thorough. Others were not. In some instances – sadly, in too many instances –
basic investigative steps were overlooked or delayed. Inconsistencies, of
whatever nature, should be addressed, in part, by specialized training and
education on how to conduct missing person investigations. However, there is
also a need for an internal guide or checklist that contains a detailed list of
investigative steps available to be employed to advance a missing person
investigation. The Missing Persons Procedure outlines some investigative
tasks specific officers at the various levels of search should undertake.
However, these tasks are far from complete and, in fact, might be regarded as
misleading if, to the detriment of the investigation, officers rely on them as a
complete list of steps that need to be taken to advance an investigation. In my
view, a detailed guide or checklist should be a “living document.” It should be
regularly updated based on experience, investigative outcomes, ongoing
learning, analysis, and research. This guide or checklist should be easily
accessible on officers’ mobile workstations and updated as required. As
reflected in Recommendation 16, such predetermined checklists (also
described as action lists) should be automated on PowerCase for particular
types of investigations, including missing person and unidentified remains
investigations. These checklists should also serve as a teaching aid during
training and education. The 2019 Missing Persons Unit year-end report
references the development of such a guide / checklist. Unfortunately, to date,
it does not exist.28
Such checklists or templates support best practices, including in
countering unconscious biases. One senior Crown attorney recognized and saw
first-hand some of the stereotypical assumptions and misconceptions that
investigators continue to hold, particularly in relation to the LGBTQ2S+
communities. That Crown attorney suggested that procedures must limit
individual discretion in how to conduct investigations, most specifically by
mandating basic steps for every missing person investigation. In that person’s
view, limiting discretion represents one strategy to counter unconscious biases.
The checklists or templates I recommend reduce inappropriate investigative
discretion. They also address my finding that, depending on various factors
including the skill sets of the investigators, there was an unacceptable degree
of variation in many of the investigative steps taken in missing person
investigations. Checklists reduce the risk of errors and facilitate the ability of
multiple officers to quickly ascertain what has and has not been done at a
particular point in the investigation.
In Chapter 13, I also comment on two tasks identified in the current
Missing Persons Procedure (DNA / fingerprint and dental record collection)
and suggest several modest changes to the procedure in relation to those tasks
28
There is a useful checklist that Records Management Services created to identify for responding officers
the information required to complete the phone-in process for the initial Missing Person Occurrence Report.
The Missing Persons Unit also created a list of resources to consider in conducting a missing person
investiga tion.
(see Chapter 13). Those changes are incorporated into the recommendations
below.
RECOMMENDATIONS
93 The Toronto Police Service should create templates or checklists for
missing person investigations to reflect the deficiencies identified by
and lessons learned during this Review. The checklists should be fully
accessible on the officers’ mobile workstations and upgraded as
needed.
should recommend to the Ministry of the Solicitor General that a
missing person checklist form part of provincial adequacy standards.
95 The Toronto Police Service should amend its Missing Person Procedure
to provide that (i) DNA evidence should be collected as soon as
practicable. Absent exceptional circumstances, DNA evidence should
be collected within 48 hours; and (ii) the Dental Chart form should be
completed as soon as practicable in all instances, and in any event,
within 30 days if the missing person is not located.
Interv iewing
The sample guidelines of the Policing Standards Manual recommend that
Missing Persons procedures include a requirement to interview the reporting
individual and associates (emphasis added) of a missing person as soon as
practicable. The Toronto Police Service’s Missing Persons Procedure requires,
where possible, the first police officer in a level 1 investigation to
interview the last person to see the missing person. At level 2, the first
supervisory officer is required to ensure that relatives of the missing person are
interviewed. In my view, the direction provided in the procedure on whom to
interview, when to interview, and how to interview is misguided and
inadequate. I recognize that the procedure is not intended to serve as an
investigative manual for missing person cases, but, in the absence of such a
manual, the minimal direction provided in the procedure is unhelpful and
potentially harmful if treated as setting out the minimal requirements for
an adequate investigation. This deficiency is particularly glaring given the
instances in which missing person investigations the Review examined reflect
failures to interview key witnesses, including those who initially reported the
disappearance, in a timely way or at all; incomplete or superficial
interviews; failures to adequately record the
information provided by reporting individuals; and poor interviewing
techniques.
In Chapter 13, I reproduce the Guide on point of the National Centre of
Missing Persons and Unidentified Remains.
RECOMMENDATION
96 The Toronto Police Service should amend its Missing Person
Procedure to address, in a more helpful and thorough fashion, the
need to interview key witnesses pertaining to the report of a missing
person and the subsequent investigation.
300 Metre Searches and Ground Searches

The Policing Standards Manual recommends that Missing Persons procedures
“require” that “any searches undertaken during a missing persons investigation
be supervised by a trained search co-ordinator and conducted in
accordance with the police service’s procedures on ground searches for lost or
missing persons.” The Service does not have a stand-alone procedure for
ground searches for lost or missing persons. Instead, the Service has
chosen to integrate the requirements for ground search into those Service
procedures that are directly impacted. I take no issue with the Service’s choice
to integrate ground search procedures, as needed, into its Missing Persons
Procedure. However, in Chapter 13, I express concerns about this aspect of
the contents of the Missing Persons Procedure.
For a level 1 search, the “first police officer” is responsible for
thoroughly searching the home and immediate area, and for completing a 300
metre radius search of the place the missing person was last seen, if known.
The supervisory officer is responsible for ensuring that the 300 metre radius
search of the place last seen, if known, is commenced. As I explain in Chapter
8, at the time Tess Richey was being searched for, there was no explicit
requirement under the procedure that a 300 metre radius search of the place
the missing person was last seen had to be conducted, although this was
already known to be a best practice. This addition represents an
improvement. However, an issue arose in relation to the Tess Richey
investigation as to which officers were properly regarded as first police
officers or responding officers, and which officers were obligated to conduct
the 300 metre radius search. The failure to conduct such a search during the
Tess Richey investigation led to a tragic conclusion – Christine Hermeston’s
discovering her daughter’s body. Supervision failed to detect the investigative
deficiency.
Under the current procedure, for a level 2 search, the supervisory officer
must consider the nature of the area to be searched (e.g., ground, urbanized,
ravine, water) and assign adequate personnel to conduct the search. The
supervisory officer must also consider obtaining assistance from support units,
such as the Emergency Management and Public Order Unit, as well as
community organizations. The officer in charge must ensure adequate and
appropriate resources are obtained to conduct the search.
At level 3, the role of a search manager is introduced. Upon being
notified by the officer in charge of the requirement for a level 3 search, the
duty inspector is to notify the search manager. The search manager then
becomes responsible for coordinating the search for the missing person.29
The evidence this Review has examined reveals that door-to-door
physical searches for missing persons, or for relevant witnesses or for video
footage, were, at times, disorganized, incomplete, and poorly documented. I
was advised that, on occasion, officers were reluctant to seek the assistance of
the Emergency Management and Public Order Unit’s search managers either
to coordinate such searches or, at a minimum, to provide advice on how those
searches should be conducted. The Review was advised that there has been
some improvement in how such searches are carried out. Nonetheless, in my
view, it is important that the procedures contemplate a more significant role
for search managers, who have a wealth of search experience, either to provide
advice or to coordinate searches, regardless of the designated level or type of
search. This view also accords with the emphasis on trained search
coordinators in the Policing Standards Manual.
On this topic, I also question whether the Service’s procedure and
practices adequately address the components of the Policing Standards
Manual’s recommended ground search procedures, particularly as they relate
to support for victims, and to coordination with volunteers and community
agencies.
RECOMMENDATIONS
97 The Toronto Police Service should amend its Missing Person
Procedure to
29
I note that the procedure also requires level 2 and 3 searches to be governed by the Service’s Incident
Management System. The Incident Management System is a model of police on-site response to
emergencies and disasters.
(a) explicitly address which officers, in addition to the “first police
officer” or the responding officer, are responsible for
conducting the appropriate 300 metre search and to ensure
that a supervisor approve the nature and location of any such
search (although not necessarily before it has been conducted).
The supervisor should ensure that any decision not to conduct
such a search is documented, together with the reason no
search was conducted; and
(b) explicitly identify the potential role of trained search managers
to either coordinate searches or to provide advice on searches,
regardless of the level or type of search being conducted; and
(c) strengthen the current language pertaining to support for
missing persons and coordination with volunteers and
community agencies, consistent with the recommendations in
this Report.
98 The Toronto Police Service should ensure that all physical searches for
missing persons, or canvassing for witnesses or relevant evidence, be
conducted in a comprehensive and coordinated way that includes:
(a) detailed search or canvassing plans;

(b) systematic reporting to a search manager or lead investigator;
(c) use of appropriate technology, such as GPS, Global Search, or
social media;
(d) use of grid searches, mapping tools, or other techniques to
ensure completeness;
(e) support, when appropriate, of outside agencies; and
(f) coordination with civilian activities and organizations.
This approach should be reinforced through training, education, and

Routine Orders. In this regard, the Service might consider the United
Kingdom’s search and canvass team model, a model that the
Vancouver police have adopted.
Video Footage
In a missing person investigation, it represents best practice for officers to
obtain relevant video footage as soon as possible and promptly view such
footage. Many businesses and residences have surveillance cameras, and video
footage often yields critical evidence. Critically, the footage is frequently
retained for only short periods of time. The evidence made available to this
Review disclosed that, in a number of the missing person investigations, video
footage was not obtained or viewed in a timely way or at all, sometimes to the
detriment of the investigations. Moreover, the video footage was often not
sought out in a comprehensive, coordinated way.
Procedure 04-21 addresses the gathering or preservation of
evidence. However, I am concerned about repeated issues relating to
timely and comprehensive searches for and viewing of video footage. These
issues need to be addressed.
RECOMMENDATIONS
99 The Toronto Police Service should ensure that video footage is sought
and viewed in missing person investigations in a timely,
comprehensive, and coordinated way. This obligation should be
reinforced through a Routine Order, training, and education.
100 The use of a grid search or mapping tool, such as that used by
members of the Emergency Management and Public Order Unit and
other officers, more recently, represents a best practice to be
employed for conducting a comprehensive, coordinated search for
video footage.
Access to Hospital-Related Information

One of the time-consuming but essential components of a missing person
investigation is to determine whether the missing person has been admitted to
any hospital, particularly in the Greater Toronto Area. At present, officers or
special constables must contact each hospital one by one. Moreover, they must
often do so more than once, since the missing person’s status may, of course,
change.
In October 2018, members of the Missing Persons Unit met with the
Ministry of Health in an attempt to develop a process by which police officers
across Ontario could access hospital admissions and related records without
having to contact each hospital and medical facility, separately. In
February 2019, the unit had a follow-up meeting with the Ministry of Health.
At the end of the meeting, the Ministry of Health agreed to take the unit’s
recommendations to the ministry’s legal team for review and approval.
Unfortunately, this process stalled. The Review was told that the plan
was
abandoned owing to practical limitations. Hospitals across Ontario are not all
on the same network, so a “one-step” process for determining whether a given
individual has been admitted is difficult to achieve. My recommendations
address this important issue. It has significant resource implications for all
police services in Ontario.
RECOMMENDATIONS
101 On a priority basis, the Toronto Police Services Board and the Toronto
Police Service should address, with the provincial and municipal
governments, inefficiencies in obtaining information from hospitals,
correction facilities, and other institutions about whether a missing
person is located in those facilities. The current practice of calling
hospital to hospital or jail to jail or analogous institutions is very
costly. It involves an unnecessary expenditure of substantial human
resources and results in investigative delay.
102 The Toronto Police Service should develop additional social media or
other effective tools, such as cross-platform mechanisms or apps that
effectively reach hospitals – as well as others who have regular
contact with those who come into contact with a vast number of
people, such as those involved in transportation services, and similar
services, locations, or agencies, through which the police can place
notifications about missing persons.
Memobooks (Chapters 5–9)

One superintendent advised the Review that officers’ memobooks have
not appreciably changed since the 1950s. In my view, the traditional
police memobooks represent a poor way to record, store, and access
information. As well, during the Review, there were important instances in
which officer memobooks were not retained with the major case files or were
accessible only several years after the investigations concluded. This is
unacceptable. It was beyond the scope of my mandate to revisit the use of
officer memobooks, how the information contained in those memobooks is
and often is not uploaded into a records management system, and how these
memobooks are or are not retained by the Toronto Police Service, and how
they are later made accessible. However, the use of these memobooks
represents a systemic issue that impedes the Service’s ability to conduct and
be accountable for its investigations. This is far from a new issue. Indeed, it
was identified in the 1998 Report of the
Commission on Proceedings Involving Guy Paul Morin led by Commissioner
Fred Kaufman (Recommendation 100, Vol. 2, 1212–16).
RECOMMENDATIONS
103 The Toronto Police Service should evaluate the continuing use of
officer memobooks, having regard to the issues identified during this
Review.
104 The Toronto Police Service should reinforce, through its procedures
and Routine Orders, that all memobooks are Service property and
must be retained as its property. All memobooks relating to specific
investigations must be preserved in the investigative files pertaining
to those investigations.
Unidentified Remains (Chapters 9, 13)
In Chapter 9, I describe the two investigations relating to Alloura Wells – the

investigation into her unidentified bodily remains and the investigation in
response to Ms. Wells’s being reported missing. Before Alloura Wells’s
remains were identified, both her father and the police contacted the Office of
the Chief Coroner to ascertain whether Ms. Wells’s body was at the morgue in
Toronto. There is no reliable record of precisely what Mr. Wells was told. Nor
is there a record of who spoke to him and to the police when they initiated
inquiries. It appears that the answers the chief coroner’s representative gave
were inaccurate, incomplete, or both. Whatever they were, the answers led
both Mr. Wells and the police to believe that the morgue did not have bodily
remains that could belong to Ms. Wells. A similar issue arose in relation to
Kenneth Peddle, whose remains went unidentified for a month when his loved
ones and the police were looking for him.
The Review identified significant deficiencies in how unidentified
remains cases had been investigated before the creation of the Missing Persons
Unit (MPU). At times, there was poor coordination between the Service and
the Office of the Chief Coroner / Ontario Forensic Pathology Service.
Misinformation or incomplete information was provided by someone at
the Office of the Chief Coroner / Ontario Forensic Pathology Service
about existing unidentified remains. This information was not properly
documented. Investigators had little or no understanding of provincial or
national databases or supports available for both unidentified remains cases
and missing person cases. The Toronto Police Service did not submit
many of these cases for
inclusion in the existing databases. The Service’s own procedures on the
discovery of bodily remains, whether identified or not, were not always
followed, most particularly in failing to notify the Homicide Unit promptly or
at all. As was true for missing person investigations, investigators did not
necessarily reach out to available resources within and outside the Service to
advance their investigations.
The situation has been much improved. The MPU’s portfolio now
includes unidentified remains cases. Its members now liaise with the Office of
the Chief Coroner / Ontario Forensic Pathology Service on behalf of the
Service in relation to unidentified remains. The Office of the Chief Coroner /
Ontario Forensic Pathology Service has a designated liaison with the Service
to avoid miscommunication and misinformation. Most significant, the MPU
has worked hard to ensure that the Service’s open missing person and
unidentified remains cases are input into the national database.
I support these steps, but some additional work needs to be done. It is
critically important that the loved ones of missing persons not be burdened by
the uncertainty of the missing person’s whereabouts and feel compelled to
embark on an inevitably fruitless and emotionally draining search when the
authorities have already found the missing person’s remains. Nor does it
represent appropriate use of resources for the police to engage in or continue
unnecessary missing person investigations.
RECOMMENDATIONS
105 The Toronto Police Service should develop, in partnership with the
Office of the Chief Coroner / Ontario Forensic Pathology Service,
protocols on addressing unidentified bodily remains. These protocols
should provide, among other things, that:
(a) the Office of the Chief Coroner / Ontario Forensic Pathology

Service should designate a person or team with sole
responsibility for informing the police about unidentified bodily
remains at the morgue;
(b) the direct contact information for that person or team should
be provided to the Missing Persons Unit and other appropriate
units or officers;
(c) any information exchanged between that designated person or
persons and the police should be memorialized in writing by
both parties;
(d) civilians who make inquiries about people who have gone
missing are dealt with in a consistent and helpful way. Civilians
should be clearly advised as to the specific person or unit to
contact with such inquiries and the relevant contact
information;
(e) the Office of the Chief Coroner / Ontario Forensic Pathology
Service should ensure that prompt notification is provided to
the Service, including the Missing Persons Unit, regarding the
bodies that have arrived at the morgue that day, detailing their
approximate age, sex, and distinguishing features; and
(f) the Missing Persons Unit should continue to be the liaison in
relation to unidentified remains investigations (other than
homicide cases) with the Office of the Chief Coroner / Ontario
Forensic Pathology Service and with the provincial Missing
Persons and Unidentified Remains.
106 The Toronto Police Service, in consultation with the RCMP and the
OPP, should request that one of its analysts be seconded to the
provincial Missing Persons and Unidentified Remains to assist in
ensuring that missing person cases in Toronto are appropriately
overseen.
Notifications to the Homicide Unit

The evidence disclosed that the Service’s Homicide Unit should have been
promptly advised when Tess Richey’s body was discovered. This was an
unexplained sudden death of a young woman. The Service’s existing
Preliminary Homicide Investigations Procedure imposed this obligation.
Similarly, as I explain in Chapter 9, the discovery of Alloura Wells’s remains
should have triggered an immediate report to the Homicide Unit. Either death
might have required the expertise of the Homicide Unit. The unit cannot lend
its expertise to the investigation or, where appropriate, assume carriage of it,
unless it is aware of the death. The unit’s ability to evaluate the situation is
also potentially impaired when its officers are prevented from promptly going
to the scene.
Although my focus is on missing person investigations and how the
police investigate unidentified bodily remains, it is obvious to say that missing
person investigators must ensure that their own conduct does not adversely
affect sudden death or homicide investigations.
RECOMMENDATION
107 Through a Routine Order and other effective methods, the Toronto
Police Service should reinforce with all relevant officers, the
circumstances under which the Homicide Unit should be advised of a
death or the discovery of bodily remains.
In Chapter 9, I explain that it is unclear whether the Service’s procedure on

preliminary homicide investigations – most particularly, on treating
unexplained bodily remains as suspicious deaths – means that the unidentified
remains investigation meets the criteria for a threshold major case under
provincial adequacy standards.
RECOMMENDATION
108 The Toronto Police Service should amend its procedure on preliminary
homicide investigations to clarify when unidentified remains
investigations meet the criteria for a threshold major case.
Internal Review of Investigations and Supervision

(Chapters 5–9, 13)
Reviews of Investigations
In interviews with senior command, certain flaws in the specific investigations
formed the subject of some questioning. Those senior members of the Service
appeared to be largely surprised by the nature and extent of the flaws. Indeed,
during the Review, some senior officers touted the investigations as models for
how to catch a serial killer. Although I find that Project Prism, on balance, was
an effective investigation, the deficiencies in Project Houston and the
investigations that preceded it were profound. It is clear that these deficiencies
were unknown to senior command and to the Board. Putting the flaws aside
for the moment, this ignorance represents a systemic failing to self-identify
and self-correct investigative deficiencies. To illustrate, I outline in Chapter 6
the substantial shortcomings in how the police interviewed McArthur,
shortcomings not only attributable to the well-intentioned officers who
actually conducted the interview, but also to those who supervised them. I find
it surprising that the Service failed to identify and address the underlying
shortcomings. It should have done so. There is no evidence that anybody
reviewed the contents of the McArthur interview until years later. Professional
case management requires an ongoing assessment of work done.
Project Houston was active for about 17 months. The Service invested
substantial human and financial resources to advance the investigation. This
was a Toronto project because of the purported connection between James
Brunton or the cannibal ring and a Toronto missing man. There turned out to
be no connection, and the project was unsuccessful in solving the
disappearances of the missing men. As I reflect in Chapter 6, despite all the
resources invested in Project Houston, no case review or case conference was
convened, as contemplated by the Ontario Major Case Management Manual,
to evaluate the investigation objectively and thoroughly, particularly in the
light of the many deficiencies and shortcomings I have identified. What the
Service missed was the opportunity to consider the lessons to be learned from
the failure of Project Houston.
RECOMMENDATION
109 The Toronto Police Service should commit itself to the professional
use of multi-disciplinary case reviews or case conferences, as
contemplated by the Major Case Management Manual, to evaluate
investigations objectively and thoroughly. In some circumstances, as is
the case in the United Kingdom, serious issues in the conduct of an
investigation should lead to an independent review accompanied by a
public report. This recommendation calls upon the Service to be far
more introspective about its own failings and to correct them.
The Approach to Supervision Generally

The evidence disclosed that supervision of a number of missing person
investigations I examined during this Review were seriously deficient. This
lack of supervision was particularly evident during the latter stages of Project
Houston. However, it is also telling that virtually none of the deficiencies I
identify during my evaluation of the various investigations were discovered
through supervision of investigative work. Major case management
includes thorough ongoing supervision of work being done. I recognize
that limited resources explain some of these supervisory deficiencies.
However, I question whether the supervisory deficiencies are also explained
by the ease with which electronic reports can be approved or signed off on
without meeting with the officers who prepared those reports. It is
instructive that members of the
Missing Persons Unit described drastic variability in the quality of
missing person documentation they reviewed from the divisions, without
supervisory intervention.
RECOMMENDATION
110 The Toronto Police Service should evaluate whether existing
supervision and oversight of major investigations should be re-
examined. This evaluation involves a more fundamental and
introspective questioning of the lines of supervision within the Service
and whether they are serving its needs.
Removing Barriers (Chapters 5–9, 12–14)

