An Independent Review Conducted by The Honourable Frank Iacobucci for Chief of Police William Blair, Toronto Police Service
- On August 28, 2013, Chief of Police William Blair of the Toronto Police Service (TPS) requested that I undertake an independent review of the use of lethal force by the TPS, with a particular focus on encounters between police and what I refer to in this Report as “people in crisis.”
- By a person in crisis I mean a member of the public whose behaviour brings them into contact with police either because of an apparent need for urgent care within the mental health system, or because they are otherwise experiencing a mental or emotional crisis involving behaviour that is sufficiently erratic, threatening or dangerous that the police are called in order to protect the person or those around them. The term “person in crisis” includes those who are mentally ill as well as people who would be described by police as “emotionally disturbed.”
- My mandate as given to me by Chief Blair was to conduct an independent review of “the policies, practices and procedures of, and the services provided by, the TPS with respect to the use of lethal force or potentially lethal force, in particular in connection with encounters with persons who are or may be emotionally disturbed, mentally disturbed or cognitively impaired.”
- I was instructed by Chief Blair that the hallmark of my Review was intended to be its independence, and that the end result of the Review was to be a report, to be made public, setting out recommendations that will be used as a blueprint for the TPS in dealing with this serious and difficult issue in the future. I elaborate on the issue of independence in Chapter 2.
- My mandate included reviewing the following topics:
- TPS policies, procedures and practices;
- TPS training, and training at the Ontario Police College;
- equipment used by the TPS;
- psychological assessments and other evaluation of TPS police officers and officer candidates;
- supervision and oversight;
- the role of the Mobile Crisis Intervention Teams (MCIT) currently employed by the TPS;
- the role of the TPS Emergency Task Force (ETF);
- best practices and precedents from major police forces internationally (in Canada, the United States, the United Kingdom, Australia and other jurisdictions)
- available studies, data and research; and
- other related matters falling within the scope of the independent review.
- As part of the independent Review, I was authorized to engage in, and did conduct, the following activities:
- receive submissions and meet with stakeholder groups or individuals;
- examine TPS use of force equipment;
- attend to observe TPS training;
- interview TPS personnel;
- consult with experts in the field of mental, emotional and cognitive disorders;
- consult with experts in the use of force, the selection and training of police, crisis intervention and all other matters that are the subject of the review;
- assemble and retain an advisory panel of experts;
- conduct research;
- make recommendations based on the work performed and the information obtained; and
- perform such other work as may be reasonably incidental to the independent Review.
C. Preliminary observations
- Three preliminary comments should be kept in mind.
- First and above all, I must emphasize the serious and tragic circumstances that are at the heart of the issues canvassed in this Review and discussed in this Report. This Report deals with the loss of life in situations that cry out for attention and raise the fundamental question: How can lethal outcomes be avoided? The impact of the loss of life is enormous, not only on family members and loved ones of the person in crisis who has died, but also on the police officer who applied lethal force, on other colleagues directly involved, and on bystanders who observed the events. All of these matters are explored in this Report.
- I met with and heard accounts of family members of people in crisis who were killed. Many of their lives have been changed forever by the profound sadness and frustration of thinking about what could or should have been done to have avoided such a disastrous result. Similarly, I met with police officers who witnessed or were otherwise were involved in the shooting of a person, whose lives, and the lives of their family members, have been emotionally scarred as a result, and who seek to deal with the traumatic effects of their involvement.
- Second, TPS encounters with people in crisis are regrettably part of an international phenomenon that presents a fundamental challenge to modern society. Police services across Canada, the United States, United Kingdom, Australia, and New Zealand—just to mention jurisdictions that we have looked at—face similar challenges in seeking to improve approaches to deal with the difficult situations that arise. It seems that no part of the world is free of these potentially tragic human outcomes.
- In Toronto, in particular, the TPS is dispatched to approximately 20,000 calls for service annually involving a person in crisis. This is between 2.0% and 2.5% of all occasions on which police are dispatched. Approximately 8,000 of these events involve apprehensions under the Mental Health Act. Some of these encounters, sadly, result in the application of lethal force by police. Between 2002 and 2012, the TPS has advised that five people considered to be “emotionally disturbed persons” were fatally shot by police.
- Third, it is important at the outset to note what this Review and Report are not about and what they are about.
- The Review and Report are not about laying blame on anyone. In fact, my mandate expressly forbids me from dealing with specific incidents, whether or not they are before the courts in a criminal or civil law context or otherwise. Indeed, I wish to emphasize that anything I express in this Report is not intended to refer to any specific event.
- The basic purpose of the Review is to consider how, going forward, we as a society can prevent lethal outcomes. Here I would mention that the TPS has done much in this area that is positive, and is a leader in this subject in a number of respects. But I believe improvements can always be made—particularly as knowledge, experience, and examination of the issues increase over time.
D. Chapter topics
- Generally the chapters in this Report correspond to the headings of the mandate assigned to me.
- Chapter 1 is an introduction and brief overview of the Review and this Report.
- The mandate of the Review, as well as its independence, scope and methodology, are described in Chapter 2.
- Chapter 3 provides a commentary on the important context surrounding the issues that arise in the mandate of my Review.
- Chapter 4 deals with the mental health system and Toronto Police Service, and underscores the reliance placed on the TPS as a part of that system to deal with the people in crisis and the numerous issues that arise.
- Chapter 5 deals with a topic about which I heard a great deal from both TPS officers and stakeholders, namely, the centrality of police culture with its positive and negative features.
- Chapter 6 deals with issues arising from selection of new recruits by the TPS, and from appointments to specialized roles within the TPS, and the relationship of these issues to encounters by the TPS with people in crisis.
- Chapter 7 deals with the important subject of training, both for recruits and in-service officers, and the role training plays in police encounters with people in crisis.
- Chapter 8 focuses on supervision, which is critical to ensuring that training is translated into practice.
- Chapter 9 deals with the role played in police encounters with people in crisis by the mental health of police officers themselves.
- Police use of force is of critical and controversial importance in the handling of police encounters and is discussed in Chapter 10.
- Chapter 11 identifies and discusses the MCIT and various other crisis intervention models that police forces have employed to better handle police encounters with people in crisis.
- Chapter 12 examines the different types of equipment used by the TPS in encounters and the debate over them as well as the procedures to regulate the use of the equipment.
- Finally, the important subject of the implementation of the 84 major recommendations of the Report is found in Chapter 13.
