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
 I The Independent Civilian
Review into
The Honourable Gloria .I.
Missing Epstein
Independent Reviewer
Person Mark .J. Sandler
Lead counsel
Investigation
s
Suite #1900, 439 University
Telephone: 416-585-9191 E-maii:
Avenue Toronto, Ontario M5G
1Y8 Fax: 416-408-2372 [email protected]
rnsandle1@m1ss111gpersonsrevie<N
ca

LETTER OF
TRANSMITTAL

April 9, 2021

Chair Jim Hart

Toronto Police
Services Board 40
College Street
Toron
to,
Ontari
o
M5G
2J3

Dear Chairman Hart,

Having been appointed by the Toronto Police Services Board to conduct the Review described in
the Board's Terms of Reference, I submit to the Board the Review's Report.

Thank you for the opportunity to be of service on this important and challenging matter.

Yours very truly,

HGJE:sv
Encl.
 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
Interior portraits by Hope Flynn

Copyright © Toronto Police Services Board 2021

 DEDICATION

I dedicate this Report to the victims identified in the Terms of Reference and
to their families and other loved ones. Neither your pain nor your loss is in
vain. They will serve as the catalyst for real and lasting improvements to how
the Toronto Police Service investigates reports of missing persons. They will
also help to identify a way forward to improved relationships between the
Service and the marginalized and vulnerable communities it serves and
protects – relationships built on trust and on mutual respect.

SKANDARAJ NAVARATNAM
ABDULBASIR FAIZI
MAJEED KAYHAN
SOROUSH MAHMUDI
KIRUSHNA KUMAR KANAGARATNAM
DEAN LISOWICK
SELIM ESEN
ANDREW KINSMAN
ALLOURA WELLS
TESS RICHEY
Contents

ACKNOWLEDGEMENTS XIII

1 OVERVIEW AND INTRODUCTION 1

The Events Leading to This Review 4
The Review’s Terms of Reference 6
Limitations on the Review 8
No Interference with Ongoing Criminal Proceedings 8
No Findings of Misconduct or Civ il or Criminal Responsibility 9
Ongoing Discipline Proceedings 10
How the Review Was Conducted 11
The Community Advisory Group 11
Collection and Examination of Documents 11
Public Outreach and Engagement Plan 11
Meetings with Stakeholders and Affected Community Members 12
Online Survey 12
Written Submissions or Anonymous Comments 12
Policy Roundtable 12
Town Hall Meeting 12
Interviews 13
Research Program 13
Confidentiality and Anonymization 14
Two Challenges Faced by the Review 14
COVID-19 14
Correcting Public Perceptions 15
How the Report Is Organized 16
The Use of Respectful Language 18

2 HONOURING THE LIVES LOST 21

In Memoriam 22
Skandaraj Navaratnam 22
Abdulbasir Faizi 23
Majeed Kayhan 23
Soroush Mahmudi 24
Kirushna Kumar Kanagaratnam 25
v Contents
i
Dean Lisowick 26
Selim Esen 26
Andrew Kinsman 27
Alloura Wells 28
Tess Richey 29
Unique Lives with Common Threads 30

3 CIVILIAN GOVERNANCE AND OVERSIGHT:

ROLES OF THE BOARD AND THE SERVICE 33
The Role of the Toronto Police Services Board 35
The Community Safety and Policing Act, 2019 37
The Role of the Ministry of Community Safety and Correctional Services 40
The Role of the Inspector General of Policing and the Ministry under the CSPA, 2019 44
The Relationship Between the Roles of the Board and the Chief of Police

47
Accessing the Needed Information 51
Exchange of Information 52
Identifying the Critical Points 52
Collaboration on Defining an Operation but Not Its Execution 56
The Impact of the Community Safety and Policing Act, 2019 56
Summary 59
Findings 61

4 MAJOR CASE MANAGEMENT AND

THE USE OF TECHNOLOGY 65
Major Case Management: Provincial Adequacy Standards 67
Ontario Regulation 354/04 67
The Manual 68
Major Case Management Definitions 68
The Command Triangle’s Functions and Responsibilities 73
The Major Case Manager 73
The Primary Investigator 74
The File Coordinator 75
Other Functions and Responsibilities 76
Multi-jurisdictional Major Case Manager and Investigations 77
Policies and Procedures on Components of Major Case Management 78
Data Entry 79
Document Management 80
Interviewing 82
The Violent Crime Linkage Analysis System (ViCLAS) 82
The Service’s Criminal Investigation Management Plan 84
The Service’s Programs and Technology 85
Records Management Systems 85
Historical Records Management Systems: COPS and eCOPS 86
Centralized Occurrence Processing System 86
Enterprise Case and Occurrence Processing System 86
Current Records Management Systems: Versadex 87
Homicide’s Electronic Filing System: The P Drive 89
PowerCase and Its Use 92
The Use of “Objects” and “Triggering” 94
Object and Free-Text Searches 97
Link Explorer 98
Action Tracking 99
The Service’s Non-compliance with Provincial Adequacy Standards 100
The Technological Crime Unit and 106
Technological Tools Available to the Service 106
The Technological Crime Unit 106
The Coordinated Cyber Centre 108
Summary and Findings 108

5 THREE MEN GO MISSING 115

McArthur’s Assault Convictions Before the 2010–17 Murders 115
Skandaraj (Skanda) Navaratnam: McArthur’s First Known Murder Victim 117
Abdulbasir (Basir) Faizi 124
Majeed Kayhan 130
Summary and Findings 132
McArthur’s Assault Conviction: Before the 2010–17 Murders 132
Skandaraj (Skanda) Navaratnam 133
Abdulbasir (Basir) Faizi 136
Majeed Kayhan 137

6 THE PROJECT HOUSTON INVESTIGATION 141

The Swiss Informant and the Cannibal Theory 141
The Lead-up to Project Houston 143
Project Houston’s Early Work 149
Mr. Navaratnam’s Computer Examined 151
viii Contents

Focus on James Brunton and the Cannibal Killer Theory 152

Contact with the OPP ViCLAS Unit 153
Clarifying the Informant’s Tip 154
Involvement of the Peterborough Police Service 156
Reinvestigation of Mr. Navaratnam’s Disappearance 156
Expansion to Include Mr. Kayhan’s Disappearance 158
An Operational Plan and the Role of Other Police Services 160
Project Houston Discovers silverfoxx51 and newyorkboy21 in Mr. Faizi’s Notepad 163
Further Investigation into Brunton 164
Mr. Navaratnam Linked to silverfoxx51 and newyorkboy21 166
Investigation of Orfanogiannis and Brunton 168
Plans to Wind Down Project Houston 172
Project Houston’s Analyst 173
Interview with the Informant in Switzerland 175
Owner of [email protected] Identified 177
Investigation of Email Addresses, but Not [email protected] 178
Arrest of Orfanogiannis 179
Planned Arrest of Brunton 179
After Brunton’s Arrest 181
Project Houston No Longer a Homicide Investigation 182
Project Houston Reduced to Three Investigators 186
Investigation of Luka Magnotta 187
McArthur Identified by Name for the First Time 187
Mr. PP Interviewed a Second Time 188
McArthur Interviewed 189
November and December 2013 193
The End of Project Houston 196
Summary and Findings 198
Overview 198
Major Case Management 199
The Serial Predator Coordinator 199
PowerCase 202
The OPP Violent Crime Linkage Analysis System 205
Technical Support 205
Underuse of the Project’s Analyst 206
Need for a Coordinated Investigation 207
 The LGBTQ2S+ Liaison Officer 208
Support for Those Affected 208
Police Transparency and Communicating with the Public 209
How Project Houston Was Wound Down and How It Ended 210
The Absence of an Internal Review 211
Notification to the Board 212
Misinformation About the Case 212
Tunnel Vision 214
The McArthur Interview 215

7 THE PROJECT PRISM INVESTIGATION 217

Events Leading Up to Project Prism 217
The Investigation into Soroush Mahmudi’s Disappearance 217
The Murders of Kirushna Kumar Kanagaratnam and Dean Lisowick 222
The 2016 Investigation into McArthur’s Choking of a Man 222
The Investigation into Selim Esen’s Disappearance 227
The Investigation into Mr. Kinsman’s Disappearance 232
A Narrow Escape: McArthur Assaults Sean Cribbin 239
Project Prism – Official Launch to Aftermath 241
The Task Force 241
The Operational Plan 242
McArthur Is Identified 245
McArthur Officially Becomes a Murder Suspect 251
The December 8, 2017, Press Conference 257
The Events Leading to McArthur’s Arrest 259
The Events Leading to More Charges 260
The Serial Predator Criminal Investigations Coordinator 262
The Violent Crime Linkage Analysis System 262
Chief Saunders’s Globe and Mail Interview 264
The Guilty Plea 265
Summary and Findings 265
The Investigation into Mr. Mahmudi’s Disappearance 265
The 2016 Investigation into McArthur’s Choking of a Man (Mr. AD) 267
Re-interviewing Mr. AD 267
The Availability of a Defence to the Allegation 268
The Photographing of Injuries 269
McArthur’s 2003 Convictions 270
x Contents

The Use of Underlying Conduct Relating to a Record Suspension 271

Police Access to Relevant Information 272
The Relevance of the Prior Conduct 273
The Dash Cam 274
Follow-up with Complainant 274
Implications of Siloed Information 274
Gender, Sexual Orientation, and Sex 275
The Investigation into Mr. Esen’s Disappearance 276
Public Warning 278
The Investigation into Mr. Kinsman’s Disappearance 279
Case Management and PowerCase 280
The Serial Predator Coordinator 284
The Violent Crime Linkage Analysis System 284
The December 8, 2017, Press Conference 285
Chief Saunders’s Globe and Mail Interview 287
Bias, Discrimination, and Differential Treatment 289
Audiotape Transcript (Partial) of Chief of Police Mark Saunders’s Interview with the
Globe and Mail

290

8 TESS RICHEY GOES MISSING 297

The Missing Person Investigation 298
November 25, 2017 – Tess Richey Reported Missing 298
November 26, 2017 299
November 27, 2017 301
November 28, 2017 304
November 29, 2017 305
Discovery of Tess Richey’s Body and the Aftermath 306
Tess Richey Is Found 306
Initial Reaction by the Coroner and the Police 307
Further Steps Taken by the Police 309
November 29, 2017 309
November 30, 2017 310
December 1, 2017 310
Preliminary Autopsy Findings 311
The Homicide Unit Takes Over 311
December 1, 2017 311
The Richey Family’s Criticisms of the Missing Person Investigation 312
The Public Response 313
The Events Leading to Schlatter’s Arrest 314
December 2–10, 2017 314
Outline of Discipline and Other Proceedings 315
Summary and Findings 317
The Failure to Conduct a Second 300 Metre Radius Search 317
Other Shortcomings in the Early Investigation 320
The Failure to Issue a Timely Media Release 320
Untimely and Uncoordinated Assembly of Video Footage 320
The Role of the Missing Person’s Loved Ones 321
The Approach to Risk Assessment 322
The Treatment of the Scene 322

9 THEALLOURA WELLS INVESTIGATIONS AND RELATED CASES 325

The Alloura Wells Investigations 325
Discovery of The Unidentified Remains 326
Initial Attempts to Make an Identification 328
The Disappearance 331
53 Division’s Initial Involvement 331
The Missing Person Investigations 332
Community Efforts to Find Ms. Wells 334
The Identification of Ms. Wells’s Bodily Remains 336
The Professional Standards Review 337
The Failure to Issue a Media Release 337
The Failure to Involve the Liaison Officer 337
Summary and Findings (Alloura Wells) 338
Engaging the Community 338
Issuing a Media Release 339
Identifying and Assigning a Lead Investigator 339
Notifying the Homicide Unit 340
Communicating with the Office of the Chief Coroner 340
Completing Timely Missing Person Reports 341
Treating Affected Persons with Respect 341
Issues Around Existing Procedures 343
The Kenneth Peddle Case 344
Mr. Peddle’s Disappearance and Death 344
The Unidentified Remains Investigation 345
xii Contents

The Missing Person Investigation 346

The Identification of Mr. Peddle’s Remains 349
Summary and Findings (Kenneth Peddle) 350
Acknowledgements

There are many individuals, organizations, and groups I wish to thank for their
participation in this Review and in the preparation of this Report. Without
their involvement, I simply could not have dealt adequately with the issues in
my mandate set out in the extensive Terms of Reference.
I start with the loved ones of the 10 people who lost their lives – the 10
people to whom this Report is dedicated. I had the privilege of meeting with
many of their friends and family members. I acknowledge the courage
they demonstrated in sharing their experiences and their feelings, often
under difficult circumstances
I met with hundreds of individuals, including, but certainly not limited
to, community members, past and current members of the Toronto Police
Service and the Toronto Police Services Board, members of other police
services, members of stakeholder groups, and a number of experts in areas
relevant to the Review’s important work. I learned from every person I
met and want to thank each of them for their time and for sharing their
knowledge, experience, and insight with me.
I am grateful to those who attended the Review’s roundtable, an event
that brought together knowledgeable representatives with experience in the
wide spectrum of issues relevant to the Review. During the roundtable,
the participants presented and discussed their views – often differing views.
These discussions were informative and helpful, and they were sometimes
emotional. I thank the participants for their time and their insights.
The Review’s robust outreach would not have been possible without the
public consultation team – Jane Farrow (Dept. of Words & Deeds) and Gillian
Kerr. I thank them for their hard work and impeccable organizational skills.
I was ably assisted by the members of my Community Advisory Group,
a diverse group of individuals who have been with me throughout the Review.
Led by Ron Rosenesand Haran Vijayanathan, they, together with Christa Big
Canoe, Monica Forrester, Justice Brian Lennox, Michele Lent, and Angela
Robertson, provided me with access to the marginal and vulnerable
communities at the centre of my investigation. They also gave me sound
advice enriched by their wisdom and their own lived experiences. Debbie
Oakley, the Review’s administrator, supported the Community Advisory
Group and me in personal ways and in ways vitally important to the Review’s
work.
I was fortunate to get Professor Kent Roach of the Faculty of Law at the
University of Toronto to be the Review’s research director. He assisted by
arranging the legal research prepared for this Review, drafting parts of
the
xi Acknowledgements
v
Report, and constructively engaging in many discussions about the complex
issues relevant to the Review’s mandate. I thank him for his good counsel and
his friendship. I also want to thank Mark Pritchard, a former Ontario
Provincial Police regional commander for the Northwest Region, who drew
on his vast experience based on a long and distinguished career as a police
officer to provide me with an invaluable independent perspective on
policing issues relevant to the Terms of Reference.
The work of this Review, leading to the production of this Report, has
been a team effort. From beginning to end, every member of the Cooper,
Sandler law firm played a key role. Without the support of Megan
Schwartzentruber, Amanda Ross, Nazampal Jaswal, Alefia Ghadiyali, and
Chelsea Sandler, I could not have produced this Report. Their assistance has
been marked by dedication and distinction, and I am profoundly grateful.
I am also grateful to our three editors, Rosemary Shipton, Mary
McDougall Maude, and Dan Liebman. I benefited and learned from their skill.
I thank them for their patience.
Finally, I turn to Mark Sandler, counsel to the Review. He has been the
Review’s backbone. He assumed the responsibility for organizing the multiple
tasks that had to be done to fulfill mymandate. He prepared detailed interviews
that had to be conducted and drafted many parts of the Report. His intellect,
sound judgment, patience, incredible work ethic, and, perhaps most important
of all to me, wonderful sense of humour deserve special mention. His
contribution can be found on every page of this Report.
Ultimately, however, the findings, conclusions, and recommendations
set out in this Report are mine alone.

Gloria J. Epstein
April 2021
Chapter 1

OVERVIEW AND INTRODUCTION

Bruce McArthur killed eight people. All were gay or bisexual. All but two
were men of colour. All were valued.
Skandaraj Navaratnam was McArthur’s first known murder victim. He
was reported missing in 2010. After that, five other victims were
reported missing between 2010 and 2017. In early 2018, the police
apprehended McArthur. His arrest followed a seven-year reign of terror.
The police could have done better. This Report is the account of what
went wrong and an examination of how things can be done differently.
Tess Richey went missing in 2017. Police failed to discover her body.
Her mother did, a short distance from where her youngest daughter was last
seen. The police could have done better. This, too, is the account of what went
wrong and an examination of how things can be done differently.
Alloura Wells, a member of Toronto’s trans community, also went
missing in 2017. Although her bodily remains had been in the morgue for
months, those remains were not quickly linked to her disappearance.
Kenneth Peddle and Dovi Henry represent others reported missing and
actively searched for by family. Their families learned, only later, that their
loved ones’ bodies lay, unidentified, in the morgue. Arthur Louttit went
missing for some time before his body was discovered not far from where he
was last seen. This, too, is the account of what went wrong in these cases and
an examination of how things can be done differently.
These and other events require us all to re-examine how missing person
investigations are done in Toronto. Make no mistake – some changes
have already taken place for the better. These initiatives are acknowledged in
this Report. But the time was right for a larger, independent examination
of how these investigations are carried out and what they tell us about the
relationship between Toronto police and our diverse communities.
The time was right for several reasons. First, much has been publicly
said about what police did and did not do. Some of it is untrue, and these
untruths cause me great concern. The public is entitled to know the truth;
indeed, it must know the truth. So are the loved ones and friends of those who
went missing.
In some instances, providing an accurate account of what happened
exposes serious investigative flaws or a lack of attention that made these cases
2 Independent Civilian Review into Missing Person
Investigations
more difficult to solve. In other instances, an accurate account corrects a
narrative that is unfair to investigators.
The Toronto police are also entitled to know what they did well and
what they did poorly. Some excellent work was done by some dedicated
officers. That account must also be provided, through an objective,
independent assessment.
As well, the Toronto Police Services Board (the Board) is entitled to
know what should change and why.
Second, the role of police in our society and their relationship with
marginalized and vulnerable communities is now at the forefront of our public
discourse. This discourse is long overdue. An examination of missing person
investigations contributes to a larger conversation, one that is about the role of
police in serving our diverse communities and whether the police should be
performing roles currently given to them.
To be clear, we are past the time for conversation only. The public is
entitled to insist on transformative change with measurable, sustainable
outcomes, timelines for completion, and accountability.
This Review identified serious flaws in how missing person cases – and
not just the ones identified in the Terms of Reference – have been handled in
Toronto. My recommendations propose ways to address those flaws. I
provide a model that both draws on recent changes for the better
and advocates a new approach to missing person cases generally. This new
approach takes some of these investigations, or certain components of them,
away from police and encourages much greater use of civilians and social
agencies where warranted. Recommendations only for more training or greater
diversity in policing ranks have limited value. Training and diversity are
important but do not, without much more, represent an adequate response to
the issues this Review has identified.
The Review was largely prompted by concerns that the McArthur-
related investigations were infected by bias. Some community members feel
the Toronto police remained uninterested in the disappearances of McArthur’s
victims until Andrew Kinsman, who was not a person of colour, was reported
missing. Many Toronto police officers rejected this view. They observed that
a number of dedicated officers worked tirelessly to solve these cases. That is
true. But the full narrative must take into consideration systemic bias,
discrimination, and differential treatment.
The disappearances of McArthur’s murder victims were often given less
attention or priority than these cases deserved. These victims were
marginalized and vulnerable in a variety of ways. The goal, of course, is to
ensure no one is treated in a less adequate way because of their
marginalization
and vulnerabilities, whether based on sexual orientation, gender identity or
expression, colour, ethnic origin, immigration status, being underhoused or
homeless, socio-economic status, or mental health – or on a combination of
these demographics.
Some officers had misconceptions or stereotypical ideas about the
LGBTQ2S+ communities.1 At times, their perceptions impeded their work.
Investigators missed opportunities to use community expertise or resources –
as well as expertise or lived experiences within the Toronto Police Service (the
Service) itself – to learn more about those communities and what leads might
be available. Investigators failed to appreciate – and attempt to address –
barriers that prevented some witnesses from coming forward. These barriers
included how police are perceived and often mistrusted by marginalized and
vulnerable communities – a perception and mistrust prompted by a long
history that includes criminalization of certain members of the
LGBTQ2S+ communities.
The police also failed to keep the public informed about what they were
doing. This lack of communication reinforced the broadly held impression that
“the police did nothing.” It heightened existing mistrust, and it ultimately
diminished, rather than protected, the integrity of existing and future
investigations. None of these issues – all existing at a systemic level – depends
on any intent to discriminate.
To the credit of Andrew Kinsman’s friends and loved ones, they
mobilized in a highly public way to ensure the police gave Mr. Kinsman’s
disappearance the attention it deserved. Proper missing person investigations,
however, should not depend on whose voices are the loudest in sounding the
alarm. This observation represents yet another systemic issue identified in this
Report.
Although overt bias does not explain why the McArthur-related
investigations between 2010 and 2017 were flawed, myextensive engagement
with community members and organizations confirmed that many people
deeply mistrust the Toronto police. This long-standing mistrust may not be
directly related to missing person cases but is often rooted in systemic or overt
bias or discrimination. Of course, it is also rooted in the legacy of how the
police have interacted with marginalized and vulnerable communities.
Mistrust remains despite a range of well-intentioned initiatives
undertaken by the Toronto police to build positive relationships. Not
surprisingly, it was only compounded by the perception that the police were
indifferent to the plights of those who went missing and by the lack of
1
I discuss the term LGBTQ2S+ at the end of this chapter, in the section on the use of respectful language.
transparency about what the police were doing. These issues must be
addressed immediately, regardless of whether they relate directly to missing
person investigations.
I am grateful to the many individuals who and organizations that shared
their insights, lived experiences, and suggestions for change. The Board and
the Service have an opportunity to learn a great deal from the tragedies
described in this Report and to build a transformative service for the future.
The Toronto Police Service can do better. And it can do better in a new
and improved environment in which its role is redefined. In my view, the
Board and the Service must start the process with a commitment to do
better. That commitment must be rooted in concrete, transparent, and strategic
plans with defined deliverables and timelines, in full partnership with
communities and accompanied by accountability measures described in this
Report.
It is my hope that this Report contributes to the changes that are needed.

The Events Leading to This Review

My introductory comments identify the specific cases that prompted this

Review.
Toronto’s affected communities, most particularly the LGBTQ2S+,
questioned why it took so long to end McArthur’s crime spree and solve the
disappearances of Ms. Richey and Ms. Wells. And it asked whether lives
could have been saved.
All these missing person cases fuelled deep concerns about how the Service
handled the investigations – specifically, whether they were tainted by overt
or systemic bias against members of Toronto’s LGBTQ2S+ or vulnerable and
marginalized communities. These expressed concerns were not confined to the
specific cases but were also systemic:

 Are such cases handled differently by the police when they involve
members of the LGBTQ2S+ or marginalized and vulnerable
communities?
 Are existing policies, procedures, or practices adequate to ensure
effective, discrimination-free, and timely investigations?
 Does the Service adequately communicate with affected communities
about safety concerns? Or does it communicate in ways that advance its
investigations?
 Should the role of the Service in missing person cases be fundamentally
changed?
 Does the Service give proper attention to missing person cases or cases
involving unidentified bodily remains?
 How can the Service build healthy and respectful relationships with
LGBTQ2S+ or marginalized and vulnerable communities in Toronto?