If friends or loved ones of a missing person feel at risk in speaking to the
police because their communities have historically been overpoliced,
underserviced, and discriminated against, they are less likely to come forward.
If people feel they are placing the missing person, if found, at risk of
adverse law enforcement or immigration consequences, they are also less
likely to come forward.
The Canadian Association of Refugee Lawyers submits that for
those individuals who have either precarious status in Canada or no status,
fears of immigration consequences inhibit their families and friends from
reporting them missing. The association correctly identifies two McArthur
victims, Kirushna Kumar Kanagaratnam and Skandaraj (Skanda)
Navaratnam, as demonstrating this problem.
As I reflect in this Report, one barrier to reporting or otherwise sharing
information with the police is the genuine fear of adverse immigration
consequences either for the missing person, if found, or for those who wish to
provide information to the police. Of course, if these fears result in
individuals’ not coming forward, even if foul play is suspected, the police are
unable to investigate these disappearances. In addition, the quality of an
investigation may be significantly undermined when relevant witnesses choose
not to come forward. The reality of these fears is reinforced by existing
research that indicates that “non-status individuals go underground because
“they live in constant fear of detention, deportation, and surveillance by the
authorities.”30
30
Peter Nyers, “The Regularization of Non-Status Immigra nts in Canada: Limits and Prospects”(2005) 55
Canadian Review of Social Policy 109.
The association advocates for the Service to adopt a comprehensive
“Don’t Ask, Don’t Tell” policy that would prohibit the police from reporting
to the Canada Border Services Agency non-status individuals who come to the
Service’s attention as missing, potential victims, or witnesses. The association
makes several points in support of this position:
(a) The absence of such a comprehensive policy is inconsistent with the City
of Toronto’s sanctuary city policy and clear direction that immigration
and citizenship information should be collected only where specifically
required by provincial or federal legislation, policies, or agreements so as
to ensure that undocumented Torontonians can access city services
without fear.
(b) In failing to adopt a comprehensive policy, the Service has
misapprehended the law. Contrary to the Service’s position, police
officers have the discretion, not the obligation, to report immigration
violations to the Canada Border Services Agency.
(c) The Toronto Police Services Board’s responsibility for providing
adequate and effective policing must be read in the light of the provisions
of the as yet unproclaimed Community Safety and Policing Act, 2019, that
closely ties policing to the needs of the population, having regard to its
diversity. The Board and the Service must ensure that adequate and
effective policing is provided to Toronto’s diverse population, including
non-status Torontonians. The association notes that there are an estimated
200,000 non-status individuals residing in Toronto alone.
(d) Inquiries by the police into immigration status and subsequent reporting
of violations to the Canada Border Services Agency exacerbate and
reaffirm the existing fear and mistrust of the police among non-status
communities, undermining the Service’s ability to serve and protect
vulnerable community members.
The Federation of Asian Canadian Lawyers also advocates for clear

guidelines and policies when it comes to issues of a victim’s / complainant’s /
witness’s’ immigration status, in relation to the Canada Border Services
Agency. The federation observes that individuals without status in Canada and
who may have had negative experiences with law enforcement in their original
country have a legitimate fear that any contact with the police will result in a
report to the Canada Border Services Agency for removal. As a result, the
Service should adopt a clear and well-publicized “Don’t Ask, Don’t Tell”
policy.
The Criminal Lawyers’ Association contends that the legislature should
adopt clearly defined and legislated protections for individuals reporting
missing persons or providing information aimed at locating missing persons.
A model for this type of legislated immunity protection can be found in the
Good Samaritan Drug Overdose Act. 31 The protection could assist in
improving relationships between vulnerable communities and the police, by
signaling to vulnerable communities that they may come within the ambit of
police protection without fearing criminal repercussions for minor non-violent
offences (sex work, substance abuse).
The HIV Legal Network promotes the human rights of people living
with, at risk of, or affected by HIV or AIDS. Its work pays particular attention
to the rights of LGBTQ2S+ people, people who use drugs, sex workers, and
prisoners. Its work is also of considerable relevance to the health and rights of
Indigenous communities and racialized people.
The network forcefully submitted that the unjustified criminalization of
specific populations and the role of the police in enforcing such criminalization
have impeded and will continue to impede the existing relationships between
those populations and the police. The network referred, in particular, to the
continued criminalization of sex work, drug possession for personal use
and the selling or sharing of limited quantities of drugs, and non-disclosure of
HIV- positive status to sex partners. The network makes a strong case for the
urgent need for legal reforms in these areas. It submitted that enforcement
of the current and pre-existing criminal laws by the police has been
arbitrary, discriminatory, or abusive, often targeting marginalized and
vulnerable community members, resulting in the affected populations being
overpoliced and underprotected.
I pause here to comment on Maggie’s, also known as the Toronto Sex
Workers Action Project. Maggie’s supports sex workers through legal
advocacy, political organizing, peer support, and education. During the half
day I spent at Maggie’s, in discussions with a number of sex workers, I heard
heart-rending descriptions of being treated by police as criminals unworthy of
equal protection.
It is well beyond my mandate to recommend changes to Canada’s
criminal laws, although I accept the underlying theme of the Criminal Lawyers
Association’s and the HIV Legal Network’s submissions that fear of
criminalization makes it less likely that those within certain populations will
directly engage with the police – by reporting someone missing or
otherwise providing information relevant to an investigation. This fear
undermines the
31
SC 2017, c 4.
quality of missing person investigations. I also accept that existing protections,
such as the Good Samaritan Drug Overdose Act, are inadequate to remove
barriers to reporting or information-sharing with police. I add that the
Service’s existing protections for those who report persons missing and for the
missing persons themselves have been poorly communicated to the public and
have not significantly reduced barriers to reporting described above.
RECOMMENDATIONS
should re-evaluate, in partnership with the City of Toronto, what
protections currently exist for those with precarious legal status who
wish to report people missing or provide information about them;
whether the Service has misinterpreted its existing enforcement
obligations, particularly under immigration legislation; and whether
its current procedures and practices are consistent with the city’s
sanctuary city policy and related directions. This re-evaluation,
supported by an independent legal opinion, should lead to enhanced,
well-communicated protections that will assist in reducing barriers to
reporting or information-sharing with the police.
112 The Toronto Police Service should consider incorporating into its
Missing Persons Procedure, a third-party or “distance” reporting
system (where trusted community leaders, organizations, or agencies
are designated to transmit, anonymously if necessary, missing person
reports or information to the police).
Third-party reporting is an important alternative for marginalized and

vulnerable individuals who otherwise would choose not to report or provide
information about a missing person to the police. As Professor Laura Huey
recognized in her report prepared for this Review, third-party reporting should
be studied with respect to vulnerable populations such as homeless and
LGBTQ2S+ groups.32
Acknowledgements of Deficiencies (Chapters 7, 12, 14)
Throughout this Report, I have documented many ways in which the specific
investigations named in the Review’s Terms of References were
defective.
32
Laura Huey, “An Absence of Evidence,” 26.
These were largely explained by systemic issues, some as fundamental as the
low priority given to missing person investigations, the differential
treatment given to a number of these investigations, and the failure to engage
or enlist affected communities to advance these investigations. These
fundamental deficiencies have disproportionately impacted LGBTQ2S+
and racialized communities.
I specifically recognize in this Report that a number of officers showed
skill, dedication, and compassion in their investigative work. I also
acknowledge that some exceptional work was done during Project Prism to
lead to McArthur’s apprehension and, ultimately, his prosecution.
Nonetheless, the systemic deficiencies in most of the earlier McArthur-
related investigations mean that important opportunities were missed to
capture him earlier. I do not accept the inevitability of his seven-year reign of
terror, that the victims’ fates were sealed, or that it was only good fortune
– that is, the discovery of the video of McArthur’s departure with Andrew
Kinsman in a red van – that could have brought about McArthur’s
identification as a serial killer. The police had evidence available to them as
early as 2011 that, properly acted upon, should have led to closer scrutiny.
McArthur’s potentially meaningful connection to all three men whose
disappearances were investigated during Project Houston went unnoticed in
2013, as did his relevant prior convictions. Much harm was done as a result of
these missed opportunities. That lives were lost is unquestionably the most
significant, but not the only, harm.
Tess Richey’s mother found her own daughter’s body. Alloura Wells’s
bodily remains would probably have been identified earlier, had some of the
deficiencies I have identified not been present.
Stakeholders had mixed feelings about whether they wanted to see the
Service apologize for the serious deficiencies in the investigations this Report
reveals. On the one hand, an apology or acknowledgement can represent a step
toward a better relationship between the police and communities. On the other
hand, a compelled apology is often regarded as contrived and therefore
worthless, especially if not followed by concrete and visible commitments and
action plans with transparent and measurable goals designed to ensure that
what happened in the past is not repeated. By way of example, a number of
LGBTQ2S+ community members were deeply troubled by Chief
Saunders’s apology for the 1981 bathhouse raids, especially when it was
followed shortly after by Project Marie.
During my consultation with the Review’s Community Advisory Group, its
members made all the above points. They also contrasted a forced apology
with the approach taken by the chief of the Edmonton Police Service,
who, after extensive consultation both within and outside the Edmonton
Police Service and the development of an action plan, apologized to the
LGBTQ2S+ communities for his service’s past conduct. The Community
Advisory Group told me that, although the affected communities would have
varied views on an acknowledgement from the Service, any such
acknowledgement could only potentially assist if it is demonstrably heartfelt –
the words must be sincere and heartfelt. They must be accompanied by a
specific action plan for change. Such an action plan must be developed in
partnership with affected communities and involve a continuing community
role in its implementation.
RECOMMENDATION
should consider whether they wish to acknowledge the deficiencies
identified in this Report, together with the adverse impact they have
had on those communities and individuals directly affected. Such an
acknowledgement should be made only if heartfelt, if it is
accompanied by a detailed action plan for change that is subject to
independent monitoring, and if the content of the acknowledgement
and the action plan is developed in partnership with communities.
Any such acknowledgement should form part of a comprehensive re-
evaluation by the Service and the Board of the urgent need to
improve relationships with Toronto’s diverse communities, including
those who suffer intersecting and overlapping grounds of systemic
discrimination and disadvantage.
In Chapter 7, I find that Chief Mark Saunders’s December 8, 2017, statement

to the public, during a press conference, that the existing evidence told police
affirmatively that there was not a serial killer in Toronto, was inaccurate and
misleading. Although I do not attribute malevolence to this statement, it had
the effect of further rupturing an already precarious relationship with the
LGBTQ2S+ communities. The statement was unfortunate because it
reinforced the views of some community members that the Toronto Police
Service and its chief were indifferent to their fears and concerns and too
willing to discount prevalent views that a serial killer was at large. Chief
Saunders was later interviewed by the Globe and Mail. Although, again, I do
not attribute malevolence to his comments, they were clumsily worded and,
in some important respects, unfortunate. Chief Saunders inaccurately
stated that
nobody came forward to assist the police, and that the police did everything
they could do with what they were given. This statement was disheartening to
those who had assisted the police. It left the impression that the chief was
blaming the public for the Service’s failure to apprehend McArthur. As I
explain more fully in Chapter 7, the emphasis on the community’s
responsibility for the inability of the police to solve the disappearances was
misplaced. He might have legitimately said that barriers exist that sometimes
prevent marginalized and vulnerable communities from coming forward.
Unfortunately, the chief’s language appeared, however inadvertently, to blame
the public for failing to come forward. He was also unequivocal in saying the
investigation was well executed, yet no internal or external review had
taken place at that point in time. It would have assisted in mending the
relationship with affected communities if Chief Saunders had reserved
judgment on the Service’s performance. Finally, he reiterated the accuracy of
what he had said at the December 8, 2017, press conference. However
inadvertent, this interview made it more difficult for his own officers to
repair the Service’s frayed relationship with affected communities, a
relationship that he was anxious to address while chief of police (see Chapter
7).
RECOMMENDATION
114 The Toronto Police Service should consider whether to acknowledge
the problems associated with Chief Saunders’s statements on
December 8, 2017, and later to the Globe and Mail and how they
contributed to the elevated mistrust that followed the McArthur-
related investigations.
Training, Education, and Professional Development

(Chapters 4–14)
I have heard policing referred to as a profession.
Profession: any type of work that needs special training or a particular skill,
often one that is respected because it involves a high level of education ~
Cambridge Dictionary (online)
Policing is a challenging job. It is especially challenging in Toronto, given the

size and diversity of the city’s population. Training, education, and
professional development of the Toronto Police Service’s members are
critically important if they are to serve and protect the public, particularly its
most marginalized and vulnerable individuals.
Training, education, and professional development are three distinct but
interrelated concepts. Historically, police placed the greatest emphasis on
training – that is, teaching officers technical or operational skills necessary to
perform their duties. One example of such training, mandated under provincial
adequacy standards, relates to use of force. Education involves reasoning and
problem-solving skills, empathy, and understanding. As I explain below,
learning cultural humility is part of the educational process. In policing circles,
such education is sometimes referred to as the teaching of critical thinking.
Professional development involves opportunities for officers to improve their
skills – through on-duty use of what they learn, evaluation, and feedback – as
their careers progress. In my view, all three concepts – training, education, and
professional development – are closely connected to whether policing is
regarded as a profession. A profession denotes high standards of practice,
rooted in specialized training, ongoing education, and professional
development. If the Service and its members aspire to professionalism, the
complexity of modern, progressive policing requires a substantial investment
not only in training, but also in education and professional development. In my
recommendations, I advocate a transformative approach to these concepts.
Such an approach includes at least eight components: (1) mandatory post-
secondary school education for all recruits; (2) training and education that alert
the Service’s members to the systemic issues I identify during this Review
and the lessons learned as a result; (3) specialized missing person training
and education; (4) much greater emphasis on education and professional
development for the Service’s members, addressing reasoning and problem-
solving skills, empathy and understanding, and cultural humility; (5)
greater emphasis on social context education designed and offered in
partnership with communities; (6) measurable outcomes for training,
education, and professional development; and (7) promotions that place
greater emphasis on competencies in relationship-building and community
engagement. Finally, as the eighth component, I advocate the creation of a
regional centre for policing excellence housed in an academic institution
that, among other things, promotes, through research and ongoing evaluation,
the development of best practices in policing among a number of regional
police services, including, in this context, best practices in training,
education, and professional development.
Minimum Educational Requirements for Recruits
At present, the minimum requirements to apply to become a Toronto police
officer are four years of secondary school. 33 The OPP, the RCMP, the Peel
police, and many other municipal and regional services have similar
requirements, although the Vancouver Police Department and the Service de
police de la Ville de Montréal both require an additional minimum of 30 units
of post–high school credits.34 In 2020, almost 3,500 people applied to join the
Service, and 192 were selected. Close to two-thirds (65 percent) of those
selected had post-secondary education. In 2019, 81 percent of new recruits had
post-secondary education.35
In my view, professionalism in policing in Toronto supports a
requirement, similar to that adopted in Montreal and Vancouver, that recruits
have a fixed number of credits of post-secondary education, a requirement that
promotes greater maturity and knowledge. The majority of Toronto recruits
meet this requirement.
RECOMMENDATION
should reflect, in their recruitment policies, the following standards:
(a) recruits must have a minimum of 30 credits of post-secondary
education (or such higher minimum as the Board and Service
might determine);
(b) post-secondary education need not include policing-related
courses, but may well include courses that promote
communication, problem-solving, and relationship-building
skills and cultural understanding and humility; and
(c) diversity and equity in hiring continue to be supported.
I say “continue to be supported” because the Board and the Service have had
success in increasing diversity and equity within the Service, although they
must develop new strategies to attract Indigenous members. The inability of
services to attract a significant number of Indigenous candidates represents a
systemic issue not unique to Toronto. In my view, significant improvement to
the relationship between the Service and Toronto’s Indigenous communities,
33
http://www.torontopolice.on.ca/careers/uni_minreq.php.
34
https://joinvpd.ca/police-officers/ a nd https://spvm.qc.ca/en/Pages/Careers/Police-Officers/Admission-
criteria -for-employment-equity-police-officers and https://spvm.qc.ca/en/Pages/Careers/Cadets/Selection-
criteria .
35
TPS Analysis on Demographic Data 2020 Cadets at p 3.
and appropriate investment in that relationship, are important steps, among
others, toward attracting Indigenous candidates.
Training and Education of Cadets and the Service’s Members

The Current Regime
Every cadet receives three weeks of orientation training at the Toronto Police
College, 12 weeks of training at the Ontario Police College in Aylmer,
Ontario, and then a further nine weeks training at the Toronto Police College.
The Toronto Police College has separate sections dedicated to
investigative training, community training, and ongoing in-service training, as
well as specialized sections relating to armament, police vehicle operations,
leadership and business systems, and learning development and standards. A
number of these sections have already developed partnerships with Humber
College and Brock University. As I suggest below, enhanced engagement with
post-secondary institutions, such as Humber College’s evaluations and work
with the Neighbourhood Community Officer Program, can help to produce
more evidence-based policing that focuses on ongoing evaluation and learning.
It can also help open police culture to outside influences and move the Service
toward greater professionalism.
The Service deserves credit for the range of courses offered, as well as
the infusion of some critical thinking content into its programming. Toronto
officers take a variety of courses: some mandatory for all; some prerequisites
for certain assignments, particularly to specialty units; and some optional. I
have familiarized myself with the full range of courses offered that are
relevant to my mandate. Senior officers are also eligible to be sent for a range
of courses or conferences, including those run by the FBI, the National
Association of Women Law Enforcement Executives in the United States,
and, in Canada, the Police Leadership Program and Excellence in
Administration Program at University of Toronto’s Rotman School of
Management.
Another component of what officers currently receive is three days of
in-service annual training at the Toronto Police College. This training largely
centres on Use of Force training. Officers are also informed of new
Routine Orders and provided procedural updates. Inspector Peter Duncan,
who is in charge of training and education at the college, told me that the third
training day was added in 2015. Much of this additional time is taken up with
issues related to the Police and Community Engagement Report
(PACER)3 6 and
36
PACER wa s delivered in 2013. It contained 31 recommendations designed to implement discrimination-
free policing. It included the creation of a community advisory committee to advise on racial profiling, new
dealing with people in mental health crisis. Senior officers take this annual in-
service training because they “are operational” in the sense of being armed.
Civilian employees who have supervisory responsibilities do not take this
training. The limited time availability for in-service training and the range of
important topics to address pose ongoing problems for trainers. Sometimes,
these constraints are dealt with through greater use of online programming.
In my view, if the Service aspires to become a national, if not global,
leader in providing its employees – sworn officers and civilians alike –
with the skills to effectively, equitably, and compassionately serve and
protect Toronto’s diverse communities, it should adopt the components of
this transformative approach to training and education that I have set out.
Adopting an approach that draws more on Toronto’s diverse communities and
involves the development of teaching best practices through a regional
centre of policing excellence will assist in building relationships with
marginalized and vulnerable communities. It will also contribute to an open
and less hierarchical police culture.
RECOMMENDATION
116 The Toronto Police Services Board and the Toronto Police Service (the
Service) should commit the Service to becoming a recognized
national, if not global, leader in police training, education, and
professional development both for recruits and the Service’s sworn
officers and for its civilian employees, with particular emphasis on
those who perform functions relevant to this Review’s mandate, such
as community engagement, equity, inclusion, and human rights.
I now turn to the content of training and education for the Service’s
members relevant to my mandate.
Training and Education Based on the Review’s Findings

117 The systemic issues identified by and lessons learned during this
Review should inform the content of the training and education of the
Toronto Police Service on the following topics:
(a) risk assessment in missing person cases;
risk thresholds on monitoring discriminatory conduct, enhanced training in colla boration with community
partners, the conduct of periodic community surveys, and enhanced community communication.
(b) the use of technology to advance investigations and
the importance of such use;
(c) the use of existing internal resources and community
partnerships to advance investigations involving diverse
marginalized and vulnerable communities;
(d) communication strategies to ensure that investigations are, to
the fullest extent possible, transparent;
(e) interviewing techniques and appropriate preparation for
interviews, including the nature and scope of work-ups
for interviewees;
(f) trauma-informed interview techniques for those emotionally
traumatized by a disappearance or the discovery of a
deceased person;
(g) how and when to effectively access relevant electronic
information, the internet, and social media personally, through
the assistance of the Technological Crime Unit or the Cyber
Crime Unit, or through legal process;
(h) how and when to utilize the Missing Persons Act, 2018;37
(i) how to determine whether a case meets the criteria for a major
case, whether threshold or non-threshold, and what the
designation as a major case means;
(j) major case management, and the use of PowerCase;
(k) when the Homicide Unit should be advised that bodies
or unidentified remains have been found;
(l) when the Homicide Unit should be consulted or engaged
in relation to a missing person investigation;
(m) tunnel vision;
(n) what is and is not available to officers on the Service’s records
management systems;
(o) the uses that can and cannot be made of underlying conduct
relating to a record suspension (previously known as a
pardon) for investigative purposes;
(p) the role of the Emergency Management and Public Order
search managers and unit members insofar as they relate to
37
SO 2018, c 3, Schedule 7.
urban canvassing and searching, and how they can be called
upon to assist in missing person investigations; and
(q) the criteria that define when missing person investigations
become major cases subject to major case management, as well
as how to interpret those criteria.
Specialized Training and Education

Some of the above topics are not specific to missing person and unidentified
remains investigations and should form part of every officer’s training and
education. As well, as recommended below, every officer should have a basic
understanding of the new model for missing person investigations and
how unidentified remains investigations should be addressed. The depth of
training and education on topics specific to missing person and
unidentified remains investigations should vary according to the current or
anticipated responsibilities of the participants. In Chapter 13, I explain
why specialist training and education is of importance and consistent with the
Toronto Police Service’s own Criminal Investigation Management Plan.
RECOMMENDATIONS
118 The Toronto Police Service should develop specialized training and
education on missing persons and unidentified remains investigations.
Such specialized training and education should:
(a) be made available, at a minimum, to those who become

members of the Missing Persons Unit, including the analyst and
missing person support workers, all missing person
coordinators, those who are expected to serve as lead
investigators in missing person or unidentified remains
investigations of any complexity, and supervisors expected to
review risk assessments in missing person cases. The Service is
best situated to decide how such training and education should
be integrated into either the existing or any new training and
education regime.
(b) be informed, in part, by the systemic issues identified during
this Review and the lessons learned as a result, as well as the
objectives of the strategic plan outlined in Recommendation 32.
Examples of the content of such training and education would
include:
 how to respond to, and take seriously, the concerns
expressed by community members or those directly
affected when someone has gone missing. It undermines
confidence in the police for officers to minimize or dismiss,
whether or not well-intentioned, the concerns expressed
about a missing person;
 the heightened risks that are associated with marginalized
and vulnerable groups and how that should inform an
investigation;
 the availability of internal and community resources to
assist in overcoming barriers to obtaining relevant
information from marginalized and vulnerable community
members in a safe environment, and “red flags” associated
with possible foul play or factors that elevate risk of serious
bodily harm or victimization.
119 Although it is not expected that every officer will receive the
specialized, more intense, training and education set out in
Recommendation 117, it is important that all officers have a basic
understanding of the new model for missing person investigations the
Toronto Police Service adopts and how unidentified remains
investigations should be conducted.
Critical Thinking and Social Context Education