E. My approach to the Review
- I assembled a team at Torys LLP to assist me with the Review. The team and I had over 100 interviews or discussions with individuals having different experiences and viewpoints (names of most of the individuals spoken to are in Appendix A), received or obtained well over 1,200 documents consisting of data, policies, procedures, academic literature and commentary, reports and so on (a selected bibliography is found in Appendix B), and received many submissions (listed in Appendix C), all as described in the Report. We also examined Ontario coroners’ inquest recommendations and interviewed U.S. and U.K. experts to seek best practices.
- I invited three distinguished individuals to be my Advisory Group: Dr. John Bradford, an eminent forensic psychiatrist, Paul Copeland, a leading criminal lawyer, and Norman Inkster, a widely respected former Commissioner of the Royal Canadian Mounted Police.
F. Approach of the Report
- With this background and effort in mind, this Report takes a holistic approach to the mandate given to me. It is clear that police are part of the mental health system—they are the front line mental health workers for many of the most dangerous encounters. Preventing deaths includes preventing the crises in the first place, as well as helping police to deal with crises better. One of the key themes of this Report is the need for inter-disciplinary cooperation, learning and teaching, involving not only police and mental health professionals, but also mental health consumer-survivors. It is their lives and deaths that are at issue and they should not be treated as the problem being discussed. They are our fellow citizens and should work with us to find solutions. I return to this topic below and in many sections of the Report.
- In preparing this Report, I have tried to be as comprehensive and helpful to the TPS as possible. That does not imply in any way that defects are widespread. Rather, it simply underscores that I have found that, because of the seriousness and complexity of the issues, there is much to be considered.
- The police have an extraordinarily important role in our society. To serve and protect, they have unique powers and authority and heavy responsibilities and duties. They can, under strict circumstances, use their firearms to take a life and to protect a life. They take their roles seriously and society could not properly function without them. In addition, modern policing has evolved in many ways and the TPS has shown its adaptability over time to make changes that are required.
- The culture of the TPS has also adapted over time, and it continues to evolve as society itself evolves. By culture, I mean the prevailing attitudes, beliefs, and values of the Service. Ultimately, in one sense the issues addressed in this Report all have to do with police culture, because my recommendations aim to affect behaviour, and meaningful change to behaviour involves assisting in the evolution of the attitudes, beliefs and values that guide behaviour. I address the issue of police culture in more detail in Chapter 5 and more generally throughout the Report.
- Encounters of the TPS with people in crisis number approximately 20,000 annually. The vast majority of these encounters end peaceably and without incident. But, most unfortunately, there are some lethal outcomes.
- The premise of the Report is that the target should be zero deaths when police interact with a member of the public—no death of the subject, the police officer involved, or any member of the public. I believe the death of a fellow human being in these encounters is a failure for which blame in many situations cannot be assigned; it is more likely a failure of a system. Policies and procedures should be designed and exercised with that zero target in mind but, of course, not at the cost of ignoring the safety of the subject, the police, or the public.
- In that connection, the Report recognizes the extreme difficulty of the situations involving police interaction with people in crisis. Police officers have to act under great pressure in life-and-death situations where tragedy can occur in seconds. Fear is felt by all concerned and often we cannot and should not judge conduct after the fact. At the same time, it is not easy to fairly understand the thoughts and condition of the person in crisis. I explore in Chapter 3 the different perspectives from which one can view such encounters.
- We therefore cannot resort to absolutes because the context of encounters varies and in each case calls for the application of judgment. Accordingly, a balanced approach must be taken to recommending improvements to existing policies, procedures and practices that will enhance the avoidance of lethal outcomes yet maintain the protection of human life and safety. I have sought to reflect this balance in the Report.
- There is a huge issue that warrants further elaboration: the mental health system. One cannot properly deal with the subject of police encounters with people in crisis and not consider the availability of access to mental health and other services that can play a role in the tragic outcomes for people in crisis in encounters with the police. Police officers, because of their 24/7 availability and experience in dealing with human conflict and disturbances, are inexorably drawn into mental and emotional fields involving individuals with personal crisis.
- As I emphasize in the Report, there will not be great improvements in police encounters with people in crisis without the participation of agencies and institutions of municipal, provincial and federal governments because, simply put, they are part of the problem and need to be involved in the solution.
- In many ways, I have found this reality the most distressing societal aspect of my work on the Review. The effective functioning of the mental health system is essential as a means of preventing people from finding themselves in crisis in the first place. There is not much I can do through my recommendations to remedy the applicable problems in the mental health system, since I can recommend changes only to the TPS. But the basic and glaring fact is that the TPS alone cannot provide a complete answer to lethal outcomes involving people in crisis.
- As for the recommendations that my mandate permits, several themes emerge. First, the recommendations are comprehensive to cover the topics in my mandate such as recruitment of police officers, their training, supervision and oversight, their wellness, their discipline and positive reinforcements, and the numerous procedures that impact encounters with people in crisis, notably those on the use of force and police equipment available to police officers. Second, the recommendations seek to achieve a balance between using the minimal force required in the circumstances while acknowledging the police officer is exercising judgment in a situation of great pressure and stress. Third, the importance of de-escalation in police encounters cannot be overemphasized nor can the importance of protecting the lives and safety of everyone. Fourth, the recommendations are many and raise resource issues that may prove to be difficult, but one cannot ignore that what is at stake is human life as well as the treatment of a vulnerable group in our society. Fifth, some recommendations involve further study—for example, regarding possible harmful effects of using conducted energy weapons or the introduction of a pilot project. Sixth, although recommendations are directed at the TPS, other parties or institutions implicitly are urged to be more involved—for example, the Ministry of Health and Long Term Care. Seventh, increased evaluation and monitoring are encouraged to continue the search for improvements. Finally, I have attempted to make recommendations that are practical.
- As for implementation of recommendations, I strongly recommend the setting up of an Advisory Committee on Implementation that would include representatives of stakeholder groups. The Advisory Committee would provide advice to the Chief of Police for his consideration. The TPS has already been most receptive to stakeholder input so this should not prove controversial. Obviously, senior TPS personnel should also participate in the Advisory Committee. The Committee would in turn make recommendations, including staging of implementation steps to meet resource requirements as is appropriate or necessary, all for the consideration of the Chief. To ensure accountability, after deliberation by the Committee, ultimately the Chief can explain publicly the status of implementation and the reasons for the implementation decisions taken.
- To conclude this executive summary, I would be remiss if I did not commend the Chief of Police, the TPS and many other stakeholders, including those with lived experience of mental illness, for the efforts they have made to achieve progress in this area. Collectively, they have not assumed that the status quo is as good as it is going to get, and is therefore good enough.