The Board acknowledged to the public that the relationship between the
Service and the LGBTQ2S+ communities had been damaged in the wake of
these events and needed to be repaired. The Board also recognized that there
are “intersections of minorities within the LGBTQ2S+ communities, including
South Asian, Middle Eastern, 2-spirited, other racialized individuals, as well
as those who are either homeless or work in the sex trade, that are particularly
vulnerable and require an improved approach to policing relationships.”
The Board has the responsibility under the Police Services Act to
provide adequate and effective police services in the City of Toronto and the
power to establish policies for effective management of the Service.
In March 2018, pursuant to the Board’s powers and responsibilities, and
as a result of the voiced concerns set out above, the Board established a
diverse Working Group to advise it on a framework for an independent
external review into how the Service conducts missing person
investigations. The chief of police publicly endorsed the creation of an
independent review. Based on the Working Group’s recommendations, the
Board commissioned this Independent Review into the Board’s policies as
well as the Service’s procedures and practices relating to missing person
investigations, particularly those involving individuals from the
LGBTQ2S+, immigrant, Indigenous, South Asian, Middle Eastern, Black,
homeless, and other marginalized and vulnerable communities.
The Working Group and its facilitator, now Justice Breese Davies of the
Ontario Superior Court, created a draft of the Review’s Terms of Reference.
Terms of reference guide the nature and scope of a review. The Working
Group also recommended that I serve as the Reviewer.
The Board then asked me to accept this appointment. At the time, I was
a judge of the Court of Appeal for Ontario. On August 31, 2018, I chose to
retire from the court to devote my full attention to this critically important
Review. I asked Mark Sandler to serve as my lead counsel. Mr. Sandler
has served as counsel to many systemic reviews and public inquiries.
Together, we provided feedback to the Working Group on the Terms of
Reference. This response resulted in some agreed-upon refinements to the
Terms of Reference, which the Board then approved.
 During the Review, the Terms of Reference were amended to
significantly expand its scope once McArthur’s murder case ended. The
current Terms of Reference appear as Appendix A to this Report.

The Review’s Terms of Reference

The Review’s Terms of Reference are detailed. Broadly speaking, they

required me to evaluate how missing person investigations, particularly those
involving LGBTQ2S+ or marginalized and vulnerable communities, have
been conducted and are now being conducted. This work required that I
examine, among other things, the Board’s policies and practices, as well as the
Service’s procedures, practices, and actions, to determine whether they
adequately promote effective, efficient, and discrimination-free missing
person investigations and, especially in the context of such investigations,
positive relationships between the Service and the LGBTQ2S+ communities.
It also required me to specifically review the missing person
investigations relating to Skandaraj Navaratnam, Abdulbasir Faizi, Majeed
Kayhan, Selim Esen, Soroush Mahmudi, and Andrew Kinsman, including
Project Houston and Project Prism, and any other opportunities to identify
McArthur as a person of interest or suspect, as well as the missing person
investigations relating to Tess Richey and Alloura Wells. Dean Lisowick and
Kirushna Kumar Kanagaratnam were victims of McArthur though not reported
as missing. The Terms of Reference also direct me to examine what prevented
these two men from being reported missing.
The Terms of Reference provide me with 12 areas to focus on in examining
these specific cases, four of which are illustrative and figure prominently in
this Report:

 whether culturally competent expertise is available to or relied upon by

the Service for missing person investigations, including but not limited to
expertise around gender identity, gender expression, race, ethnic origin,
and intersectionality;
 whether there is adequate information-sharing within the Service and
between the Service and other police services to ensure that similarities
and links between missing person investigations can be identified quickly
and effectively;
 how and when the Service decides to advise or caution the public, or
specific communities, about public safety concerns that arise from
missing person investigations, including but not limited to information
about suspected links or connections between missing person cases; and
 whether effective policies, procedures, and practices are in place to
ensure adequate investigative consideration of serial killers, especially
based on missing person reports where there is no overt evidence of foul
play.

On the topic of developing and maintaining relationships with

LGBTQ2S+ communities, especially as they have an impact on missing
person investigations, the Terms of Reference identify nine topics for
consideration. The following three are illustrative and, again, figure
prominently in this Report:

 the roles, responsibilities, and efficacy of the officer assigned to liaise

with the LGBTQ2S+ communities;
 the scope and efficacy of consultations and communications with
members and organizations within the LGBTQ2S+ communities about
missing person investigations; and
 the extent to which the police call upon organizations within the
LGBTQ2S+ communities (or other relevant communities) to assist at any
stage with missing person investigations.

The Terms of Reference also direct me to review the training of

members of the Service on relevant topics; to consider prior relevant
reports and the extent to which their recommendations have been
implemented; and to consider, in my discretion, best practices in other
jurisdictions in relation to missing person investigations, bias-free2 policing,
and positive working relationships with marginalized communities.
Ultimately, the Review focuses on making recommendations. The
Terms of Reference provide that I am to make recommendations, in my
discretion, that accord with the Review’s mandate, including
recommendations on Board policies and the Service’s procedures and
practices relevant to that mandate.
Finally, I am to propose a timeline for implementation of each
recommendation. Of importance, the Terms of Reference specify that my
recommendations are to address how to ensure LGBTQ2S+ participation in
monitoring and implementing any recommendations that are adopted, and to
address a framework for measuring, monitoring, and publicly reporting on

2
I generally use the term “discrimination-free” rather than “bias-free” policing (used in the Terms of
Reference) since biases may not always be eliminated, but discrimination or differential treatment rooted in
bias or prejudice must be.
whether my recommendations have been adopted and, if they have not been,
why not. Consideration should be given to a model for independent oversight
of compliance and continuing community consultation.

Limitations on the Review

No Interference with Ongoing Criminal Proceedings

The Terms of Reference provide that I will conduct this Review “without
prejudicing any ongoing criminal investigation or criminal proceedings,
including but not limited to the criminal prosecution of Kalen Schlatter, and
will make a report to the Board without expressing any conclusion or making
any recommendation regarding the civil or criminal responsibility of any
person or organization.”
When the Review began, Schlatter was charged with the first-degree
murder of Tess Richey. He pled not guilty, and his trial took place during the
Review. He was convicted, although his conviction is currently under appeal.
As a result, his criminal proceedings are ongoing.
I have been careful not to prejudice those criminal proceedings. I
deferred certain interviews until the criminal trial was over, and, of course,
make no findings respecting Schlatter’s criminal responsibility for Ms.
Richey’s death. This limitation did not prevent me from examining the part of
the Tess Richey investigation that is relevant to my mandate; namely, how the
Service conducted its early investigation into her disappearance.
The original Terms of Reference also directed that I was not to
prejudice the ongoing criminal proceedings involving McArthur. It also
specifically prevented me from examining facts relating to the McArthur
investigation after September 1, 2017. This limitation, though understandable
at the time, would have prevented me from a robust examination of the
McArthur-related investigations relating to issues that fell squarely within my
mandate.
Of course, the Review respected the limitations, both by deferring
certain interviews and by developing a document protocol with the Ministry of
the Attorney General and the Service. This protocol, which was strictly
adhered to, enabled the Review to obtain relevant documents and
materials relating to the McArthur investigations and prosecution, while
keeping them secure and restricting those who could access them.
In February 2019, McArthur pled guilty to eight counts of first-degree
murder. He was sentenced to life imprisonment with no eligibility for parole
for 25 years. No appeal was taken from the verdict or sentence. As a result, the
criminal proceedings against him were over. I immediately requested that the
Board amend the Terms of Reference to permit me to fully examine and
evaluate the McArthur-related investigations. On March 26, 2019, the Board
amended the Terms of Reference as requested. This revision represented a
significant, but necessary, expansion of the Review’s work to fulfill its
mandate.

No Findings of Misconduct or Civ il or Criminal Responsibility

This is a “systemic review.” A systemic review is designed to identify
and address larger issues of systemic importance; that is, issues
involving an institution’s systems, policies, or practices, rather than issues
confined to an isolated or individual error or fault. A systemic review is not
designed to find individual misconduct or civil or criminal responsibility.
Indeed, I am prohibited from doing so both by existing law and by the Terms
of Reference. These limitations are appropriate. Findings of misconduct may
be made,
in law, only if certain procedural protections are available to those
affected. These protections may include formal notice of the allegations
made; the right to confront one’s accuser; the ability to challenge incriminating
evidence, such as through cross-examination of witnesses; and the ability
to call relevant evidence and respond to allegations.
Some felt that a public inquiry, rather than a systemic review, should
have been called to address the issues. The commissioner at a public inquiry
may make findings of misconduct, though he or she is also prohibited from
making findings of civil or criminal responsibility. A commissioner also has
powers to compel witnesses to testify and to compel the production of
documents. The Working Group, composed of a highly diverse body of
dedicated community members and leaders, concluded that a systemic review
was preferable. It is not for me to express an opinion on the relative merits of
systemic reviews and public inquiries. Each has its advantages and
disadvantages. But I do make three observations.
First, I found it unnecessary to make findings of individual misconduct
to successfully fulfill my mandate. Simply put, I was able to craft
recommendations to promote effective, discrimination-free, and timely
missing person investigations; to increase transparency and accountability; and
to create a framework for implementation, none of which are dependent on
findings of misconduct. I am not prohibited from identifying – as I have done
– serious deficiencies in how the Toronto police were conducting such
investigations and in its relationship with LGBTQ2S+ or marginalized and
vulnerable communities.
Second, the Board and the Service co-operated fully with the Review in
producing any documents requested. We were able to interview everyone we
needed to interview, including many police officers. Only one officer, now a
former officer, who had attended an initial interview, declined my repeated
requests for a subsequent interview. Although I regret my inability to complete
the interview process in this isolated instance, I am satisfied that I did not need
the power to compel witnesses to attend or compel documents to be produced
to fulfill my mandate.
Third, many people spoke candidly with the Review about their lived
experiences and perspectives, knowing I could preserve their confidentiality,
if they wished me to. These individuals included community members who did
not want their sexual orientation or their specific interactions with the Service
to be publicly known, as well as police officers who would have been reluctant
to fully share, in a public setting, their criticisms of how policing was done at
the relevant time. They welcomed the flexibility that comes with a systemic
review.
To foster candid conversations, the Review also obtained undertakings
from the chief of police and from the Office of the Independent Police Review
Director that neither would seek access to our interviews to advance either
a public or an internal complaint (a chief’s complaint) through the Professional
Standards Unit of the Service. This undertaking did not impede public or
internal complaints to proceed. It merely ensured that officers could speak
freely without fear their words would be used against them. 3 Later in this
chapter, I return to how I dealt with confidentiality and anonymity.

Ongoing Discipline Proceedings

Three officers are facing discipline proceedings under the Police Services Act.
These are not criminal or civil proceedings. Two of these officers face
discipline charges in relation to the search for Ms. Richey. The third officer
faces discipline charges in relation to his 2016 investigation of McArthur’s
choking of a man. (McArthur was released without any charges going forward.
See Chapter 7.) No hearing has yet been conducted in relation to any of the
charged officers.
The Terms of Reference do not specifically refer to these ongoing
disciplinary proceedings, but the Review recognized the importance of not
interfering with them. The Review deferred one interview until it became
obvious that these proceedings would not be completed during the Review.
With the consent of all three officers, we also gained access to their interviews
with the Professional Standards Unit. Ultimately, I was able to examine the
3
Officers, other than retired officers, were also ordered to attend the Review’s interviews, not because they
would otherwise have chosen not to meet with us, but to provide additional legal protection for them since
the interviews could be regarded as compelled, in law, rather than voluntary.
circumstances around these charges, including the actions of the three charged
officers, without deciding whether the conduct of any or all of them amounted
to professional misconduct.

How the Review Was Conducted

On September 1, 2018, we formally began our work, which involved multiple

components.

The Community Advisory Group

The Terms of Reference contemplated that I would establish an advisory group
representing affected communities, to ensure the community perspective was
adequately considered throughout the Review. At the outset, I created the
Community Advisory Group (CAG), 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. A list of CAG members, along with
brief biographical sketches, appears as Appendix B to this Report.

Collection and Examination of Documents

The Review’s legal team examined well over 80,000 pages of documents
obtained from the Service and the Board. These documents included existing
policies and procedures, as well as officers’ notes, reports, emails, videotapes,
audiotapes, and other materials pertaining to the specific investigations
identified in the Terms of Reference. The Review also obtained documents
from a variety of other sources, including the Ontario Ministry of the Solicitor
General; police services across Canada and internationally; and
community organizations and members, as well as publicly accessible
reports and electronic and print media stories.

Public Outreach and Engagement Plan

In April 2019, the Review announced a robust public outreach and
engagement plan that provided all members of the public, groups, and
organizations with a number of ways to contribute to the Review’s work.
Meetings with Stakeholders and Affected Community Members
In mid-May 2019, my team and I began to meet with stakeholder groups.
These meetings were designed to allow anyone to share perspectives,
experiences, and recommendations. Virtually all these meetings took place in
community spaces. Some of these groups approached the Review, while the
CAG or the Review’s legal team identified and reached out to others. I also
met one-on- one with community members confidentially when it was
important to do so to guarantee a safe and supportive environment. I
personally met with hundreds of individuals – some more than once. No
request to meet, at any time or any location, was turned down.

Online Survey
About 1,000 community members participated in an anonymous online survey
open from mid-November 2019 to the end of May 2020. The Review
widely publicized the survey, and the response was gratifying. Data obtained
from the survey are summarized in Chapter 10.

Written Submissions or Anonymous Comments

The Review invited all members of the public to make written submissions or,
if preferred, to submit anonymous electronic comments through a portal on the
Review’s website. The Review also invited a wide range of organizations to
provide written submissions. Some of the submissions that informed my
recommendations are referred to in Chapters 14 and 15.

Policy Roundtable
On August 18 and 19, 2020, 33 community leaders and policing experts from
around the globe participated, by invitation, in a policy roundtable to provide
their perspectives and recommendations on systemic issues identified by the
Review. Mr. Sandler and Jane Farrow, our public consultation lead,
spearheaded the policy roundtable’s plenary sessions, while members of the
CAG facilitated its small group sessions. Participants are listed in Appendix C
to this Report.

Town Hall Meeting

On October 14, 2020, the Review held a public town hall meeting. Mr. Sandler
described our work to date and outlined the key data from the recently
completed survey. Most important, this was yet another opportunity for people
to express their views – in this instance, in a public setting. The video of the
town hall meeting can be viewed on the Review’s website. It is also
summarized in Chapter 10.
 In summary, the Review’s robust outreach and engagement plan was
rewarded by an overwhelming response. As indicated, about 1,000 people
filled out the survey alone. Hundreds of people, including representatives of
many organizations, spoke with me. These contributions greatly informed my
work.

Interv iews
The Review conducted many interviews. (During the pandemic, these
interviews were usually conducted remotely.) We spoke with family members,
friends, and other loved ones of McArthur’s murder victims, Tess Richey, and
Alloura Wells; with others who have reported people missing; with
Toronto police officers of all ranks, past and present, including three deputy
chiefs, former chief of police Mark Saunders, and the acting chief of police;
with civilian employees; with experts or specialists in community policing,
missing person investigations, case management software, human rights,
record management, missing person databases, and police-community
initiatives; with community leaders and service providers; with students
and young people; with employees of the Ministry of the Solicitor General4
and the Office of the Chief Coroner and Ontario Forensic Pathology Service,
as well as the chief coroner and the chief forensic pathologist; with two
chairs and the executive director of the Board; with advocates for diverse
communities; with representatives of law organizations and legal clinics;
and with individuals associated with several past inquiries and reviews.
The communities represented, whether through service providers,
executive directors, or community members themselves, included
LGBTQ2S+; BDSM5; South Asian, Black, and other racialized communities;
Indigenous; trans men and women; the homeless and underhoused; a
men’s group; sex workers; those dealing with mental health and wellness;
immigrants and refugees; HIV/AIDS networks and organizations; and
intersections of these communities.

Resea rc h P rogra m
Professor Kent Roach served as the Review’s research director. Under his
leadership, the Review commissioned four papers from leading academics on
issues relevant to my mandate. The papers are on the Review’s website and
referred to in this Report. The Review also collected relevant literature from
around the world.

4
Before April 2019, the Ministry of Community Safety and Correctional Services.
5
Bondage and discipline; domination and submission; sa dism and masochism.
Confidentiality and Anonymization

I have already explained that the Review was able to conduct interviews
and meetings in confidence because of the flexibility associated with a
systemic review. I heard from many community members through in-person
interviews or meetings, a policy roundtable, a survey, a town hall meeting, and
written submissions. The survey was anonymous. Participants had no
obligation to disclose their identities or provide information that might lead
to their identification.
We advised community members we heard from that their identities
would not be disclosed in this Report or comments attributed to them
unless they gave their permission. Similarly, unless they gave their
permission, community members involved in relevant events – even if we did
not interview or meet with them – are not identified. Sometimes, their
involvement in relevant events may already be known publicly. Even so,
we always made a point of not identifying them, unless their identity was
so obvious that anonymity could not be preserved. We are dealing with tragic
events that have affected people profoundly and sometimes traumatized them.
It was important to me to “do no harm” and to ensure that interviews were
conducted in a safe and supportive environment.
The Review interviewed many police officers. They were always
permitted to be accompanied by legal counsel, if they chose that option.
Officers were advised that they could correct or add to their statements at any
time and were provided with documents to help refresh their memories.
Unlike our practice for community members, the Review did not
undertake that officers’ names would not be disclosed in this Report or
that comments would never be attributed to specific officers. However, I
do not disclose an officer’s identity unless it is relevant to the narrative or
my findings. More important, I have tried not to attribute comments to specific
officers when these comments were highly sensitive or might expose an
officer to an uncomfortable or poisoned work environment. This approach
encouraged candour, while remaining true to the need for transparency.

Two Challenges Faced by the Review

COVID-19
Of course, during the Review, COVID-19 intruded into the lives of us all. The
Review’s work continued nonetheless. Almost all interviews during this period
were conducted by videoconference or teleconference. A few were conducted
in person, at the request of those interviewed, but with appropriate social
distancing and other protections. In some instances, relevant documents were
provided in advance, given the more cumbersome exercise of attempting to
share materials remotely.
The policy roundtable worked particularly well remotely.
Participants and facilitators could be instantly moved electronically from
plenary to small group sessions. Mr. Sandler and I could move seamlessly
from breakout group to breakout group to hear the views expressed.

Correcting Public Perceptions

Much has been written or said publicly about the facts surrounding the
investigations into McArthur’s murder victims and the victims themselves.
This information has come from media stories and interviews, opinion pieces,
podcasts, television shows, a book, community meetings, and police press
conferences, statements, and presentations. The volume of disseminated
information is not surprising. The events that prompted this public discourse
have disturbed or traumatized members of the public, spurred the call for
answers, and ultimately prompted this Review. I believe this Report provides
many of those answers.
But, as I previously indicated, the Review has been challenged by the
considerable amount of inaccurate information that has been publicly
circulated. This inaccurate information is rarely the product of malevolence
and may be explained by imperfect recollections, albeit well intentioned. It
may also be explained by unfortunate speculation. Although members of the
media showed perseverance and dedication to learn the full narrative, they did
not have the benefit of the full record, much of which was inaccessible to
them. One of my responsibilities is to correct the public record on relevant
points – whatever the source of inaccurate information. For some, my findings
differ from their expectations or perspectives. This may hold true whether
those individuals are police officers, journalists, loved ones of McArthur’s
victims, affected community members, or the public at large.
I have found serious deficiencies in how the Service has conducted
missing person cases generally and how it conducted many of the
investigations in issue in this Review. I have also found that a number of
officers performed their work, hard work, in a dedicated way. The point here
is that all the findings I make in this Report are, of necessity, evidence-based,
not based on conjecture or speculation. I was driven by the facts, not by any
preconceived notions one way or the other. Only an evidence-based approach
can justify the key recommendations I make for change.
How the Report Is Organized

Chapter 2, Honouring the Lives Lost, profiles the lives of a number of the
missing – now deceased – individuals at the heart of my work. The chapter is
intended to convey that every one of these lives has value and meaning, and
that we must keep their lives at the forefront of our thoughts as we address the
issues identified in this Report.
Chapter 3, Civilian Governance and Oversight: Roles of the Board and
the Service, describes the appropriate interplay among the Board, the chief of
police, the Service, and the Ministry of the Solicitor General. It evaluates
these roles in the context of the need for robust civilian oversight of policing.
I also make findings on the sharing of information between the Service
and the Board, particularly as it affected the McArthur-related
investigations and policy issues.

***

Chapters 4 through 7 focus on the McArthur-related investigations.

Chapter 4, Major Case Management and the Use of Technology, explains
provincial adequacy standards around how major cases are to be managed, the
mandated case management software (PowerCase), and the interplay with
record management systems. This framework then permits me to evaluate
whether the Service complied with provincial adequacy standards or best
practices, particularly as they relate to the McArthur investigations.
Chapter 5, Three Men Go Missing, describes and evaluates the original
investigations by the Service into the disappearances of Skandaraj Navaratnam
and Majeed Kayhan, and the interplay between the Peel police and the Toronto
police respecting Abdulbasir Faizi’s disappearance. It also discusses
McArthur’s first relevant encounter with the justice system in 2002 and 2003
and its relevance to this Review.
Chapter 6, the Project Houston Investigation, describes and evaluates
the investigation of that name, particularly as it relates to the three men
missing from Toronto’s Gay Village.
Chapter 7, the Project Prism Investigation, examines and evaluates the
investigation into Soroush Mahmudi’s disappearance in 2015, the
investigation into McArthur’s choking of another man in 2016, the
investigations into Selim Esen’s and Andrew Kinsman’s disappearances, and
Project Prism and its conclusion.

***
Chapter 8, Tess Richey Goes Missing, examines and evaluates the
investigation by Toronto police into Ms. Richey’s disappearance.
Chapter 9, The Alloura Wells Investigations and Related Cases6,
examines and evaluates the investigation into the disappearance of Ms. Wells
and into the identification of her bodily remains. This examination facilitates
a larger discussion in Chapters 12, 13, and 14 about how unidentified bodily
remains are dealt with and how the Service interacts with the trans community.

***
Chapters 10 and 11 provide important building blocks for my
recommendations.
Chapter 10, Toronto’s Communities Speak, describes what I learned from the
Review’s community outreach and engagement initiatives. This chapter
includes the perspectives, lived experiences, and recommendations of
community members derived from stakeholder meetings, one-on-one
dialogue, the Review’s survey, the policy roundtable, and the town hall
meeting.
Chapter 11, Other Reports Examined: Key Findings and Relevant
Recommendations, describes the findings and recommendations from a
number of reports relevant to the Review’s mandate.

***
Chapter 12, Examining Events Through the Human Rights Lens, provides a
framework for evaluating claims of overt or systemic bias, discrimination, and
differential treatment. This framework includes a discussion on the ongoing
legacy of the relationship between the Service and LGBTQ2S+, racialized,
and marginalized and vulnerable. It permits me to evaluate whether
specific missing person investigations were infected by overt or systemic
bias and, more generally, systemic bias within the Service.
Chapter 13, Models of Missing Person and Unidentified Remains
Investigations, examines and evaluates how the Service has conducted
missing person and unidentified remains investigations before and after the
specific investigations analyzed in this Report. In particular, I evaluate the
Service’s relatively new Missing Persons Unit. Finally, I describe how
missing person cases are dealt with in other jurisdictions in Canada and

6
This chapter also examines and evaluates the investigations into Kenneth Peddle’s disappearance, and how
his unidentified remains were dealt with.
internationally. The practices in Toronto and other jurisdictions have
informed my recommendations on a mid-term and long-term model for
missing person investigations.
Chapter 14, Building Better Relations Between the Service and
Toronto’s Diverse Communities, examines and evaluates how the Service
interacts with LGBTQ2S+ or marginalized and vulnerable communities, and
the initiatives of the Board and Service to build a respectful relationship with
those communities. I also describe policing initiatives in other jurisdictions in
Canada and internationally to identify best practices. Case studies of two
missing men, Arthur Louttit and Dovi Henry, precede and follow this chapter.
Chapter 15, Recommendations, sets out my recommendations for
change on a wide range of topics and includes commentary on why I
have made these recommendations. In this chapter, I also set out a plan
for implementing these recommendations in a transparent, accountable way,
in
partnership with Toronto’s communities.
Chapter 16, Conclusion, contains my final thoughts.