120(a) The Toronto Police Service should place much greater emphasis on
continuing education for its members that addresses reasoning and
problem-solving skills, empathy and understanding, and cultural
humility.
120(b) The Toronto Police Service should partner with those who
work with marginalized and vulnerable communities and
community members to design and provide mandatory social
context education that can, where possible, be integrated into
all forms of training and education. Social context education
would include:
(a) the history of the Service’s relationship with the
LGBTQ2S+ communities, and marginalized and vulnerable
communities generally, and how that history should
inform policing;
(b) the diversity of Toronto’s communities, including its most
marginalized and vulnerable members and the concept of
intersectionality and its importance to policing; and,
(c) where possible, experiential, interactive and place-based
learning: this learning could include land-based learning
about Indigenous people and placements with
community agencies that work with marginalized and
vulnerable groups.
In making this recommendation, I wish to first explain what social context

education ideally involves and then why this recommendation is necessary,
despite some relevant education already being provided to officers. Social
context education involves learning about the history, challenges, and
discrimination that various disadvantaged groups have suffered and often
continue to suffer. Judge Wally Oppal articulated the need for “mandatory and
ongoing experiential and interactive training … concerning vulnerable
community members,” including “active engagement in overcoming biases,
rather than more passive sensitivity training” as well as training “in
recognizing the special needs of vulnerable individuals and how to meet those
needs, including recognition of a higher standard of care owed by the police to
those individuals.”38 I note that the federal ombudsperson for victims of crime
described part of the education required of police as “building cultural
humility.” I fully support her expressed view that police “need to connect with
their humility, feel at ease with not knowing, and be open and ready to learn
from others. Infusing cultural humility throughout the criminal justice system
would open up greater potential to establish trust; in turn, victims and
survivors would be more likely to report victimization …”
What is required is education that makes officers question their
assumptions about marginalized and vulnerable groups. (See also the needs
identified in the Tulloch Report, summarized in Chapter 11).
Social context education should also address ways in which officers can
contribute to a safe and welcoming environment for marginalized and
38
Oppal Report, Recommendation 4.12.
vulnerable community members – for example, through a discussion on
how and when to use certain pronouns and why that is important to
community members. When possible, such education should take an
intersectional approach, explaining how community members cannot usually
be defined by a single personal identifier or membership in one
community. Education should involve on-site or “place-based” learning.
The OPP uses this type of approach in its five-day land-based learning on
Indigenous issues. By way of example, this concept can also be applied in
other contexts by placing police officers with agencies that work with
marginalized and vulnerable communities or engaging officers in discussions
or experiential activities at local community centres. Taking the police away
from their comfort zone of police colleges can also help teach cultural
humility. As well, it can help make the police more open to and accepting of
feedback and criticism from the communities and assist officers in acquiring
knowledge about, and empathy for, those most marginalized and vulnerable.
One goal of such education is to affect police culture by making it less
insular. One way this is accomplished is through greater involvement by those
who represent and serve marginalized and vulnerable groups in the design and
delivery of education, including by sharing problems they have encountered
with the police –as well as their feelings of fear and distrust. The police need
to listen respectfully to those from the communities, something I have been
told is unfortunately not always the case.
I recognize that the Service, to its credit, has introduced social context
education, sometimes described as cultural sensitivity training or education,
and has identified some strategies to address police culture. The nature and
extent of this education, however, varies at the divisional level, depending on
the commitment or interest of division leaders. Nevertheless, these
recommendations recognize that such education, despite good intentions,
remains inadequate for several reasons. Some officers regard it as peripheral
to their work or merely catering to external influences. Some officers see it as
adversarial – an opportunity to “beat up” on the police or accuse them of
racism and other forms of discrimination. I learned that some officers,
certainly not all, have been dismissive of such education and, indeed, one
incident was described in which officers walked out before the session
was completed. Equally important, even as I acknowledge that the Service
has introduced social context and critical thinking, the Service has done a
poor job in measuring the effectiveness of this education. It has also done a
poor job of helping the members of the Service understand how important
this education is and why.
If such education is to be truly transformative, the Service and its
members must understand why it is important – in other words, how it
specifically assists them, on a day-to-day basis, in performing their duties. In
21st-century policing this education is even more important. Education on
social context and critical thinking should be infused in every form of training
and education. It is relevant regardless of whether the Service’s members are
being trained and educated about substantive law, use of force, or anything
else. For example, the missing persons training I recommend includes not only
more technical training as it relates to major case management and PowerCase,
but also education about how to utilize internal and community resources to
obtain information for investigations involving diverse communities.
Recognition that critical thinking and social context education is at the
core of modern-day policing also means that in-service or on-line education
should, despite limitations of time, be more focused on these topics. I am
confident that a wholesale shift in emphasis toward education and professional
development will pay dividends both in the quality of investigations and in
public respect for and confidence in the Service, as a profession. Increased
respect and confidence will contribute to the element I have repeatedly
identified as paramount to a positive, healthy relationship between the police
and the marginalized and vulnerable communities – trust.
Measurable Outcomes in Training and Education

RECOMMENDATIONS
121 The Toronto Police Service should place much greater emphasis on
evaluating the effectiveness of training and education through
measurable outcomes. This emphasis might be reflected, for example,
in auditing the extent to which officers have incorporated their
training and education on discrimination-free policing into their
interactions with community members.
I have already said that the Service does a poor job in assessing whether its
training and education is successful. There have been well-publicized
examples of continuing non-compliance with existing procedures despite
training directly on point. In its 2019 report, Breaking the Golden Rule: A
Review of Police Strip Searches in Ontario, the Office of the Independent
Police Review Director identified the prevalence of strip searches Toronto
officers conducted in violation of the Canadian Charter of Rights and
Freedoms, despite the training taken. (The Service recently addressed this
issue in responding to the OIPRD’s Report). A transformative approach to
training and education requires the Service to develop a plan to assess the
efficacy of training and education, whether through on-line testing that is
repeated after a period of time, auditing police interactions with the public,
satisfaction surveys of community members who contact the police, or through
greater use of case scenarios in promotion interviews to evaluate an
officer’s understanding of what they have been taught.
Professional Development and Promotion

RECOMMENDATION
should, to a significant degree, through policy and procedures, link
promotions to demonstrable competency in developing and
sustaining community relationships, particularly with marginalized
and vulnerable communities. The evaluation of such competencies
can be based on prior activities, community support, and/or
responses to case scenarios that raise issues around engagement with
such communities.
Judge Oppal also identified this competency as an important component of

officers’ ongoing training and education. Indeed, a failure to promote officers
who have demonstrated a genuine commitment to improving relations with
racialized and other disadvantaged communities, could in some contexts,
constitute discrimination.39
A Centre for Policing Excellence

If the Service and other police services wish to lead the way in providing
training, education, and professional development to their members, they need
to develop best practices in what learning should be offered and how. Best
practices undoubtedly should involve research and evaluation, in partnership
with policing experts, by independent experts in pedagogy (the method
and practice of teaching). This approach should be part of a larger
enterprise that proactively develops best practices in policing generally,
rather than police services’ responding to crises or obvious shortcomings
as they arise. This proposal is hardly radical. A number of senior police
officers, former and current, have enthusiastically supported the creation of
an institution, whether
39
For a finding of discrimination when a South Asian officer who worked with such communities and did
not have such work valued for promotion, see Sandhu v Regional Municipality of Peel Police Services
Board, 2017 HRTO 445.
national, provincial, or regional, to do precisely what I advocate here. Indeed,
they model their support on the United Kingdom’s College of Policing,
although I prefer to describe the proposed institution as a centre for
policing excellence so as not to confuse its responsibilities with those of
either the Ontario Police College or the Toronto Police College. My
proposal contemplates a regional centre, with the Service and the Board as
two of the founders, but, I hope, with buy-in from other services. That is a
realistic step forward, recognizing that an appetite ultimately exists for a
provincial and/or national centre.
In my view, such a regional centre of excellence would develop best
practices on policing, including on training, education, and professional
development. It would itself provide leadership training and education for
senior officers and board members, offer “training the trainers” or “educating
the educators” programming, promote excellence in policing, create the
environment for policing to be regarded as a profession, and recommend
evidence-based statutory or regulatory changes.
The centre for policing excellence should ideally be housed within any
one of the many post-secondary institutions in the Greater Toronto area or in
the region. It would be a space for policing experts and academia to examine
and independently evaluate existing policies, procedures, and practice and for
candid discussions with a range of not-for-profit organizations and community
agencies about opportunities for policing reform.
As I mention in Chapter 14, the Toronto Police College has used an
American program of “Fair and Impartial Policing TM” which is just starting
to be independently evaluated to determine if it has any effect on the conduct
of officers who have taken the program. A centre for policing excellence
would be well situated to conduct similar evaluations of training and
education provided to Service members.
The Community Safety and Policing Act, 2019, when proclaimed in
force, will inevitably lead to increased training and education of Board
members. In addition, delegates of the chief of police and the Board are now
required to participate in the development of plans for community safety and
well-being. A centre of excellence could assist in evaluating the role of the
Service and other agencies in achieving the measurable goals that are to form
part of Toronto’s plan. It could also examine the considerable governance
challenges identified in this Report and others that accompany the broader
focus on partnerships to achieve community safety and well-being. In the
context of missing person investigations, the centre’s work would ideally
address what Professor Laura Huey identified in her paper for the Review as
a dearth of peer-reviewed research on such investigations.
In my view, in order to provide informed, credible, and constructive
criticism of existing policies, procedures, and practices, it is important that
such a centre for policing excellence have some degree of independence from
the Service, the Board, and the Ministry of the Solicitor General. The centre’s
board could include not only representatives of the Board and the Service but
also representatives of diverse community groups, as well as educational
institutions involved in research on policing. The location of the centre in an
academic institution rather than within the ministry or the police colleges
would reinforce its independence and the role of policing within the larger
network of community and government agencies.
Governments, post-secondary institutions, charitable funders, and
the private sector may believe that, given existing financial constraints, now is
not the time to invest in a centre for policing excellence. However, I accept
the arguments some police leaders have forcefully advanced that,
notwithstanding current constraints, “now is the time” for the creation of such
an institution. This is because of public demands for fundamental changes to
policing and for an evaluation of the cost effectiveness of policing. Both of
these demands predate the death of George Floyd and the pandemic. But they
have clearly intensified because of them.
I have been made aware that the new inspector general of policing
intends to conduct research and work with academics. This positive
development should be encouraged. At the same time, I recognize that the
Office of the Inspector General will have many responsibilities across the
province and cannot reasonably be expected to house or assume prime
responsibility for this scholarship and the breadth of activities contemplated.
The inspector general could, of course, be a partner in this enterprise. Such a
centre could also help solidify and enrich the Board’s and Service’s
partnerships with academic institutions that I advocate in
Recommendation 125.
I have been told that some academics are reluctant to work with the
police and may be more reluctant to do so after the summer of 2020. In
my respectful view, such attitudes are short-sighted. I am convinced that both
the police and academia, as well as post-secondary students, can benefit from
increased interaction that accepts the need for independent and published
evaluations.
In the United Kingdom, its College of Policing is operationally
independent of the Home Office. It has prepared a code of ethics, codes of
authorized professional practice and guidelines, all of which are updated in
the light of continuing research. The college has also been tasked with
building liaisons with academic institutions to ensure that policing research
can be used to evaluate and improve policing practice. It proactively examines
and publishes work on best practices in a variety of policing areas. I recognize
that the UK government has devoted enormous resources to the college. Here,
I am proposing, at first instance, a more modest model that is regional and
involves partnership between several police services and boards, academic
institutions, and the private sector. In time, I hope consideration might be
given to a national centre through federal and provincial co-operation and
joint funding.
RECOMMENDATIONS
should support the creation of a regional centre for policing
excellence, housed within an academic institution. The centre would,
through research and ongoing evaluation, promote excellence in
policing through developing best practices on policing, including
training, education, and professional development; itself provide
some leadership training and education for senior officers and board
members; offer “training the trainers” or “educating the educators”
programming; create an environment for policing to be regarded as a
profession; and, based on the research produced, recommend
evidence-based statutory or regulatory changes. Ideally, the Centre
would also be established in partnership with other regional police
services and police services boards, the Ministry of the Solicitor
General and the Office of the Inspector General of Policing, and
community, private sector, and not-for-profit stakeholders.
124 The Toronto Police Service should publicize, at a minimum on its
website, the mandatory and optional programming provided to its
employees. Community members are often uninformed about the
programming that is currently offered. Such transparency is also
consistent with the treatment of policing as a profession.
Research and Academic Institutions (Chapter 13-14)
Apart from the desirability of a regional centre of excellence discussed above,

it became obvious to me during the Review that the Board and the Service
have not adequately utilized the academic institutions in Toronto as a
means of conducting research and promoting evidence-based policing.
Although some projects have been undertaken with these institutions, they are
few and far between. The paucity of partnerships that result in independent
and public evaluations compares unfavourably with the partnerships that
exist in cities such as Seattle, Ottawa, and Saskatoon, and in the United
Kingdom in the role played by the university-based Centre for the Study of
Missing Persons in Portsmouth, England. The Seattle Police Department has
entered into research partnerships with 50 different researchers from 32
universities.
RECOMMENDATION
should proactively explore additional partnerships with academic
institutions to promote independent research on policing and on the
systemic issues and research-deficits identified in this Report.
The Board and the Service have recently developed policies and procedures on
race-based data collection. With the advent of the Anti-Racism Act, 2017, and
the incentives to collect further data to fulfill the objectives of the yet-to-be-
proclaimed Community Safety and Policing Act, 2019, the Service should be
able to provide disaggregated data to academic researchers to enable evidence-
based research on topics relevant to the Review’s mandate, including impact
of policing on marginalized and vulnerable communities, the role of
intersectionality, and correlations to trust and confidence communities have in
the Service. The data mandated by legislation should represent the base data
the Service collects, rather than the full range of data to be collected, with
appropriate privacy safeguards, to ultimately promote equitable policing.
Bias and Discrimination (Chapters 12 and 14)
In this Report, I find that systemic discrimination contributed to the

deficiencies identified in some of the McArthur-related investigations and in
the Alloura Wells unidentified remains’ investigation. The existence of
systemic discrimination is not dependent on a finding of intentional or
overt bias or discrimination. Discrimination may be manifested in a variety of
ways.
As I explain in Chapter 12, in the context of missing person investigations,
these include:
 Investigators may rely on stereotypical notions, misconceptions, or

misunderstandings about certain marginalized and vulnerable
communities that affect adversely the quality of police investigations.
Such notions, misconceptions or misunderstandings, or ignorance about
the lived experiences or practices of certain communities may cause
police to regard insignificant matters as significant or significant matters
as insignificant. For example, police might fail to recognize the strong
possibility of foul play involving a gay man based on misconceptions
about that person’s “lifestyle.”4 0 Or, police may too readily presume that
a racialized missing Black man who immigrated to Canada has returned
to his country of origin.
 The police may be unable to meaningfully access the missing person’s
community because officers have insufficient connections to it or are
uncomfortable in the community or with the community members’ sexual
orientation, gender identity or expression, or perceived “lifestyle.”
 Community members may be reluctant to volunteer information to the
police based on the historical and ongoing issues associated with the
Service’s relationship to their communities including acts described
above as overpolicing or based on attitudes or conduct exhibited by
officers who have interacted with them. This may impact adversely on
the quality and success of any investigation.
 Investigators may fail to avail themselves of all resources in the
community to assist in their work because of unfamiliarity or lack of
comfort with those communities. Such failings are associated with
underpolicing or underprotection as described above.
 Investigators may give less credence than deserved to members of certain
marginalized and vulnerable communities. This may also contribute to
underpolicing or underprotection.
 Systemic practices may promote differential treatment between how the
disappearances of marginalized and vulnerable people’s disappearances
are investigated and how empowered people’s disappearances are or
would be investigated.
40
Of course, it is also problematic to regard, for example, sexual orientation as a “lifestyle.”
In addition, in Chapter 14, I describe more generally the issues around
discrimination the Ontario Human Rights Commission has identified that
continue to exist within the Service.
The Ontario Human Rights Commission, of course, is expert in
recognizing and addressing issues of systemic and overt discrimination and
continues to use that expertise in addressing policing issues in Toronto and
province-wide. My recommendations are not intended to substitute for those
made by the Commission. Instead, these recommendations build on the good
work that is already being done by the Commission and by the Service itself.
Psychological Testing
In the 2018 OIPRD Report, Broken Trust: Indigenous People and the Thunder
Bay Police Service, the director said this in support of a recommendation
similar to the one set out immediately below:
Police services in Ontario generally include psychological assessments in

their recruitment processes. These assessments can help identify candidates
who exhibit personality traits and characteristics that may be problematic in
a police workplace. The MMPI-2 (Minnesota Multiphasic Personality
Inventory-2) assessment used in some police services does not assess
attitudes to race. A specific assessment for racist attitudes is not done in
Thunder Bay.
During the course of this review, we met with one company, Multi-
Health Systems Inc. (MHS), which has a well-established track record of
designing psychological assessment tools. MHS has designed a psychological
assessment for use in weeding out potentially racist policing candidates. Its
psychological assessment is currently used in Quebec and in some American
jurisdictions.
Since the OIPRD report, additional police services, including the
Ontario Provincial Police and the Niagara Regional Police, have adopted these
psychological assessment tools. In addition, the École nationale de police du
Québec is using these tools in its early screening of recruits. As pointed
out by the Review’s Community Advisory Group, one also has to guard
against skewed psychological assessment tools that perpetuate
stereotypical assumptions or misconceptions.
RECOMMENDATION
126 The Toronto Police Service should consider introducing recently
developed psychological testing in hiring and recruiting, in order to
assist in eliminating applicants who have discriminatory views and
attitudes.
An Equity Plan and Framework

As discussed in Chapter 14, the Equity, Inclusion and Human Rights Unit of
the Service’s human resources command is responsible for internal equity
matters. In recent years this unit has received more resources, including more
civilian employees. The unit also has responsibility for implementing human
rights settlements such as the Waterman/Kodak settlement described in
Chapter 14. The settlement extends beyond equity matters internal to the
Service insofar as it relates to the Service’s treatment of trans community
members. In my view, the unit’s responsibility for implementing human rights
settlements reinforces the connection between respect for equity in
internal matters and in the Service’s interactions with the communities it
serves. They are two sides of the same coin. Any police service that fails to
respect equity in the workplace is unlikely to treat communities equitably or
be regarded as doing so.
The Community Partnership and Engagement Unit (the CPEU), which
falls within the communities and neighborhood chain of command, is
primarily responsible for ensuring the Service deals with communities
equitably. Both liaison officers and community consultative committees are
within the unit’s mandate.
I acknowledge that the Service has taken steps to promote equity within
the Service and in its dealings with diverse communities. In Chapter 14, I set
out a number of relevant initiatives the Service has undertaken. Nonetheless, a
number of the Service’s members, past and present, sworn and civilian, from
constables to senior command, told the Review that the Service still has a way
to go. Some personal stories I heard have reinforced that view. Although their
experiences varied, LGBTQ2S+ members of the Service described challenges
they have faced within the policing environment. Some described derogatory
comments made worse when tolerated by others. Some described the need to
prove themselves to fellow officers, particularly in a situation that might
involve use of force. And some described the inability or unwillingness of a
significant number of officers within the Service to be “out.” Some pointed out
to me that they have seen improvements in attitudes during their careers. I
applaud those officers who have led the way in attempting to bring about
fundamental change.
Despite the Service’s size and diversity, and the resources that have
recently been directed to equity issues, the Service still does not have an equity
plan or strategy. Although this is troubling, I am advised that work on it is now
underway. I hope that the Service will work closely with the Ontario Human
Rights Commission in finalizing its equity plan. The commission can draw
upon a wide range of policies and guidelines it has developed on racial
discrimination, intersectionality, sexual orientation, and gender identity and
expression. A well-developed and publicly accessible equity plan would send
a clear signal to the communities that the Service takes equity seriously.
RECOMMENDATIONS
should ensure that the Service develops a robust equity plan as soon
as practicable. Whether included in the Service’s equity plan or in an
“equity framework” that guides the Service’s internal operations and
external relations, or both, such documents should, among other
things,
(a) facilitate the use of an “inclusion lens” whenever the Service

creates or amends procedures and practices,
(b) develop a tool for decision-making that considers the impact of
procedures and practices on marginalized and vulnerable
communities and on Toronto’s diverse communities more
generally,
(c) create a mechanism to ensure that the Equity, Inclusion and
Human Rights Unit and the Community, Partnership and
Engagement Unit play important roles in evaluating the
Service’s procedures and practices, insofar as they impact
marginalized and vulnerable communities, and diverse
communities generally,
(d) develop equity-based management strategies to embed equity,
inclusion, and human rights throughout the organization, so
that senior command and supervisors are responsible and held
accountable for ensuring that equitable and inclusive practices
are ingrained in their work and in the work of those they
supervise.4 1 The Equity, Inclusion and Human Rights Unit should
play a key role in developing, implementing, and evaluating
equity-based management strategies, in consultation with a
variety of stakeholders within and outside the Service, such as
the Service’s Internal Support Networks, and
(e) explicitly recognize the important connection between equity
within the Service and equity in the Service’s interactions with
the diverse communities it serves.
should consider whether the critical goal of advancing equity would
be enhanced by merging or placing the Service’s two units devoted to
equity, under the same chain of command. These units are the Equity,
Inclusion and Human Rights Unit and the Community Partnership and
Engagement Unit.
I have deliberately used the language “should consider” because it was outside
my mandate to examine the full range of considerations relevant to the
Service’s organizational chart. However, there are some equity-promoting
synergies that might be enhanced through placing both units under the same
command. For example, liaison officers could play a greater role in how
internal matters such as harassment or discrimination should be addressed
within the Service.
Another example of the synergy that might be enhanced relates to the
role the officers involved in Internal Support Networks might play in not only
mentoring officers within the Service, but also building better relations with
communities they are part of. At present, the Internal Support Networks come
within the Equity, Inclusion and Human Rights Unit’s portfolio, although
building better relations is within the Community Partnership and Engagement
Unit’s portfolio, under a separate chain of command.
Equity Audits
RECOMMENDATIONS
129 To complement recommendation 127, the Toronto Police Service
should develop additional mechanisms to measure how community
41
The assignment of Toronto’s senior officers to equity portfolios, as has been done, represents an
important step in implementing this part of the recommendation.
members, particularly members of marginalized and vulnerable
communities feel about their interactions with the Service. Such
mechanisms might include equity audits of divisions or specialty units,
through surveys, focus groups, and analytics, to determine how many
people interacted with the Toronto police, how those people self-
identify, and whether they felt they were treated in a respectful
fashion. The audits should be designed to enable community
members to provide their perspectives in a safe and confidential
environment. Respondents should feel able to include suggestions for
change and what worked well or poorly in their interactions with
police.
This is certainly not a terribly radical proposal. Businesses and professions

regularly gauge levels of satisfaction when interfacing with customers, clients,
or patients. I support the Missing Persons Unit’s consideration of
implementing a satisfaction survey for those who reported people missing.
Such equity audits could be done by the Service, by outside contractors,
or even possibly as part of a larger research initiative by academic institutions
and/or the proposed centre for policing excellence. The important point is that
they be done, made publicly available, and used as part of a process of
continuous evaluation and improvement of police procedures and practices.
RECOMMENDATIONS
should ensure that the Service’s Equity, Inclusion and Human Rights
Unit is adequately resourced to facilitate implementation of the
recommendations respecting bias and discrimination contained in this
Report and to build competencies within the unit to engage with
LGBQ2S+, trans, racialized, and Indigenous communities.
should ensure that the Service’s Wellness Unit is adequately
resourced to build competencies within the unit to provide culturally
specific wellness resources and support to diverse members of the
Service.
Discipline and Discrimination
One of the frequent complaints I heard during my community engagement had
to do with discipline. Many community members believe that discriminatory
policing is unaddressed through the Service’s discipline processes and is going
unpunished and therefore undeterred. In its August 2020 deputation to the
Board, the Ontario Human Rights Commission referred to what it
characterized as “structural impunity for systemic racism within the Service
and the Board,” including the failure to effectively address judicial and
tribunal findings that the Service’s members engaged in racial
discrimination.42 The commission stated:
[In] Elmardy v Toronto Police Services Board, the Divisional Court