- It should be noted that Chief Blair and the TPS did not have to call for an independent review. The effect of calling such a review is to take some degree of control away from the TPS over change within the organization. Not only did the TPS do that, but it also agreed in advance that the report and recommendations emanating from the Review were to be made public, without knowing what those results or recommendations would be.
- For those killed and for their families, nothing can take away their loss. For people in crisis who have had negative experiences with police, self-evaluation by the police and the larger mental health field is meaningful if there is a real change.
- Recognizing the TPS for taking this initiative is important, but the real work remains to be done, and the true test of the TPS and those organizations with which the TPS interacts will be what changes they make and the approach they take to the task. What they do in this area is fundamentally important to reinforcing public trust and confidence in the Toronto Police Service.
- The 84 Recommendations that I make in the Report are listed here in the order of the chapters in which they appear. I recommend that:
Chapter 4: THE MENTAL HEALTH SYSTEM AND THE TORONTO POLICE SERVICE
RECOMMENDATION 1: The TPS create a comprehensive police and mental health oversight body in the form of a standing inter-disciplinary committee that includes membership from the TPS, the 16 designated psychiatric facilities, the three Local Health Integration Networks covering Toronto, Emergency Medical Services, and community mental health organizations to address relevant coordination issues, including:
- Sharing Healthcare Information: developing a protocol to allow the TPS access to an individual’s mental health information in circumstances that would provide for a more effective response to a person in crisis. This protocol must respect privacy laws and physician-patient confidentiality, and should address:
- whether, in consultation with the Government of Ontario, the concept of the “circle of care” for information sharing can be expanded to include the police, in circumstances beneficial to an individual’s healthcare interests;
- how healthcare, treatment and planning information with respect to people with repeated crisis interactions with the police can be shared with the TPS while respecting all relevant privacy and physician-patient confidentiality concerns; and
- more specifically, how healthcare information shared with the TPS can be segregated from existing police databases and therefore prevented from subsequently being passed on to other law enforcement, security and border services agencies. Healthcare information should continue to be treated as such, and not as police information;
- Voluntary Registry: the creation of a voluntary registry for vulnerable persons, complementing the protocol recommended in (a), which would provide permission to healthcare professionals to share healthcare information with the police, only to be accessed by emergency responders in the event of a crisis situation and subject to due consideration to privacy rights;
- Mutual Training and Education: how psychiatric facilities, community mental health organizations, and the TPS can benefit from mutual training and education;
- Informing Policymakers: informing policymakers at all levels of government, in the aim of making the mental health system more comprehensive;
- Advocacy: advocating more comprehensive and better-funded community supports for people with mental illness. This would be a multi-party initiative led by the mental health sector. It should include, among other things, planning for community treatment supports upon discharge from the hospital, and the creation of more “safe beds” in shelters for people in crisis, to be used when they do not meet the criteria for apprehension under the Mental Health Act but need assistance to stabilize their crisis;
- Reducing Emergency Department Wait Times: a standardized approach to reducing emergency department wait times for police officers bringing in a person in crisis and transferring care to the hospital. Some relevant measures to be considered include:
- developing a standard transfer of care protocol that minimizes emergency department wait times, and across Toronto’s 16 psychiatric emergency departments. This protocol may build on existing efforts underway;
- providing cross-sectoral training for officers and emergency department staff about apprehensions under the Mental Health Act and transfer of care;
- ensuring adequate communication between officers and emergency departments when en route with a person in crisis to allow the emergency department to make necessary preparations;
- arranging a separate waiting area for police-accompanied visitors to the emergency department;
- having adequate staff to manage mental health crisis situations in the emergency department;
- designating a liaison in the emergency department to work with police officers when they arrive with a person in crisis;
- developing a protocol between police services and hospitals that sets out specific procedures, expectations, and respect for patient rights;
- conducting routine monitoring and evaluation of the protocols put in place, and making any changes warranted;
- developing a protocol for how psychiatric facilities’ emergency department capacities can be effectively communicated to officers in a timely manner; and
- developing a protocol to address how people apprehended under the Mental Health Act can be equitably distributed among Toronto’s 16 psychiatric facilities to ensure the best medical treatment and shortest emergency department wait times; and
- Other Matters: any other matters of joint interest.
RECOMMENDATION 2: The TPS more proactively and comprehensively educate officers on available mental health resources, through means that include:
- Mental Health Speakers: inviting members of all types of mental health organizations to speak to officers at the divisions;
- Technological Access to Mental Healthcare Resources: considering the use of technological means, similar to Vancouver’s “Dashboard” system, to efficiently communicate to officers a comprehensive up-to-date list or map of available mental health resources of all types in their area. Such an easily accessible reference tool should aggregate information on all community supports, in addition to major psychiatric facilities; and
- Point of Contact: working with mental health organizations to identify key resource people or liaisons, so that every TPS officer has a contact in the mental health system that they feel comfortable contacting for advice and who is able to knowledgeably give that advice.
RECOMMENDATION 3: The TPS amend Procedure 06-04 “Emotionally Disturbed Persons” to provide for the mandatory notification of MCIT units for every call involving a person in crisis.
RECOMMENDATION 4: The TPS, either through the Mental Health Sub-Committee of the Toronto Police Services Board or another body created for this purpose, consider ways to bridge the divide between police officers and people living with mental health issues. This initiative, in furtherance of the formal commitments recommended in Recommendation 5, and building on the mandate for community-oriented policing placed on all police services in Ontario under section 1 of the Police Services Act, may include:
- Divisional Meetings: inviting members of the community of people who have experienced mental health issues into Divisional meetings to speak with officers;
- Community Gathering Places: officers building collaborative relationships with people who have experienced mental health issues at drop-ins, clubhouses, and other gathering places; and
- Leadership: the TPS Mental Health Coordinator and Divisional Mental Health Liaison Officers facilitating the initiatives in subsections (a) and (b), as well as other relationship-building and de-stigmatizing programs.