The Use of Respectful Language

Chapter 12 explains, in some detail, what bias, prejudice, and discrimination

mean and how I approached the task of determining their role in the Service’s
missing person investigations and more generally.
When discussing issues of bias, prejudice, and discrimination, it is
important to use clear, well-defined terminology. It is equally important to use
language that is respectful of the diverse communities that are central to this
Review. Inappropriate or insensitive language can perpetuate stereotypes or
create unwarranted assumptions. Culturally competent language can build
bridges and begin to contribute to a discrimination-free environment. Its use is
not about “political correctness” but about creating the best opportunity for a
respectful and inclusive dialogue with those affected by the issues under
examination.
The terms used in this Report are derived from a variety of sources.
These include the Ontario Human Rights Code, section 15 of the Canadian
Charter of Rights and Freedoms and related jurisprudence, the invaluable
policies and guidelines developed by the Ontario Human Rights Commission,
and the Office of the Independent Police Review Director’s December
2018 Report, Broken Trust: Indigenous People and the Thunder Bay Police
Service.
As well, when quoting or paraphrasing what members of our diverse
communities said to me, I have generally chosen to use their preferred terms.
A glossary of some important terms appears in Chapter 12.
 Throughout this Report, I make frequent reference to the term,
“LGBTQ2S+.” The acronym refers to lesbian, gay, bisexual, transgender,
intersex, queer (or, sometimes, questioning), and two-spirited people. The “+”
is meant to include those communities not otherwise specified in the acronym.
I know other acronyms are used to attempt to capture diversity in sexual
orientation and gender identity and expression. I have chosen to use
LGBTQ2S+ for consistency and because it conforms to the Terms of
Reference.7
As well, I often use LGBTQ2S+ as part of the phrase “LGBTQ2S+
communities.” I refer to “communities” rather than “community” in
recognition that there is no monolithic LGBTQ2S+ community but instead
a wide diversity of sexual orientations, gender identities and expressions, lived
experiences, and perspectives among those who self-describe as being under
the LGBTQ2S+ umbrella. The term “communities” also recognizes
“intersectionality”; namely, that people describe themselves in multiple ways,
and not only as, for example, gay or bisexual. This distinction is important
because, as an example, a Caucasian gay man may well have a different
perspective from a Black trans woman and may be marginalized and
vulnerable in different ways and at different levels. The importance of taking
intersectionality into account is a theme fully developed in later chapters.

7
Variations on this acronym are occasionally used depending on context and the preference of a particular
group or individual.
 Chapter 2 Honouring the Lives Lost 21

Chapter 2

HONOURING THELIVES LOST

This Review was prompted by the tragic deaths of 10 people: Skandaraj
Navaratnam, Abdulbasir Faizi, Majeed Kayhan, Soroush Mahmudi, Kirushna
Kumar Kanagaratnam, Dean Lisowick, Selim Esen, Andrew Kinsman, Alloura
Wells, and Tess Richey. Each of their lives had value. Each was loved by
family and friends. Their deaths represented the loss of a brother, a son, a
father, a sister, a daughter, a partner, a friend.
Bruce McArthur, a gardener who ran his own business and sometimes
employed other labourers, murdered eight of the 10 people named in the
Review’s Terms of Reference. The remaining two were not McArthur’s
victims, but they disappeared in the same time frame and from the same
neighbourhood as the others. Each person had a unique life, a unique story,
though they also had much in common. Most of McArthur’s victims were at
the intersection of multiple marginalized identities, making them particularly
vulnerable to a serial predator. All 10 people were connected, in a variety of
ways, to the Gay Village around Church and Wellesley streets in the heart of
downtown Toronto (the Village). And all suffered terrible deaths.
In an attempt to acknowledge the loss of these victims as individuals, I
have written a brief tribute to each of them to memorialize in a small way their
tragically foreshortened lives. First, however, I want to acknowledge many
others who are not mentioned specifically in the Terms of Reference but who
are survivors of the events described in this Review. The loved ones left
behind. The other men McArthur brutalized. The members of the vibrant
communities in the Village.
I also want to thank the many family members, loved ones, friends, and
members of the Village who agreed to meet with me. I know it was painful for
them to share their experiences and their memories. I also realize they made
this sacrifice to ensure I appreciated the true nature of the suffering and loss at
the heart of this Review. Those who met with me have helped me understand
the terror of a loved one gone missing and the devastation of learning that their
worst fears have come true. I have heard of the lasting impact of these events
– the difficulties in trusting people and in forging new relationships, to name
but two. Simply put, their lives will never be the same again.
In Memoriam
Skandaraj Navaratnam
Skandaraj (Skanda) Navaratnam, the second oldest of four children,
immigrated to Canada as a refugee from Sri Lanka during that country’s long
civil war, which lasted from 1983 to 2009. According to his family members,
Mr. Navaratnam moved to Canada to better support his aging parents, who
remained in Sri Lanka. He succeeded in this goal and sent money home
whenever he could. Mr. Navaratnam was private about his sexual orientation,
although he did tell his brother he was gay. His brother reassured him that the
family accepted him for who he was.
In Toronto, Mr. Navaratnam had a wide social circle. Friends described
him as a “live wire,” a light in the lives of many people. He was known for his
good looks, outgoing personality, and easy smile. He had a wonderful sense of
humour and was a talented storyteller. I heard that Mr. Navaratnam was a
great dancer and that he “loved to dance with wild abandon,” especially to
retro music. He was also a fine singer and would often break out into
Bollywood tunes. He was unbeatable at Scrabble. This man of diverse interests
was also fascinated by nature and loved gardening.
Mr. Navaratnam was highly educated, spoke perfect English, and
enjoyed discussing politics. He was also spiritual. He frequented one particular
outdoor spot where he would meditate. He found jobs as a casual labourer,
including being employed for some time helping McArthur in his landscaping
business.
In the summer of 2010, Mr. Navaratnam adopted a dog. For weeks, the
pup was all he could talk about. That September, two of Mr. Navaratnam’s
friends grew concerned they had not seen him for several days, and they
reported him missing to the police. At the time, Mr. Navaratnam was working
as a caregiver to an elderly man.
Mr. Navaratnam was last seen on September 6, 2010, at Zipperz, a
nightclub in the Village. Those who knew him found it troubling that he did
not tell anyone where he was going. They were particularly alarmed that he
had left his beloved dog behind, alone and uncared for. His many friends
searched for him vigorously. When his family heard he was missing, they
thought he had gone into hiding because of his precarious immigration status.
Nearly a decade went by with no word about him.
Mr. Navaratnam’s remains were found on a property adjoining a ravine
on Mallory Crescent in Toronto. McArthur had a long-term contract with the
owners, who allowed him to keep his equipment in their large garage. The
police determined that McArthur killed Mr. Navaratnam on September 6,
2010. He was 40 years old.
Back home in Sri Lanka, family members decided, because of her
serious heart condition, not to tell Mr. Navaratnam’s mother of her son’s death.

Abdulbasir Faizi
Abdulbasir (Abdul) Faizi was born and raised in Afghanistan. He moved
to Canada for a better life and, in 1999, married and went on to have two
daughters. Once settled, Mr. Faizi got a job as an assistant machine operator at
a printing company. He was a hard worker and eventually earned enough to go
into business with a friend and to buy two homes as investments.
Mr. Faizi kept his sexual orientation a secret from those closest to
him
– something that caused him considerable emotional distress. Although he
lived in Peel Region, he regularly visited “hot spots” in the Village. One
person who noticed Mr. Faizi at some of the weekly barbecues at the Black
Eagle bar described him as a friendly person who smiled a lot.
On December 29, 2010, Mr. Faizi called his wife to let her know he
would be home later than expected. At that point, he was working overtime to
pay for his children’s Christmas presents. He explained he was out with a co-
worker. Mr. Faizi never returned home. He was last seen leaving Steamworks
Baths that same evening. When Ms. Faizi called her husband at midnight, he
did not answer his cell phone. The next day, his cousin reported him missing.
In 2018, Mr. Faizi’s remains were found on the Mallory Crescent
property. The police determined that McArthur killed Mr. Faizi on or around
December 29, 2010. He was 42 years old.

Majeed K ayhan
Majeed Kayhan, the son of a Muslim cleric, came from a traditional family in
Afghanistan. The household was quite conservative. While still in his home
country, Mr. Kayhan married and had two children. In 1989, the Kayhans
moved to Canada, lured by the hope they would be safe here. The family
settled in the Toronto area, where Mr. Kayhan worked as a rug salesman. In
2002, Mr. and Ms. Kayhan divorced.
As a gay Muslim, Mr. Kayhan constantly felt misunderstood. A friend
told me they would discuss the challenges Mr. Kayhan faced in dealing
with both racism and systemic cultural homophobia, which together prevented
him from living a fully “out” life. Those pressures forced Mr. Kayhan to live
partly in the closet – a situation he found difficult.
After the marriage breakup, Mr. Kayhan moved to the Village, where he
could openly embrace his sexual orientation. All the while, he remained
devoted to his children. His almost daily contact with his son provided both of
them with much happiness. It was important to him that his children knew he
was still their father. Mr. Kayhan also kept two pet birds that brought him joy.
He faithfully cared for them and always arranged for someone to look after
them when he was away.
Mr. Kayhan became a familiar presence in the Village. Those in his
circle described how they would see him chatting with friends on Church
Street, always with a wide grin. He was a talented singer: as he worked, he
sang tunes from movies in both Farsi and English. Sometimes he dressed in
traditional Afghani garb and walked along Church Street, celebrating his
cultural identity. He was also a soccer fanatic. As one friend told me: “If the
soccer game was on TV, you didn’t talk.”
In October 2012, Mr. Kayhan simply vanished, leaving his cherished
birds unattended. His son reported him missing on October 25. He had last
been seen about two weeks earlier.
Mr. Kayhan’s remains were discovered in a ravine near the Mallory
Crescent property. The police determined that McArthur killed him on or
about October 18, 2012. Mr. Kayhan was 58 years old.
Soroush Mahmudi
Soroush Mahmudi came to Canada as a refugee from Iran in 1985, when he
was 20 years old. He was one of four children.
In 2003, Mr. Mahmudi married Fareena Marzook, who had a son from
a previous relationship. They settled in Barrie, Ontario, where he got a job first
in an automotive factory and then as a taxi driver. Later, after the family
moved to Toronto, Mr. Mahmudi worked in construction and landscaping. At
one point he was a professional painter.
Mr. Mahmudi was a family man: he took care of his wife and stepson
and established a loving relationship with the boy. By all accounts, the
marriage was a good, indeed an affectionate, one. Ms. Marzook told me she
enjoyed “getting all dolled up” for her husband’s return from work. He
liked to take her to the salon to get her hair and makeup done. Mr. Mahmudi
also remained close with his parents, calling them several times a week.
Cooking was one of Mr. Mahmudi’s favourite pastimes. He usually
prepared the family dinner as soon as he got home from work and constantly
experimented with different kinds of food. Movies were another favourite
leisure activity. Mr. Mahmudi and Ms. Marzook liked to watch movies
together in English, and, because his English was better than hers, he
translated for her. Friends described him as an “easygoing” jokester. He
enjoyed camping and also playing soccer and pool.
 On August 15, 2015, Mr. Mahmudi made breakfast for his stepson and
left the house. He was never seen again. His disappearance was reported a
week later, on August 22.
The police determined that McArthur killed Mr. Mahmudi on or around
August 15, 2015. He was 50 years old. His remains were found on the Mallory
Crescent property.

K irushna K umar K anagaratnam

Kirushna Kumar Kanagaratnam was born and raised in Sri Lanka. He was one
of a family of six children. In 2010, Mr. Kanagaratnam fled Sri Lanka in
the aftermath of the civil war – a war that took the life of one of his brothers.
For a full three months, he, along with almost five hundred other Sri
Lankan asylum seekers, risked their lives in their escape on the MV Sun Sea, a
derelict old cargo ship.
During the intolerable journey, Mr. Kanagaratnam found ways to pass
the time and soothe the suffering of others. He sang with a makeshift band and
played cards. One fellow passenger described him as being helpful and
trusting. Another recounted how Mr. Kanagaratnam shared his ration of water,
despite being allotted only seven or eight litres for the 37-day voyage. At the
time, Mr. Kanagaratnam was 32 years old. Friends described him as a happy
and talkative man, outgoing, and a willing participant in karaoke.
Mr. Kanagaratnam arrived on the shores of British Columbia in 2010.
His application for refugee status was denied, but he remained in Canada as an
illegal immigrant and eventually made his way to Toronto to connect with
distant relatives. They also said he was generous, taking time off work as a
handyman when asked to help move furniture or shovel snow. In
particular, Mr. Kanagaratnam was devoted to his parents. He regularly sent
money he earned to his impoverished family at home, despite his own meagre
resources. He called his mother two or three times a week and last spoke with
his family in August 2015. The calls suddenly stopped, and Mr.
Kanagaratnam’s family became worried when they were unable to reach him.
Sadly, Mr. Kanagaratnam was never reported missing. His family and
friends assumed that, owing to his immigration status, he had gone into hiding.
Understandably, they feared that if they reported him as missing, he would be
deported back to Sri Lanka.
McArthur killed Mr. Kanagaratnam in January 2016, when he was
37 years old. His remains were discovered on the Mallory Crescent property
in 2018.
Dean Lisowick
Dean Lisowick was born in Winnipeg in 1973 and moved with his family to
Toronto as a child. By the time he was eight, Mr. Lisowick had been placed
into foster care with a family on Lake Simcoe. For a brief time, he enjoyed a
relatively stable childhood, exploring local creeks with his foster brothers.
Mr. Lisowick kept in touch with his birth parents. He had inherited his
mother’s artistic talent, and on one occasion reached out to her by sending her
a painting he had done. Mr. Lisowick’s mother passed away in 2011, never
having given up hope that, some day, she would be reunited with her son.
As a young adult, Mr. Lisowick moved to Toronto and began spending
time in the Village. He was unable to resist the temptation of drugs. At that
point in his life, Mr. Lisowick became involved in a relationship that produced
a child, but, sadly, his drug addiction led to his separating from his partner.
According to a friend, Mr. Lisowick would periodically talk about the
possibility of one day reconnecting with his daughter.
Mr. Lisowick described himself as bisexual. He became a familiar face
in the Village, where he was a sex worker. Although he was essentially a
loner, a man who had difficulty trusting people, he did have another side – a
sweet, gentle, caring, and generous side. I heard that “if he saw someone
being harassed, he was always the first to come to the rescue.” If he saw a
friend who was hungry, he would say, “Here’s five bucks.” Recognized as a
“good guy,” he became known affectionately as “Laser.”
For a while, Mr. Lisowick worked at Sneakers, a popular bar in the
Village. Its closure hit him hard, and he resorted to panhandling and other
ways to survive. Although he was homeless at the time of his death, a cousin
who kept in touch with him said he was in the midst of “making plans, setting
goals, and doing things needed to accomplish them.”
Mr. Lisowick was recorded as leaving the Scott Mission shelter on April
26, 2016. There is no evidence he was ever seen again.
Tragically, there is no evidence he was ever reported missing. Mr.
Lisowick’s disappearance became apparent only when his remains were found
and identified on the Mallory Crescent property. The police have determined
that McArthur killed Mr. Lisowick sometime between April 2016 and July
2017. He was about 43 years old.

Selim Esen
Selim Esen, the youngest of three boys, was born and raised in Turkey.
His parents easily accepted his sexual orientation, even though they well knew
the challenges he would face living there as an openly gay man.
After completing school and 18 months of compulsory military service,
Mr. Esen worked in the textile industry, earning money to support his family
while he studied sociology and philosophy. He graduated from Hacettepe
University in Ankara and then moved to Australia, where he worked as a
barista.
In the summer of 2012, Mr. Esen landed a dream job. Australian friends
bought a new café in a popular tourist area in Istanbul and hired Mr. Esen to
be the manager. All the employees but one were gay. By all accounts, this
period was a happy one for Mr. Esen.
In 2013, Mr. Esen and his partner, who was from Syria, moved to
Canada and married. Unfortunately, adjusting to a new country and a new
culture took its toll. After several separations, the couple broke up
permanently.
Mr. Esen’s friends described him as an intelligent and inquisitive
man who was always asking “Why?” According to his brother, Mr. Esen loved
nature and maintained his interest in textile design and philosophy. Most of all,
he was passionate about new experiences, learning new things, travelling to
new places, and meeting new people. His friends told me he had a calm nature
and a kind heart. He had a strong sense of social justice and was never
judgmental. His generosity prompted him to support others. He helped his
sister-in-law find a job when her husband passed away, and he gave financial
support to family and friends. They also described him as a romantic:
sometimes he walked the streets of Toronto at night, not aimlessly but
purposefully, hoping to cross paths with “the one.”
At the time of his disappearance, Mr. Esen had just completed a peer
training program at St. Stephen’s Community House. This achievement
positioned him to begin providing peer support, a role that would have been a
natural fit given his warm and welcoming personality. According to a
friend, in the spring of 2017, when Mr. Esen received his certificate from
St. Stephen’s, he was at a high point. He had just applied for a position at a
local Second Cup coffee shop.
Mr. Esen never showed up for his employment interview. He was
reported missing on April 30, 2017, 15 days after he was last seen. His
remains were discovered on the Mallory Crescent property. The police have
determined that McArthur killed Mr. Esen on or around April 16, 2017. He
was 43 years old.

Andrew K insman
Andrew Kinsman was born and raised in Ontario. After graduating from
Pickering High School, he went on to earn a BA in humanities from McMaster
University. As an adult, Mr. Kinsman dedicated much of his time to agencies
that assisted marginalized people. He became a staff member with the Toronto
HIV/AIDS Legal Network as an events and outreach coordinator. He was also
a contract employee and a long-time volunteer at the Toronto People with
AIDS Foundation.
Friends considered Mr. Kinsman an important part of the fabric of the
Village – a wise but passionate social justice advocate. As part of his advocacy
efforts, he educated people with HIV on where and how to access help. A
friend told me that, through his example, particularly his generosity, Mr.
Kinsmen made those around him “want to connect, to offer, to give, to share
and to make meaning together.”
Mr. Kinsman was described as “irresistibly charming” and
“uncommonly decent,” regularly welcoming people with a wide smile. He had
a “razor wit” and laughed easily. He also had a serious side. His wide studies
motivated him to debate the issues of the day fervently. Combining his
advocacy and love for cooking, he baked every week for the People with
AIDS Essentials Market. He frequently left treats at the doors of friends
and neighbours.
On June 26, 2017, Mr. Kinsman was last seen near his home in the
Village. When he went missing, friends quickly noticed something was amiss.
He had recently made plans with a friend to take his driving test. More
alarming, his cherished, elderly cat was found in his apartment, alone and
without food or water. It was completely incomprehensible for him to just
disappear.
The police determined that McArthur killed Mr. Kinsman on the day he
went missing. He was 49 years old. His remains were found on the
Mallory Crescent property.
Alloura Wells
Alloura Wells was born and raised in Toronto, the third of four children. Her
mother managed a Tim Hortons, and her father was a labourer. Ms. Wells was
enrolled in a special program at a school for the arts, where she completed
Grade 11.
Ms. Wells came out to her family as transgender when she was 18.
When she told her father she would be transitioning, he wisely told her:
“Do what you need to do. Just be a good person.” She found her way to
the Village, where she was quickly embraced as a vibrant, bubbly person and
“a great soul.” Her gregarious nature led her to be highly active on social
media.
In addition to her artistic gifts, Ms. Wells was a talented singer and had
a knack for fashion. Her ability to hit any note and reach four octaves sparked
her dream of becoming a professional singer, and she went on to make four
demo tapes. She set goals for herself in other areas of interest, particularly
those related to her Indigenous background. She participated in drum groups
and researched Indigenous history, medicines, and teachings.
Despite her many talents, Ms. Wells faced many challenges because she
was transgender. She found it difficult to apply for jobs when her physical
appearance didn’t match the gender on her government-issued identification.
She often met with inappropriate questions and outright hostility. Ms. Wells
had the emotional support of her father, her sister, and a network of friends,
but she needed an income. She turned to sex work.
In 2012, Ms. Wells signed up for the Ontario Works income support
program and rented an apartment near her sister. Her mother’s death a short
time later was devastating for the entire family. Her father and brother lost
their housing. After Ms. Wells herself was evicted from her apartment, she
lived in a tent in the Rosedale Valley ravine. She and her father kept in regular
contact, and even though he had very little money, Mr. Wells did what he
could to support his daughter.
In July 2017, Ms. Wells’s friends noticed that she had stopped updating
her Facebook page. Monica Forrester, an outreach worker at Maggie’s Sex
Workers Action Project, and other friends tried in vain to locate her. They
received information that she was in jail. It took months for this
misinformation to be corrected. On November 4, 2017, Mr. Wells reported his
daughter’s disappearance to the police.
On November 30, the coroner determined that an unidentified body that
had been found in the Rosedale Valley ravine three months earlier was, in fact,
Alloura Wells. Her cause of death remains an open investigation. Ms.
Wells was 27 years old.
Tess Richey
Tess Richey, the youngest of five sisters, was born in North Bay, Ontario. The
Richey women were very close. As the youngest, Ms. Richey was cherished –
and, in return, she put a high priority on connecting with and supporting her
family. She never missed a family function.
After she finished high school, Ms. Richey moved to Toronto for
greater opportunity. She took on part-time jobs as she furthered her studies. At
all times she remained loyal to her family. At one point, she returned to North
Bay to help her ailing aunt and, after her aunt passed away, she stayed with her
mother for a year.
Friends described Ms. Richey as engaging and funny, kind and
generous, a person of integrity. Her community benefited from her generosity
and passion for social justice. She combined her dedication to fitness and to
social issues by running in the Terry Fox Run every year and in another run
for a not-for-profit organization committed to educating youth about HIV and
AIDS.
Ms. Richey was also an advocate for women’s rights. She attended
George Brown College to earn a certificate in Assaulted Women’s and
Children’s Counselling and Advocacy. After her family reported she was
missing, they found a number of buttons in her apartment promoting an
awareness of violence against women. She regularly donated her hair to
the Angel Hair Foundation.
In addition to her advocacy work, Ms. Richey loved animals and kept
two dogs. She was also an animal rights activist: she protested against circuses
and supported the organization People for the Ethical Treatment of Animals.
She was interested in gardening, amateur photography, and especially travel.
She graduated from the Flight Services program at Seneca College, hoping to
become a flight attendant and to travel the world.
Tragically, this plan was not to be. On November 24, 2017, Ms. Richey
went with a friend to Crews & Tangos, a drag bar in the Village. She
didn’t return home. She was reported missing the next day. Four days
later, Ms. Richey’s mother found her daughter’s body in a stairwell close to
where she was last seen. She was 22 years old.