concluded that a Black man was the victim of racial discrimination when he
was on his way back from prayers in 2011. He was stopped by TPS
[Toronto Police Service] officers, punched twice in the face, searched,
handcuffed and left injured out in the cold. The police officers were also
found to have lied when the trial judge questioned them about their
behavior. However, it appears there were no serious disciplinary
consequences; there were no Notices of Hearing or TPS Disciplinary
Tribunal decisions regarding the officers’ conduct.
Furthermore, the TPSB [Toronto Police Services Board] has not
issued any policy guidance in this area. For example, the TPSB did not
establish guidelines on how internal complaints in these circumstances
should be effectively triggered and administered. In the absence of requisite
protocols, meaningful reform and remedies continue to be denied to Black
communities, resulting in little faith in the TPS and TPSB’s ability to
address misconduct and racial bias. [Emphasis added.]
The commission also called for the early intervention system that
PACER recommended in 2013. It further called for the province to reform the
police discipline process to ensure that “appropriate discipline” is applied
to findings of discrimination by courts and human rights tribunals. The
commission also noted the lack of transparency of disciplinary hearings. In the
words of the commission:
The Police Services Act’s current confidentiality provisions mean that the
public does not know when and whether an officer was subject to some form
of discipline for engaging in racial profiling, racial discrimination or other
42
http://www.ohrc.on.ca/en/ohrc-written-deputation-toronto-police-services-board-re-police-reform-toronto-
systemic-racism
police misconduct. Only decisions from police service disciplinary tribunals
are not confidential.43
The commission also supported Toronto City Council’s June 2020

request that “the Province of Ontario amend the Police Services Act and
the Community Safety and Policing Act, 2019, to require that complaints that
allege a police officer’s serious misconduct be investigated by the Province’s
independent police complaints agency (currently, the Office of the
Independent Police Review Director) and not by any police service’s
professional standards unit.”44
It is beyond the scope of my mandate to address the province’s
discipline and complaints processes for police officers. Volumes have been
written on this topic alone and the legislation respecting police discipline has
been highly controversial. But there are some important ways in which issues
around bias and discrimination can be better addressed through the
Service’s discipline processes.
With respect to discipline, the concern most frequently expressed was
that the discipline process lacks transparency. For this and other reasons,
community members lack confidence in the process, the result, and its impact.
This lack of transparency and lack of confidence interfere with attempts to
improve community relations. The public has little opportunity to know about
discipline cases that involve allegations of discriminatory policing. Indeed, the
police tribunal’s discipline decisions are not accessible on a public website
such as CanLII or indexed for the public’s use unless they are appealed to the
Ontario Civilian Police Commission.45 This approach compares unfavourably
to how the discipline processes and outcomes for a range of Ontario
professions are publicly available. I hope that the minister of community safety
and correctional services will make regulations, pursuant to s. 148(2) of the
Community Safety and Policing Act, 2019, as yet unproclaimed, to ensure that
all decisions from adjudication hearings under the Act are promptly published
on the Internet and moreover, easily searchable.
As the Ontario Human Rights Commission suggests, it is important
that the Service responds to findings about discrimination made by courts and
tribunals. Some of these findings may merit formal discipline proceedings. In
other situations, informal methods of discipline, combined with education,
43
Ibid.
44
Ibid.
45
https://www.canlii.org/en/on/oncpc/.
may be appropriate. In the case of informal discipline, transparency and active
community involvement will be important if the response is to have public
confidence, particularly among members of disadvantaged communities.
RECOMMENDATIONS
should take steps, through a strategic plan or strategy, to address
issues around transparency and accountability in how conduct by the
Service’s members is addressed that raise concerns about
discrimination, including harassment, and differential treatment
based on human-rights personal identifiers. This recommendation
applies regardless of whether the conduct raises concerns about
discrimination against the Service’s members or against members of
the public. Such steps should include, at a minimum:
(a) timely and transparent identification by the Service of
complaints that raise concerns about discrimination, whether
overt or intentional or systemic;
(b) timely and transparent identification by the Service of findings
by courts or tribunals that raise concerns about discrimination;
(c) the creation or amendment of policies and procedures to
provide for a consistent, comprehensive and transparent
strategy for dealing with these cases;
(d) involvement of the Equity, Human Rights and Inclusion Unit in
developing and implementing such a strategy, advising the
Professional Standards Unit, and monitoring compliance with
relevant policies and procedures;
(e) consideration of the enhanced role that marginalized and
vulnerable communities that are the subject of discrimination
can play in the investigative, resolution, and disciplinary
processes, including feedback on resolution and community
victim statements to be filed with the discipline tribunal,
consistent with existing legislation and procedural and
substantive fairness to those accused of misconduct; and
(f) regular reporting to the Board on implementation of the
strategic plan or strategy, consistent with the role of the Board
as described in Recommendations 1-4.
RECOMMENDATIONS
133(a) The Toronto Police Services Board and the Toronto Police Service
should ensure that Service-related disciplinary decisions (in addition
to those appealed to the Ontario Civilian Police Commission) are
easily accessible to and searchable by the public and/or indexed for
the public’s use. Lack of transparency in decision-making contributes
to mistrust, particularly on the part of marginalized and vulnerable
communities. It also undermines accountability of the Toronto Police
Service for how discipline is being addressed.
133(b) The Toronto Police Services Board and the Toronto Police Service
should also urge the minister of community safety and correctional
services to make regulations, pursuant to s. 148(2) of the Community
Safety and Policing Act, 2019, as yet unproclaimed, to ensure that all
the decisions from adjudication hearings under the Act are published
on the Internet and moreover, easily searchable.
Pursuant to s. 107 of the Community Safety and Policing Act, 2019,

“any person,” with limited exceptions, may complain to the inspector general
about the adequacy and effectiveness of policing, the failure of a police
services board, chief of police, or police service to comply with the Act or
its regulations, other than misconduct, including a systemic failure, the
policies of a board or the procedures established by the chief of police. Under
s. 107, the inspector general is empowered to forward a complaint about
policies or procedures to a police board for it to report back about any
steps taken in response to the complaint. As I later explain in addressing
implementation of my recommendations, this process may be very useful as
another accountability measure, given, for example, my recommendation
that the Board and the Service create or amend policies and procedures on
missing persons and on other topics relevant to my mandate.
should facilitate, preferably together with the Ministry of the Solicitor
General and the Office of the Inspector General of Policing, the
publication of the ability of any person to make complaints under s.
107 of the Community Safety and Policing Act, 2019.
Relationship Building (Chapter 14)
In Chapter 14, I explain why my recommendations to improve
relationships between the Service and marginalized and vulnerable
communities are not, and should not be seen as, a detailed blueprint that the
Service or the Board can impose on the communities. The most successful
models for community buy- in involve true partnerships between the police
and the communities in designing and implementing measures to bring
about change. A diverse advisory group determined that this independent
civilian systemic review was needed to address the communities’ deep
concerns about how the Service conducts missing person investigations
involving, in particular, LGBTQ2S+ community members. That same advisory
group largely crafted the Review’s Terms of Reference.
The Board empowered those community representatives by
accepting and acting on their recommendations without making any changes –
a critical step in promoting confidence in the process. The communities should
now design any blueprint for building relationships. At this critical point in
time, community partnerships are particularly important, given the current
momentum to re-image the role of the police within a larger holistic approach
to community safety and well-being.
Marginalized and vulnerable communities are, however, exhausted from
consultation fatigue. First, their members often feel they have repeatedly
shared their lived experiences, with little to show for their efforts. For many,
the problems they have with the Service are hardly new. Those who have
experienced overpolicing and underprotection may understandably become
reluctant to continue to engage in consultations with the Service – particularly
if they see no measurable and lasting changes. Second, the laudable
recognition of the importance of consultation has brought with it a
dizzying array of consultative committees, working groups, advisory
panels, and accountability tables or circles. As but one example, the
Service has 17 consultative committees at the divisional level, nine
community consultative committees, and two committees to advise the chief
of police. The Board has recently made permanent two pre-existing
advisory panels or consultative committees, one dedicated to mental health
issues and the other to anti-racism. The city also has numerous consultative
committees and an accountability table.
From the perspective of the city, the Service, and the Board, all these
committees make good sense, if genuine consultation is the objective.
However, the proliferation of consultative committees also creates risk –
risk that strong, consistent, effective messaging from communities is more
difficult, and that duplicate forms of consultation complicate and even
interfere with the ultimate goal of making the Service more responsive to the
city’s multiple and intersecting communities. In addition, consultation
places an enormous personal burden on those repeatedly called on to serve.
My recommendations are designed to identify both the fundamentals for
effective consultation and community partnership and the impediments to
them. Ultimately, effective consultation is an essential component of
improving relationships – as are collaboration, acknowledgement of past
harms, empowerment of communities to be partners in decision making, and,
ultimately, buy-in from all those involved in the relationships. But there is no
easy fix. The Service must be open to broader outside influences and more
welcoming of constructive criticism. Propitiously, the Service and many of its
officers have agreed that the time has come for a change in culture.
I refer above to the momentum for fundamental change in policing. As
I discuss in Chapter 3, the Community Safety and Policing Act, 2019 will soon
be proclaimed in force. It places new emphasis on plans for community safety
and well-being and the importance of diversity and intersectionality.
Responding to events in the summer of 2020, both the Toronto City Council
and the Board have recognized this new emphasis. Giving life to it will be a
work in progress. This momentum for change has already produced a plethora
of recommendations from the city, the Board, the Ontario Human Rights
Commission, and now from me. In this Report, I have attempted not to pile
recommendations on top of previous recommendations. Rather, in formulating
my own, I have taken into consideration the range of existing
recommendations. One of the themes of my Report is the need to test any new
initiatives through measurable outcomes, research, and evaluation.
To its credit, the Service has introduced many initiatives not only to
address community relations along with training and education but also to
change its own culture. However, these initiatives, as well intentioned as they
are, are still lacking in certain ways. Unfortunately, with the exception of the
Humber College evaluation of the Neighbourhood Community Officer
Program, the Service has done little to evaluate objectively which initiatives
work, and which do not. Communities are largely unaware of these initiatives:
How, then, does the Service expect these initiatives to resonate with
marginalized and vulnerable people? Superimposed on all this is one very
public and often-cited manifestation of the difficult issues to be addressed –
namely, the exclusion of the Service’s LGBTQ2S+ members from the Pride
parade. Against that background, I tackle these difficult relationship issues in
the recommendations that follow.
Community Consultative Committees

The Service, like other Canadian police services, is re-examining the role of
its community consultative committees. In my view, this exercise is necessary
because the status quo is simply not acceptable for the 11 reasons I
explain here.
First, the identity of members of the Service’s nine community
consultative committees is not known to the public. Moreover, the committees
have only limited web and social media presence or none at all. As a result, the
committees have no established means to receive information from the public
or to convey information, so it is difficult to understand how they can
effectively do their work or inspire confidence in what they are doing.
Second, the separation of community consultative committees into nine
distinct groups fails to grasp the reality of intersectionality. There is little or no
evidence that the community consultative committees interact with each other.
This concern is not new: as I reflect in Chapter 14, the silos in which these
committees operate were identified years ago by the Audit Steering Committee
in connection with how the Service was responding to sexual assault
cases.46 Although some committees have recognized the importance of
intersecting grounds of discrimination, the current committee structure
impedes full consideration of intersectionality. The committees can only be
effective if they can fully address, for example, differential treatment
against South Asian LGBTQ community members other than through
separate siloed South Asian and LGBTQ communities. Seattle’s approach of a
larger 21-person community consultative committee that can represent
multiple groups and also include a representative of the police association
and one of police management in addition to the committee’s own staff is, in
many ways, preferable.47
Third, some disadvantaged groups that are overpoliced and
underprotected, such as the homeless and sex workers, are not specifically
represented by community consultative committees. Again, although some
46
Jane Doe, Amanda Dale, and Beverly Bain, “A New Chapter in Feminist Organizing: The Sexual Assault
Audit Steering Committee” (2009/2010) 28(1) Canadian Woman Studies 6.
47
The City’s Black Partnership and Accountability Circle tries to ensure that its members represent the
diversity of Toronto’s Black community and includes four elders, four people between 12 and 29 years of
age with diverse lived experiences, and four people representing key stakeholder groups such as health and
social services, arts, culture, and government. The 12 members are also paid expenses and modest honoraria
for their work over a two-year term. See https://www.toronto.ca/community-people/get-
involved/community/confronting-anti-black-racism/partnership-accountability-circle/partnership-
accountability-circle-terms-of-reference/.
committees have recognized this deficiency, 48 it may send an unfortunate
message that these seriously disadvantaged groups are not equally worthy of
protection. The solution is not necessarily separate committees for all
marginalized and vulnerable communities but, instead, an approach that
focuses more intently on intersectionality.
Fourth, senior citizens and those living with disabilities are grouped
together, although these distinct but overlapping communities are represented
by two different liaison officers within the Service.
Fifth, these consultative committees have minuscule budgets, some
operating on $1,000 a year. It is creditworthy that non-Service community
members volunteer their time, but the absence of any remuneration for
community members, regardless of their situation, excludes those most
marginalized and vulnerable from participating in the work. This point was
forcefully communicated to me during the Review’s policy roundtable and at
stakeholder meetings. Committees that are not financially supported are
unlikely to operate as true decision makers and to feel valued.
Sixth, despite an existing Board policy to the contrary, there has been
no regular evaluation of these committees. I was unable to learn, except
through individual interviews, whether committee members are satisfied with
their experience or with the impact of their work. Nor do I know, except
through individual interviews and the Review’s own engagement survey, how
communities feel about these committees or even if they know the committees
exist.
Seventh, the committees do not announce goals or measurable outcomes
they hope to achieve. This vacuum, too, prevents any meaningful evaluation
of their work.
Eighth, the committees have no public voice. Aside from having little or
no active or consistent web or social media presence, the minutes of their
meetings reflect that police officers on the committees have expressed
concerns that any messaging from the communities should not be “political.”
In my view, it is unlikely that such committees can perform, and be seen to be
performing, a meaningful role in decision making if they feel unable to speak
publicly about their concerns. Of course, committees can themselves establish
rules around confidentiality and public disclosures.
Ninth, the committees are co-chaired by senior police officers.
Unquestionably, there should be a full exchange of information between the
48
For example, the Senior Citizens and People with Disabilities Committee has taken a commendable
interest in mental health issues, although there is no committee (other than the Board’s committee) otherwise
mandated to deal with mental health and addiction issues.
police and the communities. However, this communication can be done either
by police participation in the committees as members or as invitees (as often
occurs), rather than as co-chairs. Again, the goal is to invest these
communities with both perceived independence and actual independence, even
though such independence may generate some painful but necessary dialogue.
Tenth, there is no transparent process for how committee members are
selected. I heard concerns that some committee members did not even live in
Toronto. More significant, community members I spoke with perceive, rightly
or wrongly, that selected members are “pro-police,” though community
members and police officers alike stated that the Service needs to hear from
those in the community who are not “pro-police.” Events such as the killing of
George Floyd, and related Canadian events in the summer of 2020, make it
even more important that the necessary and vital task of community
consultation be robust, independent, and, at times, difficult.
Eleventh, as I already indicated, 17 community police committees also
exist at the divisional level. It is important that the Service consult not only on
city-wide issues but also on local issues. However, many of the same concerns,
such as effectiveness, duplication, mixed messaging, selection,
intersectionality, and transparency need to be considered in relation to the
divisional committees as well.
In 1995, the Commission on Systemic Racism in the Ontario Justice
System recommended that the Board appoint and provide support for
community policing committees at “either divisional levels of each police
service or another geographical area or community grouping appropriate to the
jurisdiction.” The Commission proposed seven members who would be drawn
from community organizations active in the area after a fully open and
advertised search. A criminal record would not bar appointment. Each member
would be paid and would serve for three years, and every effort would be
made to make committees gender balanced and include youth and
racialized members. Meetings would be public, occur monthly, and not be
held in police stations. The Board would support the committees with
relevant research, which in turn would help the committees develop
policing objectives that could then be forwarded to the Service and, if
necessary, the Board. The committees would also have resources to monitor
the implementation of their recommendations.49 I cite this example not because
I think a 1995 blueprint that has never been adopted should necessarily be
instituted today. However, the transparency of the committees the
Commission on Systemic Racism
49
Report of the Commission on Systemic Racism in the Ontario Criminal Justice System (Toronto: Queens
Printer, 1995), 348–49 (Co-chairs Margaret Gittens and David Cole).
proposed is to be commended, as does a model that involves public meetings,
selection criteria that address diversity and intersectionality, and
administrative and financial resource allocation.
In addition to these 11 issues, the role of the Service’s community
consultative committees should be re-examined in the light of related
consultations taking place through the city and through the Board.
Under both the Police Services Act and the yet to be proclaimed
Community Safety and Policing Act, 2019, municipalities must now
prepare community safety and well-being plans. 50 These plans are to be
prepared with the assistance of a multidisciplinary advisory committee that
must include, at a minimum, the chief of police or a delegate; a police
services board member or a delegate; representatives of a local health
integration network or an entity that provides services to improve physical
or mental health; and representatives of entities that provide education,
community, or social services in the municipality and to children or youth,
and custodial services to children or youth. There are also requirements for
consultation with youth, members of racialized communities, and Indigenous
communities as well as the community organizations that work with such
communities.
The community safety and well-being plan adopted by the
municipality must identify risk factors including “systemic discrimination and
other social factors that contribute to crime, victimization, addiction, drug
overdose and suicide.” It must also identify which risk factors should be
treated as priorities, together with reduction strategies, and provide new
services, change existing services, improve their integration, or
coordinate them differently. The plan must “set out measurable outcomes that
the strategies are intended to produce.” The municipality must also monitor,
evaluate, and report on the effectiveness of the plan.
This promising 21st-century approach to community safety has a direct
impact on the role of policing. If, however, it is simply layered on top of the
Service’s outdated approach to consultative committees and liaison officers
(discussed below), there is a danger of making things much worse owing to
duplicate and triplicate consultation, competing visions, and consultation
fatigue.
As I discuss above, the Board has also created two consultative
committees or advisory panels, now permanent, focused on mental health and
anti-racism (see Chapter 14 for the origins of these committees). To their
credit, the committees have responded to some specific issues with
50
Police Services Act, Part XI; Community Safetyand Policing Act, 2019, Part XVI.
considerable success. However, I also heard from a senior officer that the
Service sees the Board’s consultative process as being totally separate from its
own. Again, although consultation between the communities and the city, the
Board, and the Service is critically important, particularly consultation with
disadvantaged communities and those who work with them, a more integrated
approach is essential.
One goal of this broader approach to community safety and well-being
is to break down bureaucratic silos, not to create them. It is essential that the
Service and the Board not operate in separate silos with respect to Board
policies and critical Service procedures; otherwise, the Service’s reputation
with marginalized and vulnerable groups will be further damaged. Fortunately,
there are some precedents, including those in connection with The Way
Forward report, for the Service and the Board to take joint responsibility for
certain committees.51 Together, the Service and the Board may also be better
positioned to work with the city to promote meaningful community
consultations that are not unnecessarily duplicative.
To end this commentary where it started, my recommendations are not
a blueprint for what the consultative process should be. Rather, they identify
the principles and the impediments that should guide much needed reform.
RECOMMENDATION
135 In the light of the issues this Report identifies, the Toronto Police
Services Board and the Toronto Police Service should re-evaluate and
rationalize, in partnership with the diverse communities they serve,
the ways in which community consultation takes place, especially in
relation to marginalized and vulnerable communities. In particular,
they should take into consideration these points:
(a) The need to ensure that the intersecting requirements of

Toronto’s marginalized and vulnerable communities are fully
addressed in the consultative process and that intersectionality
should figure centrally in how the consultative process takes
place. These goals might be accomplished through a process
modelled on Seattle’s Community Police Commission; a process
whereby existing committees regularly interact and share
51
Toronto Police Service, Transformational Task Force Report, Action Plan: The Way Forward –
Modernizing Community Safety in Toronto. January 2017.
information on common issues; and/or a process that ensures
that intersectionality forms part of the selection criteria for
each committee. The process might also involve greater
inclusiveness to ensure that marginalized and vulnerable
groups, such as the homeless and sex workers, are heard.
(b) The need to avoid unnecessarily duplicative consultations that
result in consultation fatigue, unwise use of limited human and
financial resources, and diluted or unclear messaging from
communities.
(c) The need to ensure that the Board is able to provide
appropriate civilian oversight of the Service, in part through
reducing or eliminating the divide between community
consultations with the Board and the Service. The Board must
always be aware of “critical points” that may affect its policies
and the Service’s reputation.
(d) The need to rationalize how communities that are spread
throughout the city and those that are located in particular
geographic sectors are consulted in relation to both city-wide
and local divisional issues, while avoiding unnecessarily
duplicative consultations.
(e) The need to ensure that the consultative processes of the
Service and the Board complement the development of the
city’s community safety and well-being plan and related
consultations.
(f) The need to build community confidence in the consultative
process through measures such as
(i) transparency in how committee members are selected –
for example, through an advertised search;
(ii) outreach to those not regarded as “pro-police”;
(iii) facilitating participation by those most marginalized and
vulnerable through the provision of remuneration and/or
accommodation;
(iv) holding meetings in community spaces;
(v) holding meetings, in some instances, in public;
(vi) the ability and independence of committees to report
publicly and to offer recommendations or commentary;
and
(vii) the ability of senior officers to participate in community
consultative committees as members or invitees, but not
as co-chairs.52
(g) The need to promote an effective consultation process through
measures, in addition to those set out above, such as
(i) fixed, renewable terms for committee members;
(ii) appropriate administrative and research support;
(iii) regular setting of goals, with measurable outcomes;
(iv) a credible evaluation process; and
(v) a web and social media presence.
The Board and the Service might also consider, in this regard, features
of the model for community policing committees proposed by the
Commission on Systemic Racism in the Justice System.
Broader Community Engagement