Chapter 5: POLICE CULTURE
Statement of TPS commitments relating to people in crisis
RECOMMENDATION 5: The TPS prepare a formal statement setting out the Service’s commitments relating to people in crisis and, more broadly, relating to people experiencing mental health issues. The statement should be made public and treated as of equal weight to the Service’s Core Values. Among the commitments listed, the Service should consider including the following items:
- A commitment to preserving the lives of people in crisis if reasonably possible, and the goal of zero deaths;
- A commitment to take all reasonable steps to attempt to de-escalate potentially violent encounters between police and people in crisis;
- A commitment by the Service to continuous self-improvement and innovation relating to issues of policing and mental health;
- A commitment to eliminating stereotypes and providing education regarding people with mental health issues;
- A commitment to involving people with mental health issues directly, where appropriate, in initiatives that affect them, such as police training, and the development of relevant police procedures;
- A commitment to working collaboratively with participants in the mental health system (individuals, community organizations, mental health organizations and hospitals);
- A commitment to institutional leadership in the area of policing and mental health, and to becoming a pre-eminent police service in this field; and
- A commitment to fostering a positive mental health culture within the TPS.
Chapter 6: SELECTION OF POLICE OFFICERS
The hiring of new constables
RECOMMENDATION 6: The TPS change mandatory application qualifications for new constables to require the completion of a Mental Health First Aid course, in order to ensure familiarity and some skill with this core aspect of police work.
RECOMMENDATION 7: The TPS give preference or significant weight to applicants who have:
- Community Service: engaged in significant community service, to demonstrate community-mindedness and the adoption of a community service mentality. Community service with exposure to people in crisis should be valued;
- Mental Health Involvement: past involvement related to the mental health community, be it direct personal experience with a family member, work in a hospital, community service, or other contributions; and
- Higher Education: completed a post-secondary university degree or substantially equivalent education.
RECOMMENDATION 8: The TPS amend its application materials and relevant portions of its website to ensure that applicants for new constable positions are directed to demonstrate in their application materials any qualifications relevant to Recommendation 7.
RECOMMENDATION 9: The TPS consider whether to recruit actively from certain specific educational programs that teach skills which enable a compassionate response to people in crisis, such as nursing, social work, and programs relating to mental illness.
RECOMMENDATION 10: The TPS direct its Employment Unit to hire classes of new constables that, on the whole, demonstrate diversity of educational background, specialization, skills, and life experience, in addition to other metrics of diversity.
RECOMMENDATION 11: The TPS instruct psychologists, in carrying out their screening function for new constable selection, to assess for positive traits, in addition to assessing for the absence of mental illness or undesirable personality traits. In this aim, the TPS, in consultation with the psychologists, should identify a specific set of positive traits it wishes to have for new recruits and should instruct the psychologists to screen-in for those traits.
RECOMMENDATION 12: The TPS include the psychologists in the decision-making process for new constable selection, in a manner similar to their involvement in selecting officers for the ETF.
RECOMMENDATION 13: The TPS compile data to allow the Service to evaluate the effectiveness of the psychological screening tests that it has used in selecting recruits. Relevant data may include data that show what test results correlate with officers who have satisfactory and unsatisfactory interactions with people in crisis.
Working group regarding Psychological Services
RECOMMENDATION 14: The TPS strike a working group that includes participation from the TPS Psychological Services unit to comprehensively consider the role of Psychological Services within the TPS, including:
- More Information: whether the current process for psychological screening of new constables is effective and whether it could be improved, including whether TPS psychologists should be given more information about candidates to assist them in interpreting their test results;
- Involvement of Psychologists in other Promotion Decisions: whether Psychological Services should be authorized to conduct evaluations of, and otherwise be involved in, discussions regarding the selection processes for officer promotions within the Service, and the selection of coach officers;
- MCIT: whether the TPS psychologists should be involved in the selection and training of officers and nurses for the MCIT. More broadly, the TPS should consider how to facilitate a close and ongoing relationship between the psychologists and the MCIT in order to enable collaboration and information sharing between the Service’s two units with a primary focus on mental illness;
- Organizational Structure: whether the TPS should amend its organizational structure so that Psychological Services reports directly or on a dotted-line basis to a Deputy Chief, in order to give greater recognition to the operational role that they play; and
- Expanding Psychological Services: how Psychological Services should be expanded to accommodate the officer selection duties and TPS members’ wellness needs, as described in this Report.
Chapter 7: TRAINING
RECOMMENDATION 15: The TPS place more emphasis in its recruit training curricula on such areas as:
- Containment: considering and implementing techniques for containing crisis situations whenever possible in order to slow down the course of events and permit the involvement of specialized teams such as ETF or MCIT as appropriate;
- Communication and De-escalation: highlighting communication and de-escalation as the most important and commonly used skills of the police officer, and the need to adjust communication styles when a person does not understand or cannot comply with instructions;
- Subject Safety: recognizing the value of the life of a person in crisis and the importance of protecting the subject’s safety as well as that of the officer and other members of the public;
- Use of Force: making more clear that the Use of Force Model is a code of conduct that carries (i) a goal of not using lethal force and (ii) a philosophy of using as little non-lethal force as possible; and that the Model is not meant to be used as a justification for the use of any force;
- Firearm Avoidance: implementing dynamic scenario training in which a recruit does not draw a firearm, as a means of emphasizing the non-lethal means of stabilizing a situation and reducing the potential for over-reliance on lethal force;
- Fear: including discussions of officers’ fear responses during debriefings of practical scenarios that required de-escalation and communication techniques to defuse a crisis situation;
- Stigma: addressing and debunking stereotypes and stigmas concerning mental health. For example, the Toronto Police College (TPC) could build on its use of video presentations involving people with mental health issues by adding interviews with family members of people who have encountered police during crisis situations and police officers who were present during a crisis call that resulted or could have resulted in serious injury or death;
- Experience and Feedback: incorporating mental health and crisis situations into a larger number of practical scenarios to provide recruits with more exposure to, and feedback on, techniques for resolving such situations; and
- Culture: laying the foundation for the culture the TPS expects its officers to promote and embody, and preparing recruits to resist the aspects of the existing culture that do not further TPS goals and values with respect to interactions with people in crisis.
RECOMMENDATION 16: The TPS consider whether officers would benefit from additional tools to assist them in responding to crisis calls, such as a quick-reference checklist for dealing with people in crisis that reminds officers to consider: whether the person is demonstrating signs of fear versus intentional aggression; whether medical, background and family contact information is available; whether alternative communication techniques are available when initial attempts at de-escalation are unsuccessful; whether containment of the person and the scene is a viable option; and whether discretion should be used in determining whether to apprehend, arrest, divert or release the person in crisis.
RECOMMENDATION 17: The TPS consider whether the 20-week recruit training period should be extended to allow sufficient time to teach all topics and skills required for the critically important work of a police officer.
RECOMMENDATION 18: The TPS consider placing more emphasis, within the existing time allocated to in-service training if necessary, on the areas identified in Recommendation 15.