Unique Lives with Common Threads

My mandate on this Review focuses on one aspect of the state’s response to

these tragedies – the police response. However, an examination of the police
response cannot be carried out in isolation. It is important to pay attention
to the broader forces that left the victims vulnerable to exploitation and
violence in the first place.
Skandaraj Navaratnam, Abdulbasir Faizi, Majeed Kayhan, Soroush
Mahmudi, Kirushna Kumar Kanagaratnam, Dean Lisowick, Selim Esen,
Andrew Kinsman, Alloura Wells, and Tess Richey – each person was unique,
yet they all had something in common. Virtually all the people who went
missing from the Village between 2010 and 2017 were marginalized for one
reason or another, and often for multiple reasons: race, religion, sexual
orientation, gender identity, poverty, immigration status, addiction,
homelessness.
Marginalization is the social process by which individuals and
groups find themselves on the fringes of society. It blocks people from
rights, opportunities, and resources that others take for granted.
Marginalization can
be compounded by intersectionality, where co-existing identities make one
person’s life significantly more difficult than another’s. In this Report, I use
the terms “intersectionality” and “intersectional marginalization” to
describe those broader forces that made the victims at the heart of this
Review particularly vulnerable to harm.
The 10 people I have memorialized in this chapter shared another
common feature: they all (except for Tess Richey, a visitor) found refuge
in the Village as a place of acceptance. Against the background of this
rich diversity, the Village has been described as offering the connectedness of
a small town in a large city. Each June, Toronto plays host to Pride month with
numerous celebrations that culminate in one of the largest Pride festivals in the
world. This world-renowned celebration turns the streets in the Village into
parades and its parking lots into parties. The festival culminates on its last day
with the famous Pride parade. In essence, the Village gives people a place
where they can be their true selves. McArthur shattered any sense of safety by
targeting victims in his own community, preying on their vulnerability in the
very places they felt most shielded from harm.
I ask readers, as you go through this Report and consider my findings
and recommendations, to keep in mind the people whose lives, and deaths, lie
at the heart of this Review. Remember too the deeply affected
marginalized and vulnerable communities they left behind. Putting McArthur
behind bars has not brought matters to an end: many questions must be
answered and many issues must be addressed. The focus of these questions,
these issues, centres on “why so long?” Why did it take so long for the
Toronto Police Service to recognize there was a serial killer in the Village?
Why is it taking so long to identify and implement ways to heal the schism of
distrust that has permeated the relationship between the Police Service and
these communities? The Terms of Reference require me to examine both of
these important issues.
 Chapter 3 Roles of the Board and the 33
Service

Chapter 3

CIVILIAN GOVERNANCE AND

OVERSIGHT: ROLES OF THE BOARD
AND THE SERVICE

My mandate includes an examination of the bylaws, policies, and practices of

the Toronto Police Services Board (the Board), as well the procedures and
practices of the Toronto Police Service (the Service) particularly as they relate
to missing person investigations.
The Board, the Service, and the chief of police have critical roles to play
in ensuring that the Service conducts fair, efficient, and discrimination-free
missing person investigations and that appropriate oversight and
accountability exists for how such investigations are conducted. All three also
have critical roles to play in promoting positive relationships between the
Service and the communities it serves. It follows that it is essential to
understand the roles to be played by each and the relationship between them.
Such an understanding informs my findings and recommendations.
That understanding is largely derived from the provisions of the Police
Services Act (the Act), 1 as amended, and related jurisprudence, reports, and
commentary. I outline the relevant provisions of the Act below. I also consider
the language contained in the new Community Safety and Policing Act, 2019
(CSPA, 2019),2 although not yet proclaimed in force. When enacted, it will
replace the current Act and will reinforce the importance of the Board’s role in
the governance of the police and the need for the Board to be responsive
to diverse communities. I have also drawn heavily on the earlier Independent
Civilian Review into Matters Relating to the G20 Summit (the G20
Review) conducted by the Hon. John W. Morden, former associate chief
justice of the Court of Appeal for Ontario.3 Judge Morden’s June 2012
Report, also commissioned by the Board, sets out the legal relationship
between the Board, the Service, and its chief in terms that remain relevant
today.
Judge Morden identified certain misconceptions about the Board’s role.
These misconceptions led him to make recommendations to clarify the Board’s
1
RSO 1990, c P.15, as amended.
2
SO 2019, c 1, Schedule 1, not yet proclaimed.
3
John W. Morden, Independent Civilian Reviewinto Matters Relating to the G20 Summit: Report, Canadian
Electronic Libra ry, Documents Collection (Toronto: Toronto Police Services Board, June 2012) (hereafter
Morden Report).
role to ensure that the Board is able to fulfill the purpose for which it was
intended; namely, to provide effective civilian governance and oversight of the
Service. I am indebted to Judge Morden for his careful articulation of the
legislative regime that governs the Board, the Service, and its chief and of how
civilian oversight in policing should ideally function, consistent with that
legislative regime.
I agree generally with Judge Morden’s views on how the Board’s
civilian oversight should function. I have, however, refined and added to his
analysis, particularly in relation to his discussion of “critical points” that
trigger the obligation of the chief of police to disclose operational matters to
the Board.
Despite Judge Morden’s guidance in 2012, the Board has often not
functioned or been able to function in the way it should. For the purposes of
this Review, these shortcomings have manifested themselves, in part, in the
Board’s lack of awareness of critical issues relevant to its oversight role. In the
context of this Review, the Board and its chairs were unaware of:

 Project Houston,4 both while it was taking place and, more importantly,
when it had, in effect, been “wound down,” despite its clear implications
for the Service’s objectives and priorities, and despite the potential impact
of unsolved missing person investigations involving the LGBTQ2S+
communities on the Service’s relationship with those communities and on
the Service’s reputation;
 much of Project Prism,5 despite its implications for the relationship
between the Service and the LGBTQ2S+ communities and on the
Service’s reputation;
 systemic flaws in how missing person investigations were being
conducted;
 non-compliance with provincial adequacy standards relating to major case
management and the use or, more accurately, the underuse of PowerCase,
the provincially mandated case management tool for major cases; and
 relevant internal audits or other internal documents showing that the
Service was not compliant with provincial adequacy standards and raising
the potential impact of non-compliance on the Service’s reputation and
investigative effectiveness.
4
Project Houston, fully examined in Chapter 6, investigated an a lleged cannibalism ring that potentially
explained the disappearances of one or more of the three men reported missing from Toronto’s Gay Village
(the Village). Ultimately, the alleged ring proved to be irrelevant to the men’s disappearances.
5
Project Prism, fully examined in Chapter 7, investigated the disappearances of two additional men reported
missing from the Villa ge and ultimately uncovered Bruce McArthur’s multiple homicides.
 I have witnessed a commitment to changing how the Board functions,
especially in the interviews conducted with the Board’s executive director,
who brings to his position the added benefits flowing from his having been
counsel to Judge Morden. However, there remains a need for a renewed
understanding – on the part of both the Service and the Board – of the Board’s
governance and oversight responsibilities and of the requirement that the
Service overcome a legacy of withholding relevant information from the
Board. Such an understanding must be accompanied by a commitment on the
part of both the Board and the Service to conduct themselves in
accordance with the Board’s important governance obligations.
This renewed understanding must involve addressing the longstanding
misconception, despite Judge Morden’s clear direction, that the distinction
between operational and non-operational matters prevents the Service from
sharing information with the Board relevant to its mandate or immunizes the
Service from appropriate but circumscribed Board scrutiny of operational
matters. The statutory (and appropriate) prohibition against the Board’s
directing the chief of police on day-to-day operational matters continues to be
misinterpreted, much to the detriment of civilian governance and oversight. I
acknowledge the need for the Board to avoid political interference with the
police. However, my examination of the issues relevant to the Review’s
mandate supports my view that a more informed and active Board, albeit with
important safeguards, would be better positioned to improve not only police
practices but also relationships with marginalized communities – relationships
that are essential to better policing.

The Role of the Toronto Police Services Board

Under s. 27(1) of the Act, every municipality in Ontario that maintains a

police force must have a police services board.6 Such boards, including the
Toronto Police Services Board, have a critical function as civilian
oversight bodies. Indeed, according to s. 31(1) of the Act, such boards “are
responsible for the provision of adequate and effective police services in the
municipality.” This core responsibility largely defines the Board’s mandate
and its authority to establish this Review.

6
New legislation, not yet proclaimed, substitutes the term “police service board” for “police services board.”
I continue to use the current term to avoid confusion. Similarly, some of the legisla tion cited still refers to
“police forces” rather than the current term, “police services.”
 As stated in the Morden Report, Ontario policing legislation has
evolved. This evolution has significantly impacted the interpretation of the
roles and responsibilities of boards, police services, and their chiefs of police.
When the Act was introduced in the Legislature in 1989 and 1990, the solicitor
general indicated that it was designed (1) to provide boards, police
officers, and chiefs of police with a “clear direction and a more precise
definition of their roles and responsibilities”; (2) “to strengthen the role of
the police services board,” and (3) to bring about “an enhanced level of
interaction between the police and the community and to make our police
services more reflective of the community they serve.”7 Subsequent
amendments further affected how those roles and responsibilities are
understood. For example, the 1997 amendments first introduced the phrase
“adequate and effective police services,” reinforcing the responsibility of
Ontario boards to address both the quantity and quality of police services
provided in their municipalities.8
The Ontario Civilian Commission on Police Services, in its 1992 Report
of an Inquiry into Administration of Internal Investigations,9 articulated
the Board’s responsibility to the community under the Act:
Those who are responsible for the quality of policing must be accountable to
the public. Our whole system is predicated on accountability. The Chief is
accountable to the Police Services Board and through the Board to the
community.
The Police Services Board is responsible for providing civilian
monitoring of the force and setting policies for its operation. Because of this
obligation to monitor and because police investigate allegations against their
own members, expectations for scrutiny by the Police Services Board, as
representatives of the community, are high. It is imperative that Police
Services Boards understand their role and are held accountable to the public.
Their function is a crucial one; Boards exist to ensure that the policing
services provided meet community standards.10

7
Morden Report, 51.
8
Morden Report, 52. Note that s. 4(2) of the Act provides that adequate and effective police services must
include, as a minimum, the following: crime prevention, law enforcement, assistance to victims of crime,
public order maintenance, and emergency response. See also CSPA, 2019, s. 11.
9
Ontario Civilia n Commission on Police Services, Report of an Inquiry into Administration of Internal
Investigations by the Metropolitan Toronto Police Force ([Toronto: the Commission], 1992) (hereafter
Civilia n Police Commission, Report). The Commission examined, among other things, the propriety of an
agreement with an officer engaged in serious misconduct to withdraw a criminal charge, to undertake to lay
no other charges, and a promise to destroy evidence and to keep the terms secret if the officer resigned. The
Commission addressed what was known to the Board and what should have been known to it.
10
Civilia n Police Commission, Report, 5.
 The balance of s. 31(1) of the Act elaborates on what a board’s
responsibilities entail:

31(1) A board … shall,

(a) appoint the members of the municipal police force;
(b) generally determine, after consultation with the chief of police,
objectives and priorities with respect to police services in the
municipality;
(c) establish policies for the effective management of the police force;
(d) recruit and appoint the chief of police and any deputy chief of police,
and annually determine their remuneration and working conditions,
taking their submissions into account;
(e) direct the chief of police and monitor his or her performance;
(f) establish policies respecting the disclosure by chiefs of police of
personal information about individuals;
(g) receive regular reports from the chief of police on disclosures and
decisions made under section 49 (secondary activities);
(h) establish guidelines with respect to the indemnification of members of
the police force for legal costs under section 50;
(i) establish guidelines for dealing with complaints under Part V, subject
to subsection (1.1);
(j) review the chief of police’s administration of the complaints system
under Part V and receive regular reports from the chief of police on his
or her administration of the complaints system. [Emphasis added.]

As stated in s. 31(1)(c), a board shall establish policies for the effective

management of the police force. Under s. 31(6), a board may also use bylaws
to accomplish the same purpose.
I have examined the Board’s relevant policies in formulating the
recommendations in this Report. In so doing, I have been careful to avoid
confusing the policies the Board creates to manage the police force, and the
procedures or processes the chief creates to implement the Board’s policies.11

The Community Safety and Policing Act, 2019

In my view, a board’s role as set out in the CSPA, 2019, is fundamentally the
same as that described in the current Act, despite some differences in how that

11
Sometimes, the term “policies” is used by others, including those the Review interviewed, to refer to
procedures and processes created by the Service or chief of police.
role is articulated, and despite added specificity and responsibilities in the
CSPA, 2019.
Under ss. 10(1) and 37(1) of the CSPA, 2019, a board shall, among
other things, “provide adequate and effective policing in the area for which it
has policing responsibility in accordance with the needs of the population in
the area and having regard for the diversity of the population in the area”;
monitor the chief of police’s performance and review that performance at least
annually in accordance with any regulations; and monitor the chief’s
handling of discipline within the police service.
Under s. 38(1) of the CSPA, 2019, a board shall also establish policies
respecting, among other things, the administration of the police service; the
provision of adequate and effective policing; the handling of discipline within
the police service; and any other prescribed matters. Under s. 39, a board is
also required to establish a strategic plan:
39 (1) The police service board shall, in accordance with the regulations, if
any, prepare and adopt a strategic plan for the provision of policing, which
shall address at least the following matters:12
1. How the police service board will ensure the provision of adequate and
effective policing in accordance with the needs of the population of the
area.
2. The objectives, priorities and core functions of the police service.
3. Quantitative and qualitative performance objectives and indicators of
outcomes relating to,
i.the provision of community-based crime prevention initiatives,
community patrol and criminal investigation services,
ii. community satisfaction with the policing provided,
iii. emergency calls for service,
iv. violent crime and clearance rates for violent crime,
v. property crime and clearance rates for property crime,
vi. youth crime and clearance rates for youth crime,
vii. police assistance to victims of crime and re-victimization rates,
viii. interactions with persons described in paragraphs 4 and 5 of this
subsection,
ix. road safety, and
x. any other prescribed matters.
4. Interactions with,
i. youths,
ii. members of racialized groups, and
12
These matters track many of the items identified as components of a “businessplan” under the current
Ontario Regulation 3/99, s. 30. Items 3(viii), 4, and 5 above represent additional matters that must be
addressed in a stra tegic pla n.
 iii. members of First Nation, Inuit and Métis communities.
5. Interactions with persons who appear to have a mental health
condition.
6. Information technology.
7. Resource planning.
8. Police facilities.
9. Any other prescribed matters.

Both the Act and the CSPA, 2019, require a police services board to
establish policies to advance adequate and effective policing, to address
objectives and priorities of the service, and to monitor the performance of a
chief of police. Both also permit a police services board to “direct” the chief
of police, with similar limitations on the scope of that direction. I address the
scope of such direction below.
I outline above the specific matters that the CSPA, 2019, requires a
board to include in its strategic plan. These specific matters do not include
missing person investigations although I later recommend, based on the
systemic issues identified during this Review, that the Board’s future strategic
plan specifically address missing person investigations and related
performance objectives and indicators of outcomes. Of course, the Board may
choose to do so, regardless of whether the legislation requires it.
I said that the CSPA, 2019, does not fundamentally change the role of
police services boards. However, it does impose important, additional
obligations on boards. These obligations are relevant to my mandate. The
CSPA, 2019, requires that all board members take training approved by
the minister of community safety and correctional services (the minister) 13 on
the board’s role and its members’ responsibilities, on human rights and
systemic racism, and on recognition of and respect for “the diverse,
multiracial and multicultural character of Ontario society, and the rights and
cultures of First Nation, Inuit and Métis Peoples."14
This focus on diversity is also reflected in at least four other
requirements. First, a municipality must prepare and adopt a diversity plan to
ensure that the members of its municipal boards, including the police services
board, who are appointed by the municipality, are representative of the
municipality’s population.15 Second, both the minister and municipal councils
must take additional steps as set out in the CSPA, 2019, to promote diversity

13
In this Report, the terms “solicitor general” and “minister of community safety and correctional services”
and the related ministries are used interchangeably. Both were in use at various times.
14
CSPA, 2019, s. 35(1).
15
CSPA, 2019, s. 28(1).
in their appointments to police services boards, especially in relation to
members of demographic groups that have been historically underrepresented
on such boards, including racialized groups and First Nation, Inuit, and Métis
communities.16 Third, in developing its mandatory strategic plan, a board must
consult with the chief of police and “groups representing diverse communities
in the board’s area of policing responsibility” and consider the needs of such
communities, including those of racialized groups and of First Nation, Inuit,
and Métis communities.17 And, fourth, a board is required to prepare and adopt
a diversity plan to ensure that the members of the service itself reflect the
diversity of the area for which the board has policing responsibility.18
In its emphasis on diversity, the CSPA, 2019, both recognizes the
challenges of providing effective and fair police services to diverse
communities and reinforces and modernizes the traditional idea Robert Peel
first articulated in 1829 that a police service should reflect the public. I refer to
these statutory provisions again when addressing human rights issues and
systemic bias and discrimination in later chapters. They represent a
welcome addition to the current legislation, particularly given that police
services, including the Service and its Board, must respond to and address, on
a priority basis, concerns about overpolicing and underservicing of our
diverse, marginalized and vulnerable communities and issues around systemic
bias, discrimination, and differential treatment.

The Role of the Ministry of Community Safety and

Correctional Services

A complete understanding of the roles played by a board and the chief of

police also compels consideration of the roles assumed by the Ministry of
Community Safety and Correctional Services (the ministry), the minister, and
the Ontario government in promoting adequate and effective policing in
the province.19 The provision of such policing in Ontario is a joint
responsibility of the province and the board. The province serves as an
important backstop should any police service fail to abide by minimal
provincial adequacy standards.
Paragraph 135(1) 1.1 of the Act empowers the Lieutenant Governor in
Council (that is, the Ontario Cabinet) to make regulations establishing and
governing standards concerning the adequacy and effectiveness of police

16
CSPA, 2019, s. 29(1).
17
CSPA, 2019, ss. 39(3) and 39(4).
18
CSPA, 2019, s. 37(1)(e).
19
In July 2019, the Ontario government resurrected use of the designations “solicitor general” and “Ministry
of the Solicitor General.”
services, including prescribing methods for monitoring and evaluating the
adequacy and effectiveness of police services against such standards. One key
regulation made under that power is Ontario Regulation 3/99. Called
“Adequacy and Effectiveness of Police Services,” it is designed to
promote province-wide standards for police services. Thus, although boards
and chiefs of police continue to have discretion in the creation of policies,
procedures, or processes, Ontario Regulation 3/99 requires every board to
establish policies with respect to a range of identified matters. These
generally correspond to requirements imposed under the Regulation on chiefs
of police to establish procedures or processes about these matters.
The Regulation also requires every board and chief of police to
implement a process ensuring the delivery of adequate and effective police
services and compliance with the Act and its regulations. Every board is
required to evaluate the adequacy and effectiveness of the services provided
by its police force by comparing those services with the requirements of this
Regulation.20 Of course, the Regulation must be read in conjunction with
requirements for board policies already set out in the Act. The same will hold
true for any regulations created under the CSPA, 2019.
Ontario Regulation 3/99 requires a board to have policies on
investigations into missing persons, on joint force operations, on internal task
forces, and on undertaking and managing general criminal investigations. 21
Similarly, the Regulation requires the chief of police to establish procedures
and processes in respect of those matters. 22 Regulations do not represent the
only way in which the government may promote province-wide policing
standards. Subsection 3(2) of the Act imposes statutory requirements on the
solicitor general, including the requirement that the solicitor general shall:

 monitor police services to ensure that adequate and effective police

services are provided at the municipal and provincial levels,
 develop and promote programs to enhance professional police practices,
standards, and training,
 conduct a system of inspections and review of police services across
Ontario,
 assist in the coordination of police services,
 provide information and advice respecting the management and operation
of police services,
20
Ontario Regulation 3/99, ss. 35 and 37.
21
Other relevant policies are identified, and addressed, in subsequent chapters.
22
Ontario Regulation 3/99, ss. 12(1)(l), 13(1)(a) and (b), s. 29.
 issue directives and guidelines on policy matters, and
 develop and promote programs for community-oriented police services.

In 2000, in accordance with this mandate, the Ministry of the Solicitor

General, Policing Services Division, created the Policing Standards Manual.
It is designed to assist boards, chiefs of police, police associations, and
municipalities with their understanding and implementation of the Act and its
regulations, including Ontario Regulation 3/99. The manual sets out sample
policies on what must be the subject of a policy and guidelines on what must
be the subject of procedures. As these sample policies and guidelines are
advisory only, boards, chiefs of police, police associations, and municipalities
“may consider comparable equivalents when addressing compliance with the
Act and its regulations.”23
The sample policy on missing person investigations provides that the
chief of police will develop and maintain procedures that:

(a) set out the steps to be followed for undertaking investigations into reports of
missing persons, including situations involving children, teenagers, and elderly
and vulnerable adults,
(b) ensure investigative follow-up on outstanding cases, and
(c) where circumstances indicate a strong possibility of foul play, require officers to
comply with the procedures set out in the Ministry’s designated Ontario Major
Case Management Manual (the MCM Manual).

The guidelines provide that every police service’s procedures on investigations

into missing persons should contain at least 18 specified items. Some of these
items are elaborated on in Chapters 4 and 13.
Undoubtedly, changes will be made to Ontario Regulation 3/99 and the
related Policing Standards Manual to correspond not only to the CSPA, 2019,
or other legislative changes, but also to changes already made or to be made to
related documents, such as the ministry’s MCM Manual.
To state an obvious but important point, Ontario Regulation 3/99 and
the Policing Standards Manual certainly do not prevent a board or chief of
police from developing policies, procedures, and processes on matters not
mandated by legislation24 or policies, procedures, and processes on mandated
matters that exceed the standards articulated in the sample draft policies
or
23
Policing Standards Manual, Preamble, 1/1.
24
A board’s discretion to determine whether a policy on a subject matter is required was confirmed in
Odhavji Estate v Woodhouse, [2003] 3 SCR 263 at paras 65–66. However, fulfilment of the board’s role and
responsibilities may obligate the board to create a policy on subject matters not provided for in the Act or
regulations.
guidelines. It is also true that, strictly speaking, a board and chief of police are
not obliged to accept the guidance the manual provides on the content of
policies, procedures, and processes. Simply put, they might choose to include
less content than that set out in the manual. However, in my view, insofar as
the manual addresses policies, procedures, and processes relevant to my
mandate, its content represents bare minimum requirements, consistent with
the roles and responsibilities of a board and chief of police and the overriding
requirement to provide adequate and effective policing in the municipality.
I also observe that this manual does not represent the only guidance or
direction the ministry provides, relevant to my mandate. Ontario Regulation
3/99 and the Policing Standards Manual must also be read together with the
subsequently enacted Ontario Regulation 354/04, entitled “Major Case
Management.” Ontario Regulation 354/04 requires every board to establish
policies with respect to major cases in accordance with the MCM Manual. It
also requires every police chief to develop and maintain procedures on and
processes for undertaking and managing investigations into major cases25
in accordance with the manual. Subsection 1(2) of the same Regulation
also requires every police service involved in major cases to use the
software approved by the ministry. In Chapter 4, I examine in detail the
provisions of Ontario Regulation 354/04 and the MCM Manual. They provide
direction on how missing person investigations are to be conducted. Indeed, in
subsequent chapters, I explain how the Toronto police were not in compliance
with these provisions when conducting the Bruce McArthur–related
investigations.
I interpret Ontario Regulation 354/04 as preserving the discretion of the
board and the chief respecting the content of their policies, procedures, and
processes respecting major cases with at least two limitations – such policies,
procedures, and processes must conform to the MCM Manual, and police
services must use the ministry’s approved software when conducting
investigations into major cases, as defined by the Regulation.
The MCM Manual represents an important tool in providing direction to
the police services province-wide on matters relevant to my mandate.
There are other tools. For example, under its inspection and review
powers, the ministry may audit and report on a service’s compliance with
the Act and regulations. Later in this Report, I discuss the ministry’s recent
major case management audit of the Service.

25
Subsection 1(1) of Ontario Regulation 354/04 relates this requirement to the pre-existing requirement in
Ontario Regulation 3/99 for every chief to develop and maintain procedures on and processes for
undertaking and managing general criminal investigations.
 In Chapters 4 and 13, I examine the Board’s and the Service’s existing
policies, procedures, and processes on matters relevant to my mandate. I
measure them against Ontario Regulation 3/99, Ontario Regulation 354/04, the
Policing Standards Manual, and the MCM Manual, as well as other documents
that promote provincial adequacy standards, such as ministry audits. I also
evaluate them in the light of recommended changes to existing practices,
developed as a result of the lessons I believe can be learned from the missing
person investigations that prompted this Review, our community outreach and
engagement, and from other jurisdictions in Canada and internationally.