A senior police leader warned me that a committee or a liaison officer
dedicated to a particular community may actually inhibit communication with
that community if all communication and initiatives must be channelled
toward and vetted by that committee or that officer. Building better relations
with diverse communities is the responsibility of everyone in the Service.
A vigorous consultative process with selected community members does not
relieve the Service of the need for broader community engagement that
includes effective communication.
I agree with an Ontario police chief that, because of the fundamental
importance to the police of communication and trust, most police forces
“could invest in corporate communications and issues management via a factor
of 10 and still be nowhere near where [they need] to be on these types of
issues.” One of Toronto’s deputy chiefs similarly stated:
There is a direct relationship between the strength of your communication

strategy and the ability to execute from public trust ... [I]n the absence of
information, people just fill it in … [S]omebody who walks by posters of
missing men for years, and never heard a formal response and was asking
internally … [H]ey what’s happened with this[?] [Y]ou know you can see
how the community thinks in that vortex [–] they just think that you don’t
care. And so, this is an area I think we need to invest in.
52
It has also been suggested that lia ison officers remain well situated to serve as co-chairs.
In Recommendation 75, I propose that a communication strategy be
developed, in partnership with community organizations, in relation to missing
person investigations. It should be part of a larger strategy to build community
relationships, particularly with marginalized and vulnerable communities,
through more effective communication strategies. This objective will not be a
revelation to either the Board or the Service. Effective communication
with diverse communities has been referred to in a number of documents.
However, the reality remains that the Service has not effectively conversed
with diverse communities about what it is doing or attempting to do to build
relationships. One example is its website, which is not user friendly or
accessible and compares unfavourably to the websites of smaller-budget
services such as the Edmonton Police Service. I am reminded of the
criticism directed to the Toronto Police Service’s website in 1999 by Auditor
Jeffrey Griffiths that it was being used as a public relations tool instead of a
resource to provide women with information to assist them. Not to be unkind,
but that criticism continues to have some validity today.
RECOMMENDATION
should develop a strategy specifically directed to communicating
effectively with the public, particularly diverse communities, about
what they are doing. This strategy should include the following:
(a) The initiatives the Board and the Service are making to build
relationships, and independent evaluations of these initiatives
should be well publicized in a variety of ways.
(b) Greater use should be made of town halls, which the Board has
recently organized effectively, as well as interactive small-group
discussions in community spaces.
(c) The Service’s website should be completely redesigned (over
and above the missing person webpage) to be truly user-
friendly, having the users’ needs foremost in mind, and to
overcome barriers such as language and accessibility.
(d) Full-time and part-time liaison officers should have a greater
social media presence.
Liaison Officers
In Recommendation 83, I address the Service’s systemic failure to use its own
internal resources, such as liaison officers, to advance investigations into
missing person and unidentified remains among marginalized and vulnerable
communities. Similarly, the LGBTQ2S+ liaison officer was not consulted
before the Service embarked on Project Marie in 2016. This incident, too,
represented a failure that had an adverse impact on the Service’s relationship
with the LGBTQ2S+ communities. Earlier in this chapter, I also contemplated
an increased role for liaison officers in promoting equity within the workplace.
Here, I address the liaison officer program generally, in the sense of how it
can better assist the Service in building relationships – its primary role, apart
from involvement in specific investigations or internal equity.
The current program faces many challenges. First, it is difficult to
see how the present complement of liaison officers, such as the single
officer dedicated to the LGBTQ2S+ communities, can possibly fulfill their
roles. For example, the LGBTQ2S+ communities are so diverse that one
officer cannot have a meaningful connection with all the community members
– especially within the transgender community. Many members of that
community are so marginalized and vulnerable, subject to overpolicing,
misgendering, underprotection, and disproportionate violence and
discrimination even from others within the LGBTQ2S+ communities, that
they require particular attention. Second, the liaison program must, as I stated
in connection with consultative committees, be especially attentive to the
complexity of intersectionality. This need suggests a more inclusive or “fluid”
approach to how the responsibilities of liaison officers are defined. Third,
some people see the liaison program as closely tied to corporate management
and the Service’s official positions, and, depending on the particular
officer, insufficiently connected to life “on the street.” Even some officers
expressed that view.
On the other hand, I also heard about valuable connections that liaison
officers have established with community members, and how these officers are
accessible in ways that others are not. I believe that the liaison officer
program, if certain important changes are made, can play a critical role in
building relationships with disadvantaged communities. This observation
reminds me of the memorable day I spent with Dave Dickson, a retired
Vancouver police officer. We walked through the Downtown Eastside, an
area where many of Vancouver’s marginalized and vulnerable people, live
and congregate. “Officer Dave” has chosen to dedicate the remainder or his
career to engaging with and supporting the members of that community.
Notably, he was one of the first within the Vancouver police to raise alarm
bells about a serial killer
preying on disadvantaged individuals many regarded as “nobodies.” As I
watched him interact with people on the street, I was struck by how impactful
someone like Officer Dave can be, how he represented my vision of an ideal
liaison officer.
As I discuss in Chapter 14, I am also impressed with the wealth of
resources the OPP devotes to liaison activities. Although the OPP is a bigger
service with much larger geographical boundaries, it has 25 full-time liaison
officers and 74 officers who serve in a part-time liaison role within the OPP’s
Indigenous Policing Bureau. By way of contrast, the Service has 10 liaison
officers. Its neighborhood community officers, however, devote significant
time to building relationships with diverse communities.
Ultimately, the goal of any police service, regardless of the number of
officers who formally fill liaison positions, is to make every officer and
civilian employee feel responsible for and play a meaningful role in
building relationships. The LGBTQ liaison officer in San Francisco told
Arnold Bruner during his research for his 1981 report summarized in
Chapter 11 that the ultimate goal should be that every officer is also a
“community relations officer.” If so, he said, “I won’t be needed.” 53 I agree
with this goal, even though these words were spoken 40 years ago.
RECOMMENDATION
should support and significantly enhance the liaison officer program in
the following ways:
(a) increasing the number of liaison positions consistent with the

full range of responsibilities this Report proposes and the
critical importance of building relationships with Toronto’s
marginalized and vulnerable communities;
(b) using a combination of sworn officers and civilian members of
the Service to fill additional liaison positions;
(c) as elaborated on in Recommendation 139, including a cadre of
part-time liaison positions at the divisional level within a
strategy to embed relationship building into all aspects of
policing in Toronto;
53
Arnold Bruner, Out of the Closet: Study of Relations Between the Homosexual Community and the Police
(1981), 151.
(d) providing enhanced training, education, and professional
development for full-time and part-time liaison officers and
civilian members of the Service, to ensure that they can address
issues of intersectionality through familiarity with a range of
intersecting, marginalized and vulnerable communities;
(e) developing additional strategies to enable liaison officers and
civilian members of the Service to potentially serve multiple
marginalized and vulnerable communities, including team
approaches to intersecting communities;
(f) regularly reallocating liaison resources to address evidence-
based needs – for example, assigning several liaison officers
and/or civilian members of the Service to address the needs of
a particular community or communities otherwise
underserviced by the program, such as the homeless or the
underhoused;
(g) expanding the Aboriginal Peacekeeping Unit and/or the current
complement of a single liaison officer dedicated to the
Indigenous communities. The current complement is
inconsistent with existing Board policy and the priorities
identified in the Community Safety and Policing Act, 2019 (SO
2019, c 1, Schedule 1, not yet proclaimed); 54
(h) providing analytic support for the liaison program to enable it
to allocate resources appropriately;
(i) explicitly recognizing in the mandate and job descriptions
relating to the liaison program, the responsibilities articulated
in this Report over and above the current duties of liaison
officers, including;
(i) the responsibilities set out in Recommendation 56;
(ii) participation in equity-related issues within the Service,
such as responding to internal discrimination or
harassment that may affect the Service’s ability to build
better relationships;
54
Toronto Police Services Board, Aboriginal Policing – Statement of Commitment and Guiding Principles
[no date], at https://www.tpsb.ca/policies-by-laws/board-policies/send/5-board-policies/121-aborigina l-
policing-sta tement-of-commitment-and-guiding-principles.
(iii) assisting, where appropriate, in remedial or restorative
measures associated with informal discipline;
(iv) assisting in designing and participating in the training and
education of Service members and part-time liaison
officers or civilian liaison members of the Service relating
to the lived experiences of intersecting marginalized and
vulnerable communities; and
(v) in partnership with communities, assisting the Service in
designing and offering training, education, and
professional development relating to marginalized and
vulnerable communities; in building relationships with
such communities; and in identifying for investigators
resources inside and outside the Service to advance
investigations relating to these communities; this training,
education, and professional development, some of which
the current liaison officers are involved in, would also be
provided to part-time liaison officers and civilian liaison
officers.
Pa rt-T ime Liaison Officers at the Divisional Level

As I indicate above, the OPP now has three times the number of part-time
liaison officers as full-time liaison officers. They receive special education on
Indigenous issues in addition to the mandatory education provided to all OPP
officers who work with Indigenous communities. OPP liaison officers are
supported by a civilian analyst who assists with detailed reports on their work
and by a policy and training coordinator. I was told that part-time liaison
officers in the OPP are selected on the basis of their community focus and
their ability both to communicate effectively and to build and maintain
relationships based on trust. Part-time liaison officers are expected to engage
in community outreach and are given the time to do so.
In my view, the introduction of part-time liaison officers in Toronto is
one way to address the urgent need to build better relations with diverse
communities, signal that relationship building represents a core function of the
Service, and do so in a more cost-effective way. To perform liaison functions,
the Service may also use civilian liaison officers, particularly where they have
pre-existing competencies, based on education, work experience, and/or lived
experiences. For example, Judge Oppal recommended that two civilian liaison
positions be created in Vancouver, to be populated by those with experience
respecting the survival sex trade.
Before OPP officers assume part-time liaison positions, they must take
an eight-day course on Indigenous issues followed by an examination. They
also receive two days of additional training and education every year. The
development and delivery of this training and education could itself be part of
a strategy to build better relations with Toronto’s marginalized and vulnerable
communities. Indeed, the continuing education of liaison officers and civilian
members of the Service could be combined with onsite community visits and
two-way conversations between new and existing liaison officers and members
of disadvantaged communities.
The intersectionality approach that is key to my recommendations
supports the idea that the Service should build competencies among its full-
time and part-time liaison officers and civilian members to deal with multiple
intersecting marginalized and vulnerable communities. At the risk of being
presumptuous, I would hope that Chapter 14 of this Report could play a role
in the training and education of liaison officers and civilian members of the
Service.
Some community members told me that because of past bad experiences
with the Service, they were reluctant to call 911. However, when they have
problems or seek information, they will call the personal cell numbers of
neighbourhood community and liaison officers. Both full-time and part-time
liaison officers and also civilian members of the Service should be encouraged
to establish and maintain these personal relationships and should be
reimbursed by the Service for modest expenses (currently personally assumed
by officers) related to improving and maintaining relationships. The same
should hold true for neighbourhood community officers.
RECOMMENDATIONS
138 The Toronto Police Service should create part-time liaison positions in
each division composed of officers and/or civilian members of the
Service who receive special training and education in relation to their
duties. Their responsibilities should be similar to those of full-time
liaison members of the Service, with appropriate modifications to
reflect their part-time status. They should also work with full-time
liaison officers or civilian members of the Service on issues that arise
at the divisional level.
139 The Toronto Police Service should enable liaison officers, civilian
liaison members, and neighbourhood community officers to spend
modest amounts to promote relationship building with marginalized
and vulnerable communities. The Service should reimburse expenses
that have been approved.
140 The Toronto Police Service should arrange for an independent
evaluation of the liaison program within a reasonable time frame
after modifications of the program have been introduced. The
independent evaluation should assist the program in identifying
underserviced marginalized and vulnerable communities and
reallocate resources, commensurately. Such an evaluation should be
made public.
The Neighbourhood Community Officer Program

In Chapter 14, I discuss in detail the Neighbourhood Community Officer
Program. I also endorse the Service’s decision to have researchers at Humber
College independently evaluate the program. As I have made abundantly clear,
the Service’s initiatives to build relationships with those in the marginalized
and vulnerable communities must be tested and refined based on these
independent evaluations. Otherwise, there is no guarantee that such initiatives
are successful or cost-effective.
The Humber College study examined trends in calls for service and
major crime index data. It also included interviews with focus groups of
adults, youth, and neighborhood community policing officers. The evaluation,
which was conducted over a two-year period, began one year after the
program was introduced in 2014. As I explain in Chapter 14, the
evaluation demonstrated that the program has been successful in meeting
its objectives. I strongly support the continuation and expansion of the
Neighbourhood Community Officer Program.
RECOMMENDATION
should continue to support and expand the Neighbourhood
Community Officer Program as an effective means of promoting
community safety while also building relationships with marginalized
and vulnerable communities.
I provide two cautionary notes. First, the Service cannot assume that programs
that have been successful in the past and the subject of positive
evaluations will continue to be successful. As circumstances change,
programs may lose community support or require renewal or modification.
The Service should regularly evaluate whether such programs continue to
enjoy public support and whether the analytics continue to show they are
successful. Second, both the liaison program and the neighbourhood
community program must remain sensitive to the concerns about
overpolicing expressed by marginalized and vulnerable community
members. In other words, community members may not welcome an
increased police presence in their communities unless it is accompanied by
clear understandings as to the roles being played by liaison officers and
neighbourhood community officers.
Internal Support Networks

My recommendations that the liaison and neighbourhood community
programs should be supported and enhanced do not relieve other Service
members of their obligation to build relationships with marginalized and
vulnerable communities – indeed, with all community members.
In Chapter 14, I describe existing tension within the Service about the
appropriate role of internal support networks. Some within the Service argue
that internal support networks that exist for LGBTQ2S+, Black, East Asian,
South Asian, and No-Boundaries (those with a variety of disabilities)
individuals should play a role only in mentoring and supporting Service
members. They view an external role of the support networks as a threat to the
chain of command, a usurpation of the role of the liaison officer, and a
corporate risk.
I respectfully disagree. In my view, internal support networks
representing LGBTQ2S+ Service members and those from other
disadvantaged groups are an important and underused asset within the Service.
They have an important role to play internally with respect to recruitment,
mentorship, and education. They also have an important role to play in
community engagement. As outlined in Chapter 14, I disagree with attempts
made to dissuade members of the LGBTQ2S+ internal support network from
having a luncheon with the Orlando chief of police and the Orlando Police
Department LGBTQ officers when they were in Toronto shortly after the mass
shooting in a gay nightclub in Orlando. It was suggested that the internal
support network should not be involved in what was regarded as
community engagement. Some senior officers were also concerned that the
LGBTQ2S+
internal support network publicly dissented from the Service’s official position
concerning participation in the Pride parade.
I state earlier that internal equity within the Service is, simply, the other
side of the coin of the Service’s external obligations to provide equitable
and equality-respecting services to the communities it serves. The idea that
internal support groups representing those in the Service who come from
disadvantaged groups should confine themselves exclusively to internal
matters is short-sighted. It conforms with a hierarchical, closed, and
paramilitary police culture that silences dissent and, ultimately, may be an
impediment to building better relations with marginalized and vulnerable
groups.
Similarly, the conventional wisdom in policing that officers should not
publicly criticize the Service or deviate from official policy also stems from its
hierarchical and para-military orientation. In my view, the time is long
overdue for a reconsideration of this orientation. It is inconsistent with a
more progressive modern view of policing as a profession. Simply put, I
am not
troubled by the prospect that internal support networks may hold views that
diverge from the Service position on issues relating to the communities
they represent. Officers have told me how difficult it is at times to raise
issues relating to the way the Service operates or the views of those in
higher positions of rank.
A new orientation invites a more introspective view within the
Service and greater prospects for positive change. Some public dissention
is a small price to pay for such a change. In relation to LGBTQ2S+ Service
members, I am also aware that many – or, it has been suggested, most – remain
unwilling or unable to be open within the Service about their sexual
orientation, gender identity, or gender expression. This hesitancy speaks to a
culture that persists within a Service that must become creative and proactive
in supporting its own vulnerable members. An enhanced role for internal
support networks will signal greater support for these Service members.
RECOMMENDATION
142 The LGBTQ2S+ and other internal support networks should be
recognized as important assets in community engagement and in the
Service itself.55 Network members, either individually or collectively,
should participate in community outreach and other activities that
serve their communities. Allowing the support networks to play an
external role may help inform the public, the Toronto Police Services
Board, and the Toronto Police Service of the problems confronted by
minority groups within the Service and also advise them of reforms
these officers propose based on their lived experiences. This approach
will also contribute to a positive change in culture within the Service
and signal greater support for the Service’s own vulnerable members.
Need to Involve Other Community Safety Partners

In Chapter 14, I discuss how the Winnipeg Police Service has welcomed and
tangibly supported the work of the Bear Clan – volunteers from Indigenous
communities who patrol and offer assistance to those communities. The
Winnipeg police also work closely with other Indigenous agencies. In Toronto,
many public and community agencies that provide services to the Indigenous
community have expressed their willingness to respond to the call to
action from the National Inquiry into Missing and Murdered Indigenous
Women and Girls. This response, which involves welfare, health, and child
welfare agencies, is consistent with a broader approach to community safety
and well- being.
Unfortunately, the Service does not appear to have been an active player
in this new collaborative community safety approach to the pressing problems
surrounding missing and murdered Indigenous women and girls. This
hesitancy may be related to the fact that the Service has reduced its Aboriginal
Peacekeeper Unit – a unit that was innovative when it was started in the early
1990s – to only one dedicated officer. I also note the paucity of
Indigenous recruits to the Service. In my view, the Service must recommit
itself to improving relations with Toronto’s growing Indigenous
communities. One overdue way of doing so is for the Service to develop
its response to the National Inquiry in collaboration with both the Indigenous
communities and the agencies that provide services to them.
55
In Chapter 14, I suggest that lia ison officers and internal support network members may also play a
remedial role within the Service when informal discipline is appropriate to deal with discrimination-related
conduct.
RECOMMENDATIONS
143 The Toronto Police Services Board and the Toronto Police Service, in
consultation with Toronto’s Indigenous communities and agencies
providing services to them, should develop a formal response to the
call to action from the National Inquiry into Missing and Murdered
Indigenous Women and Girls.
I conclude that much can be learned from the way the Winnipeg police
have worked with Indigenous communities. Although, as I discuss in Chapter
14, each Indigenous community is unique in its experience with
colonialism, together they share much with other marginalized and vulnerable
communities in being overpoliced and underprotected. Those who have lived
this experience have expert knowledge that should be respected and, to the
extent possible, integrated into policing and broader community safety
strategies.
During the missing person investigations that are the subject of this
Review, the Alliance for South Asian Aids Prevention developed several
initiatives to assist vulnerable members of the South Asian LGBTQ2S+
communities. One such initiative was SAFE, a check-in program that
gives people a secure platform to share personal information before they
engage with a stranger to report someone’s disappearance. 56 Community safety
work done by the community should, where appropriate and feasible, be
funded out of the Service’s budget. Similarly, part of the Service’s budget
could also be spent on relevant research conducted in collaboration with
community agencies. As Becky MacFarlane, from The 519 stated during our
consultations, “Like we have to do the work of the police, we should be
resourced by the police to do it ... and other organizations similarly.”
144 The Toronto Police Services Board and the Toronto Police Service, in
order to improve relationships with marginalized and vulnerable
communities and the groups that represent them, should recognize
that such groups have expert knowledge, networks, and skills that the
Board and the Service cannot replicate easily or cost effectively. They
should consider partnerships with community agencies that can help
fund promising community safety initiatives such as the Bear Clan and
56
Sam Edwards, “South Asian LGBTQ group starts safe date program after Village murders,” March 29,
2018, at https://nowtoronto.com/news/LGBTQ-safe-date-program/.
SAFE. They should also encourage research into the effectiveness of
such community programs, with attention to having clearly
articulated goals, gathering baseline statistics, and measuring the
success of these programs in both quantitative and qualitative terms,
as well as to identifying any improvements that can be made in them.
Pride (Chapter 14)
As I discuss in Chapter 14, the parade has become symbolic of Pride Toronto.
From 2000 to 2015, uniformed members of the Service marched in the parade,
thereby demonstrating improved relationships between the Service and the
LGBTQ2S+ communities. However, events in 2016 led to controversy about
the Service’s involvement in the parade, and leaders of Pride Toronto put the
matter to a series of votes. Since 2016, the police have not been allowed in the
parade, though the 2019 vote was close, separated by only two votes in favour
of the No side.
Although the Pride parade is not expressly part of my mandate, I feel it
is important for me to recognize the unique position it holds in the relationship
between the Toronto police and the LGBTQ2S+ communities. For five years
the turmoil over whether members of the Service should be allowed to march
in the parade has been an irritant, like salt on a wounded relationship. During
my outreach in this Review, I heard from many in the LGBTQ2S+
communities that until that irritant is removed, there will never be true
reconciliation between the Service and the communities. I have also heard that
the Service and many community members want the officers back in the
parade. I am aware that the city wants members of the Service back in the
parade. There are diverse views on how to resolve this impasse. There is no
magic solution. It will take time.
The harm the police have inflicted on the LGBTQ2S+ communities is
at the root of the impasse – and, to them, the uniform symbolizes this damage.
Many community members take the position that the police have to earn their
way back into the parade. In response, the police must be patient yet
committed. They must wait for a propitious moment with humility, mindful
that they don’t control the decision. During the “time out,” the Service must
publicly invest in building better, stronger relationships with the LGBTQ2S+
communities.
I hope that by acknowledging its mistakes of the past, including those
made in the investigations that are the subject of this Review, and by
implementing the Review’s recommendations, the Service can make a
persuasive case that it has earned its way back into the Pride parade. I do not
intend to dictate to the LGBTQ2S+ communities how to respond. The
recommendation that follows provides an option for these communities
that ties participation in the parade to measurable implementation of
relevant change.
RECOMMENDATION
145(a) The Toronto Police Service should consider partnering with the
LGBTQ2S+ communities to establish a committee to assess, on an
annual basis, whether members of the Service have earned their way
back into the Pride parade. Among other things, the assessment
should be based on the extent to which the Service has implemented
this Report’s recommendations. Depending on the assessment, the
Service may have to defer discussions on whether and under what
conditions its members might be welcome to march in the parade or,
based on demonstrable outcomes in establishing a positive
relationship with the LGBTQ2S+ communities, engage in such
discussions.
145(b) The committee could include leaders in the LGBTQ2S+
communities and current and past members of the Service who are
also members of the LGBTQ2S+ communities.
Implementation
I am hopeful that the Board’s decision to commission an independent civilian

review into missing person investigations, the public endorsement of the chief
of police for an independent review, and the full co-operation of both the
Board and the Service in the Review itself, signal a commitment to take
these recommendations and their timely implementation seriously. However,
many who spoke with me expressed the concern that my recommendations
might never be implemented – that this Report will “gather dust on a shelf.”
Some also questioned whether they would ever be able to accept, at face
value, assurances by the Board or the Service that the Report’s
recommendations had been implemented. A former chair of the Board
publicly challenged the Service’s representations that the Report on Police
Encounters with People in Crisis had been implemented as the Service said it
had. In fairness, work has since been done to address the Service’s response to
people in crisis.
I have no legal authority to compel the Board or the Service to
implement these recommendations. However, my position is no different from
that of a number of reviewers or commissioners of public inquiries whose
recommendations have substantially been adopted. In my view, the key to
success in the circumstances of this Review is in articulating a specific,
completely transparent implementation plan that involves community
participation, regular reporting to the public on the extent to which the
recommendations have been adopted, involvement of oversight agencies in
monitoring implementation, and, ultimately, public accountability if the
recommendations are not substantially implemented.
As I indicate earlier, the Office of the Inspector General of Policing
under the yet to be proclaimed Community Safety and Policing Act, 2019,
has a mandated role in monitoring and conducting inspections of, and
advising, police services boards, chiefs of police, and police services
respecting compliance with the Act and its regulations, which would
include provincial adequacy standards. As well, the Office of the Inspector
General is empowered to investigate complaints against the Board or the
Service respecting systemic failures or inadequate or inappropriate policies
and procedures. It follows that the Inspector General has the authority to
monitor implementation of this Report’s recommendations, insofar as they
relate to compliance with the Act or its regulations, and to address any
complaints that might arise from systemic failures or from inadequate or
inappropriate policies and procedures that are not corrected owing to non-
implementation of this Report.
The Ministry of the Solicitor General will also continue to have
statutory powers of policing oversight. In addition, the Ontario Human
Rights Commission plays an important role in investigating and reporting
on discrimination-related issues at the Service. Its role can include
monitoring implementation of those recommendations in my Report that
intersect with its own work. Also, the city auditor has been called on, in the
past and more recently, to provide independent audits in relation to policing
issues. In other words, oversight agencies and complaint mechanisms exist
to monitor and address failures to implement, in addition to the public
accountability that will accompany an implementation team that includes
community stakeholders and public reports on implementation. If all else
fails, I outline additional legal remedies below.
I start with independent monitoring. Earlier in this chapter, I
recommend independent monitoring of the Service’s compliance with
provincial adequacy standards in a number of specific areas. I explain why
such independent monitoring is necessary to restore confidence in the
Service and the Board.
However, the current need for independent monitoring does not relieve the
Board of its responsibility to ensure that the Service complies with provincial
adequacy standards and also implements those recommendations necessary to
ensure adequate and effective policing in Toronto. Long-term, the Board is
best situated, if it performs the vital role I and the applicable legislation
contemplate, to provide sustainable oversight of the Service.
RECOMMENDATIONS
146(a) On or before June 30, 2021, an implementation team comprised
of a diverse team of community representatives and Service members
should be assembled. This team should be responsible for developing
an implementation plan, to be modified as circumstances warrant,
and for monitoring and reporting on progress in implementation.
146(b) The implementation team should be co-led by a community
representative and a past or present member of the Service’s senior
command.
146(c) The implementation team’s community members should be
representative of the diversity of Toronto’s communities, with
appropriate attention given to the LGBTQ2S+ and marginalized and
vulnerable communities addressed in this Report.
146(d) The implementation team may create subgroups with subject
matter expertise and/or relevant lived experiences, although the
team should always remain mindful of the significance of
intersectionality in defining expertise and relevant lived experiences.
146(e) The community members should ideally include some individuals
who have already acquired knowledge of the issues this Report
identifies, either as members of the advisory group that
recommended this Review and drafted its Terms of Reference or as
members of the Review’s Community Advisory Group.
146(f) The policing members should ideally include members of the
Service’s Missing Persons Unit Procedures Working Group.
146(g) Community members should be remunerated for their
participation as members of the implementation team.
147(a) On or before September 30, 2021, the implementation team
should complete its implementation plan and post it on the Toronto
Police Service’s website or some other suitable venue. The plan
should specify goals, timelines, and measurable outcomes.
147(b) The implementation team should issue progress reports at least
once a quarter that should be posted on the Toronto Police Service’s
website or some other suitable venue. The first progress report
should be issued no later than December 31, 2021. The team might
also consider the use of an online tracking tool for implementation, as
has been used by the City of Toronto.
148 On or before April 30, 2022, the Toronto Police Services Board and the
Toronto Police Service should publicly release a detailed report on the
extent to which each recommendation has been implemented. If the
Board and/or the Service decides that a particular recommendation
should not be implemented, or be delayed or modified, the report
should set out why this decision has been made and how the
underlying objectives of the recommendation are being met in
another way.
In my view, the full participation of a diverse group of community