RECOMMENDATION 19: The TPS consider requiring officers to re-qualify annually or otherwise in the areas of crisis communication and negotiation, de-escalation, and containment measures.
RECOMMENDATION 20: The TPS consider whether to tailor in-service mental health training to the needs and experience levels of different audiences, such as by offering separate curricula for officers assigned to specialty units or divisions with high volumes of crisis calls.
RECOMMENDATION 21: The TPS consider how decentralized training can be expanded and improved to focus on such issues as:
- Platoon training: increasing opportunities for officers to engage in traditional and online mental health programming within their platoons;
- Exposure: providing officers with in-service learning exercises that involve direct contact with the mental health system and community mental health resources; and
- Peer learning: instituting a model of peer-to-peer education within divisions, such as discussions with officers who have experience with mental health issues in their families, who have worked on an MCIT, who received Crisis Intervention Team (CIT) training, or who have other related experience.
Research and curriculum design
RECOMMENDATION 22: The TPS collaborate with researchers or sponsor research in the field of police education to develop a system for collecting and analyzing standardized data regarding the effectiveness of training at the TPC, OPC and the divisional levels, and to measure the impact that improvements in training have on actual encounters with people in crisis.
RECOMMENDATION 23: The TPS consider whether a broader range of perspectives can be considered in designing and delivering mental health training, for example, by involving TPS psychologists, Police College trainers, additional consumer survivors, mental health nurses and community agencies who work with patients and police.
Chapter 8: SUPERVISION
Coach officers and supervisors
RECOMMENDATION 24: The TPS further refine its selection and evaluation process for coach officers and supervisory officers to ensure that the individuals in these roles are best equipped to advise officers on appropriate responses to people in crisis; in particular, that the TPS:
- Consider requiring additional mental health training and/or experience for candidates interested in coach officer and sergeant positions, such as CIT training or MCIT experience;
- Create an evaluation mechanism through which officers can provide anonymous feedback on their coach officers or supervisors, including feedback on their skills regarding people in crisis; and
- Ensure that performance evaluation processes for supervisors include evaluation of both their skills regarding mental health and crisis response, as well as their monitoring of their subordinates’ mental health and wellness.
RECOMMENDATION 25: The TPS create a Service-wide procedure for debriefing, including the debriefing of incidents involving people in crisis and incidents involving use of force, which includes consideration of such factors as:
- Discretion: the circumstances under which debriefing is mandatory, as opposed to when it is subject to the discretion of the appropriate supervisor;
- Participants: which members should participate in the debriefing process, particularly where there is a risk of re-traumatizing an officer suffering from critical incident stress;
- Institutional Learning: how the learning points from the debriefing can be shared with other members of the Service;
- Process: the appropriate circumstances, methods and selection of appropriate personnel for debriefing incidents that involved people in crisis, whether they were resolved successfully or resulted in unsatisfactory outcomes;
- Timing: how to create an expectation that debriefs will be conducted immediately after an incident, where appropriate, to encourage learning through debriefs without the fear of resulting sanctions;
- Self-analysis: whether the incident was resolved with the least amount of force possible, as well as whether the officer experienced fear, anxiety and other psychological and emotional effects during the encounter, and techniques for coping with those effects while trying to de-escalate a situation;
- Direct Feedback: direct feedback to officers on incidents that could have been resolved with less or no force, including whether the officer considered inappropriate circumstances or failed to consider appropriate factors and any alternative force options that could have been employed;
- Critical Incident Response: the importance of conducting debriefs in a manner that respects officers’ mental health needs following an incident of serious bodily harm or lethal force, and the role of the Critical Incident Response Team;
- Stigma: how to foster discussions regarding stereotypes or misconceptions about people in crisis that may have contributed to the officer’s decision-making during the crisis situation; and
- Valuing the Role of Debriefs: methods for creating a culture of debriefing and self-assessment within the Service, rather than a systemic perception of debriefing as a routine administrative duty.
RECOMMENDATION 26: The TPS develop a procedure that permits debriefing to occur on a real-time basis despite the existence of a Special Investigations Unit (SIU) investigation. The TPS should work with the SIU and appropriate municipal and provincial agencies to craft a procedure that does not interfere with external investigations, and that maintains the confidentiality of the debriefing process in order to promote candid analysis and continuous education.
Mental health champions
RECOMMENDATION 27: The TPS develop a network of mental health champions within the Service by appointing at least one experienced supervisory officer per division with experience in successfully resolving mental health crisis situations to:
- provide formal and informal divisional-level training, mentoring and coaching to other officers;
- lead or participate in debriefings of mental health crisis calls when appropriate;
- provide feedback to supervisors and senior management on officers who deserve recognition for exemplary conduct when serving people in crisis and those who need additional training or coaching;
- meet periodically with other mental health champions at various divisions to discuss best practices, challenges, and recommendations; and
- report to the appropriate deputy chief or command officer on the above responsibilities.
RECOMMENDATION 28: The TPS establish an appropriate early intervention process for identifying incidents of behaviour by officers that may indicate a significant weakness in responding to mental health calls. Relevant data would include: propensity to draw or deploy firearms unnecessarily; use of excessive force; lack of sensitivity to mental health issues; insufficient efforts to de-escalate incidents; and other behaviours.
RECOMMENDATION 29: The TPS review its discipline procedure with regard to the following factors:
- Consistency: whether appropriate consequences are consistently applied to penalize inappropriate behaviour by officers in connection with people in crisis;
- Appropriate Penalties: whether officers who demonstrate conduct inconsistent with the role of a police officer are appropriately disciplined, including through suspension without pay or removal from their positions when appropriate;
- Supervisory Responsibility: whether there are appropriate disciplinary consequences for supervisors who fail to fulfil their duties to identify and rectify weaknesses in training or performance by officers subject to their oversight;
- Use of Force Reports: whether the information recorded in previous Use of Force Reports could be used in determining the appropriate level of discipline in particular incidents involving excessive use of force; and
- Legislative Reform: whether the factors listed above require the TPS to work with the provincial government to modify legislative or regulatory provisions.
RECOMMENDATION 30: The TPS create incentives for officers to put mental health training into practice in situations involving people in crisis, and to reward officers who effectively de-escalate such crisis situations. In this regard, the TPS should consider inviting community organizations or other agencies to participate in determining division-level and Service-wide awards for exceptional communications and de-escalation skills.