The Role of the Inspector General of Policing and the Ministry

under the CSPA, 2019
The ministry’s role in promoting province-wide policing standards is expanded
under the CSPA, 2019. Part VII of the CSPA, 2019, creates a new agency, the
Office of the Inspector General of Policing. Since the Ontario government
recently named its first inspector general, 26 we can reasonably expect that Part
VII of the CSPA, 2019, will be proclaimed in whole or in part. I note, with
interest, that under the 2019 Act, the inspector general and his deputies, like
police service board members, shall receive training about “the diverse,
multiracial and multicultural character of Ontario society, and the rights and
cultures of First Nation, Inuit and Metis Peoples.”
Under Part VII, the inspector general’s duties include

 monitoring and conducting inspections of police services boards, chiefs of

police, and police services to ensure compliance with the CSPA, 2019, and
its Regulations;
 consulting with and advising such boards, chiefs, and services
regarding such compliance;
 monitoring and conducting inspections of board members to ensure
they do not commit misconduct;
 conducting analyses regarding compliance with the CSPA, 2019, and
its regulations; and
 dealing with complaints against board members and, more important to my
work, complaints respecting the adequacy and effectiveness of police
services being provided; the failure of a board, chief of police, or
police service to comply with the CSPA, 2019, or its regulations (other
than failures amounting to misconduct), including a systemic failure;
and the
26
The inspector general is a Cabinet appointment, though pursuant to s. 102(9) of the CSPA, 2019, the
minister shall not direct the inspector general with respect to the performance of his or her functions under
the legisla tion.
 policies of a board or the Minister or the procedures established by a chief
of police.27

With certain exceptions, the inspector general is to forward to the board

and the minister complaints about board policies or procedures established by
a chief of police. The board must report back to the inspector general and the
minister about steps taken to respond to the complaint. The minister is also to
consider whether changes are required to training or to requirements under the
CSPA, 2019, or its Regulations.28
The CSPA, 2019, confers significant inspection powers on the inspector
general and his or her inspectors.29 The minister may also request an
inspection.30 The CSPA, 2019, provides for publication of inspection reports. 31
Finally, I note that the inspector general may issue directions to a board, chief
of police, or service to remedy or prevent non-compliance with the CSPA,
2019, or its regulations, and has a range of remedies available if these
directions are not complied with, including suspending or removing board
members or a chief of police, or, as a last resort, dissolving the service or the
board.32
In this Report, I find that, in a number of important ways, the Service
failed to comply with existing provincial adequacy standards in relation to
major case management and the use of mandated case management software.
I have concentrated on the new inspector general’s responsibilities since my
recommendations take into consideration the inspector general’s anticipated
role in developing a strategy to ensure future compliance. The inspector
general has many new powers and responsibilities under the CSPA, 2019.
Once the Act is proclaimed into force, it will be up to the inspector general to
decide his or her priorities. In my view, the general findings contained in this
Report suggest that ensuring compliance with minimal provincial
adequacy standards should be given top priority. The inspector general should
try to take a preventative approach that, among other things, engages both
police services and boards, thus attempting to break down any silos that may
exist between these entities.
Subsection 3(1) of the CSPA, 2019, sets out the minister’s general
duties. Some of these duties are similar to the minister’s current

27
CSPA, 2019, s. 102(4); ss. 106 and 107. The minister may also make a complaint under ss. 106 or 107.
28
CSPA, 2019, s. 107(6–9).
29
CSPA, 2019, ss. 111, 113–17.
30
CSPA, 2019, s. 111(11).
31
CSPA, 2019, s. 123(3).
32
CSPA, 2019, ss. 125(1) and 126.
responsibilities. I refer to coordinating policing, operating the Ontario Police
College, and developing and maintaining standards of training and education
provincially. I will return to the important issues surrounding training and
education later in this Report. At this juncture, suffice it to say that the lessons
learned during this Review should inform the content of the Ontario Police
College’s curriculum, the training and education of board members, and
provincial adequacy standards for the training and education of police officers
by municipal services. The focus of CSPA, 2019, on human rights, diversity,
and systemic racism should also underlie new provincial adequacy standards
for training and educating police officers on issues such as racism,
discrimination, differential treatment, diversity, and intersectionality, concepts
explored in detail in Chapters 12 and 14.
Several of the minister’s newly articulated duties are of importance
here. First, the CSPA, 2019, states that the minister is to conduct research
and analysis:

 on policing, the administration of police services, and related matters,

including “the effectiveness, efficiency, sustainability and legitimacy of
different methods of providing policing,” and compliance with the Charter
and the Human Rights Code “(and that the Minister is to consult with and
advise boards, chiefs of police and police services on these topics)”; and
 “to inform policy and program development, system planning, and the
evaluation of service delivery and outcomes in respect of policing, public
complaints and related matters.”33

As Professor Laura Huey’s research paper shows, there is a dearth of

evidence-based research and analysis concerning best practices around missing
person investigations, particularly on risk assessment. 34 There is, therefore, a
compelling case for the minister to contribute to research in this area, in
partnership with others including academic institutions. In my view, the
CSPA, 2019, supports the creation of a “centre for policing excellence” to
proactively examine policing best practices in a variety of areas. In Chapter 15,
I outline the contours of a proposed centre for policing excellence.
Second, under the CSPA, 2019, the minister has a duty to “develop
programs for community-responsive policing” and consult with boards, chiefs
of police, and police services regarding the preparation, adoption, and
33
CSPA, 2019, ss. 3(1)(d)(e) and (g). See also s. 3(1)(b).
34
Laura Huey, “An Absence of Evidence: Mapping the Evidence / Gaps, Themes and Other Issues with
Canadian Research on Missing Persons,” https://www.missingpersonsreview.ca/researchprogram. This
research paper was one of those commissioned by the Review.
implementation of community safety and well-being plans. 35 In my view, this
provision and others contained in the current Act and in the CSPA, 2019,
underscore the importance of the province addressing the issues identified
during this Review, to ensure that the best possible practices in policing,
including community-responsive policing, are applied province-wide. In
general, the province should set minimal standards, and local boards should
aim to tailor and enhance these standards for their own communities.

The Relationship Between the Roles of the Board and

the Chief of Police

Subsections 31(3) and (4) of the existing Act impose important restrictions on
the board’s role. They also inform the relationship between the board and its
chief of police. These subsections state:

31(3) The board may give orders and directions to the chief of police, but
not to other members of the police force, and no individual member of the
board shall give orders or directions to any member of the police force.
31(4) The board shall not direct the chief of police with respect to specific
operational decisions or with respect to the day-to-day operation of the
police force.

A board’s responsibilities must be read and interpreted in conjunction with the

statutory duties of a chief of police. Section 41 provides as follows:
41(1) The duties of a chief of police include,
(a) in the case of a municipal police force, administering the police force
and overseeing its operation in accordance with the objectives,
priorities and policies established by the board under subsection 31 (1);
(b) ensuring that members of the police force carry out their duties in
accordance with this Act and the regulations and in a manner that reflects
the needs of the community, and that discipline is maintained in the
police force;
(c) ensuring that the police force provides community-oriented police
services;
(d) administering the complaints system in accordance with Part V.

35
CSPA, 2019, ss. 3(1)(f) and (i). See also s. 3(1)(j) respecting the monitoring and evaluation of programs
and their outcomes relating to policing or community safety and well-being plans, funded in whole or in pa
rt by the ministry.
 41(2) The chief of police reports to the board and shall obey its lawful orders
and directions. [Emphasis added.]
To perform their respective functions effectively, a board and the chief of
police cannot operate in silos. Paragraphs 31(1)(b) and 41(1)(a) are
illustrative. A board shall generally determine, after consultation with the
chief of police, the service’s objectives and priorities, and the chief is to
administer the police force and oversee its operations in accordance with the
objectives, priorities, and policies the board establishes. It follows that the
chief, and not merely the board, has an important role to play in developing
the service’s objectives, priorities, and related procedures. As Judge Morden
observed:

It is sometimes said, in simple and general terms, that policies are for the
Board and operations are for the chief of police and that the two must
always be kept separate. Apart from being impossible to apply in its own
terms, this statement does not represent what the statute provides.36

I have already referred to the chief of police’s role in working with the
board to develop the service’s objectives and priorities, and to create its
policies. The corollary of this principle is that the board has an important role
to play in operational matters, as long as it does not violate the prohibition
contained in s. 31(4) of the Act.
What does this mean in practice? First, the board is prohibited from
directing the chief of police about specific operational decisions or the day-to-
day operation of the police service. The Code of Conduct governing board
members, set out in Ontario Regulation 421/97, reinforces this prohibition.
Section 2 of the Code of Conduct states that board members shall not interfere
with the police service’s operational decisions and responsibilities or with the
day-to-day operation of the police force, including the recruitment and
promotion of police officers. As Judge Morden observed, the prohibition
contained in s. 31(4) “gives expression to a very important common law
principle relating to police independence from political, and other interference
with its law enforcement responsibilities.”37
Second, the prohibition in s. 31(4) does not prevent the board from
expressing its opinion or making suggestions to the chief on any matter
relating to policing in Toronto, including operations. However, in my view, a
board must proceed cautiously in expressing an opinion or making suggestions
to the chief concerning a specific, ongoing criminal investigation. I say
that for
36
Morden Report, 54.
37
Morden Report, 56.
several reasons. First, decisions on who should be investigated, arrested,
and/or charged have been described as the law enforcement function at “the
core of police independence.”38 The distinction between providing
direction and discretionary opinions or suggestions can be fraught with
danger.
One of the observations Judge Sidney Linden made in the Ipperwash
Report is the difficulty of maintaining a distinction between government
directions and advice in practice. 39 At the Ipperwash Inquiry, Judge Linden
regarded such a distinction to be “neither sound nor sustainable.” Of course,
Judge Linden was considering this distinction in the context of allegations that
the Ontario government pressured the OPP to remove Indigenous occupiers
from a park. Although he found that the government did not direct the OPP, its
comments put unwarranted pressure on the OPP in relation to an active
operational matter.
In my view, the answer is not to foreclose the Toronto Police Services
Board from making non-binding recommendations or suggestions, or
expressing opinions about ongoing operational matters, especially since,
historically, criticisms of the Board have had more to do with inadequate
oversight, rather than improper interference with the Service. So, the answer
is to ensure the Board is always mindful of the prohibition against directing
day-to-day operations. When the Board believes it appropriate to make
recommendations or provide suggestions or advice on an ongoing operational
matter, it should always be able to articulate how the recommendations,
suggestions, or advice relate to policy, the Service’s objectives or priorities, or
the Board’s mandate. If the chief is of the view that the Board’s intervention
transcends the prohibition against directing day-to-day operations, the Board
should memorialize its position in writing.
A board’s ability to ask questions, make recommendations, or provide
advice or suggestions is important to ensure that it is fully informed about
ongoing and completed operational matters relevant to its mandate. I say that
for several reasons. Policy and operations are not watertight compartments.
Operational matters can reveal the need for new and revised policies,
particularly if policing is, as it should be, evidence-based and subject to
continuous improvement. The objectives and priorities the board sets, after
consultation with the chief of police, directly impact operations. Only a robust
appreciation of contemplated or completed operations, so long as that

38
Ontario, Report of the Ipperwash Inquiry, Volume 2: Policy Analysis (4 vols., Toronto: Ministry of the
Attorney General, 2007), 310ff (Commissioner Sidney B. Linden) (hereafter Ipperwash Report); see also: R
v Campbell, [1999] 1 SCR 565.
39
Ipperwash Report, 308, 334.
appreciation has relevance to the adequacy or effectiveness of policing,
enables the board to develop appropriate objectives and priorities.
Similarly, although the board’s policies cannot violate the prohibition in
s. 31(4) (for example, by providing that the board shall direct the chief of
police on when specific arrests for certain crimes will take place), they can set
out a context or framework within which police operations take place. A
policy on building partnerships with Indigenous communities, for instance,
will be relevant to the types of human resources deployed by the police (such
as an Indigenous incident commander or liaison officer, active
involvement of Elders, etc.) in advance of or during an impasse to resolve a
matter.
The board can develop policies that affect operations without
impermissibly directing the chief of police with respect to specific operational
decisions or day-to-day operations. Indeed, policies that have no potential
effect or impact on operations may justifiably be regarded as worthless. And
sometimes policy issues may crystalize in the light of ongoing operations. As
well, non-interference with core law enforcement activities does not mean that
police should not be called upon to explain and justify their actions. It does not
mean that a board cannot scrutinize such activities, when relevant to larger
issues within the board’s mandate. As stated by Judge Linden: “Tipping the
balance too far in favour of police independence … can result in the police
effectively becoming a law onto themselves.”
Tipping that balance too far can undermine accountability. This Review
is a perfect example of the appropriate role of the Board – by commissioning
this independent Review, the Board is effectively scrutinizing police
operations, with a view to implementing systemic changes. Finally, the police
may need a board’s intervention during an ongoing criminal investigation to
address issues, such as availability of resources or the need to engage
marginalized communities. These issues may affect the continuing
investigation or similar investigations, or the relationship between the police
and those communities generally, and ultimately a service’s reputation.
In summary, when relevant to its statutory duty, a board has a duty
to obtain operational information, in relation to contemplated, ongoing, and
past operations.
Accessing the Needed Information

The …. Board appears to have boxed itself into a Catch-22 situation. The
Chief did not tell the Board more because it did not ask. The Board did not
ask because it assumed the Chief would not tell.
In order for the … Board to know whether its policies have been
followed in the Junger matter, and whether the Chief had exercised good
judgment, it should have required answers from the Chief.
~ Civilian Police Commission, Report, 34.

It is imperative that a board have access to information relevant to its mandate.

Information pertaining to contemplated, ongoing, or completed operations
is generally known to the chief of police, rather than the board. Accordingly,
it is necessary that the chief of police provide all relevant information to
the board. The board must have such information and in a timely fashion to
fulfill its statutory obligations. As Judge Morden stated:

The relationship between the board and the chief imposes duties on each of
them: on the board to ask questions about past and future situations and
events related to policing in the municipality; and on the chief to inform the
board on situations and events that the board should know about. Most of
the time, the chief has the information and the board does not. The board
cannot ask questions about the information of which it is unaware.
Accordingly, the burden is on the chief to take the initiative in ensuring that
the board is properly informed about matters – past, present or future – that
fall under the purview of the board’s responsibilities.40 [Emphasis added.]

When Judge Morden issued his report in 2012, he concluded that,

despite the clear wording of the Act, Toronto Police Services Board members
continued to incorrectly define their responsibilities in terms of a complete
separation between policy and operations. This meant that the Board, at times,
incorrectly limited its oversight role to “view it as improper to engage in a
discussion that involves the Board asking questions about, commenting on, or
making recommendations concerning operational matters.”41
To address this problem, Judge Morden outlined three elements of a
consultation protocol he proposed the Board use in its interactions with
the chief of police. He identified those elements as (1) exchange of
information,

40
Morden Report, 59.
41
Morden Report, 84.
(2) identifying the critical points, and (3) collaboration on defining an
operation but not its execution.

Exchange of Information
I have discussed this element earlier. The chief must be prepared to share
operational information with the board: “a police board cannot be satisfied that
it is properly analyzing a policy issue and developing an appropriate policy if
it does not see any material that shows what the situation ‘on the ground’
actually is.”42 Inherent in an information exchange, however, is that it is
reciprocal. The board and the chief of police must discuss an issue that may
result in a new policy. After all, operational decisions are affected by the
policies framing those decisions. Judge Morden explained how the absence of
an exchange that involves all relevant information erodes the foundation
of civilian oversight:

Refusing to create and maintain a reciprocal exchange of information could

lead to a situation where a police board does not engage in certain
discussions or ask certain questions for fear that it will be told it is treading
on operational matters. This “[t]imidity” is what has caused police boards to
be seen to be “‘lame duck’ institutions.” This is dangerous. We must avoid
an approach to civilian oversight where the objective becomes separating the
policy decision from the operational implementation of that decision, as this
can open up “‘escape hatches’ though which policy maker (i.e., the police
board) and policy implementers (i.e., the police service) can avoid
responsibility.”43

Sometimes, operational information must be given to and discussed by

the board confidentially, for example, where it is provided in relation to a
contemplated or ongoing operation or where the information, if public, might
reveal sensitive information (such as some investigative techniques, the
disclosure of which could undermine ongoing or future operations). Judge
Morden outlined the powers available to board members to receive
information confidentially, and their related duty to keep that information
confidential.44

Identifying the Critical Points

Not every operational detail need be provided to the board for it to ensure
adequate and effective policing in Toronto. Judge Morden referred to the
threshold or “critical points” for disclosure. He regarded a “critical point” as
a
42
Morden Report, 85–86.
43
Morden Report, 87 (citations omitted).
44
Morden Report, 88–89.
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.
In Judge Morden’s view, where a “critical point” exists, the chief
“should provide the Board with an operational briefing that outlines the broad
contours of the operation / event / issue, highlights the existing Board policies
that may apply, if any, and generally ensures that the Board is informed of
what is going to take place. If the Board has knowledge of a “critical point,” it
can discharge its important governance role by analyzing the policy
framework that may apply and determine whether a vacuum in that policy
framework must be filled.”45 Judge Morden recommended that the Board, in
consultation with the Service, draft a policy that defines a “critical point” in
policing and that identifies criteria to be applied in determining when a
“critical point” is reached.46
The Board never created such a policy. It should have. Judge Morden’s
proposed definition of a “critical point” provides one useful litmus test for
when operational information should be provided to the Board. However,
Judge Morden did not set his definition of a “critical point” in stone. He
suggested that the definition should be reviewed by the Board on a
continual basis.47
In my recommendations, I provide additional guidance to the chief and
the Board on the circumstances under which a “critical point” is reached. For
example, some major operations have such a potential impact on the Service’s
objectives, priorities, or reputation to compel disclosure to the Board in
circumstances where senior command may not have formally approved the
operations or been involved in their advance planning. After all, there are no
clear criteria in the Service as to what operations must be approved by senior
command.
As well, given the focus of CSPA, 2019, on human rights, systemic
racism, and the adequacy and effectiveness of policing marginalized and
vulnerable communities, the definition of “critical point” should, in part,
be tied to operations likely to have an impact on the Service’s relationship
with those very communities. One example of such an operation was
Toronto’s Marie Curtis Park Project.48 The project is elaborated on in
Chapter 14. The Service’s approach to the Marie Curtis Park issue further
undermined, to a considerable extent, its relationship with the LGBTQ2S+
communities. The
45
Morden Report, 89–90.
46
Morden Report, Recommendation 5, p 9.2.
47
Morden Report, 8.
48
Also known as Project Marie.
Board could have played a meaningful role in raising with the chief
whether this project aligned with the Service’s objectives and priorities
and, equally important, whether the Service was working with the
LGBTQ2S+ communities, community leaders, and consultative committees to
resolve the issues in a way that did not involve charges.
Of course, the use of “critical points” to assess whether operational
information should be provided to the Board in advance of or during an
operation does not address the need to share such information after an
operation or event has occurred. As I have already said, such operations,
events, or issues may affect the Service’s ongoing objectives and priorities on
the development or refinement of policies and, ultimately, on accountability
for decisions made. I can do no better than to reproduce Judge Morden’s
comments:

After the police have acted and the operation is over, the police board is able
to consult with the chief of police and ask questions about why a certain
operational decision or activity was or was not taken. In applying this
principle of retrospective accountability after an operation is over, a police
board could seek reports from the chief of police, initiate reviews into
particular policing matters that arise from a specific operation that has taken
place, and engage in a process with the chief of police to identify priorities
and objectives for future operations of a similar nature.49

Judge Morden accurately identified typical issues or questions that a

board might wish to raise with a chief of police in a consultation after a
specific operation or activity has taken place. The following questions arising
from my Review are illustrative:

 Why was Project Houston unsuccessful in solving the disappearances of

the missing men?
 Why was it wound down when it was?
 Was solving these disappearances treated as a priority before, during, or
after the project was wound down?
 Were there any deficiencies in the project’s operational plan or in its
implementation?
 Did the project have the resources it required to conduct its investigation
in an effective and timely way? Were disproportionate resources
devoted to the international investigation of alleged cannibalism?

49
Morden Report, 97.
 Did the project fully utilize existing technology? If not, why not? What
steps, if any, should be taken to promote optimal use of technology in the
future?
 Did the Service work effectively with other police services? If not,
why not? What steps should be taken to rectify any deficiencies in this
regard?
 Did the project appropriately engage and communicate with affected
communities? If not, why not? What steps should be taken to rectify any
deficiencies in this regard?
 Were the investigations into the disappearances of Mr. Skandaraj
Navaratnam and Mr. Majeed Kayhan before Project Houston effective? If
not, why not?
 Were those investigations and Project Houston conducted in
compliance with existing policies, procedures, and processes? If not, why
not?
 Were those investigations and Project Houston conducted in
compliance with existing provincial adequacy standards, for example, in
compliance with the Major Case Management Manual? If not, why not?
 Did the Service give appropriate priority to missing person
investigations generally?
 How has the relationship between the Service and the communities it
serves been affected by how specific missing person investigations
were conducted? How can any impairment in that relationship be
rectified?
 Did bias, systemic or otherwise, impact the missing person
investigations being scrutinized? If so, how should this be addressed?
 Is there a need to create or modify existing policies, procedures, or
processes to address deficiencies identified in missing person
investigations and Project Houston?
 Why did Project Houston fail to identify McArthur as the perpetrator (once
his name was known)? What, if any, systemic issues need to be addressed
as a result of this failure? What, if any, lessons have been learned?50

Had Project Houston been discussed with the Board, and these questions
raised with the chief of police, the Board could have addressed the
adequacy and effectiveness of the Service in a variety of ways, for example,
through revised policies, new objectives or priorities, or directions or
advice on systemic issues.

50
Of course, the types of questions that might be asked would be different if critical pointsare reached at the
outset or during an operation.
 Both Judge Morden’s review and this Review represent instances in
which the Board initiated independent reviews into policing matters arising
from specific operations. They fall squarely within the Board’s mandate since
findings concerning specific operations have systemic implications relevant to
the Board. These two reviews make crystal clear that the old dichotomy
between policy and operations is no longer a definitive guide for either the
Service or the Board. In short, to properly fulfill its oversight responsibilities,
the Board must be informed about certain operational matters and take a
policy-oriented interest in them.