members in the implementation process is critically important not only for
the perspectives they bring but also to build confidence in the process itself. I
was inspired by the contributions made by the diverse advisory group that
recommended this Review and largely designed its Terms of Reference. I
believe that the Board’s empowerment of this advisory group enhanced its
ultimate decision making in a way consistent with true community partnership.
Similarly, the Review’s equally diverse Community Advisory Group greatly
contributed to my Report as its members facilitated and participated in our
extensive community outreach and engagement and provided me with valuable
insights.
My approach is also modelled on the Board’s Anti-Racism
Advisory Panel. The Board established this panel in April 2018 in
response to the recommendation of a coroner’s jury at the inquest into the
death of Andrew Loku, a young Black man. The Board adopted and
developed a monitoring framework for the implementation of the jury’s
recommendation. Later, it made the panel permanent to enable it to address
systemic racism and related issues. The panel’s membership included one
Board member, four Service
members, six community members (including a representative from the
Andrew Loku Committee), and two experts in racism and in mental health and
addictions.
As I indicate above, I regard the Board’s decision to commission this
Independent Review, the Service’s public support for such a review, and the
support I received from the Service and the Board during my investigation, as
a signal of commitment to this process. Nonetheless, in the above
recommendations, I have built in and described specific mechanisms for
implementing my recommendations, monitoring implementation, and publicly
reporting on implementation. I have also identified the oversight agencies that
have the authority to evaluate the scope and the pace of implementation.
Finally, I wish to address legal remedies available in the event that the
response to this Report is seriously deficient.
As I explain above, the Community Policing and Safety Act, 2019, when
proclaimed, will, with limited exceptions, empower anyone to file a complaint
with the inspector general of policing in relation to a range of systemic failures
as well as inadequate or inappropriate policies or procedures. As a last resort,
civilian members of the implementation team could file such a complaint.
Similarly, members of the implementation team could file a human rights–
related complaint under the Human Rights Code. That could lead to a binding
settlement under s. 45.9 of the Code. 57 This settlement would be subject to
independent monitoring and enforcement by the Ontario Human Rights
Tribunal under s. 45.9 of the Code. Under s. 45.9(8), the Tribunal could make
any order it considers appropriate should it determine that a party has
contravened the settlement. The advantages of such an approach are its
enforceability and the Tribunal’s ability to respond to a lack of full
implementation and, if necessary, to devise supplemental remedies. Its
disadvantages are that discrimination-related recommendations form only part
of my Report, and that resort to s. 45.9 is dependent on a complaint being
made and potentially lengthy litigation being avoided through a settlement
agreement.
There is precedent for the use of settlement agreements under the Code
to address much needed reforms. For example, an independent monitor, Justice
David Cole, assessed the provincial government’s compliance with a
settlement arrived at in relation to solitary confinement and segregation in
Ontario prisons. Based on measurable outcomes, he concluded that the
57
RSO 1990, c H 19.
government had not complied with the settlement.58 The Ontario Human
Rights Commission subsequently applied to the Human Rights Tribunal
for additional remedies, including a prohibition on segregation for anyone with
a mental health disability, along with strict limits on the use of segregation. 59
As set out in Chapter 14, the Service has also entered into settlement
agreements with the Ontario Human Rights Commission.
The United States has greater familiarity with settlement agreements, or
“consent decrees” as they are characterized there. In my numerous discussions
with the Seattle Police Department (SPD), I learned about a consent decree
that helped move that department in a promising direction. The SPD was
initially apprehensive about the consent decree signed between the City of
Seattle and the Federal Department of Justice – an anxiety fueled, in part, by
the loss of control through the creation of an independent process. However, I
learned that the consent decree forced the SPD to invest in a more data-driven
and evidence-based form of policing and in better mechanisms for community
relations. The consent decree allowed flexibility in implementation while
achieving measurable outcomes.60
The United States Department of Justice acknowledged “the good faith
of the City of Seattle in trying to address the remedial measures that are
needed to ensure constitutional policing in Seattle.” It committed to using
informal means of dispute resolution, but also “reserve[d] its right to seek
enforcement of the provisions of the Settlement Agreement if it determines
that the City and SPD have failed to fully comply with any provision of this
Agreement.”61
The City of Seattle publicly expressed the view that the SPD became a
national model for other police departments across the country and that the
settlement agreement became the foundation for the development of best
practices and a new police culture. The city’s praise was supported by
independent evaluations that showed, for example, high compliance with use
of force policies (a key issue that prompted the consent decree) and no
statistically significant racial disparities among those on whom police
force was used. The improvements were also confirmed through public
opinion and equity surveys of the type I have recommended in this Report,
with much of the improvement among Black and Latino respondents. As I
further explain in
58
Justice David P. Cole, Final Reportof the Independent Reviewer, February 15, 2020, at
https://www.mcscs.jus.gov.on.ca/english/Corrections/JahnSettlement/FinalReportIndependentReviewer.html
59
http://www.ohrc.on.ca/en/segregation-and-mental-health-ontario’s-prisons-jahn-v-ministry-community-
sa fety-and-correctional.
60
https://www.seattle.gov/Documents/Departments/Police/Complia nce/Consent_Decree.pdf.
61
Ibid, para 224.
Chapter 14, the Seattle consent decree also addressed the need for meaningful
community consultation of multiple and intersecting disadvantaged
communities. My recommendations on community consultative
committees have been informed by Seattle’s approach.
I chose to learn about the Seattle experience largely because its police
service, and its chief at the time, Chief Carmen Best, were regarded in the
United States as truly innovative, particularly in relation to building positive
relationships with diverse communities. In addition to freeing up the time of
many of the SPD’s senior officers to meet with me, Chief Best assisted the
Review by participating in our roundtable. Although in recent months Seattle
and its police department have had formidable challenges, as I outline in this
Report, I continue to believe we can learn much from the SPD’s approach.
In relation to consent decrees and settlement agreements, I have elaborated
on them because, in the past, reform efforts that did not involve legally
enforceable remedies – whether involving the Service or other institutions
– have, at times, been unsuccessful. The resort to litigation to enforce
implementation would represent an unfortunate development. Nonetheless,
legal remedies remain available if absolutely necessary.
149 When Part VII of the Community Safety and Policing Act, 2019 is
proclaimed, the Toronto Police Services Board and the Toronto Police
Service should support the role to be played by the Office of the
Inspector General of Policing in independently monitoring the
implementation of this Report’s recommendations.
150 The Toronto Police Services Board, the Toronto Police Service, and the
implementation team should consult regularly with the Ontario
Human Rights Commission in relation to the implementation of this
Report’s recommendations, insofar as they relate to the Commission’s
mandate.
151 As a last resort, the civilian members of the implementation team
should be made aware of the option to file a complaint under the
Human Rights Code or under the Community Safety and Policing Act,
2019, when proclaimed, to the Office of the Inspector General if they
believe that either the Toronto Police Services Board or the Toronto
Police Service are not prepared to make needed changes to address
the systemic issues this Report identifies.
In my discussions, the importance of leadership in making systemic change
was emphasized by many people, police officers and community members
alike. The Board is currently engaged in a search for a new chief of police, and
it has indicated that the process will involve substantial community
engagement. I am hopeful that one criterion for selection will be a candidate’s
commitment to and alignment with the key recommendations contained in this
Report. If so, this consideration will represent another component to
success in the implementation of my recommendations.
Records in the Possession of the Toronto Police Service
The Review received the full co-operation of the Board and the Service in
facilitating the collection of relevant documents and interviews of relevant
witnesses. However, despite that full co-operation, I was struck by the
difficulty, at times, that the Service had in assembling relevant documents in a
comprehensive way. This was not a failing of the officers who served
diligently as liaisons to our Review – quite the contrary – but was concerning
nonetheless. It sometimes potentially worked to the Service’s disadvantage.
For example, the Review worked hard to construct a comprehensive list of the
Service’s initiatives relating to relationship building. There was no such
comprehensive list. Similarly, the Review worked hard to reconstruct relevant
chronologies. Our work was often frustrated by less-than-complete records,
documents lost in transition, notes not kept. Parts of this Report were
rewritten, sometimes more than once, as questions by my lead counsel and
team uncovered new procedures or even existing policies, not previously
provided to the Review. I am convinced that there was no effort to
suppress these documents – indeed, the documents in issue showed
improvements that inured to the Service’s benefit. But my frustration over
securing documents from the Service does speak to the need for the Service to
re-evaluate how it stores and maintains its procedures, practices, and
initiatives, as they are developed. It should not be so difficult to secure relevant
documents for an independent review or for any other valid purpose.
Resources
Any systemic review that makes significant recommendations for change must
be mindful of cost implications. Many of my recommendations are cost neutral
or involve modest implementation costs, including those to upgrade or
enhance existing policies and procedures to ensure compliance with
provincial
adequacy standards and promote best or improved practices. That being said,
some of the recommendations, particularly those that call for a new model for
how missing person investigations are conducted, require significant
investment in the Missing Persons Unit as well as in divisional investigations
through increased assignments and hires, including civilian missing person
coordinators. The steps needed to build community partnerships and a
transformative approach to training, education, and professional development
are also substantial and involve additional time and resource allocation.
I am well aware that these recommendations come at a time when there
are pressures on the city and the Board to reduce the Service’s budget. There
is pressure to reallocate those monies to communities to address a range of
issues. I am also aware that the pandemic has placed additional financial
pressures on all levels of government to address the extraordinary reduction in
revenues and the heightened expenditures the city has incurred during this
period.
It is not within my mandate to address these larger budgetary
matters, but I sound this cautionary note. In relation to the issues I
examine in this Report, the status quo is simply not acceptable.
Fully realizing the potential of the Missing Persons Unit must come
with an appropriate investment. Recognizing the need to meaningfully partner
with vulnerable and marginalized communities to build a respectful
relationship with them must also come with an appropriate investment.
Similarly, being a true leader in training, education, and professional
development comes with a price tag.
Indiscriminate budget cuts can imperil one of the underlying
reasons being advanced in favour of ultimately reducing police budgets –
building community capacity to address a range of issues. My
recommendations are illustrative. The most significant costs relate to those
recommendations designed to enable social service, public health, and
community agencies to assume greater responsibility for missing person
cases and to reduce dependence on the Service to perform tasks better
assumed by others – precisely what many community members and police
officers would like to see. In the long term, many of my
recommendations, if implemented, will reallocate resources from the Service
to communities. Others will position the Service to perform its
responsibilities in a more effective, timely, and discrimination-free way.
The public is entitled to no less.
Equally important, we must consider the financial and social costs that
would come from a failure to address the issues identified in this Report. It is
abundantly clear that the failure to act comes at a far more substantial cost – to
lives, to the ability of the Service’s members to serve and protect, to the safety
and well-being of Toronto’s marginalized and vulnerable communities, and to
the public at large. The failure to act also comes at a substantial financial cost,
not easily measured, but nonetheless real financial cost – costs incurred when
investigations go awry, crimes remain undetected, and frayed relationships
must be repaired.
When Detective Constable Manherz said that the Service had to change
the way it conducted missing person investigations or risk, among other
things, an inquiry, he was right. The goal must be to make any future public
inquiry or systemic review unnecessary. That is how we can best honour the
lives lost.
Chapter 16 Conclusion 871
Chapter 16
CONCLUSION
This Report is titled Missing and Missed. It remembers those who went
missing and who are missed. It also identifies missed opportunities. Against
the background of the circumstances that prompted this Review, the Toronto
Police Services Board and the Toronto Police Service now have two valuable
opportunities. The first is to fundamentally improve how missing person cases
are responded to. The second is to invest in strategies designed to improve
their relationships with Toronto’s marginalized and vulnerable communities.
However, the pursuit of these opportunities is not the responsibility of
the Board and the Service, alone. To the contrary. I propose a new approach to
missing person cases that builds capacity for social service, public health,
community agencies, and not-for-profit organizations to play a central role –
sometimes in partnership with the police – to address missing persons in a
holistic way. An approach that addresses the underlying issues that sometimes
explain why someone goes missing. A way that ensures that when the police
are needed, they conduct effective, timely, and discrimination-free missing
person investigations. Finally, a way that will contribute to the building and
strengthening of relationships between the Toronto police and the
communities they serve, particularly the marginalized and vulnerable.
These two valuable opportunities are intertwined. They require the
police to work together with the communities they serve. This is particularly
true for LGBTQ2S+, Indigenous and racialized communities; the
homeless and underhoused; and those who struggle with mental illness and
addictions. Indeed, it is true for a wide range of intersecting, marginalized and
vulnerable communities described in this Report. But a successful working
relationship with communities cannot be realized unless the Service
recognizes and
thoughtfully addresses the frayed relationships it has with many marginalized
and vulnerable community members.
The Board and the Service should be commended for initiatives
they have taken to improve missing person investigations and to improve
these relationships. But my recommendations suggest that what is
undeniably needed is truly transformational change.
Such change is long overdue. Given the history of these frayed
relationships as discussed in this Report, the impact of the tragic events that
prompted this Review, and the momentum of the current discussions about re-
imagining policing, there is but one conclusion. There is no better time than
now. It is how we honour the lives of those who have been lost:
Skandaraj Navaratnam
Abdulbasir Faizi
Majeed Kayhan
Soroush Mahmudi
Kirushna Kumar Kanagaratnam
Dean Lisowick
Selim Esen
Andrew Kinsman
Alloura Wells
Tess Richey
Arthur Louttit
Dovi Henry
Kenneth Peddle
… and so many others.
Appendices
APPENDIX A
1 Toronto Police Services Board
2
3 Terms of Reference for the Independent Civilian Review into
4 Missing Person Investigations
5
6 WHEREAS the Toronto Police Services Board (“the Board”) is responsible, pursuant
7 to subsection 31(1) of the Police Services Act, R.S.O. 1990, c. P.15 (“the Act”), for the
8 provision of adequate and effective police services in the City of Toronto;
9
10 AND WHEREAS the Board must, pursuant to subsection 31(1) of the Act, generally
11 determine after consultation with the Chief of the Toronto Police Service (“the
12 Chief”) objectives and priorities with respect to police services for the City of
13 Toronto, establish policies for the management of the Toronto Police Service (“the
14 Service”) and direct the Chief and monitor his performance;
15
16 AND WHEREAS the Board may, pursuant to subsection 31(6) of the Act, by by-law,
17 make rules for the effective management of the Toronto Police Service;
18
19 AND WHEREAS the Board may express its opinion or make recommendations to the
20 Chief of Police on any aspect of policing in the municipality, while not directing the
21 Chief of Police with respect to specific, operational matters or with respect to the
22 day-to-day operation of the Toronto Police Service;
23
24 AND WHEREAS the Report of the Independent Civilian Review Into Matters Relating
25 to the G20 Summit provides relevant guidance on interpreting the statutory
26 mandate of the Board;
27
28 AND WHEREAS a number of people, and in particular members of the LGBTQ2S+
29 communities in the City of Toronto, have gone or been reported missing and have
30 later been identified as victims of serious violence;
31
32 AND WHEREAS Project Houston, the Toronto Police Service’s 18-month
33 investigation into the disappearance of three missing men who have now been
34 identified as victims of serious violence, was closed in April 2014 having found no
35 evidence of criminal conduct;
36
37 AND WHEREAS Bruce McArthur has now entered guilty pleas and been sentenced
38 for eight counts of first degree murder, allowing for the Reviewer to fully examine
39 the circumstances surrounding the investigations into the disappearance of his
40 victims, including but not limited to how and when he was identified as a person of
41 interest or suspect and any deficiencies in such investigations;
42
43 AND WHEREAS members and groups within the LGBTQ2S+ communities in the City
44 of Toronto have expressed concern over the manner in which the Toronto Police
45 Services handle and have handled missing person investigations, and specifically,
875
2
1 the investigations into the disappearance of Mr. McArthur’s victims, including