Performance reviews and promotion
RECOMMENDATION 31: The TPS consider revising the process for performance reviews and promotions to:
- establish an explicit criterion that experience with people in crisis will be considered in making promotion decisions within the Service;
- place a greater emphasis on crisis de-escalation skills such as communication, empathy, proper use of force, patience and use of mental health resources; and
- determine the appropriate use of information contained in Use of Force Reports in assessing an officer’s performance and suitability for promotion or particular job assignments.
RECOMMENDATION 32: The TPS enforce, in the same way as other TPS procedures, those procedures that require an officer to attempt to de-escalate, such as Procedure 06-04 “Emotionally Disturbed Persons”. In particular:
- Professional Standards investigations under Section 11 of Regulation 267/10 under the Police Services Act should investigate whether applicable de-escalation requirements were complied with and, if not, a finding of contravention of Service Governance and/or misconduct should be made;
- in appropriate cases, officers who do not comply with applicable de-escalation requirements should be subject to disciplinary proceedings; and
- supervisory officers should be formally directed to (i) monitor whether officers comply with applicable de-escalation requirements, and (ii) take appropriate remedial steps, such as providing mentoring and advice, arranging additional training, making notations in the officer’s personnel file, or escalating the matter for disciplinary action.
Chapter 9: THE MENTAL HEALTH OF POLICE PERSONNEL
RECOMMENDATION 33: The TPS create a formal statement on psychological wellness for TPS members. This statement should:
- acknowledge the stresses and mental health risks that members face in the course of the performance of their duties;
- confirm the Service’s commitment to providing support for members’ psychological wellness;
- emphasize the importance of members attending to their mental health needs;
- emphasize the importance of members monitoring the mental health of their colleagues, and assisting colleagues to address mental health concerns;
- emphasize the role of supervisory officers in monitoring the mental health of those under their command, and in intervening to assist where appropriate;
- set out the psychological wellness resources available to members of the Service; and
- be accessible online and used in training at all levels of the Service.
RECOMMENDATION 34: The TPS consider whether to establish a comprehensive psychological health and safety management system for the Service.
RECOMMENDATION 35: The TPS provide a mandatory annual wellness visit with a TPS psychologist for all officers within their first two years of service.
RECOMMENDATION 36: The TPS consider providing less frequent periodic mandatory wellness visits with a TPS psychologist or other counsellor for all police officers, or, if it is not immediately possible to provide wellness visits to all officers, for any officer who works as a first responder, coach officer, or supervisory officer. The TPS should also encourage all officers to seek counselling voluntarily.
RECOMMENDATION 37: The TPS promote a greater understanding of the role and availability of the TPS psychologists, the EFAP and peer support groups as confidential resources that officers are encouraged to make use of to help them stay mentally healthy.
RECOMMENDATION 38: The TPS consider whether it would be helpful to establish an Internal Support Network for people who have experienced a shooting or other traumatic incident, or more generally to help officers with work-related psychological stresses.
RECOMMENDATION 39: The TPS consider creating a new procedure, substantially modelled after Procedure 08-05 “Substance Abuse,” to address members’ mental health, and specifically to require officers in supervisory roles to monitor for mental health concerns of TPS members under their command, in order to identify means of providing help for mental health issues before a fitness for duty issue arises.
RECOMMENDATION 40: The TPS provide officers in supervisory roles with training specific to monitoring other officers’ psychological wellness and guiding preventive intervention where it is warranted.
Chapter 10: USE OF FORCE
Improving the Use of Force Procedure to reflect best practices
RECOMMENDATION 41: The TPS revise its Use of Force Procedure to supplement the Ontario Use of Force Model and guidelines with best practices from external bodies such as the International Association of Chiefs of Police, the United Nations and other police services in order to:
- incorporate approaches to minimizing the use of lethal force wherever possible;
- increase the emphasis placed on the seriousness of the decision to use lethal force in response to a person in crisis;
- further emphasize lethal force as a last resort to be used in crisis situations only where alternative approaches are ineffective or unavailable;
- articulate the importance of preserving the lives of subjects as well as officers wherever possible;
- recognize indicators of mental health crises as symptoms rather than threats to officer safety;
- acknowledge that many mental health calls result from crisis symptoms rather than criminal behavior;
- emphasize that police responding to people in crisis are usually required to play a helping role, not an enforcement role; and
- articulate that communication with a person in crisis should be a default technique in all stages of assessing and controlling the situation and planning a response.
Updating the Use of Force Procedure
RECOMMENDATION 42: The TPS regularly update its Use of Force Procedure to reflect best practices and the results of further research into the most effective means of communicating with people in crisis. In this regard, the TPS should seek alternative approaches for officers when a person in crisis does not appear to comprehend or have the ability to comply with the Police Challenge; and consider consulting with provincial agencies, the Ontario Police College, mental health experts, consumer survivors, and others with specialized experience to ensure that the Use of Force Procedure reflects best practices.
Chapter 11: MCIT AND OTHER MODELS OF CRISIS INTERVENTION
Crisis Intervention Teams
RECOMMENDATION 43: The TPS develop a pilot Crisis Intervention Team (CIT) program, intended to complement the MCIT program, along the lines of the Memphis/Hamilton model, in the aim of being able to provide a specialized, trained response to people in crisis 24 hours per day.
RECOMMENDATION 44: The TPS fully implement the 10 core elements of the Memphis/Hamilton CIT model comprehensively discussed in this Report.
RECOMMENDATION 45: The TPS should study the effectiveness of CIT officers who participate in its pilot program by analyzing, among other things:
- whether a greater proportion of calls involving a person in crisis are addressed by a specialized response;
- whether CIT officers use various forms of force less frequently than non-CIT officers;
- whether CIT officers feel more capable and confident in interacting with people in crisis than non-CIT officers;
- whether the relevant community notes a difference in the way they are treated by CIT officers versus non-CIT officers;
- whether the proportion of persons entering the criminal justice system who suffer from mental illness declines; and
- any other metrics deemed relevant.
RECOMMENDATION 46: The TPS should amend its procedures and training to enable, where appropriate, a CIT officer to take charge of a call when a person in crisis may be involved, regardless of whether they are the first officer to arrive.
The Mobile Crisis Intervention Team
RECOMMENDATION 47: The TPS establish a six-month probation period for MCIT officers, which culminates in a review, to ensure that the best-suited people are in these roles. Those who successfully complete probation should be subject to a minimum commitment of two years as part of the MCIT.