Collaboration on Defining an Operation but Not Its Execution

As the final element of a consultation protocol, Judge Morden drew a
distinction between defining what an operation is going to be, as opposed to
how it is going to be executed: “The Board should always be able to
collaborate in defining the “what” but not the “how” of an operation.” 51 He
observed that the initial determination of what the Service’s objectives and
priorities will be for a particular operation, event, or organizationally
significant issue is the Board’s to make, after consultation with the chief. The
consultative process also enables the Board to recommend aspects of the
operational plans to the Service, without directing the chief on specific
operational decisions. Finally, the collaboration enables the Board to ensure
that the operations are supported by an adequate policy framework. However,
the chief and the Service retain the autonomy to develop and execute the
specific operational plans. The chief may also choose to reject
recommendations made by the Board, though remaining accountable for the
operational decisions made.52
In large measure, this third element Judge Morden identified reinforces
and helps to explain the prohibition contained in s. 31(4) of the Act. In my
view, however, the distinction between “what” and “how” may be difficult to
apply in practice and should not act as a substitute for careful consideration of
whether the Board’s input adheres to its appropriate oversight role and its
limitations.
The Impact of the Community Safety and Policing Act, 2019
In my opinion, the analysis of the relationship between the roles of the board
and the chief of police and the service should not be affected by the
proclamation of the CSPA, 2019. Subsection 40(4) of the CSPA, 2019, states:

51
Morden Report, 92.
52
Morden Report, 92–95.
 The police service board shall not direct the chief of police with respect to
specific investigations, the conduct of specific operations, the discipline of
specific police officers, the day-to-day administration of the police service,
or other prescribed matters.”53

This provision is similar to the current prohibition against the

board’s providing directions respecting “specific operational decisions” and
“the day- to-day operations of the police force.” However, the Ontario
Association of Policing Boards expressed concern about this language. Mr.
Ryan Teschner, on behalf of the association, said this when the legislation
was introduced:

As currently worded, these sections use the terminology of “specific

investigations” and “the conduct of specific operations.” Again, the
unintended consequences of this wording could prevent boards from
engaging in core aspects of their governance and oversight roles. Two
examples illustrate this. Carding practices could be immune from policy
review if it fits within the definition of “specific investigations” or “the
conduct of specific operations.” Similarly, for missing persons
investigations generally, a board may wish to have a general policy that
applies to this type of investigation. The current wording of these sections
may prohibit this.
Although a board should have no intention of creating a policy or
direction that applies to a specific, ongoing matter – that is, a missing person
investigation involving person X – the current wording of these provisions
may well prohibit these broader and important policies and directions from
being developed and issued.
Therefore, we recommend changing the wording in both subsection
38(5) and subsection 40(4) to read “a specific investigation” and “the
conduct of a specific operation.”54

In my view, subsection 40(4) should be read in conjunction with the

larger purposes of the CSPA, 2019, that encourage more active policy making
and performance and outcome monitoring by the board. Indeed, it would be
contrary to these larger purposes if subsection 40(4) were interpreted to
increase the ambit of areas where a board could not create policies or direct the
53
Subsection 40(7) of the CSPA, 2019, adds content to s. 40(4) by providing that the board should not direct
the chief of police to do anything contrary to his or her duties under the Act or with respect to collecting
information for the purposes of a criminal investigation or prosecution.
54
Ontario, Legislative Assembly, Standing Committee on Justice Policy, “Comprehensive Ontario Police
Services Act, 2019” in Official Report of Debates (Hansard), JP-2 (7 Ma rch 2019) at JP-28, 1600. Accessed
online at https://www.ola.org/sites/default/files/node-files/hansard/document/pdf/2019/2019-03/07-MAR-
2019_JP002.pdf
chief of police. In addition, consistent with the Morden Report, nothing in the
CSPA, 2019, diminishes the need for a board to be informed on
operational matters that rise to a level of critical points, regardless of
whether they result in the board’s providing any direction to the chief of
police or the service.
I also believe that the new focus in the CSPA, 2019, on diversity,
human rights, systemic racism, and traditionally marginalized and
vulnerable communities discussed earlier also underlines the Board’s
important role in monitoring the Service’s work in these areas, including its
investigative performance and outcomes in relation to those same
communities. This is especially the case in the communities central to this
Review where a legacy of mistrust exists between their members and the
police.
Subsection 40(9) of the CSPA, 2019, requires the board to publish on
the internet any direction it provides to the chief of police. This requirement is
consistent with heightened accountability and transparency for the conduct of
both the board and the chief and may serve as a further protection against
misuse of the board’s power to direct. It is also consistent with what Professor
Kent Roach described as a democratic policing model – a model Judge Linden
adopted in the Ipperwash Report. The democratic policing model recognizes
that the respective roles of the board and the chief will vary over time and in
different contexts, but that, when the board exercises its democratic powers of
direction, it should do so in a transparent manner and be held accountable.
I also observe that subsection 40(8) of the CSPA, 2019, provides that a
chief of police may decline to provide information under a direction from the
board, if the regulations so authorize. Concern has been expressed that this
gives a chief of police a potential veto over providing information to the board
relevant to its mandate. In my view, it is unnecessary to create such a
regulation given the statutory prohibitions that already exist against a
board’s inappropriate intervention and the confidentiality that binds board
members. If such a regulation is created, the scope for denying the board
information about operations should be restricted, as it is in Victoria, Australia,
to information whose disclosure would prejudice an investigation or
prosecution or endanger the life or safety of a person. 55 Subsection 40(8) of the
CSPA, 2019, presumes, by implication, that the general rule will be a free flow
of information between the board and the chief of police, consistent with
Judge Morden’s views and my own.

55
Victoria Police Act 2013 (Vic), Act 81 of 2013, s. 11(3).
Summary

I cannot overemphasis the importance of effective civilian oversight of the

police. It 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 as it affects communities
with a troubled relationship with the police, including racialized, LGBTQ2S+,
Indigenous, homeless or underhoused, and others identified in this Report.
The board is an essential feature of responsive and democratically
accountable policing. However, a 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 its chief’s role or to
interfere with the service’s protected core of independence around specific
investigations. To paraphrase Judge Linden in the Ipperwash Report, requiring
the police to explain and justify their activities and modify existing
policies and procedures to ensure adequate and effective policing is not
inconsistent with protecting the core of police independence. 56 Simply put,
robust oversight makes a police service more effective rather than less.
It follows that such oversight should not be seen as an imposition on the
chief of police or the service. As contemplated by the existing Act and the
CSPA, 2019, the chief and the board should “work together as partners.” 57 In
successful partnerships, both partners benefit. The chief of police benefits by
ensuring that the board is informed or given a “heads up” about issues and
operations that affect the board’s policies and the service’s relationships and
reputation. It should be in the police chief’s interest to inform what is
essentially his or her employer of critical challenges facing the service so that
the board can help address those challenges.
Where a culture of sharing information with the board exists, it can have
a “ripple effect” throughout the service. It promotes greater sharing of
information between the chief and senior officers. After all, the chief cannot
inform the board about a critical point if he or she is unaware of it. The chief
should not be blindsided by critical events and operations in a large
organization. The best antidote to silos and walls both between the chief and
the board and within the service is a free flow of information. Because the
flow
56
Ipperwash Report, 322.
57
“Police Encounters with People in Crisis,” An Independent Review Conducted by the Hon. Frank
Iacobucci for Chief of Police William Blair, Toronto Police Service, June 2014, p 67, para 44, online:
www.torontopolice.on.ca/publications/files/reports/police_encounters_with_people_in_crisis_2014.pdf
of information between the chief and the board is two-way, the chief will also
benefit from information the board receives from the community and
other levels of government.
The board in turn benefits from the information, expertise, and
professional judgment of the chief of police. The board is then better able to
discharge its responsibilities to ensure adequate and effective policing and,
when appropriate, advocate for the police service with other levels of
government. The board will have hired the chief of police and will want that
person to succeed. There should be mutual trust, respect, and a commitment to
better policing shared by the board and the chief. The board and the chief
should never distrust each other or develop an adversarial relationship. All this
is to say, a proper and broad understanding of “critical points” can facilitate a
better flow of information both within the police service and between the
board and the chief.
In the Civilian Police Commission Report, the Commission said the
following in the context of the accountability of the Service and the Board in
relation to addressing serious misconduct by a member of the Service:

The law is clear that the Board cannot usurp or replace the management role
of the Chief of Police. However, the Board clearly has overall responsibility
for the operation of the force. The Chief reports to the Board and must obey
its lawful orders and it is the view of this inquiry panel that a Police
Services Board cannot fulfill its responsibilities for monitoring the policies it
sets and the performance of the Chief unless it insists on having the
necessary information. And there must be an obligation on the Chief to
report fully.
The hands-off stance taken by the Metropolitan Toronto Police
Services Board in the matter of the resignation of Constable Gordon Junger
represents a misunderstanding of its role and a failure to assume its rightful
responsibilities.”58 [Emphasis added.]

An understanding of the appropriate roles and responsibilities of the

board, the chief of police, and the police service enables me to evaluate
whether those roles and responsibilities were fulfilled in relation to this
Review’s subject matter, and, if not, what improvements can be made. That is
the task to which I now turn.

58
Civilia n Police Commission, Report, 33–34.
Findings

During the Review, we interviewed many former and current Toronto officers.
Our interviews also included two former Board chairs, the Board’s executive
director, former chief Mark Saunders, four current or former deputy chiefs,
including Acting Chief James Ramer. In this section, I focus on the
relationship between the Board and the Service and its chief of police, using
the McArthur- related investigations as illustrative. The evidence revealed
that, during the McArthur-related investigations, the Board members,
including its chairs, were unaware of major operations described in this
Report that potentially impacted on the Service’s reputation, its
relationship with the LGBTQ2S+, racialized, and marginalized and
vulnerable communities generally, on the Service’s objectives and
priorities, and on policy initiatives and advice or direction that might be
given to the chief of police.
Project Houston mobilized considerable resources – human and
financial. It was investigating an alleged international cannibalism ring, said
potentially to be related to the disappearances of Mr. Skandaraj Navaratnam,
Mr. Abdulbasir Faizi, and Mr. Majeed Kayhan, all connected to the
LGBTQ2S+ communities and last seen in the Village. Investigators interacted
with several Ontario police services and with law enforcement agencies
around the world. Deputy Chief Saunders signed off on Project Houston’s
operational plan. James Brunton, the prime focus of the project, was ultimately
arrested on child pornography charges completely unrelated to the
disappearances of the three missing men. After Brunton’s arrest, Project
Houston’s operations were wound down. A number of officers returned to
other duties. The small remaining team was unable to complete all remaining
tasks before the project ended. Despite the significant resources dedicated to it,
the project cast no light on the disappearances.
The Board and its chair were never advised that Project Houston
was taking place or had taken place. I find this disturbing. It is beyond doubt
that Project Houston was precisely the type of operation that passed the
“critical point” Judge Morden described, especially once it wound down its
operations. It brought about several arrests on charges unrelated to the three
missing men. Its lack of success in solving the disappearances, coupled
with its use of a significant amount of scarce resources, invited the types of
questions I set out earlier in this chapter. A discussion between the chief or his
designate and the Board could have and should have prompted an internal
review of the project by the Service. An internal review could have
introduced any number of changes or improvements, such as an enhanced
communication strategy to
build trust with the LGBTQ2S+ communities, as well as changes to the
Service’s approach to missing person investigations generally, and to its
existing processes.
Furthermore, Project Houston was appropriately designated as a
major case. But it was not compliant, in important ways, with provincial
adequacy standards relating to major case management and its mandated
case management tool, PowerCase. As discussed in Chapter 4, the Service’s
Audit and Quality Assurance Unit identified this as an issue within the Service
during the early stages of Project Houston and expressed concern about the
impact of non-compliance on the Service’s investigative effectiveness,
legal exposure, and reputation. The situation was described as “high risk.”
Board members were unaware of these concerns. They should have been.
Frankly, it is difficult, one might say impossible, to even characterize systemic
issues around major case management and the Service’s use of technology as
“operational matters” as that term is meant in the legislation.
Similarly, Board members were not briefed on Project Prism.
Project Prism was the Service’s 2017 investigation initially prompted by
the disappearances of Andrew Kinsman and Selim Esen. The Board chair
heard from a member of the LGBTQ community that there was an issue
around missing men from the Village. He asked Chief Saunders about it. The
Board chair was told only that it was being addressed. The nature of this
project easily met the “critical point” threshold Judge Morden described.
The Service’s failure to share operational matters that potentially impact
on the Service’s reputation, its relationship with diverse communities, and on
potential policies of the Board or appropriate advice or direction to the
chief represents a serious systemic issue. The evidence supports my view that
this failure can be explained as follows:

1. During the period I examined, there continued to be a misunderstanding

about information that must be shared with the Board and a reticence
on the part of chiefs of police to share operational information with the
Board. My recommendations on what constitutes “critical points” provide
clarity on this requirement.
2. Given this misunderstanding, there is also a reluctance on the part of the
chief to share information with the Board. That reticence is grounded
in both a cultural problem and a perceived practical problem. First, the
cultural problem. The evidence supports a finding that the Service hasn’t
fully embraced the opportunities, indeed the benefits, afforded
through Board oversight. Chief Saunders advised the Review that he was
reluctant to share operational information with the Board due, in part,
to concern
 about having to track, for prosecution purposes, who received what
information and when.

With respect, I do not accept this rationale for non-disclosure of

information that the Board must have in order to fulfill its civilian oversight
responsibilities. First, as Judge Morden observed, disclosure of “critical
points” need not extend to all or even most of the details of an operation.
Second, implicit in the Service’s reticence to share operational information is
a concern over whether Board members will maintain confidentiality. The
withholding of such information on the basis of confidentiality is completely
unwarranted. As Judge Morden also noted, Board members have a
statutory duty to preserve confidentiality. Violations can lead to removal,
discipline, and even prosecution. It should be presumed, in the absence of
evidence to the contrary, that Board members will respect their statutory
obligations in this regard.
The evidence also showed that sometimes the amount of information
shared by a chief of police informally with the chair of the Board depended on
their personal relationship at the time. It is important that the appropriate and
indeed necessary sharing of information not depend on personal relationships.
The chair can serve, of course, as the conduit of information to the Board, as
long as all Board members are ultimately made aware of critical information.
I am firmly of the view that the Board’s oversight can and should bring
about improvements to the Service, improvements that can be embraced by its
members and senior leadership in a collaborative way.
The Service’s proper sharing of information with the Board
presumes that the chief will be adequately briefed by his or her senior staff
about the operations and systemic issues within the Service. As reflected in
Chapter 6, there was a disconnect between the evidence available to Project
Houston and what was conveyed to senior officers. Misinformation about
the status of operations, even where inadvertent, interferes with senior
command’s ability to fulfill their responsibilities.
It is obvious that the information sharing that is the foundation of the
Board’s oversight responsibilities, as described in the 2012 Morden Report
and the 1992 Civilian Commission on Police Services Report has not always
taken place. It goes without saying that the Board cannot fulfill its
statutorily imposed obligations relating to civilian oversight – designed to
protect the Service’s reputation with the public and the public’s confidence in
the Service
– without sufficient information about what is happening within the Service.
This situation must change. And priority must be given to such change. In
Chapter 15, I outline my recommendations respecting civilian oversight.
 Chapter 4 Major Case Management and the Use of 65
Technology

Chapter 4

MAJOR CASE MANAGEMENT

AND THE USE OF TECHNOLOGY

In 1995, Paul Bernardo was convicted of many serious crimes, including first-
degree murder, kidnapping, and aggravated sexual assault. Deep concerns
were raised as to how Bernardo’s crimes went unsolved for years. The Hon.
Mr. Justice Archie Campbell was asked to examine and report on the roles
played by several police forces, the Centre of Forensic Sciences, the Office of
the Chief Coroner, and the Ontario government during the Bernardo-related
investigations.
Justice Campbell’s 1996 Report (Campbell Report) identified a series of
systemic failures within law enforcement and justice systems in Ontario,
including a lack of co-operation, coordination, and communication between
police forces and other participants in the justice system.
1
These failures contributed to a serial predator’s ability to “fall between
the cracks.” Justice Campbell recommended that the province create a major
case management system for all the major and interjurisdictional serial
predator investigations. The system should be based on co-operation rather
than rivalry, specialized training, early recognition of linked offences,
coordination of interdisciplinary and forensic resources, and mechanisms to
ensure unified management, accountability, and coordination among
police services and law enforcement agencies.
Justice Campbell concluded that such a system was required in order to
ensure five key goals:

 unified direction by someone in charge of and accountable for related

investigations;
 supervision of timelines and systemic follow-up of crucial investigative
steps;
 consistent and organized classification and elimination of suspects;
 systematic use of relevant information from other police services; and

1
Ontario, Bernardo Investigation Review: Report of Mr. Justice Archie Campbell [Toronto: Ministry of the
Solicitor General and Correctional Services, 1996] (Campbell Report). See also Chapter 11.
 provincial oversight and intervention when a serial predator investigation
is not pursued vigorously or is given low priority.

Like Bernardo’s crimes, those committed by Bruce McArthur also attracted a

high level of scrutiny. I have highlighted these five goals of major case
management because none of them were achieved during a large part of the
Toronto Police Service’s (the Service’s) McArthur-related investigations.
Central to Justice Campbell’s recommendations was the creation of a
province-wide automated case management software, mandated by regulation,
for use in the investigation of serious crimes. The Campbell Report continues
to be cited in Ontario and in other jurisdictions as a model for effective
investigations and as a cautionary note against “siloed” approaches to
investigations that affect multiple jurisdictions or multiple divisions within a
large urban police force. In 2012, Forsaken: The Report of the Missing Women
Commission of Inquiry (Oppal Report) found that police services in British
Columbia were severely hampered in identifying and apprehending serial
killer Robert Pickton in part because of the absence of a province-wide major
case management system and also because of the failure of police services to
co-operate and coordinate their work.2
In October 2004, Ontario Regulation 354/04, entitled “Major Case
Management,” was enacted in direct response to Justice Campbell’s
recommendations. At the same time, the Ontario government introduced the
Major Case Management Manual (the manual). Both the regulation and
the related manualhave since been amended.
In order to identify some of the serious deficiencies in parts of the
McArthur-related investigations, it is essential to understand both Ontario’s
provincial adequacy standards for major case management and PowerCase, the
provincially mandated case management software. In the remainder of this
chapter, I examine the Service’s records management and case
management systems as well as its use of technology to advance
investigations in the context of these (and other) provincial adequacy
standards. Ultimately, I show how existing systems and technology were not
used effectively during the McArthur-related investigations.
The evidence reveals that the Service was often not in compliance with
existing provincial adequacy standards and that it failed to use existing
technology and analytical support to full effect. These failures undermined,
2
British Columbia, Missing Women Commission of Inquiry, Forsaken: The Reportof the Missing Women
Commission of Inquiry [4 vols and Executive Summary, electronic resource, British Columbia, 2012]
(Commissioner Wally T. Oppal) (Oppal Report). See also Chapter 11.
sometimes in critical ways, the quality of the McArthur-related investigations.
Sadly, it appears that, at times, the Service failed to fully learn the lessons
Justice Campbell identified, failed to consider how Toronto’s missing person
investigations should be modified in the aftermath of the Oppal Report, and
failed to address adequately the deficiencies the Service’s own internal audit
identified.
In short, in this chapter I cover the following points:

 I describe relevant provincial adequacy standards relating to major case

management and to PowerCase, the related case management software.
Those standards also describe the role of the serial predator criminal
investigations coordinator (the serial predator coordinator) in the Ministry
of Community Safety and Correctional Services (the ministry).
 I describe the Violent Crime Linkage Analysis System (ViCLAS), a
national RCMP computer storage system, and the Ontario Provincial
Police (OPP) ViCLAS Unit.
 I describe the evolution of the Service’s records management and case
management systems, and its existing technological and analytic support
for investigations within the Service.

These descriptions enable me to evaluate here and in subsequent

chapters the Service’s compliance with provincial adequacy standards in
relation to both major case management and PowerCase. I also evaluate the
Service’s use of external and internal technological and analytic supports,
particularly during the McArthur-related investigations.
This chapter is necessarily highly technical at times and may make
difficult reading for the uninitiated. However, these detailed descriptions are
important in understanding what went wrong and why.

Major Case Management: Provincial Adequacy Standards

Ontario Regulation 354/04

Ontario Regulation 354/04 requires every police services board to establish
policies that accord with the manual with respect to major cases. It also
requires every police chief to develop and maintain procedures and processes
that again accord with the manual for undertaking and managing
investigations
into major cases. In addition, the regulation requires every Ontario police
service involved in major cases to use the software approved by the ministry.3
Under the regulation, major cases include (but are not limited to)
homicides, non-familial abductions, missing person occurrences where
circumstances indicate a strong possibility of foul play, 4 occurrences involving
found human remains that are suspected to be homicide, and any other types
of cases designated by the manual.
The inclusion of other cases designated by the manual cannot be
overlooked because it has since modified the definition of major cases. Most
importantly, the 2017 manual expanded the definition to include missing
person occurrences “where police have yet to ascertain whether foul play is
involved when the individual remains outstanding and unaccounted for 30
days after being reported missing.” Although this change was formally made
to the manual only in 2017, all Ontario police chiefs adopted it as of
November 14, 2013.
Ontario Regulation 354/04 preserves the discretion of a police services
board and the chief of police respecting the content of their policies,
procedures, and processes, though with at least two limitations: such policies,
procedures, and processes must conform to the manual; and police services
must use the ministry’s approved software when conducting investigations into
major cases.

The Manual
There have been three versions of the Major Case Management Manual: the
original, dated October 1, 2004; the second, dated March 2, 2012; and the
most recent, dated December 1, 2017. I refer, as is necessary, to each
version because the chronology of McArthur-related missing person
investigations spans the period 2010 to 2018.

Major Case Management Definitions

The manual divides its list of major cases into two groups: threshold offences
and non-threshold offences. There are some important differences in the way
they must be investigated. For example, a threshold offence must be
investigated by a “primary investigator,” an officer with specialized training.
3
The earliest iteration of Ontario Regulation 354/04 specified that PowerCase software be used for
managing investigations. As of 2016, the regulation requires the use of “software approved by the Minister
of Community Safety and Correctional Services.” Although this change provides greater flexibility, the
minister has demonstrated a long-term commitment to PowerCase.
4
“Foul play” is not defined in the regulation or in provincial adequacy standards. In my view, the strong
possibility of foul play involves the strong possibility of being victimized by crime involving a missing
person’s death, abduction, or serious bodily harm.
A non-threshold offence may be assigned to someone who is not a primary
investigator, although that officer must have the knowledge, skills, and
abilities to undertake the investigation. The distinction between threshold and
non-threshold offences is also relevant to how the investigation must be
structured and the types of data that must be entered into the approved
software.
The 2004 manual provided that the following major case
occurrences were deemed to be threshold offences:

 homicides and attempted homicides;

 non-familial abductions and attempted such abductions;
 sexual assaults, related sexual crimes, and attempts where certain factors
(unnecessary to outline here) are believed to exist;
 missing person occurrences, where the circumstances indicate a strong
possibility of foul play;
 occurrences, suspected to be homicides, involving found human remains;
and
 any major case that is linked to another major case within the same or
another jurisdiction.

The 2012 manual made some changes to the types of sexual assaults and
non-familial abductions that are deemed to be threshold, as opposed to
non- threshold, offences. These changes are irrelevant to this Report. It
also provided that certain offences (including child pornography–related
offences) were deemed to be major cases for the purposes of using the
ministry-approved software. In these cases, the software may be used at the
discretion of the police service. The less-demanding non-threshold data entry
standard would apply to them.
On November 14, 2013, an All Chiefs’ Memorandum was issued
regarding the major case designations contained in the regulation and in
the 2012 manual. It read as follows:

Approval has been granted by the MCM Steering Committee to enter

tombstone data [certain core or basic data] into PowerCase concerning
missing persons’ cases where persons remain outstanding and unaccounted
for 30 days after the individual is reported missing. Offences deemed as
major cases for the purposes of using the ministry-approved software are set
out in the MCM Manual, under section 5, Definitions. The following item
has been added to the list of major cases:
 • Missing persons, where police have yet to ascertain whether foul play
is involved when the individual remains outstanding and unaccounted
for 30 days after being reported missing.
Missing persons’ cases that precede this directive may be entered into
PowerCase at the discretion of the Major Case Manager. This directive
will be incorporated into the MCM Manual at the next scheduled review
in 2015.

The effect of this memorandum was twofold:

 missing person cases, where police have yet to ascertain whether foul
play is involved when the individual remains outstanding and
unaccounted for 30 days after being reported missing, became major
cases; and
 only tombstone information for such cases had to be entered into the
PowerCase software; in other words, the same type of information that
had to be entered for non-threshold major cases.