2 concerns that the handling of missing person investigations in the City of Toronto
3 may have been tainted by implicit or explicit, specific and systemic bias;
4
5 AND WHEREAS there are intersections of minorities within the LGBTQ2S+
6 communities, including South Asian, Middle Eastern, 2-spirited, other racialized
7 individuals, as well as those who are either homeless or work in the sex trade that
8 are particularly vulnerable and require an improved approach to policing
9 relationships;
10
11 AND WHEREAS the Board recognizes the need to repair its relationship with the
12 LGBTQ2S+ communities in the City of Toronto and to foster ongoing positive
13 relations with members and organizations within those communities;
14
15 AND WHEREAS the Board created a Working Group consisting of one Board
16 member and three external members to advise the Board on the structural and
17 process options for an independent external review or reviews;
18
19 AND WHEREAS the Working Group has recommended that the Board commission
20 an independent review of Board policies as well as Service procedures and practices
21 in relation to missing person investigations, particularly those involving individuals
22 from the LGBTQ2S+, immigrant, Indigenous, South Asian, Middle Eastern, Black,
23 homeless and marginalized communities more generally;
24
25 AND WHEREAS the Board believes that the recent guilty pleas and sentencing of Mr.
26 McArthur require that it significantly expand the original Terms of Reference
27 recommended by the Working Group to enable the Reviewer to conduct a complete
28 and thorough examination of the relevant issues;
29
30 AND WHEREAS the Board believes it would be beneficial and of assistance to the
31 Board in carrying out its responsibilities pursuant to subsection 31(1) and
32 subsection 31(6) of the Act to conduct a Review of the adequacy of the Board’s
33 policies, as well as the Service’s procedures and practices related to missing person
34 investigations, including a systemic evaluation of the manner in which the Service
35 conducts such investigations and a review of certain specific missing person
36 investigations identified in paragraph 2 below, including but not limited to those
37 investigations into the disappearance of Mr. McArthur’s victims;
38
39 AND WHEREAS the Board believes that it is important that the terms of reference of
40 such a Review must be designed, among other things, to ensure that the Reviewer is
41 truly independent;
42
43 THEREFORE the Board is appointing a Reviewer to conduct an Independent Review
44 into Board policies as well as Service procedures and practices in relation to missing
45 person investigations, particularly those involving individuals from communities
46 described above;
876
1
2 AND to conduct the Review, the Reviewer will be provided with such resources as
3 are required, and be authorized by the Board to engage lawyers, experts, advisors,
4 researchers and other staff as the Reviewer deems appropriate, at reasonable
5 remuneration, as approved by the Board;
6
7 AND the Chief will cooperate fully with the Reviewer in conducting the Review and
8 will instruct members employed by the Service to cooperate fully with the Reviewer
9 conducting the Review as deemed necessary;
10
11 AND the Chair and members of the Board will cooperate fully with the Reviewer in
12 conducting the Review and will instruct all members employed by the Board to
13 cooperate fully with the Reviewer in conducting the Review;
14
15 AND the Reviewer may request any person, organization, the Chief, members of the
16 Board, and any member employed by the Board or the Service to provide relevant
17 information or records for the Review where the Reviewer believes that person or
18 organization has such information or record in his, her, their, its possession, custody
19 or control;
20
21 AND the Reviewer may hold such meetings, interviews and consultations, and may
22 make such procedural decisions with respect thereto, as the Reviewer deems
23 advisable in her discretion in the course of the Review;
24
25 AND the Reviewer, prior to commencing and throughout the Review, will consult
26 with the Ministry of the Attorney General for Ontario, specifically Andrew Locke,
27 Regional Director of Toronto Region or his designate (hereinafter “MAG”), and
28 others in the Reviewer’s discretion in relation to the ongoing criminal proceedings
29 involving Kalen Schlatter in order to ensure that such criminal proceedings are not
30 prejudiced by this Review;
31
32 AND the Reviewer will consult with members, groups and organizations within the
33 LGBTQ2S+ community, including those who have filed missing person reports in the
34 past, and will engage an advisor to assist with the design and implementation of the
35 community consultations;
36
37 AND the Reviewer will ensure that adequate accommodations and supports are
38 available to maximize community participation in the consultation process,
39 including receiving submissions from various stakeholders, community groups and
40 organizations;
41
42 AND the Reviewer will establish an advisory group representing affected
43 communities, such as the LGBTQ2S+ communities, the South Asian and Middle
44 Eastern communities, the sex trade and the homeless communities in the City of
45 Toronto, to ensure the community perspective is adequately considered prior to
46 commencing and throughout the Review; advisory groups representing other
877
1 stakeholders may be created formally or informally in the discretion of the
2 Reviewer;
3
4 AND the Reviewer will establish and maintain a website and may use other
5 technology to promote accessibility and transparency to the
public; 6
7 AND the Reviewer will provide updates to the public, through the website or other
8 means, on the status of the review, the contents of which cannot prejudice any
9 ongoing criminal investigation or the criminal proceedings involving Kalen
10 Schlatter,
11
12 AND the Reviewer will conduct the Review without prejudicing any ongoing
13 criminal investigation or criminal proceedings, including but not limited to the
14 criminal prosecution of Kalen Schlatter, and will make a report to the Board without
15 expressing any conclusion or making any recommendation regarding the civil or
16 criminal responsibility of any person or organization;
17
18
19 AND the Reviewer may produce an interim report at the Reviewer’s discretion and
20 will produce a final report containing the Reviewer’s findings, conclusions and
21 recommendations and deliver it to the Chair and members of the Board for
22 distribution to the public at or before January 31, 2021;
23
24 AND the report will be prepared in a form appropriate for release to the public,
25 pursuant to the Municipal Freedom of Information and Protection of Privacy
Act; 26
27 AND these Terms of Reference should be interpreted in a manner consistent with
28 the jurisdiction of the Board to ensure a broad and comprehensive Review;
29
30 AND in the event that the Reviewer is unable to carry out any individual term of
31 these Terms of Reference, the remainder of the Terms of Reference will continue to
32 operate, it being the intention of the Board that the provisions of these Terms of
33 Reference operate independently;
34
35 AND the subject matter of the Review will be:
36
37 1. A review of Board by-laws, policies and practices, as well as The Way
38 Forward and any related reports that may have been considered by the
39 Board, dealing with or relevant to missing person investigations and
40 community relations to determine whether they are adequate to ensure
41 effective, efficient and bias-free responses to missing person reports.
42
43 2. Without prejudicing any ongoing criminal investigation or the criminal
44 proceedings involving Kalen Schlatter, a review of Service procedures,
45 practices, protocols, and actions in relation to missing person
46 investigations, including but not limited to a review of Project Houston,
878
1 Project Prism, any other opportunities to identify Bruce McArthur as a
2 person of interest or suspect and the missing person investigations of
3 Skandaraj Navaratnam, Abdulbasir Faizi, Majeed Kayhan, Salim Esen,
4 Soroush Mahmoudi, Andrew Kinsman, Alloura Wells and Tess Richey, with
5 a specific focus on
6
7 a. When a missing person event or report becomes a missing person
8 investigation;
9
10 b. Whether adequate resources are dedicated at the Divisional and/or
11 Service level to missing person investigations at inception and
12 throughout the course of the investigation;
13
14 c. Whether culturally competent expertise is available to or relied upon
15 by the Service for missing person investigations, including but not
16 limited to expertise around gender identity, gender expression, race,
17 ethnic origin and intersectionality;
18
19 d. Whether the policies and practices adequately protect against implicit
20 or explicit bias or discrimination (at the individual and systemic level)
21 against members of the LGBTQ2S+ and other marginalized groups;
22
23 e. Whether the Service is conducting missing person investigations in a
24 unbiased, non-discriminatory manner, including consideration of the
25 exercise of discretion by members of the Service in relation to
26 decisions to record a person missing, or launch, resource and/or
27 terminate missing person investigations and the experience of those
28 who file missing persons reports with the
Service; 29
30 f. Whether there is adequate information sharing within the Service and
31 between police services to ensure that similarities and links between
32 missing person investigations can be identified quickly and
33 effectively;
34
35 g. Whether the Service has procedures, practices or protocols that limit
36 who will be considered and/or investigated as a missing person and
37 whether those policies are discriminatory or biased in their effect or
38 application;
39
40 h. Whether the Service has procedures, practices or protocols and
41 whether members of the public believe the Service has procedures,
42 practices or protocols that intentionally or unintentionally discourage
43 marginalized people, including but not limited to those without legal
44 status in Canada or who are homeless, from being reported missing –
45 including, without prejudicing any ongoing criminal investigation or
46 criminal prosecution, an examination of what prevented Dean
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1 Lisowick and Kirushna Kumar Kanagaratnam from being reported
2 missing;
3
4 i. How and when the Service decides to advise or caution the public, or
5 specific communities, about public safety concerns that arise from
6 missing person investigations, including but not limited to
7 information about suspected links or connections between missing
8 person cases;
9
10 j. How public messaging around missing person investigations is
11 developed and whether cultural competence expertise is available or
12 relied on by the Service in drafting public communications;
13
14 k. How information about missing person investigations and policies
15 surrounding missing person investigations are communicated
16 internally within the Services and whether those methods of
17 communication are effective; and
18
19 l. Whether effective policies, procedures, and practices are in place to
20 ensure adequate investigative consideration of serial killers,
21 especially based on missing person reports where there is no overt
22 evidence of foul play.
23
24 3. A review of Service procedures, practices and protocols for developing and
25 maintaining relationships with individuals and organizations within the
26 LGBTQ2S+ communities, especially as they impact on the effectiveness and
27 adequacy of missing persons investigations, including but not limited
to: 28
29 a. The roles, responsibilities and efficacy of the LGBTQ Liaison Officer;
30
31 b. The roles, responsibilities and efficacy of relevant Board and Service
32 Advisory Committees or Working Groups in terms of maintaining and
33 promoting communication between the Service and the LGBTQ2S+
34 communities;
35
36 c. The scope and efficacy of consultations and communications with
37 members and organizations within the LGBTQ2S+ communities about
38 missing person investigations;
39
40 d. The extent to which the Service engages or consults with individuals
41 and groups that reflect the diversity within the LGBTQ2S+
42 communities;
43
44 e. The extent to which the police call upon organizations within the
45 LGBTQ2S+ (or other relevant communities) to assist with missing
46 person investigations at any stage;
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1
2 f. The extent to which individuals and organizations within the
3 LGBTQ2s+ communities are advised of public safety concerns arising
4 from missing person reports and investigations, including but not
5 limited to information about possible links between
cases; 6
7 g. The views and perceptions of members of the LGBTQ2S+ and
8 marginalized communities more generally about the manner and
9 substance of public communications by the Service about missing
10 person investigations;
11
12 h. The experience of members of the LGBTQ2S+ and marginalized
13 communities more generally reporting concerns to the police,
14 including but not limited to the experience of individuals with non-
15 heteronormative sexual expressions (such as those who participate in
16 public cruising or BDSM), and whether there are actual or perceived
17 barriers in relation to their willingness or ability to share information
18 with the police; and
19
20 i. The accessibility, transparency and effectiveness of any complaint
21 process for identifying concerns on the part community members or
22 groups about missing person investigations.
23
24 4. A review of current training of Service members in relation to missing
25 person investigations, bias-free policing and community liaison to
26 determine whether it adequately addresses
27
28 a. Cultural competence to respond to missing person reports within the
29 LGBTQ2S+ communities;
30
31 b. Intersectionality and its impact on marginalization; and
32
33 c. Protecting against biased assumptions being made about individuals
34 reported missing based on their race, sexual orientation, immigration
35 status etc.
36
37 5. A review of the efficacy of current training in relation to missing person
38 investigations in ensuring that concepts taught are being operationalized by
39 the Service.
40
41 6. In the Reviewer’s discretion, a review of formal and informal complaints
42 made to the Service, the Board or the OIPRD related to missing person
43 investigations.
44
45 6. Consideration of prior reports dealing with missing person investigations in
46 Canada, relations between the LGBTQ2S+ community and the police, and the duty
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1 on the police to notify the public of potential safety threats (including but not
2 limited to Out of the Closet: Study of Relations Between the Homosexual Community
3 and the Police, 1981, Bernardo Investigation Review, 1996, The Review of the
4 Investigation of Sexual Assaults – A Decade Later, 2010 and the Report of the Missing
5 Women Commission of Inquiry in British Columbia in 2012) to determine if past
6 recommendations have been implemented and/or effective and if not, why past
7 recommendations have not been implemented by the Board and/or the Service.
8
9 7. Consideration, in the Reviewer’s discretion, of best practices in other jurisdictions
10 in relation to missing person investigations, bias-free policing and maintaining
11 positive working relationships with marginalized communities.
12
13 AND the Reviewer will make recommendations as the Reviewer deems fit for the
14 mandate of the review and terms of reference, including but not limited to
15 recommendations on:
16
17 1. Board policies and Service procedures and practices relating to receiving and
18 recording missing person reports, and conducting effective, efficient and
19 bias-free missing person investigations;
20
21 2. Board policies and Service procedures and practices related to the collection
22 of data about the effectiveness of missing person investigations, including the
23 satisfaction of those who filed or attempted to file missing person reports;
24
25 3. Board policies and Service procedures and practices to ensure adequate
26 training of Service members in relation to missing person investigations and
27 bias-free policing;
28
29 4. Board policies and Service procedures and practices to ensure that officers
30 conducting or supervising missing persons investigations are qualified and
31 well situated to ensure effective, efficient and bias-free investigations;
32
33 5. Board policies and Service procedures and practices that will ensure
34 appropriate accountability, including remedial and/or disciplinary measures,
35 if members of the Service engage in biased or discriminatory conduct when
36 receiving or investigating missing person reports;
37
38 6. Board policies and Service procedures to create a framework for ensuring
39 participation of members and organizations within the LGBTQ2S+
40 communities in the process of monitoring and implementing any
41 recommendations adopted by the Board and Service; and
42
43 7. A framework for measuring, monitoring and publicly reporting on whether
44 the recommendations of the Reviewer have been implemented by the Board
45 or Service and if not, why not, as well as the effectiveness of any
46 recommendations that are implemented by the Board or Service, including
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1 giving consideration to a model for independent oversight of compliance and
2 continuing community consultation;
3
4 AND the Reviewer will propose a timeline for the implementation of each
5 recommendation.
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APPENDIX B
Community Advisory Group
The Community Advisory Group (CAG) is made up of community leaders who

worked to ensure that diverse voices within Toronto’s communities were heard. It
included a community advisor, Ron Rosenes, who led the group’s meetings; a
coordinator, Haran Vijayanathan, who was heavily involved in facilitating the
Review’s community outreach; and five other outstanding individuals. They met
regularly, provided me with advice and guidance, and were directly involved in the
design and implementation of the Review’s public outreach and engagement plan.
Ron Rosenes
Ron Rosenes is a highly respected community leader, health advocate, researcher
and consultant, working primarily in HIV and the LGBTQ community. He has
served on the Boards of many local and national organizations and is passionate
about the systemic and structural issues that make people vulnerable to HIV and
other forms of exclusion. After the death of his partner of 15 years in 1991, Ron
became involved with the Boards of the AIDS Committee of Toronto, AIDS
ACTION NOW!, the Sherbourne Health Centre and the Canadian Treatment
Action Council. Ron has served on advisory committees for Health Canada, the
Canadian Institutes of Health Research (CIHR) and the Ontario Advisory
Committee on HIV/AIDS. He holds a B.A. (Honours) in French and Russian
from Carleton University, and a M.A. in Slavic Languages and Literature,
University of Toronto. In 2012, he was awarded an LL.D (Hon.) by Carleton
University. In 2015, he was awarded the Order of Canada for his voluntarism and
advocacy in HIV.
Haran Vijayanathan
Haran Vijayanathan is the Executive Director of the Alliance for South Asian
AIDS Prevention (ASAAP), an organization committed to providing culturally
responsive holistic health and support services for South Asian and Middle
Eastern community members at risk of or affected by HIV. In 2011, he founded
My House: Rainbow Resources of York Region, a resource centre allowing those
who identify as LGBTQ2S to gather in a safe and inclusive space. He has
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performed volunteer work for the Winnipeg Zoo, Nine Circles Community
Health Centre, Tamil Service Providers Council, the Don Jail, as well as
committees and working groups that look at diversity and inclusivity. In 2018,
Haran served as Grand Marshal of Pride Toronto. He has provided much needed
support to grieving families of deceased community members named in this
systemic Review’s Terms of Reference.
Christa Big Canoe

Christa Big Canoe is an Indigenous lawyer known for her work as Legal
Advocacy Director for Aboriginal Legal Services and as an advocate for
Indigenous women and children. She is a mother and a member of Georgina
Island First Nation, an Anishinabek community in Ontario. While at Legal Aid
Ontario, she led the province-wide Aboriginal Justice Strategy aimed at
removing barriers to accessing justice for First Nation, Métis and Inuit people.
Ms. Big Canoe has represented survivors of violence in various capacities, and
her experience includes inquest work. She represented six of the seven families
of the students (“the Fallen Feathers”) whose deaths were subject to an inquest
in Thunder Bay, leading to important recommendations for change. All of the
students came to the city from remote First Nations to attend high school. Ms.
Big Canoe is currently lead counsel for the National Inquiry into Missing and
Murdered Indigenous Women and Girls. The Inquiry’s report was to be
completed by April 30, 2019.
Monica Forrester
Monica Forrester is a 2 Spirit Trans woman of colour who has worked within the
Trans/Sexwork community’s grassroots programs for 20 years and worked on
Trans led initiatives in Toronto. Currently, Monica is Program Coordinator at
Maggie's Toronto Sex workers Action Project and also Executive Director and
Founder of Trans Pride Toronto that has been bringing inclusion, awareness and
equality to Trans and larger LGBTQ2S+ non-binary communities since 2004.
She was a member of the initial working group that recommended the creation
of this systemic review.
Brian W. Lennox
Justice Lennox is a per diem judge of the Ontario Court of Justice. He was Chief
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Justice of the Ontario Court of Justice from 1999 to 2007 and, from 2007 to 2014,
Executive Director of the National Judicial Institute. He holds a B.A. from York
University, an LL.B. from the University of Toronto, a graduate degree in
criminal law (Diplôme d’études supérieures de sciences criminelles) from the
University of Paris and an LL.D. (Hon.) from the Law Society of Upper Canada.
Called to the bar in 1975, he practiced law in the city of Ottawa with the firm of
Paris, Mercier, Sirois, Paris & Bélanger, was appointed an Assistant Crown
Attorney in 1978, and a judge of the Provincial Court (Criminal Division) in
1986. He was appointed a Regional Senior Judge of the Ontario Court (Provincial
Division) in 1990 and Associate Chief Judge in 1995. Justice Lennox has taught
and lectured in the areas of judicial education, criminal law, advocacy and court
administration.
Michele Lent
Michele Lent spent 26 years as a member of the New York Police Department
(NYPD) in progressively senior roles and retired as a Deputy Inspector in 2007.
In her last five years, she was the Commanding Officer of the Specialized
Training Section of the New York Police Academy overseeing training for
17,000 uniformed police officers and 8,000 civilians. Michele helped design the
City Incident Management System training program for New York City as
required by the National Incident Management System (NIMS) training protocol.
After leaving the NYPD, she trained thousands of officers nationally in the NIMS
as well as officers in second and third world countries in emergency management
and investigation techniques. She is a lifetime member of the Gay Officers
Action League (GOAL) and marched in the New York City Pride parade both as
a lieutenant and captain. Michele was also the Vice President of the Police
Women’s Endowment Association that focused on ensuring gender parity in all
aspects of policing. She lives in Toronto with her partner Deb.
Andrew Pinto
The Honourable Mr. Justice Andrew Pinto was a member of the Community
Advisory Group until his appointment to the Superior Court of Justice of Ontario in
February 2020. The Review is grateful for his important contribution to its work.
His biography while serving as a member of the Community Advisory Group
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included the following:
Andrew Pinto practiced law with Pinto James LLP in Toronto in the areas of civil
litigation, workplace and administrative law. He has been recognized in Best
Lawyers in Canada (Administrative and Public Law) and as a Leading
Practitioner by Canadian Legal Lexpert Directory (Employment Law, Workplace
Human Rights). Andrew is currently the Chair of the Board of Governors of the
Law Commission of Ontario, Ontario’s leading law reform agency. Andrew has
taught administrative law as an Adjunct Professor at the University of Toronto
Faculty of Law and is a past Chair of the Equity Advisory Group of the Law
Society of Ontario. In 2011-12, Andrew was appointed by the Attorney General
of Ontario to conduct a major review of the changes to Ontario’s human rights
system. His report and recommendations were released in November 2012.
Andrew received the South Asian Bar Association’s inaugural “Lawyer of the
Year” award in November 2008 and Windsor Law School’s Distinguished
Alumni Award in 2018.
Angela Robertson
Angela Robertson is the Executive Director of Parkdale Queen West Community
Health Centre. Parkdale is a community-based health service organization
serving south-west Toronto. Angela is dedicated to people and communities
facing discrimination, poverty and marginalization. Beginning in the 1990s,
Robertson worked as an editor of social issues manuscripts at Women’s
Educational Press, served as an adviser to the Minister Responsible for Women’s
Issues, was a manager at Homes First Society and the Community Social
Planning Council of Toronto, and was the Executive Director of Sistering – A
Woman’s Place for more than a decade. Sistering provides support and services
for homeless and at risk women, many of whom are racialized. She is a founding
member of Blockorama, which focuses on forging a space for racialized people
at Pride. She has also worked as the Director of Equity and Community
Engagement at Women’s College Hospital.
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APPENDIX C
PARTICIPANTS IN THE POLICY ROUNDTABLE,

AUGUST 18–19, 2020
Fareeda Adam
Fareeda Adam is a staff lawyer at the Black Legal Action Centre (BLAC). During
her time as a law student at the University of Ottawa, she served as president of the
McMaster Debating Society and was involved with the Black Law Students’
Association (BLSAC) as co-president and as mentor. Before joining BLAC, Fareeda
worked for Legal Aid Ontario in various capacities as a lawyer, dealing with
low- income Ontarians in both the family and the criminal law contexts.
Chief Carmen Best

Chief Carmen Best has served with the Seattle Police Department for 28 years and
assumed her current role as chief of police on August 13, 2018 – the first Black
woman to hold that position. Previously, Chief Best served as deputy chief and
oversaw Patrol Operations, Investigations, and Special Operations bureaus as well
as the Community Outreach Section.
Christa Big Canoe

Christa Big Canoe is an Indigenous lawyer known for her work as legal advocacy
director for Aboriginal Legal Services and as an advocate for Indigenous women
and children. She is a mother and a member of Georgina Island First Nation, an
Anishinabek community in Ontario. While at Legal Aid Ontario, Christa led the
province-wide Aboriginal Justice Strategy aimed at removing barriers to
accessing justice for First Nation, Métis, and Inuit people. She also served as lead
counsel for the National Inquiry into Missing and Murdered Indigenous Women and
Girls.
Gwen Boniface
Senator Gwen Boniface is globally recognized for bringing justice and equity to a
wide range of issues and having a profound impact on women in policing. A lawyer
and educator, she was the first woman to be appointed as commissioner of the
Ontario Provincial Police (OPP) and the first female president of the Canadian
Association of Chiefs of Police. She is a consultant on policing and justice issues,
both internationally and domestically, and has provided services to universities,
municipalities, government, and non-profit organizations in areas of human
rights,
888
policing, and justice. Senator Boniface also served as commissioner on the Law
Commission of Canada for five years.
Brenda Cossman
Brenda Cossman is a professor of law at the University of Toronto. She served as
director of the University of Toronto’s Mark S. Bonham Centre for Sexual Diversity
Studies from 2009 to 2018. Her teaching and scholarly interests include family law,
law and sexuality, and freedom of expression.
Raj Dhir
Raj Dhir is the executive director and chief legal officer at the Ontario Human
Rights Commission (OHRC), and he served there as legal counsel for 10 years.
He also served as the portfolio director of Indigenous lands and resources at the
Ontario Ministry of the Attorney General for seven months and as the director of
the Legal Services Branch at the Ontario Ministry of Indigenous Relations and
Reconciliation for over four years.
Fiona Didcock
Fiona Didcock is the missing and exploitation manager at Thames Valley
Police, where she has served for almost 13 years. She has been instrumental in
developing a multi-agency approach to dealing with missing persons. Thames Police
developed a software called ELPIS, which allows professionals from
various agencies to share information about people who are repeatedly at risk of
going missing.
R. Doug Elliott
R. Douglas Elliott is a partner in Cambridge LLP. He is known for his work on
landmark constitutional cases such as same-sex marriage and is also a leader in the
field of class actions. One of his notable successes is Hislop v Canada, the largest
class action trial judgment in Canada (valued at $50 million), brought by a group of
gay and lesbian Canadians seeking CPP survivor pensions.
Michael Erickson
Michael Erickson is a high school teacher, activist, and co-owner of Glad Day
Bookshop – an independent bookstore and restaurant specializing in LGBTQ2S+
literature and the oldest surviving such bookstore in North America. Glad Day is
also home to Naked Heart: The LGBTQ Festival of Words, the largest LGBTQ2S+
literary festival in the world, as well as numerous panels, readings, workshops,
performances, and special events.
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Jane Farrow
Jane Farrow is a writer, former CBC broadcaster, and advocate for livable cities. Her
books include the bestselling Wanted Words and Wanted Words 2, and, as co-editor,
Any Other Way: How Toronto Got Queer. She hosted the radio programs And
Sometimes Y and Workology. As part of her social activism work, she founded and
acts as principal of the Department of Words & Deeds.
Lana Frado
Lana Frado is the executive director at Sound Times Support Services in Toronto.
She has worked there for more than 26 years.
Rachel Giese
Rachel Giese is a journalist and the editorial director of Xtra Magazine, the world’s
oldest LGBTQ2S+ media organization. Her book Boys: What It Means to Become a
Man examines how toxic rules on masculinity can hinder boys’ emotional and social
development. She has also taught journalism at Ryerson University and at the
University of Toronto’s Munk School of Global Affairs.
Dr. Sulaimon Giwa

Dr. Sulaimon Giwa is an assistant professor of social work at Memorial University
of Newfoundland, where he teaches graduate and undergraduate courses in critical
thinking and reflection and in social justice and social work practice. His doctoral
research explored the experiences of gay men of colour and their resilience to
racism, including their coping strategies. He has also taught social work
programs at Ryerson University and York University, and in the Police
Foundations program at Sheridan College.
Ruth Goba
Ruth Goba served as the executive director of the Black Legal Action Centre
(BLAC). She was a commissioner with the Ontario Human Rights Commission for
11 years and, in 2015, was named interim chief commissioner. In 2016, Ruth was
cross-appointed to the board of the Human Rights Legal Support Centre, and in
2017 she was appointed as a mediator and adjudicator with the Human Rights
Tribunal of Ontario.
Rev. Dr. Brent Hawkes

Brent Hawkes began his career as pastor of the Metropolitan Community Church of
Toronto in 1977. As the senior pastor of this congregation, he has challenged the
church to examine prejudice against gays and lesbians, inclusive language, and the
ordination of women. In addition, he played a significant role in promoting the
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inclusion of sexual orientation in the Ontario Human Rights Code and the Canadian
Human Rights Act, and he co-chaired the Campaign for Equal Families. He
graduated from Trinity College, University of Toronto, with both a Master of
Divinity and a Doctorate of Ministry degree.
Christopher Hudspeth
Christopher Hudspeth has owned the Pegasus Bar on Church Street for almost 20
years. He is also the chair of the Church–Wellesley Village Business Improvement
Area and a community activist.
Dr. Kyle Kirkup

Dr. Kyle Kirkup is an assistant professor in the University of Ottawa’s Faculty of
Law (Common Law Section). His research explores the role of constitutional law,
criminal law, and family law in regulating contemporary norms of gender identity
and sexuality. In 2010–11, Dr. Kirkup served as a law clerk to the Hon. Madam
Justice Louise Charron at the Supreme Court of Canada.
Sergeant Tyson Lavallee

Sergeant Tyson Lavallee began his career with the Saskatoon Police Service in 1999
in the Patrol Division. Currently, he serves as the supervisor of the Missing Persons
Unit as well as the coordinator for the Missing Persons Task Force. Sergeant
Lavallee previously supervised the Guns and Gang Unit and the Serious Habitual
Offender Unit.
Maura Lawless
Maura Lawless has served as executive director of The 519 since December 2007.
She has more than 25 years of experience working in housing, homeless, and
community services in senior non-profit positions as well as in the public service for
the City of Toronto.
Justice Brian W. Lennox