RECOMMENDATION 48: The TPS expand the availability of MCIT to provide at least one MCIT unit per operational division. The following matters related to expanding MCIT should be addressed, in cooperation with applicable Local Health Integration Networks and partner hospitals:
- Hours: Whether MCIT service should be provided 24 hours per day;
- First Response: Whether MCIT can act as a first response in certain circumstances; and
- Alcohol and Drugs: Whether MCIT can respond to calls involving alcohol or drug abuse.
RECOMMENDATION 49: The TPS require all coach officers and supervisory officers to attend the training course designed for MCIT officers so that they gain greater awareness of mental health issues and the role of specialized crisis response.
RECOMMENDATION 50: The TPS establish a system of awards and recognition within TPS for exemplary MCIT service as part of the overall system of recognition and awards identified in Recommendation 30.
RECOMMENDATION 51: The TPS encourage supervisory officers, coach officers, and others with leadership roles to promote awareness of the role of the MCIT program within the TPS so that all front line officers know the resources at their disposal in helping a person in crisis.
RECOMMENDATION 52: The TPS, as part of training at the platoon level, include sessions in which MCIT units educate other officers on the role of the MCIT unit and best practices for interacting with people in crisis.
RECOMMENDATION 53: The TPS consider whether to amend Procedure 06-04 “Emotionally Disturbed Persons” to identify exceptions to TPS requirements such as handcuffing, the use of in-car cameras, and other measures, in recognition that the apprehension of a person in crisis under the Mental Health Act differs from other types of police apprehensions.
RECOMMENDATION 54: The TPS solicit the input of MCIT members to learn from their first-hand experience, with respect to any proposed changes to the MCIT program.
Chapter 12: EQUIPMENT
Conducted Energy Weapons
RECOMMENDATION 55: The TPS advocate an interprovincial study of the medical effects of conducted energy weapon (CEW) use on various groups of people (including vulnerable groups such as people in crisis), as suggested by the Goudge Report.
RECOMMENDATION 56: The TPS collaborate with other municipal, provincial, and federal police services to establish a central database of standardized information concerning matters related to the use of force, and CEW use specifically, such as:
- the location of contact by CEW probes on a subject’s body;
- the length of deployment and the number of CEW uses;
- any medical problems observed by the officers;
- any medical problems assessed by Emergency Medical Services (EMS) or hospital staff;
- the time period between the use of a CEW and the manifestation of medical effects;
- the subject’s prior mental and physical health condition;
- the use of CEWs per ratio of population;
- the use of CEWs per ratio of officers equipped with the devices; and
- the use of CEWs in comparison to other force options.
RECOMMENDATION 57: The TPS review, and if necessary amend, the Use of Force and CEW Report forms to ensure that officers are prompted to include all standardized information required for the database proposed in Recommendation 56.
RECOMMENDATION 58: The TPS collaborate with Local Health Integration Networks, hospitals, EMS, and other appropriate medical professionals to standardize reporting of data concerning the medical effects of CEWs.
RECOMMENDATION 59: The TPS consider conducting a pilot project to assess the potential for expanding CEW access within the Service, with parameters such as:
- Supervision: at an appropriate time to be determined by the TPS, CEWs should be issued to a selection of front line officers in a limited number of divisions for a limited period of time with the use and results to be closely monitored;
- Cameras: all front line officers who are issued CEWs should be equipped either with body-worn cameras or audio/visual attachments for the devices;
- Reporting: the pilot project require standardized reporting on issues such as:
- frequency and circumstances associated with use of a CEW, including whether it was used in place of lethal force;
- frequency and nature of misuse of CEWs by officers;
- medical effects of CEW use; and
- the physical and mental state of the subject;
- Analysis: data from the pilot project be analyzed in consideration of such factors as:
- whether CEWs are used more frequently by primary response units, as compared to baseline information on current use of CEWs by supervisors;
- whether CEWs are misused more frequently by primary response units, as compared to baseline information on current use of CEWs by supervisors;
- the disciplinary and training responses to misuses of CEWs by officers and supervisors;
- whether use of force overall increased with expanded availability of CEWs in the pilot project;
- whether use of lethal force decreased with expanded availability of CEWs in the pilot project; and
- whether TPS procedures, training or disciplinary processes need to be adjusted to emphasize the objective of reducing deaths without increasing the overall use of force or infringing on civil liberties; and
- Transparency: the TPS report the results of the pilot project to the Toronto Police Services Board (TPSB), and make the results publicly available.
RECOMMENDATION 60: The TPS ensure that all CEWs issued to members (including those CEWs already in service) are accompanied by body-worn cameras, CEW audio/visual recording devices, or other effective monitoring technology.
RECOMMENDATION 61: The TPS ensure that CEW Reports are reviewed regularly, and that inappropriate or excessive uses are investigated.
RECOMMENDATION 62: The TPS discipline, as appropriate, officers who over-rely on or misuse CEWs, especially in situations involving non-violent people in crisis.
RECOMMENDATION 63: The TPS provide additional training, as appropriate, to officers who misuse CEWs in the course of good faith efforts to contain situations without using lethal force.
RECOMMENDATION 64: The TPS require officers to indicate on CEW Reports whether, and what, de-escalation measures were attempted prior to deploying the CEW.
RECOMMENDATION 65: The TPS carefully monitor the data downloaded from CEWs on a periodic basis, investigate uses that are not reported by Service members and discipline officers who fail to report all uses appropriately.
RECOMMENDATION 66: The TPS periodically conduct a comprehensive review of data downloaded from CEWs and audio/visual attachments or body cameras, to identify trends in training and supervision needs relating to CEWs as well as the adequacy of disciplinary measures following misuse.
RECOMMENDATION 67: The TPS revise its CEW procedure to emphasize that the purpose of equipping certain officers with CEWs is to provide opportunities to reduce fatalities and serious injuries, not to increase the overall use of force by police.
RECOMMENDATION 68: The TPS review best practices on safety of CEWs in different modes, both from TPS personnel that are already using CEWs and from other jurisdictions that have implemented policies on permitted methods of discharging CEWs.
RECOMMENDATION 69: The TPS consider the appropriate threshold for permissible use of CEWs, and in particular whether use should be limited to circumstances in which the subject is causing bodily harm or poses an immediate risk of bodily harm to the officer or another person, and no lesser force option, de-escalation or other crisis intervention technique is available or is effective.
RECOMMENDATION 70: The TPS require that all officers equipped with CEWs have completed Mental Health First Aid or equivalent training in mental health issues and de-escalation techniques.
RECOMMENDATION 71: The TPS ensure that training on potential health effects of CEWs, including any heightened risks for people in crisis or individuals with mental illnesses, is updated regularly as the state of knowledge on the topic advances.