Although the memorandum stated that these changes would be

incorporated into the manual in 2015, no new changes were made to the
manual until 2017. For the purposes of this Report, I need to refer to only three
changes in the 2017 manual. First, the manual incorporates the expanded
definition of missing person occurrences that qualified as major cases (as
captured in the earlier All Chiefs’ Memorandum), categorizing them as non-
threshold major cases. Second, unlike the All Chiefs’ Memorandum, the 2017
manual provides that in these non-threshold missing person cases (the
“outstanding for 30 days” cases), the same data entry procedures as for
threshold cases must be followed. In other words, both threshold missing
person cases (involving a strong possibility of foul play) and non-threshold
missing person cases share the same data entry procedures. Other procedures
applicable to threshold major cases (such as the investigation’s command
structure) continue to have no application to the non-threshold missing person
cases. Third, the 2017 manual provides that all major cases that are serial
or predatory in nature are designated as threshold offences.
In summary, missing person occurrences where the circumstances
indicate a strong possibility of foul play, occurrences suspected to be
homicides involving found human remains, and any major case that is linked
to another major case within the same or another jurisdiction have been
designated as threshold offences in all three versions of the manual – and,
therefore, throughout the period of the McArthur-related investigations as well
as the Tess Richey and Alloura Wells missing person investigations. As of
November 2013, missing person occurrences, “where police have yet to
ascertain whether foul play is involved when the individual remains
outstanding and unaccounted for 30 days after being reported missing,”
became non-threshold major cases. These occurrences did not qualify as major
cases under the earlier manuals. This change becomes relevant in Chapters 6
and 7 when I examine how missing person investigations were conducted after
Project Houston ended in 2014 and before Project Prism commenced in 2017.
Finally, near the end of 2017, when the 2017 manual was introduced, any
major cases that were serial or predatory in nature became threshold offences.
As well, non-threshold missing person cases shared the same data entry
requirements as threshold missing person or other threshold major cases.
The manual contains other definitions relevant to this Review which I
reproduce below. Unless otherwise indicated, these definitions have remained
the same in all versions of the manual.

Case Conference: Consultation with appropriate representation from all

involved agencies and any other experts who may assist in the investigation.
This includes obtaining inter-disciplinary input at the earliest opportunity to
assist in developing investigative strategies, establishing priorities, and
determining the sequence of any necessary investigative procedures.

Case Review: An examination of the administrative management and/or

operational aspects of the investigation including a peer evaluation. This can
take place anytime during the investigation.

Investigative Consultant Team: The group that is formed to “case

conference.” The formation of this Team is mandatory in a multi-
jurisdiction investigation, and discretionary in a single jurisdiction
investigation. An Investigative Consultant Team may include, but is not
limited to, forensic experts, medical experts, Centre of Forensic Sciences
experts, Office of the Chief Coroner, forensic psychiatry, Office of the local
Crown Attorney, forensic pathology, an alternate Multi-jurisdictional Major
Case Manager, and other experienced investigators. The Investigative
Consultant Team shall include members of the Command Triangle.

[As of the 2012 manual] Linked Cases: Two or more defined major cases
where there is a reasonable suspicion that the same person(s) is responsible
for the commission of the offences.5

5
“Linked” cases were referred to in the 2004 manual, but not defined.
 Multi-jurisdictional Major Case Identification Systems: This is a process
for early detection of similarities and linkages in crimes to prompt multi-
jurisdictional police investigations. The analysis and recognition of linked
crimes provide additional information that leads to the prevention and early
apprehension of serial offenders.

The manual states that early recognition of serial crimes may be

achieved through several “mechanisms.” I need refer only to the following
ones:

 Violent Crime Linkage Analysis System (ViCLAS): An automated case

linkage system designed to capture, collate, and compare crimes of
violence through the analysis of victimology, offender / suspect
description, modus operandi, forensic and behavioural data.
 Centre of Forensic Sciences: The mandate of the Centre of Forensic
Sciences is to provide scientific laboratory services in support of the
administration of justice and public safety. The laboratories conduct
scientific investigations in cases involving injury or death in unusual
circumstances and in crimes against persons or property.
 Office of the Chief Coroner:6 The Chief Coroner’s office is the central
repository of all death reports that have been investigated by all Coroners
throughout the Province of Ontario. Through this data bank, investigators
can draw on province-wide comparisons involving unidentified human
remains and other death investigations.
 Canadian Police Information Centre (CPIC): National repository of data
on charged, wanted, missing persons, stolen vehicles, property and other
crime-related data.
 Major case management software: The Minister-approved case
management software.
 Serial predator criminal investigations coordinator (SPCIC): The Serial
Predator Coordinator is responsible for the review, development and
coordination of multi-jurisdictional and single jurisdiction investigations
of linked major cases.

The 2012 manualadds one relevant mechanism to this list:

6
The 2012 manualadded a reference to the Ontario Forensic Pathology Service here and elsewhere in the
manual. This addition reflected the reconfiguration of the Offices of the Chief Coroner and the Chief
Forensic Pathologist in the aftermath of the Inquiry into Pediatric Forensic Pathology in Ontario (2008).
 Police Information Portal (PIP): Accessed through CPIC and managed by
the RCMP, PIP is a searchable index of all policy agency records
management systems across the country and is an important means of
gathering information during serial predator investigations, organized
crime investigations, and investigations where the subject moves from
one jurisdiction to another.

The 2017 manualadds another relevant mechanism:

 Major case management bulletins: On receipt of a bulletin from the serial

predator coordinator, the recipient shall make sure that the bulletin is sent
to all relevant officers within the police service.

The Command Triangle’s Functions and Responsibilities

The 2004 manual stipulated that a command triangle must be formed for every
major case within a single jurisdiction. The triangle must consist of the
functions and responsibilities of a major case manager, primary investigator,
and file coordinator. In a smaller or less complex investigation, one person
might be responsible for more than one function. The 2012 and 2017 manuals
require command triangles only in threshold major cases.
In every linked multi-jurisdictional major case investigation, the
command triangle is to consist of a multi-jurisdictional major case manager as
well as the command triangles for each police service involved. The multi-
jurisdictional major case manager may blend the existing triangles.

The Major Case Manager

Since 2004, the major case manager has been responsible for the effective
governance of the investigation and required to perform certain functions and
responsibilities. The ones that follow are relevant to this Review:

 assume overall responsibility and accountability for the investigation;

 determine strategies regarding the direction, speed, and flow of the
investigation;
 on notification of any potential linkage between major cases identified
through any investigative technique or process, ensure the linkage is
investigated as soon as possible;
 if there is a reasonable likelihood that the same person(s) has committed
the crime(s) within a single jurisdiction or multi-jurisdiction, notify the
serial predator coordinator within seven days;
 identify, acquire, and deploy necessary investigative and support
resources;
 in consultation with officers performing primary investigation and file
coordination functions, develop investigative strategies and make sure the
strategies have been implemented;
 ensure that all necessary investigative functions are conducted;
 ensure compliance with the manual for threshold major cases and, where
applicable, non-threshold major cases;
 facilitate a case conference at the earliest possible stage of the
investigation and involve different disciplines, where applicable:
 make sure that a detailed chronology of the investigation is maintained;
and
 ensure that all involved criteria offences are reported to ViCLAS in
accordance with Ontario Regulation 550/96.

The 2012 manual made some minor changes to these functions and
responsibilities, but they need not be reproduced here. The manual also added
that the major case manager is responsible for assigning a victim liaison and a
media liaison to the investigation. No further changes were made in the 2017
manual in these functions and responsibilities.
In multi-jurisdictional major case investigations, each major case
manager shall also, among other things, meet daily, or as required, with the
multi-jurisdictional major case manager to obtain information for briefing each
investigative team.

The Primary Investigator

The 2004 manual required that, in every major case, a primary investigator be
selected and assigned by the major case manager to perform certain functions
and responsibilities. They include:

 report directly to the major case manager;

 report as soon as possible any potential linkage to the major case
manager;
 identify the human and material resources required to conduct
investigations of this type and advise the major case manager
accordingly;
 audit and review all information relevant to the investigation and ensure
that the information is communicated to the investigative team;
 assign duties, authorities, and responsibilities to personnel within the
investigative team commensurate with their skills, experience, and
training;
 in consultation with the major case manager, control the direction,
speed, and flow of the investigation;
 provide clear, concise instructions on job duties to all personnel;
 ensure the completion of all assignments in a timely fashion [the 2012
version reads: “ensure actions are generated and completed in a timely
fashion”]; and
 in consultation with the file coordinator, make sure that a detailed
chronology of the investigation is prepared and maintained [the 2012
version also includes “maintain meeting / briefing notes” with this
responsibility].

The 2012 manual stipulated that, as additional duties, the primary

investigator was responsible for ensuring, in consultation with the
command triangle, that each tip or message was prioritized for action and
investigated. It also required the primary investigator to be trained in the
ministry-approved case management software, although this obligation was
removed in 2017. The 2017 manual required the primary investigator to
maintain thorough and complete investigative notes.

The File Coordinator

The 2004 manual stipulated that, in every major case, the major case manager
must select and assign a file coordinator to perform certain functions and
responsibilities. They include:

 report to the major case manager;

 scrutinize all documents received during the investigation to ensure
their quality and completeness;
 report any potential linkage to the major case manager;
 ensure all documents are appropriately organized and indexed [the
2012 manual replaced this item with “ensure all investigative
information is researched, indexed, and cross-referenced by a person
who has successfully completed the Ontario MCM software course or
an equivalent, as defined by the Ontario Police College”];
 implement standards and controls for the file coordination system;
 in consultation with the primary investigator, create and maintain the
detailed chronology of the investigation;
 in conjunction with the primary investigator, ensure that each tip or
message is quickly and thoroughly investigated or prioritized for action
[the 2012 manual transferred this responsibility to the primary
investigator];
 ensure that all information is entered and maintained on the ministry-
approved major case management software; and
 maintain minutes of the investigative consultant team meetings in the
records of the investigation.

The 2012 manual made several significant changes. The file coordinator
was now required to “maintain meeting / briefing minutes through consultation
with the primary investigator” and to “select and assign data entry personnel
whose duties may include reporting to and following the directions of the file
coordinator; inputting data arising out of the investigation; and ensuring the
information submitted for data entry is complete and is consistent.” The 2017
manual added a requirement that the file coordinator must have received
training on the ministry-approved case management software.
Each version of the manual has required that all three positions be filled
by individuals who have the requisite knowledge, skills, and abilities to
perform their work. In addition, they must have successfully completed the
Ontario major case management course or an equivalent.7

Other Functions and Responsibilities

The manual describes other functions and responsibilities. It also identifies the
person within the command triangle whose duty it is to select or assign them.
To provide an illustration relevant to my Review, the 2012 manual
required that in every threshold major case, an interviewer or interviewers be
selected and assigned by the primary investigator to perform functions and
duties as required, including the following:

 report directly to the primary investigator;

 conduct interviews of witnesses, suspect(s), etc., as assigned;
 provide the file coordinator with all documentation concerning the
interviews conducted;

7
The 2017 manualtied the phrase “or equivalent” to “asdefined by the Ontario Police College.” It added
that the major case manager shall have the resources to manage investigations through the ministry-
approved software.
 where practicable, before any interview, debrief any member of the
investigative team who may be able to provide information relevant to the
interview;
 where practicable, review all documentation relevant to the interview in
preparation for the interview;
 provide a detailed summary of all interviews, ensuring that all
investigative information is captured (names, personal identifiers,
vehicles, locations, events – including dates, times, and objects); and,
 in consultation with the primary investigator and the file coordinator,
develop appropriate interviewing strategies that will maximize the value
of information and evidence obtained from interviews.

Multi-jurisdictional Major Case Manager and Investigations

In addition to the functions and responsibilities of a major case manager in a
single jurisdiction investigation, the manual requires that a multi-jurisdictional
major case manager perform additional duties and responsibilities in
investigations of that kind. These duties and responsibilities include
consultation with the command triangles of the linked investigations in
developing an operational plan to be approved by the joint management team,
in ensuring that adequate resources are available to conduct the
investigation and that duplication of effort and counterproductive
interference are eliminated. The multi-jurisdictional major case manager is
also to prepare, where necessary, a request for provincial funding in
consultation with the serial predator coordinator. The manual also sets out the
added qualifications needed to become a multi-jurisdictional major case
manager.
Under the 2004 manual, two criteria needed to be met for a case to be
designated a multi-jurisdictional investigation: first, two or more police
services must establish a possible connection between two or more major case
investigations; and, second, there must be a reasonable likelihood that the
same person(s) committed the crimes. Under the 2012 manual, the first criteria
substituted the phrase “establish a link” for “establish a possible connection.”
The 2017 manual then went on to use language more closely connected to the
definition of “linked cases.” It reads: “For a case to be a multi-
jurisdictional investigation, two or more police services working on
independent major case investigations must establish a link between two or
more defined major cases where there is a reasonable suspicion that the
same person(s) is responsible for the commission of the offences.” As I
explain above, under the 2012 manual, linked cases are defined as two or
more major cases where there is a
“reasonable suspicion” that the same person(s) is responsible for the
commission [of the] offences.”
Once a case qualifies as a multi-jurisdictional investigation, the
major case managers must notify the ministry’s serial predator coordinator
within seven days. A joint management team (the JMT) must be formed, made
up of senior representatives of each involved service and of other
disciplines as appropriate. The JMT’s functions and duties, including the
appointment of a multi-jurisdictional major case manager, are set out in the
manual. The JMT must also consider whether the linked investigations
should be integrated. If so, it may result in a decision by the multi-
jurisdictional major case manager to blend the command triangles.
The manual also sets out the composition, functions, and duties of the
investigative consultant team (the ICT). The ICT, a multidisciplinary team,
acts as an advisor to the multi-jurisdictional major case manager. If required
or requested by the JMT, the ICT may also review the investigation.

Policies and Procedures on Components of Major Case Management

The balance of the manual sets out detailed policies and procedures on specific
components of major case investigations. It may be confusing to describe them
as “policies,” given the use of this term generally in policing legislation
and regulations to describe police services board documents, so I prefer to
describe them as “standards.” Indeed, they are also described as such in the
manual. Nothing turns on this language. After all, it is mandatory that board
policies and a service’s procedures conform to these standards.
The specific standards addressed in the manual relate to the following
topics:

 victims
 media relations
 information management
 suspect identification
 data entry
 interviewing
 canvassing
 crime scene examination
 accessing expert resources – Office of the Chief Coroner8
 post-mortem examinations

8
The 2012 and 2017 manuals do not confine this section to the Office of the Chief Coroner.
 behaviour sciences services
 document management
 in-custody informants

At this point, I intend to refer only to the standards for data entry.

Data Entry
The manual sets out the data entry requirements for the approved software for
both threshold and non-threshold major cases. It states that “the maintenance
of these standards will ensure the integrity of the case management
investigative data and the triggering database.”
The standards for data entry include the following points:

 All data shall be entered in the software within 30 days of receipt of the
information. Where an investigation has been reclassified as a major case,
then all data shall be entered within 90 days of the reclassification. [In
2012, the 90-day requirement was changed to “as soon as resources
allow.”]
 It is recommended that all data being entered into the software (except an
“action”) emanate from a document.9

Normally, there is an important distinction between the data that must

be entered into the PowerCase software for threshold major cases and for non-
threshold major cases. At the risk of oversimplification, for threshold major
cases, virtually all investigative information must be entered into the software.
The file coordinator must ensure that the information is filed in the appropriate
location. The 2012 manual added that such investigative information must not
only be entered but also indexed, researched, and cross-referenced into the
ministry-approved software.
For non-threshold major cases, at a minimum, tombstone (core or basic)
information must be entered, indexed, researched, and cross-referenced into
the software. In 2004, tombstone information included the following:10

9
Special provisions exist for how to treat data pertaining to confidential informants, agents, and undercover
officers. “Actions,” or tasks, are explained below.
10
Elsewhere, tombstone information is said to include the following relevant information: full name(s),
alias(es), date of birth, all associated telephone number(s) and address(es), unique identifier (e.g., driver’s
licence), and vehicle(s).
 a summary of the offence providing the date and time, location, and
circumstances;
 the name and personal identifiers of the victim;
 the name and personal identifiers of the accused or suspect [in 2012, a
person of interest was added];
 any other significant information that may, in the opinion of the case
manager, assist in the early detection of serial predator behaviour;1 1
and,
 where there is evidence of serial predatory behaviour, full functionality
(that is, the data entry standards for threshold major cases) shall be
implemented.

The 2017 manual made changes to the standards governing data entry.
It provides, as I indicate above, that in missing person cases, where the police
have yet to ascertain whether foul play is involved, and where the individual
remains outstanding and unaccounted for 30 days after being reported missing,
the data entry procedures for threshold cases must be followed.

Document Management
All documents collected are to be managed in accordance with the filing
system set out in the manual: numbered files organized by categories and
accompanied by a brief description of each file’s contents. Some of the file
categories and content descriptions have remained identical throughout the
history of themanual, as these examples show:

 MCMS 2 Original Occurrences: This file shall contain a copy of the

original Occurrence Report, any supplementary report(s), and computer-
aided dispatch (CAD) printouts.
 MCMS 3 Related Occurrences: This file shall contain a copy or copies of
all occurrences on file as they relate to the accused or any other person or
place relevant to the investigation.
 MCMS 7 Operational Plans: This file shall contain operational plans
related to the investigation or project.

Some of the categories, content descriptions, and file organization have

changed from version to version of the manual. For example, the 2004 manual
had separate files for officer statements and “will says” (what the officer is
expected to testify to) and for daily memobook entries. The 2012 manual

11
The 2017 manual’s wording is slightly different, although not material to this Review.
created a single file for all officer statements and will says, daily memobook
entries, police reports (other than forensic reports), and investigative notes.
I need not reproduce most of the file categories or their descriptions.
However, the following categories are relevant to this Review:

 MCMS 4 Meetings / Briefings Summaries: This file shall contain the

minutes and decisions made at all investigative team, investigative
consultant team, joint management team, and case conferencing meetings
and briefings regarding the direction, speed, and flow of the investigation.
The minutes shall be filed chronologically.12
 MCMS 5 Detailed Investigative Chronology:13 This file shall contain the
detailed investigative chronology and any other chronologies (timelines)
created.
 MCMS 9 Statements (Civilian):14 This file shall contain civilian
statements filed alphabetically and, where there are multiple statements
from the same subject, filed chronologically. This file shall include
witness background information.
 MCMS 27 Tip Forms / Register:15 This file shall contain tip forms
generated during the investigation and the tip register, which shall be
used to numerically track all tips.
 MCMS 31 Action Forms / Register:1 6 This file shall contain copies of all
actions assigned, as well as the action register that provides for the
tracking of actions assigned by the primary investigator.
 MCMS 41 ViCLAS Reports: This file shall contain ViCLAS submissions
and reports.
 MCMS 46 Telephone / E-Communication Information:1 7 This file
shall contain phone toll, text messages, tower dumps, and subscriber
information. (This does not include emails.)18

12
This language is slightly different from the original language contained in the 2004 manual.
13
The 2012 manualadded a reference to any other chronologies (timelines) created. The name of this
category also changed slightly.
14
The 2012 manualspecified what background information includes – e.g., credit checks as well as CPIC
and Ministry of Transportation data.
15
In the 2012 manual, this category combined two separate categories that existed in the 2004 manual.
16
In the 2012 manual, this category combined two separate categories that existed in the 2004 manual.
17
In the 2004 manual, there was a category entitled Telephone Toll Information. It did not contain text
messa ges or tower dumps. The current category was created in the 2012 manual. MCMS 54 Email was a lso
added in the 2012 manualto capture emails generated during the investigation.
18
It was unclear to the Review where emails (other than emails generated during the investigation itself) are
to be filed. It was obvious from our inquiries that there is no consistent approach to how emails are filed.
 MCMS 53 Internet-Based Information:1 9 This file shall contain the results
of the search of any device’s electronic memory for Voice Over Internet
Protocols information (Skype, MSN, Yahoo, Facebook, VOX, etc.).

Interviewing
The interviewing standards are also important. They include the following
points.

 Appropriate personnel shall be assigned to conduct interviews on the

basis of their qualifications and experience.
 The interviewer shall fully prepare and plan for any interview to be
conducted. Interviews shall be recorded in one of the methods set out,
including audiotape or videotape.
 Where an electronically recorded statement is not transcribed, a detailed
summary of the relevant information from the interview shall be recorded
for data entry purposes.
 The victim of a sexual assault shall be asked if he or she would prefer to
be interviewed by a qualified officer of a particular gender, if available. 20

All the above provincial adequacy standards figure prominently in my

evaluation of the specific investigations I examined during this Review.

The Violent Crime Linkage Analysis System (ViCLAS)

ViCLAS is an investigative tool specifically designed to assist police agencies

in identifying offenders committing violent crimes that may be serial in nature.
It functions as an automated case linkage system for major case crimes and
permits the analysis and linkage of such cases based on physical, sexual, and
verbal behaviours. It was intended to address concerns that, because police
agencies across Canada are not on the same reporting system, offenders could
offend in different jurisdictions and potentially not be identified. In 2020,
ViCLAS contained about 644,000 cases from across the country. About
247,000 of those cases were from Ontario.
Provinces in Canada maintain provincial ViCLAS centres. In Ontario,
the ViCLAS centre is located at OPP headquarters and is managed by the OPP
in concert with other police agencies. Ontario’s ViCLAS centre is staffed by
uniformed and civilian members of the OPP, together with four officers

19
This category was created in the 2012 manual.
20
The 2012 manualmakes inconsequential changes to earlier language.
seconded from other services. As I write, two of the seconded officers are
from Toronto. (For convenience, Ontario’s provincial centre is also referred to
as the OPP ViCLAS Unit.) The unit processes ViCLAS submissions or
booklets (described below), performs quality control functions, and
analyzes collected data relevant not only to all OPP detachments but also to
the province’s police agencies.
Ontario Regulation 550/96 is entitled “Violent Crime Linkage Analysis
System Reports.” It imposes obligations on an officer in charge of an
investigation involving a “criteria offence” (see below). Within 30 days of the
investigation’s start, the officer in charge must complete and submit one or
more ViCLAS crime analysis reports (also referred to as “booklets” or
“submissions”) to the provincial ViCLAS centre. The officer in charge must
also update these reports within 30 days of a material change or of
acquiring information that is significant to the investigation. These reports are
to be done in accordance with ViCLAS established standards.21
The ViCLAS booklets contain answers to 156 questions to which a
response is mandatory. ViCLAS analysts 22 review this data and research
similar cases in the ViCLAS database to identify potential similarities between
or among cases. This analysis and research may indicate that, potentially, a
serial offender is involved. A potential linkage report will be shared with the
affected police agencies.
The following constitute criteria offences:

 homicides or attempted homicides, solved or unsolved;

 sexual assaults, solved or unsolved, that are not familial or domestic;
 familial or domestic sexual assaults, if the victim is under 16 years of age
at the time of the assault or the assault includes unique or significant
physical, sexual, or verbal behaviour;
 missing persons, where the circumstances indicate a strong possibility of
foul play and the person remains missing;
 unidentified bodies, where the manner of death is known, or suspected, to
be homicide;
 non-parental abduction or attempted non-parental abduction;
 luring of a child or attempted luring of a child, solved or unsolved; and
 a type of investigation that is added to the submission criteria of ViCLAS
and is designated as such by the ministry.
21
Ontario Regulation 550/96, as amended, ss. 1, 2(1), 2(2), and 2(4).
22
ViCLAS analysts are tra ined at the Canadian Police College in the behavioural attributes of violent
crime; offender typologies; and verbal, physical, and sexual behaviours that can link cases.
 I point out that although the definition of “major cases” contained in the
manual has been expanded to include missing person cases, where an
individual remains outstanding and unaccounted for 30 days after being
reported missing – even without a strong possibility of foul play – the
corresponding change has not been made to the ViCLAS criteria. However, I
was advised that Ontario investigators are encouraged to submit non-
criteria cases if they have reason to believe that a known or unknown person
may have been responsible for multiple violent crimes or may potentially
offend or reoffend. I was also told that consideration is currently being
given to an expansion of the ViCLAS criteria in relation to missing person
cases to correspond to the major case management criteria.
When the OPP ViCLAS Unit is informed of missing person or
unidentified remains investigations, the unit automatically notifies the Ontario
Centre for Missing Persons and Unidentified Remains (OCMPUR) of the file.
This notice ensures consistency in information collected by the OPP ViCLAS
Unit and the OCMPUR and allows the units to collaborate on cases. I explain
the role of the OCMPUR in Chapter 13.
ViCLAS categorizes all investigations as priority 1, 2, or 3 cases.
Priority 1 represents the most pressing cases. These cases are analyzed within
24 hours of their being submitted to ViCLAS. All missing person cases that
are submitted are given priority 1 status.
Every investigator who receives a potential linkage report from the
provincial ViCLAS centre is required to conduct a follow-up investigation
promptly. Within 60 days of receiving the report, the investigator is required
to submit a potential linkage response form to the provincial ViCLAS centre,
reporting the results of the follow-up investigation. Every chief of police must
also submit an annual report to the minister setting out the number of ViCLAS
crime analysis reports the police service submitted in the previous year.23
As I later explain, in a number of instances, the Service’s officers in
charge failed to submit ViCLAS booklets as or when required. This issue is of
particular relevance when I examine the Service’s McArthur-related
investigations.