Justice Brian W. Lennox is a per diem judge of the Ontario Court of Justice. He was
chief justice of the Ontario Court of Justice from 1999 to 2007 and, from 2007
to 2014, executive director of the National Judicial Institute. Justice Lennox has
taught and lectured in the areas of judicial education, criminal law, advocacy,
and court administration.
Michele Lent
Michele Lent spent 26 years as a member of the New York Police Department
(NYPD) in progressively senior roles before she retired as a deputy inspector
in
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2007. She helped design the City Incident Management System training program for
New York City, as required by the National Incident Management System
(NIMS) training protocol, and through it has trained thousands of officers globally.
She is a lifetime member of the Gay Officers Action League (GOAL), and she
marched in the New York City Pride parade both as a lieutenant and as a captain.
Marcus McCann
Marcus McCann is a Toronto human rights andemployment lawyer. In the aftermath
of the Toronto Police Service’s Project Marie in 2016, he defended men accused of
“lewd behaviour” in Marie Curtis Park in south Etobicoke. Since 2006, he has
contributed to Xtra Magazine, an LGBTQ2S+ publication.
Becky McFarlane
Becky McFarlane is a community organizer with 17 years of experience working in
the community sector. She joined The 519 as director of programs and community
services. In this role, she is also responsible for overseeing the centre’s education
and training initiatives. Previously, Becky served as director of Working for Change,
an organization that develops employment and leadership opportunities for
individuals with mental health and addiction issues and for others who have been
marginalized by poverty.
Yasmeen Persad
Yasmeen Persad is a member of The 519’s education and training team and has been
providing education on LGBTQ2S+-related issues and taking up trans-activism for
the past 15 years. Her experience includes working with trans youth, HIV-positive
women, sex workers, and many diverse populations. She coordinates The 519’s
trans people of colour project and provides training to front-line shelter workers on
trans community inclusion and support.
Mark Pritchard
Mark Pritchard served as chief superintendent and commander for the OPP
Northwest Region. All told, he has more than 30 years of service with the OPP,
including as a case manager in the Criminal Investigation Branch, helping to update
the OPP’s Quality Assurance Manual for homicide investigation and serving as the
commander of the Aboriginal Policing Bureau at the OPP general headquarters.
Shakir Rahim
Shakir Rahim is an associate lawyer at Kastner Lam LLP. He co-led the advocacy
campaign of the Alliance for South Asian AIDS Prevention (ASAAP) to establish
the Independent Civilian Review into Missing Person Investigations, and he
was
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appointed to the working group that drafted the Review’s terms of reference and
recommended its Independent Reviewer. He is a vice-chair of Demand Inclusion, an
organization advocating for greater equity, diversity, and inclusion in the legal
profession, and a member of the Canadian Bar Association Sexual Orientation &
Gender Identity Executive.
Professor Kent Roach

Professor Kent Roach is recognized as one of Canada's leading academics on issues
relating to the criminal justice system, including policing. He has served as a
research director or advisor to a number of public inquiries or reviews. Since 2006,
he has been the Prichard-Wilson Chair of Law and Public Policy at the University
of Toronto and, since 1999, a professor in the Faculty of Law at the University of
Toronto.
Ron Rosenes
Ron Rosenes is a highly respected community leader, health advocate, researcher,
and consultant working primarily in the HIV and the LGBTQ2S+ communities. Ron
became an active volunteer member of the HIV/AIDS community in Toronto in
1991, at which point he was involved with the boards of the AIDS Committee of
Toronto, AIDS ACTION NOW!, the Sherbourne Health Centre, and the Canadian
Treatment Action Council. Ron’s work as a consultant is focused on a framework of
social justice, equitable access, and an understanding of the social determinants of
health.
Dr. Hugh Russell

Dr. Hugh Russell, PhD, has consulted as a social psychologist with provincial
governments and major police leaders in Canada on best practices related to crime
prevention through social development and engagement. In 2017 he wrote the book
Transforming Community Policing: Mobilization, Engagement and Collaboration.
For his contributions to the Ontario Association of Chiefs of Police and Policing in
Ontario, Peterborough Police Chief Murray Rodd named Dr. Russell the first
honorary police chief in the history of that city’s police department.
Maureen Trask
Maureen Trask is an advocate for families with missing loved ones. Her son Daniel
disappeared on November 3, 2011, and after three-and-a-half years of searching, his
remains were found by the Michigan Backcountry SAR Team. To honour Daniel,
and in support of the families with missing loved ones, Maureen has advocated for
legislative changes in many areas, including the Missing Persons Act in Ontario; a
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Missing Person Day (and month) in Canada; a Silver Alert Strategy in Canada; a
standard missing person police process; and a missing person framework across
Canada.
Justice Michael Tulloch

Justice Michael Tulloch was appointed to the Court of Appeal for Ontario in
2012 after serving as a justice on the Ontario Superior Court of Justice since 2003.
Before this first judicial appointment, he served as an assistant Crown attorney in
both Peel and Toronto from 1991 to 1995. He then went into private practice,
where he specialized in criminal law. Justice Tulloch has written two
independent reviews: Report of the Independent Police Oversight Review
(2017); and Report of the Independent Street Checks Review (2018).
Haran Vijayanathan
Haran Vijayanathan is the national strategic director at Fierté Canada Pride. He
previously served as the executive director of the Alliance for South Asian
AIDS Prevention (ASAAP) for more than three years. Haran also founded
Rainbow Resources of York Region, a resource centre allowing those who
identify as LGBTQ2S+ to gather in a safe and inclusive space.
Andrea Zanin
Andrea Zanin has been writing and teaching internationally about BDSM / leather /
kink, power dynamics, non-monogamy, and queer sexuality for more than 15 years
She has organized events in the Canadian queer leather / BDSM community
since the early 2000s, including the annual leatherdyke weekend, An Unholy
Harvest (2007–17), and Queering Power (2013–17). She holds an independent
minor in sexuality studies and a master’s degree in gender, feminist, and women’s
studies with a focus on BDSM. At present she is also studying for her doctorate in
these same areas.
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APPENDIX D
ORGANIZATIONS AND COMMUNITY GROUPS THAT
COMMUNICATED WITH THE REVIEW
Access Alliance
Africans in Partnership Against AIDS (APAA)
AIDS Committee of Toronto (ACT)
Alliance of Healthier Communities
Alliance for South Asian Aids Prevention (ASAAP)
Barbra Schlifer Commemorative Clinic
Black Coalition for AIDS Prevention (Black CAP)
Black Lives Matter
Canada’s Source for HIV and Hepatitis C Information (CATIE)
Canadian Association for Equality (CAFE)
Canadian Association of Refugee Lawyers
Canadian HIV/AIDS Legal Network
Casey House
Church–Wellesley Village Business Improvement Area (BIA)
Council of Agencies Serving South Asians (CASSA)
Covenant House
Criminal Lawyers Association
Dixon Hall
Durham Community Legal Clinic
EGALE
Ernestine’s Women’s Shelter
Federation of Asian Canadian Lawyers
Hassle-Free Clinic
HIV and AIDS Legal Clinic of Ontario (HALCO)
Homes First
Indus Community Services of Peel
Interval House
Maggie's Toronto Sex Workers Action Project
Metropolitan Community Church
Missing Adults Ontario
Office of the Federal Ombudsman for Victims of Crime
Ontario Bar Association
Ontario Council of Agencies Serving Immigrants (OCASI)
Parkdale Activity Recreation Centre (PARC)
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People with AIDS Foundation
Queers Crash the Beat
Rainbow Committee
Salvation Army
Sherbourne Health
Sistering
Sound Times
South Asian Legal Clinic of Ontario (SALCO)
South Asian Women’s Centre (SAWC)
TAIBU Community Health Centre
The 519
Toronto Community Addiction Team, St. Stephen’s Community House
Toronto Council Fire Native Cultural Centre
Toronto HIV/AIDS Network
Toronto Lawyers Association
Toronto Police Association
Women’s Habitat of Etobicoke
YMCA Sprott House
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APPENDIX E
89
7 Community Engagement Survey
October 2020
Presentation Report
Methodology
Sample Responses Online Study

t-in survey
89
available to the public via Review Website 985 Completed Completed online
8 ~10 minutes to complete
Nov. 11, 2019 to May 1, 2020. 15 for those who supplied detailed responses
2
Demographics
As an opt-in survey, data was not weighted to reflect demographics of the city. E.g. The sample skews female & middle-aged, but still with large subsamples of
those aged <35 and 60+. Almost all live in the GTA, 9 out of 10 in the city of Toronto, half within the old city of Toronto (closer to downtown). Only 20% are
immigrant Canadians, yet we have 197 respondents who are. More than 200 respondents in total identified as racialized/visible minority.
Asexual, Bisexual,
Total Transgender, Non- Gay Lesbian Heterosexual
Male Female binary, Other Queer, 2S
n= 985 317 571 77 147 51 239 504
% of total = 100% 32% 58% 8% 15% 5% 24% 51%
89 <35 35-49 50-59 60+ Experience w. TPS investigation in last 9 years Experience w. TPS 10+ years ago
9
n= 220 264 327 147 614 104
% of total = 22% 27% 33% 18% 62% 11%
None of the
City of York East York North York Etobicoke Scarborough Toronto
above
n= 36 88 64 70 110 501 100
% of total = 4% 9% 6% 7% 11% 51% 10%
Identify as visible or Do not identify as vis. min or

New Cdn 1st. Gen 2nd Gen. Cdn. racialized minority racialized minority
n= 197 729 217 660
% of total = 20% 74% 22% 67%
3
Key Findings
Nearly half of all respondents have little to no confidence in the TPS when it comes to:
• Conducting missing persons investigations effectively - 42%
• Bias-free policing - 45%
Those who have dealt with TPS in the last decade have less confidence in the service overall than others.
90 • 37% with low to no confidence among those who dealt with the police in an investigation in the last decade
0
• Compared with 32% among those who have never dealt with the police
• And 21% among those who dealt with police over a decade ago
Those who have reported a missing adult to police also have less confidence.
• 36% with little or no confidence in the TPS overall
• 47% said the TPS performed poorly when it comes to acting in a non-biased manner in the course of the
investigation
4
Assessments of TPS Performance
The TPS received relatively lower scores on bias-free policing and missing persons than on overall public safety.
Help ensure the safety of the neighbourhood in which you live Help ensure safety of the community(s) you identify with
34% 30% 30% 6%
Conduct investigations effectively Maintain good relationships w. different communities it serves
Ensuring safety 30% 26% 36% 7%
29% 30% 35% 7%
26% 23% 45% 6%
Timely, non-
90 Conduct investigations in a non-biased manner 24% 25% 45% 6%
biased,
1 good
relations Conduct investigations in a timely fashion 22% 27% 40% 11%
Respond to reports of missing persons effectively 21% 23% 42% 14%
Missing persons
Respond to reports of missing persons in a timely fashion 20% 22% 41% 17%
Respond to reports of missing persons in a non-biased manner 19% 18% 46% 16%
Communicate adequately w. victims during/after investigation 17% 21% 37% 25%
Communication Communicate adequately with families/friends of victims 17% 18% 39% 26%
Communicate adequately w. families/friends of those missing 14% 18% 38% 30%
A great deal of confidence (7-9) Some confidence (4-6) No confidence at all (1-3) Don't know
Q3: Now we'd like to understand your confidence in the Toronto Police Service when it comes to the following.
All participants n= 985 5

Assessing the Interactions w. the TPS
(For those that interacted with the TPS in last 10 years)
Those who had recent interactions with the TPS relating to an investigation assigned similar levels of confidence. I.e. nearly 4 in 10 with
low to no confidence when it comes to conducting its work in a non-biased fashion.
Respond to a call or report in a timely fashion
33% 22% 36% 4%4%
Communicate adequately and appropriately
32% 23% %4%
40% 1
with you
Conduct its work and/or investigation(s)

90 28% 21% 40% 7% 4%
2
effectively
Conduct its work in a non-biased manner Conduct its 28% 20% 39% 9% 4%
investigation(s) in a timely
25% 21% 37% 12% 5%
fashion
Communicate adequately and appropriately with

19% 17% 39% 17% 9%
the victims of crime
Excellent (7-9) Somewhat good (4-6) Poor (1-3) Don't know Prefer not to say + Not applicable
Q9: Thinking specifically of your interactions with the Toronto Police Service about an investigation or safety related concerns, how would you assess its
performance on a 9-point scale with respect to the following? (Scale 1= poor 9=excellent, offer don’t know AND not applicable - and prefer not to say)
Those that have interacted with the TPS less than 10 years ago n= 614 6
TPS’s Interactions w. Communities
Less than half have confidence in the ability of the TPS to work with LGBTQ2s+, visible minority & immigrant communities. Most have
little to no confidence in its ability to work with underhoused, Indigenous peoples & those with mental health issues.
The neighbourhood in which you live 34% 26% 31% 9%
The community or multiple communities 28% 22% 41% 9%
Immigrant & refugee communities 18% 21% 44% 17%
90
3 Visible minority communities 18% 22% 49% 12%
LGBTQ2s+ communities 17% 20% 48% 16%
People experiencing mental health issues 15% 21% 56% 8%
Homeless and underhoused communities 14% 18% 56% 12%
Indigenous peoples 11% 14% 57% 18%
Q4: How much confidence do you have that the Toronto Police Service currently acts in a professional and non-biased fashion with members of the following
communities...?

Confidence in the TPS
There are substantial differences by gender, age, sexual orientation, gender identity or expression, when it comes to confidence in the
TPS. Confidence is clearly lower among LGBTQ2S+ communities and particularly younger respondents who chose to do the survey.
Total 38% 29% 32%
Male 34% 31% 33%

Female 44% 29% 26%
Transgender, Non-binary, Other 13% 16% 71%
90 <35 14% 32% 52%

4
35-49 28% 31% 41%
50-64 51% 26% 20%
65+ 59% 26% 15%
Heterosexual or Straight 50% 29% 19%

LGBTQ2S+ 23% 30% 47%
Gay 24% 36% 40%

Lesbian 27% 33% 37%
Asexual, Bisexual, Queer, Two-Spirited 19% 26% 55%
Q2A: How much confidence do you have in each of the following organizations overall? - The Toronto Police Service

Reported Missing Adults
One in five have reported someone missing (i.e. an adult) or information about a “missing persons” case to police. Mental-
health/addictions related cases make up the lion’s share of those cases. Three in-ten said they relate to a member of the LGBTQ2S+
communities.
Incidence of reporting Descriptions of the reported missing person(s)

missing persons
Someone w mental health/addictions 49%
Yes,
Yes, once
once 11%
11% A family member 38%
A member of the LGBTQ2s+ communities 28%
90 Yes,
Yes, more
more than
than 9% A friend or neighbour
5
once 9% 28%
A visible minority 26%
Never 68% A member of homeless/underhoused communities 23%

A senior citizen 15%
Someone with dementia or Alzheimer's 15%
Don't know 7%
A member of immigrant/refugee communities 14%
Indigenous person* 14%
Prefer not to say 5% Other 11%
Q10: Have you or has someone in your household, Prefer not to say 3%
close family or an organization you belong to ever
reported an adult missing to the Toronto Police Q11: Please let us know if one or more of the following descriptions apply to the missing person or people you or a member of
Service or provided the Service with information your household, family or organization reported or provided information about to the Toronto Police Service. Select all that
apply.
about a missing person investigation?
All participants n= 985 Those that have interacted with the TPS about missing adult n= 199 *Aboriginal, Inuit, Métis, First Nations, Status Indian 9
Reporting Missing Adults
Those who have dealt with the TPS about a missing persons case tend to be negative on balance, especially when it comes to the TPS’s
ability to work in a non-biased fashion: 37% to 47%.
Respond to a call(s) or report(s) in a timely 32% 22% 37% 8% 2%

fashion
Conduct its work and/or investigation(s) 29% 21% 38% 10% 3%

effectively
90
6 Conduct its work and/or investigation(s) in 28% 22% 39% 7% 4%
a timely fashion
Communicate adequately and appropriately 27% 22% 41% 8% 3%

with you
Conduct its work and/or investigation(s) in 27% 16% 47% 9% 2 %

a non-biased manner
Excellent (7-9) Somewhat good (4-6) Poor (1-3) Don't know Prefer not to say & Not applicable
Q12: Thinking of the interactions you, a member of your household, family or organization had with the Toronto Police Service about a missing adult(s), how would
you assess its performance on a 9-point scale when it comes to the following? (Scale 1= poor 9=excellent)
Those that have interacted with the TPS about missing adult n= 199 10
Reasons for Not Approaching the TPS
12% of respondents have chosen NOT to approach police about a specific missing persons case.
• This group tends to be younger and more likely to be transgender, non-binary
Most common reasons for not approaching the TPS about a missing adult were:
• A belief that the police would not take matters seriously
• A lack of comfort with the police
90
7 • Concern about how personal information would be used
Those identifying as LGBTQ2S+ were concerned about how information re identity or health would be
used.
For those identifying as transgender/non-binary a range of concerns were important:
• How information relating to gender, identity or gender expression would be used
• Privacy of health/mental health information
• Concern about treatment of visible minorities
11
Overcoming Barriers to Reporting to
the TPS
Primary suggestions to overcome barriers to reporting on missing persons relate to: (All Participants)
• The need to build trust (16%) and rapport with communities (14%) or organizations (5%)
• Better training (19%) and hiring (8%) to address biases
• Better investigation procedures (14%) or systems to communicate with the public (5%)
Secondary comments relate to:
• Better funding for more investigations (8%)
• More accountability/consequences (7%) and oversight (2%)
Better training, prevention, work on overcoming bias
19%
Build & earn trust or confidence/be professional
90 16%
8 Establish a better/unbiased rapport, treat everyone equally
14%
Improve the processes of policing policies, reporting policies, and “third party” reporting
14%
Better funding and support for the police
8%
Better hiring, better representation of different groups
8%
Accountability, recognizing biases, transparency
7%
Reports/people/communities taken seriously, listened to
5%
Establish better communication with trusted community-based organizations
5%
Communicate progress, educate and inform the public
5%
General neutral or positive comments about the TPS
4%
Independent body to oversee police
2%
Q15: Thinking about barriers that may prevent people from reporting community members who are missing or providing information about an investigation to the
Toronto Police Service, how do you think those barriers can be overcome so more people feel safe or comfortable approaching police with such information?
ALL RESPONDENTS VALID ANSWERS n= 787 – not shown n=199 giving no response skipping this question 12
Steps to Repair TPS’s Relationship
with LGBTQ2S+
LGBTQ2S+ respondents also identified building trust, better training & overcoming bias as important steps in improving relations
between their communities and the TPS.
Build & earn trust or confidence/be professional
28%
Better training, prevention, work on overcoming bias
20%
Establish a better/unbiased rapport, treat everyone equally
10%
Accountability, recognizing biases, transparency
14%
'Serve LGBTQ2S+ community better
14%
Establish better communication with trusted community-based organizations
9%
90 Respect the Pride parade
9 14%
Better hiring, better representation of different groups
10%
Apologize, acknowledgment, admit mistakes, repair relationships
10%
Improve the processes of policing policies, reporting policies, and “third party” reporting
7%
Reports/people/communities taken seriously, listened to
7%
Communicate progress, educate and inform the public
Better funding and support for the police 3%
2% 1% or
less
Independent body to oversee police 4% Neutral or positive

comments about the
Bruce McArthur case - negative mention 3% TPS
Dedicated resources to missing persons 2%
Other 8%
Serve black/immigrant/vis min community better 3%
Don’t know 7%
Q18: What steps, if any, do you think should be taken to repair, build or enhance the Toronto Police Service’s relationship with the LGBTQ2S?
LGBTQ2S+ n= 389 responding 13

Conclusions
This survey is not necessarily representative of the Toronto population or LGBTQ2S+ communities.
Specific groups in this survey appear to have pronounced concern about relations w. the TPS:
• Younger respondents (under 35)
• LGBTQ2S+ respondents
91
0
Yet concern about bias-free policing goes beyond younger or LGBTQS+ respondents.
Broad concern about the TPS’s ability to serve visible minority, mental health, at-risk groups.
Top of mind solutions respondents from various perspectives emphasized were:

1. Revisiting training & hiring to overcome biases
2. Establishing better relations with communities & taking issues/concerns seriously to build trust
3. Better investigative procedures & systems (including dedicated resources)
14

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AND SSED

Report of The Independent Civilian

The Honourable Gloria J. Epstein

The Honourable Gloria J. Epstein

Volume I – Executive Summary and Recommendations

Statement for cover design:

Copyright © Toronto Police Services Board 2021

Templates or Checklists for Missing Person Investigations 795

There is nothing we can do to change the past but we can still

Organizationally, we continue to work on our relationship with the

 in giving these cases the priority they deserve;

The Review has been successful in engaging on a broad basis with

Civilian Oversight (Chapter 3)

The importance of effective civilian oversight of the police cannot be

(a) a policing operation, event, or organizationally significant issue

A concrete example of an operational matter that raised questions of public

 requires unexpected financial or other resources

5 The Toronto chief of police should establish corresponding

As explained in Chapter 14, the latter point is part of a larger, important

8 The Toronto chief of police should establish procedures specifying

10 The Toronto Police Services Board should be allocated sufficient

The above recommendations do not merely impact missing person

Toronto Police Services Board Policies

Major Case Management and Technology (Chapter 4)

In Chapter 4, I outline provincial adequacy standards pertaining to major case

I recommend independent monitoring of the Service’s compliance with

15 The Toronto Police Service, in consultation with the Ministry of the

(a) addressing the inefficiencies, associated with the number of

16 The Toronto Police Service, in consultation with its own Missing

Changes to the Ontario Major Case Management Manual

 to elaborate on the definition of “linked cases,” in the light of

Records Management Systems

21 The Toronto Police Service should ensure, through its procedures,

The Serial P re dator Criminal Investigations Coordinator

Missing Person Investigations (Chapters 5–9, 12)

The Components of a Missing Person Strategic Plan

(a) recognize the heightened priority that needs to be given to

Priority of Missing Person Investigations

 the number of such cases;

The Mid-Term Missing Person Model

Changes to the Missing Persons Unit and Divisional Staffing

 receive specialized training and education in missing person

In one United Kingdom jurisdiction, all risk assessments are reviewed by a

40 The Toronto Police Service should double the complement of sworn

I elaborate on the support to be provided to those directly affected by missing

Support for Those Directly Affected by Someone Missing

The ombudsperson also pointed out that in missing person cases,

(a) Information about an ongoing investigation is regularly

44 The Toronto Police Service should develop, in partnership with diverse

In relation to Recommendation 43(g), I agree with the federal ombudsperson

The Role of Not-for-Profit Organizations or Charities

 providing 24-hour confidential support to those who have gone

 level 1 search (more investigation required)

I acknowledge that the current approach to risk assessment

50 The Toronto Police Service should build capacity to have risk

(a) the types of risks, if any, associated with a person’s reported

(a) In accordance with the National Centre of Missing Persons and

58 The Toronto Police Service should amend its Missing Persons

59 In the light of the concerns and deficiencies identified in this Report,

I return to the topic of research later in this chapter.