RECOMMENDATION 72: The TPS issue body-worn cameras to all officers who may encounter people in crisis to ensure greater accountability and transparency for all concerned.
RECOMMENDATION 73: The TPS develop a protocol for protecting the privacy of information recorded by body-worn cameras. The protocol should address the following matters:
- Use and Retention: The privacy protocol should address the appropriate methods of storage and length of retention of body camera recordings, limits to accessing and sharing this information, and mechanisms through which individuals recorded can request access to, and the deletion of, information stored by the TPS;
- Discretion: The TPS should establish the scope of discretion for officers to disable recording, reporting measures to be taken when a camera is deactivated, and consequences of misusing that discretion. Examples include requiring officers to notify Communications Services of the reason for disabling a body camera and the duration of the deactivation, or requiring officers to file reports detailing any circumstances in which their body cameras were deactivated;
- Discipline: The TPS should establish and enforce clear disciplinary measures for members of the Service who do not comply with the privacy protocol and the discretionary/use protocol to be developed concerning body cameras;
- Balancing Interests: The TPS should investigate appropriate options for balancing an individual’s right to privacy, an officer’s discretion, and the need for accountability in public policing; and
- Collaboration: The TPS should work closely with civil liberties groups, legal advisors, consumer survivors, provincial government agencies, privacy commissioners and other appropriate stakeholders in developing the protocol.
Alternative equipment options
RECOMMENDATION 74: The TPS conduct a review of alternative equipment options and tactical approaches, including examples from other jurisdictions, to assist in further reducing the number of deaths arising from police encounters with people in crisis.
Chapter 13: IMPLEMENTATION
Advisory committee on implementation
RECOMMENDATION 75: The Chief of Police strike an advisory committee, to advise the Chief of Police on how best to implement the recommendations contained in this Report. In this regard, I recommend:
- Stakeholder Membership: The advisory committee should include leading members of key stakeholder groups, including hospitals, community mental health organizations, the police and those with lived experience of mental illness;
- Limited Membership: The advisory committee should be of manageable size—large enough to provide adequate representation of stakeholder groups, but small enough to be efficient;
- Advisory Role: The advisory committee should play only an advisory role and should not have decision-making authority, unless the Chief of Police determines otherwise;
- Defined Role: The role of advisory committee members should be defined in clear terms at the time of the creation of the advisory committee, so that there is no misunderstanding as to their function and authority;
- In Camera Meetings: The discussions of the advisory committee should be held in camera in order to promote candour and collegiality, unless otherwise directed by the Chief of Police. Advisory committee members should agree as a condition of membership that they will not disclose the committee’s discussions;
- Communications with the Public: The advisory committee and its individual members should not advocate publicly or use the media as a vehicle for seeking to persuade the Chief of Police (or the TPS more broadly) to make specific decisions, or to criticize the TPS. The advisory committee should not be a political body but rather a true advisory body, with the effectiveness of its advice deriving from the quality of its membership;
- Staffing: The advisory committee should be provided with reasonable assistance by staff as needed, whether using existing TPS personnel or otherwise; and
- Annual Reports: The advisory committee should prepare annual reports for the Chief of Police, summarizing the state of progress in implementation, any significant divergences between the advice of the committee and the decisions taken by the TPS in the past year, and major recommendations going forward relating to implementation, prioritization, scheduling, planning, resource allocation, public reporting and related topics.
Transparency and accountability
RECOMMENDATION 76: In order to ensure transparency and accountability during the implementation stage, the TPS issue a public report at least annually after the date of release of this Report, with the following contents:
- a list of recommendations implemented in whole or in part to the date of the report, with an explanation of what was done and when;
- a list of those recommendations still to be implemented, with an indication of the anticipated timing of implementation;
- if applicable, a description of resource constraints that affect the ability of the TPS to implement any recommendations, or the timing of implementation;
- if applicable, a description of any other limitations on the ability of the TPS to implement any recommendations (such as lack of cooperation from other organizations, change in circumstances, etc.);
- if applicable, a list of recommendations that the TPS decided not to implement at all, and an explanation of the reasons for decision;
- if applicable, a list of recommendations that the TPS decided to implement in modified form (different from what was recommended in this Report), and an explanation of the reasons for decision; and
- a discussion of any significant divergences between the advice of the advisory committee and decisions made by the TPS.
RECOMMENDATION 77: The Chief of Police and the Executive Management Team of the TPS play a significant leadership role in requiring implementation of the recommendations in this Report, and in encouraging (through leadership by example and otherwise) voluntary compliance.
RECOMMENDATION 78: The TPS appoint a senior officer to assume overall operational responsibility and executive accountability for the implementation of the recommendations in this Report, subject to the direction of the Chief of Police or the chief’s designate.
RECOMMENDATION 79: The TPS create an implementation team, led by the senior officer identified above and composed of those TPS members charged with responsibility to implement recommendations within specified areas of the Service (e.g., within the MCIT program, within Psychological Services, within the Toronto Police College, etc.).
RECOMMENDATION 80: The Chief of Police or his delegate appoint, within each TPS division and unit, at least one TPS member formally charged with responsibility for ensuring effective implementation of the recommendations in this Report at the division or unit level.
RECOMMENDATION 81: In connection with those recommendations above that call for further study, examination and analysis of specific issues:
- Stakeholder Input: Where appropriate, the TPS seek to involve representatives of affected stakeholders meaningfully in the work;
- Deliverables: The TPS identify specific deliverables sought from those tasked with the work, and a timeframe for delivery; and
- Reporting Requirement: There be a regular reporting requirement for any work taking place over an extended period, whereby the senior TPS officer in charge of implementation is kept informed regarding the progress of the work.
Third-party cooperation and relationships
RECOMMENDATION 82: In connection with those recommendations above that call for the TPS to work with outside organizations such as government ministries, hospitals and others, the TPS take a leadership role in forging and fostering the necessary relationships.
RECOMMENDATION 83: The TPS collaborate with academic researchers, hospitals and others to evaluate the effectiveness of TPS initiatives undertaken as a result of this Review, including, where applicable, both quantitative and qualitative evaluations.
RECOMMENDATION 84: A follow-up review be conducted—whether by TPS personnel, by an independent review body or by committee of interested stakeholders—in five years’ time to assess the degree of success achieved in minimizing the use of lethal force in encounters between the TPS and people in crisis, and to make further recommendations for improvement. I recommend that the results of that review be made public, and that the reviewers be similarly tasked with developing recommendations for implementation.