The Service’s Criminal Investigation Management Plan

In addition to the provincial adequacy standards set out in the manual, the

23
Ontario Regulation 550/96, as amended, ss. 2.1 and 3.
Service has its own Criminal Investigation Management Plan. 24 The plan
addresses the manner in which the Service deals with criminal investigations.
It is intended to ensure that all occurrences are investigated thoroughly and
that all levels of supervision and management are kept informed of
investigations. For example, the plan sets out the appropriate “flow” of a
criminal investigation and identifies the types of occurrences that require a
supervisor to be notified.
With respect to major case management, the plan requires major cases
to be investigated and managed in accordance with the manual.

The Service’s Programs and Technology

It is impossible to evaluate how the Service conducts missing person cases

without a robust understanding of its software programs and existing
technology. I have divided this discussion into four sections:

 records management systems

 Homicide’s electronic filing system: the “P Drive”
 PowerCase and its use
 Technological Crime Unit and its analytic and technological tools

Records Management Systems

Records management systems (RMS) are electronic information storage
systems. They provide for the storage, retrieval, retention, editing, archiving,
and viewing of information, records, documents, or files pertaining to law
enforcement operations. Records management systems are used to integrate
incident-based information into a cohesive database or databases available to
all Toronto police officers. They allow these officers to access information
about ongoing and historical investigations, arrests, and civilian interactions
with police.
The Service’s records management systems are maintained by its
Records Management Services. This unit operates “24/7.” Its civilian members
correct and update information in the databases, move certain “concluded”
information, and are responsible for ensuring that priority information is added
to the appropriate RMS as soon as possible. My Review team and I met with
most of the unit’s members, and they demonstrated what they do. I was
24
The Crimina l Investigation Management Pla nis mandated by s. 11 of Ontario Regulation 3/99, Adequacy
and Effectiveness of Police Services, under the Police Services Act. The first version of the plan was
released in June 2006, and it was revised in March 2013.
impressed with their dedication and insights on how best to support front-line
officers.
The Service has used a confusing array of records management systems
over the last few decades. In my view, the use of multiple systems has
contributed to a loss of efficiency in investigative work.

Historical Records Management Systems: COPS and eCOPS

Centralized Occurrence Processing System
Between 1991 and 2003, the Service used the Centralized Occurrence
Processing System (COPS) as its primary occurrence-based database.
COPS contained Occurrence Report information, including names, addresses,
dates of birth, licence plates, telephone numbers, and offence details. The
Service’s Records Management staff were responsible for entering information
into and maintaining the COPS database. The staff entered tombstone data
from hard copy Occurrence reports. Officers could also call Records
Management staff to provide information to be inputted into COPS. Front-
line officers were generally unable to input information themselves into
COPS.

Enterprise Case and Occurrence Processing System

In 1996, the Service began a project to improve on and replace COPS. Its
successor, the Enterprise Case and Occurrence Processing System (eCOPS),
was developed slowly in-house. From September 2003 to November 2013, it
was used as the Service’s primary occurrence-based database. This database
enabled officers to enter all Occurrence reports directly into the system from
their desktop and mobile workstations. As a “one-time” data entry process, it
largely eliminated the need for officers to phone in database entries and for
Records Management staff to enter information from hard copy reports. It also
meant that occurrences entered by front-line officers into eCOPS could
immediately be viewed by all Toronto officers.
As part of the eCOPS initiative, the Service developed a “Unified
Search” query tool. Unified Search featured one-stop search capability for
several databases. For example, an officer could conduct a single electronic
search for information about a particular individual using Unified Search and
obtain results from all the linked databases. These databases included eCOPS
and its predecessor COPS as well as the Criminal Information Processing
System (CIPS), the Repository for Integrated Criminalistic Imaging (RICI),
the Master Name Index (MANIX), Field Information Reports (FIR), the
Canadian Police Information Centre (CPIC), and the Ministry of
Transportation database (MTO):
 CIPS was a database the Service developed in-house to record
information about arrests, prisoner management, and Highway Traffic Act
charges. It was used from 1996 to 2013 and functioned as the Service’s
primary arrest database. McArthur’s 2001 first arrest occurrence,
including a synopsis of his violent assault with a pipe on an unsuspecting
community member, was stored on CIPS. In September 2017, a Project
Prism officer located this occurrence. There is no evidence that this
occurrence was known to the officer who interviewed McArthur in 2013
or to the officer who investigated a choking occurrence involving
McArthur as the attacker in 2016. This occurrence should have been
known to both officers (see Chapters 5 to 7).
 RICI stores digital images of arrest photographs (commonly known as
“mugshots”) and fingerprints.
 MANIX operated as part of COPS and contained street contact
information (“carding” information). It was used from 1996 to 2007. In
February 2008, the FIR application, which was created by the Service,
replaced MANIX and provided officers with the ability to enter street
contact information directly into the application, rather than entering it
second hand from hard-copy contact cards. The use of “carding” has
since been curtailed through legislation.
 CPIC is a national repository for policing agencies to enter law
enforcement and public safety operational information (as I note above).
It contains data on charged, wanted, and missing persons; stolen vehicles
and property; and other crime-related data.
 The MTO database contains driver’s licence and registration information.

Current Records Management Systems: Versadex

The Service regarded eCOPS as leading-edge technology when it was first
introduced. However, the delay from its initial development in 1996 to its
ultimate use in 2003 created difficulties for the Service. By the time it was
functional, other superior and more cost-effective off-the-shelf records
management system products were available. The issues around eCOPS
prompted the Toronto Police Services Board (the Board) to request that
the auditor general review the implementation of eCOPS.
The auditor general’s 2005 report identified significant defects in
how the eCOPS project was managed, including its failure to address previous
audit recommendations. Of relevance here, the auditor general also
criticized the lack of communication between eCOPS, used solely by the
Service, and the records management systems used by other Ontario
police services. In
response to the Campbell Report, the Service and other police agencies had
proposed a province-wide records management system solution. However, the
Service then decided that the response to the proposal did not satisfy its own
business requirements. As a result, Toronto went it alone and built eCOPS.
The absence of a province-wide records management system for police
services continues to complicate coordinated policing in the province.
Once the Service concluded that eCOPS was no longer adequate to
support its operations, it pursued a commercial off-the-shelf system rather than
attempting to enhance the in-house eCOPS database. In 2008, the Board
approved a capital project for a new records management system. In a March
2011 report to the Board, the chief of police advised that the proposed
new system would integrate the functionality available through numerous
“silo applications” beyond eCOPS, including CIPS, FIR, RICI, Unified
Search, and the Property and Evidence Management System (PEMS).
The procurement process for the replacement program ran from July
2009 to May 2010 and was evaluated by a team of policing and administration
staff. Many of the Service’s members conducted hands-on product evaluations
as part of the process. At its May 2010 meeting, the Board approved the
selection of Versaterm Inc. as the vendor for the supply and delivery of both
software and maintenance and professional services in relation to the new
records management system. The program developed by Versaterm Inc.,
Versadex, was said to meet the highest number of the Service’s business and
technical requirements, provide a user interface well received by officers and
the administration, and, given its ease of use, involve the lowest training
effort. Ultimately, the Board approved the acquisition and implementation
of Versadex. For reasons I need not elaborate on here, the Service
replaced eCOPS with Versadex only in November 2013. This delay meant
that the transition to Versadex took place while Project Houston was in
progress (see Chapter 6).
An upgraded version of Versadex remains in use today, though the
Unified Search tool has been replaced by “Legacy Search.” It incorporates
queries for the Service’s historical records management services,
including CIPS, COPS, and eCOPS. The need for Legacy Search reflects
that some of the historical content of the Service’s records management
services was not loaded into Versadex when it replaced eCOPS. 25 As of April
2019, every police vehicle equipped with a mobile data terminal has access
to the web

25
For example, Mr. Kayhan’s missing person occurrence was not moved from eCOPS to Versadex until
September 2017.
version of Versadex. Officers can therefore perform searches on Versadex,
send CPIC messages, and resolve follow-ups while in their police vehicles.
Despite improvements over the previous records management services,
some officers continue to express frustration over Versadex:

 Some officers find it difficult to use. Despite the process leading to its
acquisition, a number of officers complain it is not as user-friendly as
eCOPS. They say it is time-consuming to enter data and that the system
requires a great deal of navigation to work properly.
 Not all the data were moved into Versadex when it was implemented, as I
indicate above. These gaps make proper searches more complex.
 At times, officers fail to enter new case information into Versadex. For
example, before 2018, when the new Missing Persons Unit was formed,
the Service discovered a large gap between the number of missing person
calls for service and the much lower number of missing person
Occurrence reports recorded in Versadex. The Service’s own analysis
revealed that some officers who attended a missing person call chose not
to create a missing person Occurrence Report, hoping that the missing
person would be found before the officer had to complete a report in
Versadex. The extent to which this issue was attributable to perceived
difficulties in working with Versadex is unclear. In Chapter 13, I describe
and evaluate what the Service has done to address this serious issue.
 Most officers still make notes in their hard-copy memobooks and then
type the relevant information into Versadex. This duplication is time-
consuming and inefficient. Some officers suggested to the Review that
they should be equipped with tablets, to allow them to enter information
directly into the tablet as the first step in uploading it automatically into
Versadex.

Homicide’s Electronic Filing System: The P Drive

In addition to Versadex – the records management system used by all Toronto
officers – specialty units such as the Homicide Unit use a P Drive for specific
investigations or projects. Because Project Houston and Project Prism both
employed a P Drive for electronic file storage and organization, I pause
here to describe its role in investigations. First, it functions as a digital filing
system for documents relating to a specific investigation, and its contents
are accessible only to designated officers. Second, it is organized around
principles of major case management, with files that correspond to the file
categories I set out above. Third, it supposedly serves as the entry point or
source for data
to be uploaded into PowerCase, the mandatory case management system for
designated major cases. I say “supposedly” because the Review learned that
much of the data that is supposed to be uploaded into PowerCase never makes
its way there.
Documents created in Versadex are copied into the P Drive and moved
through its file structure. Documents can also be created directly in the P
Drive. When officers complete a task, they save their work product,
such as a supplementary report, in the file coordinator’s file in the P
Drive. The file coordinator should review the document; rename it, if
necessary, to ensure consistency and accuracy; and move the document
into the primary investigator’s file. The primary investigator should also
review each document to ensure that tasks are properly completed and to
determine if follow-up is required. If it is required, the primary investigator
should send the original officer a follow-up “action” that sets out the work to
be done. Once the primary investigator is satisfied with the work done and the
status of the document, he or she should move the document into the major
case manager’s file for review and approval. After approving each
document, the major case manager is supposed to move the document into
the PowerCase data entry file. Again, I say “supposed to” because many
documents are never entered into PowerCase. Assuming the document is
placed into the PowerCase data entry file, a civilian indexer assigned to the
investigation, who is a member of the Service’s PowerCase Unit, should
review the document, temporarily residing in the PowerCase data entry
file, enter it into PowerCase, and index it. The indexer should then move
the document into the file coordinator’s major case management file,
and the file coordinator should file the document in the
appropriate major case management file.
If the investigation leads to criminal charges, the organization of the
information collected during a major investigation into files also facilitates
disclosure to the prosecution and the defence. The disclosable materials can
easily be reformatted into a disclosure package, saved as a large PDF file, and
moved into a disclosure staging area file.
In practice, the P Drive is also used as a storage site for
investigators’ work in progress. The Project Prism P Drive, for example,
contained a “documents in progress” file that allowed officers to store
documents while they were still working on them. On completion, the
documents would be moved into the file coordinator’s file to initiate the
process already outlined.
In a February 2013 audit report, 26 the Service’s Audit and Quality
Assurance Unit described the P Drive as follows:

26
I discuss the unit’s February 2013 MCM Audit Report in greater detail later in this chapter.
 During the audit, the network P-drive of several units and divisions were
examined. This drive is designed for the exclusive use of capturing and
retaining disclosure material. Files and photographs unrelated to disclosure
items were located in some of the drives. This was brought to the attention
of the immediate supervisor of the officers involved as well as eDisclosure
Project staff who through Detective Services will be issuing a Routine Order
instructing officers to use the P-drive for disclosure purposes only and to
delete any non-disclosure items immediately. This has been addressed as an
issue not requiring Command approval, therefore no recommendation has
been made.

Despite the audit findings, it became clear during the Review team’s
analysis and interviews that both Project Houston and Project Prism included
non-disclosable items in the P Drive, including confidential files marked “Do
not disclose” and active working files.
The Homicide Unit appears to conduct its investigations largely out of
the P Drive. Its officers copy documents created in Versadex and place them
in the P Drive, do their work in the P Drive, and then, often well after the fact,
move only limited documents into PowerCase. Project Houston and Project
Prism adopted the same approach, although, as I outline in Chapter 7, Project
Prism uploaded far more documents into PowerCase than Project Houston did.
Simply stated, the P Drive, rather than PowerCase, is, in effect, being used to
manage major cases – despite the fact that it is not designed to be used as a
case management tool.
The Service’s approach is very different from that taken by a number of
other Ontario services, including at least four large services. These other
services use PowerCase efficiently to manage their major cases. Although the
Service has dedicated PowerCase indexers to handle data entry, it does not use
PowerCase effectively, often treating it as a “data dump” rather than a case
management tool. Moreover, the Service’s way of using PowerCase does not
comply with the provincial adequacy standards that govern its use. Some
senior officers, including former police chief Mark Saunders and Detective
Sergeant Hank Idsinga,27 expressed dissatisfaction with PowerCase,
complaining that it is ill suited for Toronto’s needs. Others strongly disagree.
For example, Acting Chief James Ramer believes that PowerCase was
underused during Project Houston and that indexers were siloed from the
investigative team. In his view, the Service never resourced PowerCase, a

27
Detective Sergeant Idsinga has since been promoted to the rank of inspector.
labour-intensive product when first introduced, the way it should have been,
and a lot of senior detectives never became accustomed to its use. Acting
Chief Ramer indicated that, although numerous changes have been
introduced to make PowerCase more user friendly, the old attitudes persist.
He would like to see it used as intended.
I address the expressed dissatisfaction with PowerCase below once I
have described how PowerCase is designed to work. As I will explain,
regardless of the competing views on the effectiveness of PowerCase for the
Service, the status quo is completely unacceptable.

PowerCase and Its Use

As the names suggest, case management systems differ fundamentally
from records management systems. The latter essentially store information
for officers to access as needed, while the former are digital tools that
assist in organizing and managing a specific investigation. They facilitate
the organization of all investigative information into an accessible
electronic format, track the flow of collected information throughout an
investigation, monitor tasks and workflow of assigned officers, perform
automated case analysis to identify links within and between cases, and, if
a criminal case materializes, facilitate the creation of a disclosure brief to be
provided to the prosecution and the defence. If we think of a records
management systems as an electronic filing cabinet of information, we can
view a case management tool as the program to sort and make sense of
that information for a specific investigation. Case management tools are
supposed to allow the command triangle of a major investigation to answer
such questions as: What did we know? When did we know it? What did we
do with it?
Case management software is particularly important in complex
interjurisdictional and/or potentially linked cases, including serial killer
investigations. When used properly, it reduces human error, facilitates
investigative supervision, lowers expenses by limiting the “people power”
otherwise needed to perform or monitor some tasks, and automatically
looks for and identifies links between potentially connected cases. The
existence of case management software represents a recognition that no
officer, however capable, can possibly assimilate all the information
collected in a complex investigation, easily keep track of all the tasks or
assignments, and know whether or how they have been completed.
With this context in place, I turn now to PowerCase. In 1996, the
Ontario government contracted Xanalys, the company that designed
PowerCase, as its major case management software provider. The
government’s contractual commitment to use PowerCase extends to at least
2027.28
In major case management threshold offence investigations, also known
as full functionality PowerCase cases, all the relevant information is, with
limited exceptions, supposed to be entered into PowerCase. For example, if an
investigator interviews a witness, the audio or video recording of that interview
should be entered into PowerCase as well as the investigator’s notes and
summary of the interview. As I explain in Chapter 6, although Project Houston
easily met the criteria for a major case management threshold offence
investigation and was regarded as such internally, a great deal of relevant
information was not uploaded into PowerCase.
This observation is not of mere theoretical interest. McArthur’s
interview with police in November 2013, for example, was never entered into
PowerCase. No one followed up on what he said, although his interview
revealed, for the first time, a potentially meaningful connection with all three
men whose disappearances were being investigated. I later provide other
troubling examples of critical information never being uploaded into
PowerCase. The effectiveness of any case management system depends on
whether such information is entered into it. Even if the Service, the Homicide
Unit, or senior officers regarded PowerCase as unhelpful during Project
Houston, the fact remains that no adequate case management tools were in
place to catch the deficiencies this Review has identified. Simply put, it is no
answer to say that Versadex, the P Drive, or oral or written directions to
investigators adequately substituted for a comprehensive case management
tool.
Documents can be moved directly into PowerCase from Versadex. For
example, reports produced at a crime scene by front-line officers and recorded
in Versadex can then be “pushed” into PowerCase. Most investigative material
can be formatted for entry into PowerCase. Items such as Word documents,
Excel spreadsheets, telephone records, and emails may be converted into
searchable PDF documents for entry or can be manually typed into the
program as plain text documents.
Massive amounts of data can be entered into PowerCase if the user
knows how to do so. For example, the Peel Regional Police Service regularly
uploads tens of thousands of toll records at a time. Toll records contain
thousands of rows of data from cellphone towers, including telephone
numbers, dates and times of calls, and duration of calls. Civilian
members
28
The RCMP recently adopted PowerCase as its electronic major case management software. This will give
PowerCase added prominence in use nationally.
format the toll records for entry into PowerCase, and a designated toll data
PowerCase entry member uploads the toll data into PowerCase.29 The York
Regional Police have also adopted Peel’s approach to toll data uploads.
Some material is not easily uploaded into PowerCase. For example, the
full contents of a forensic extraction from a cellphone or a computer’s hard
drive are not uploaded. This is because much of the content extracted from a
cellphone or computer is irrelevant for investigative purposes: a computer hard
drive may contain tens of thousands of programming files that are essential to
the computer’s functioning but that have no evidentiary value. Instead,
computer and cellphone data extractions can be entered into PowerCase by
way of a log prepared by a given police service’s electronic discovery
software. The log (capturing, for example, internet search history, saved
files, and emails) can be uploaded as a searchable PDF into PowerCase and
indexed.
As well, most officers still prepare handwritten notes contained in their
memobooks. These notes cannot easily be translated into a usable or a
searchable form in PowerCase. Despite major case management guidelines to
the contrary, memobook notes are usually entered into PowerCase only at the
end of an investigation and only to facilitate disclosure in criminal
prosecutions.

The Use of “Objects” and “Triggering”

Once a document is saved in an appropriate format, the indexer should upload
the document into PowerCase, review it, and identify “objects” contained in it.
Objects include names of persons, addresses, vehicles, and telephone
numbers.30 In 2011, “e-communication” objects were added to PowerCase,
such as social media usernames, email addresses, webpages, and IP addresses.
The 2012 manual added e-communication objects. A person may be
categorized as an object in several different ways – as a suspect, person of
interest, associate of a person of interest, witness, relative, or by the catch-all
word, “other.” PowerCase also automatically identifies what it believes to
be objects within uploaded documents and flags them for the indexer’s
confirmation.
Investigators can use objects in a variety of ways. One way is through
an automatic mechanism called “triggering.” I was told that PowerCase is
29
Members who upload toll data into PowerCase are granted a special profile within the program. This is
because toll data entry into PowerCase is extremely time consuming for the program. The program
sometimes needs to run overnight to process the amount of data being entered. The toll data profile allows
the user’s profile to stay connected to PowerCase for an extended period to avoid the program“timing out”
and disrupting the upload. This allows the user to leave for the evening while the program continues to
work.
30
Each version of the manual identifies the types of entities that constitute an object.
currently the world’s only law enforcement software that performs proactive
triggering. However, Ontario police services do not use PowerCase’s internal
triggering system. Instead, Ontario developed its own triggering software
system that works alongside PowerCase: Ontario’s major case
management triggering software relies on data from PowerCase to form the
basis of triggers. When a trigger is identified by Ontario’s system, the
trigger is sent to PowerCase. PowerCase then sends notifications of the
trigger to the PowerCase accounts of the relevant users.
Within the Service, the value of PowerCase’s triggering mechanism is
somewhat controversial. To explain why, I briefly describe how triggering
works.
As already stated, all Ontario police services are required to upload
relevant information pertaining to certain designated investigations into
PowerCase. These designated investigations include missing person cases
involving a strong possibility of foul play or an individual who remains
outstanding and unaccounted for 30 days after being reported missing.
Ontario’s triggering system automatically generates a trigger when it locates
an exact match or “Soundex” (that is, sounds like) match between objects
referred to in different investigations in Ontario, whether the investigations all
relate to the same police service or multiple services. These trigger
notifications are sent to PowerCase and then to the PowerCase account of a
designated officer, such as the primary investigator or the file coordinator, and
are visible when that officer logs in – preferably daily.31 If a notification within
PowerCase is not reviewed and acknowledged within one week,
PowerCase sends an email to a designated Service bureau administrator to
notify the administrator of the outstanding notification.
Triggering is designed to allow investigators to identify potential links
between cases. For example, an address may have come up in an investigation
the OPP conducted several years ago. That address may, in turn, be associated
with a person of interest in a current investigation. This connection may
ultimately not prove to be relevant to the current investigation, but the trigger
notification enables a current investigator to explore its relevance.
The triggering system generates over five hundred triggers daily across
Ontario. Most of the triggers are “false positives” – the connection or link
between cases is ultimately irrelevant. Many of the false positives are caused
by the “Soundex” match function. For example, an officer entering the
name

31
Every PowerCase user has a personalized PowerCase account. The user must log in to the PowerCase
account to use the program. Trigger notifications are sent to the relevant user’s account and are visible when
the user logs in.
“John Smith” into PowerCase may receive a trigger match for “John Smyth.”
Other potential false positives are linked to common addresses. A particular
hospital, for example, may appear in many different investigations but is
unlikely to be relevant to a current investigator. However, this issue has
largely been rectified. Ontario Major Case Management maintains a list of
common locations that will not raise triggers, including hospitals and shopping
centres. Officers in individual investigations can also manually turn off
triggers for an object that is unlikely to be helpful or relevant to an
investigation.
There is some controversy around the usefulness of triggering. A senior
investigator involved in the McArthur-related investigations told the Review
that PowerCase triggering is unhelpful and that he never received a meaningful
trigger during his years with the Service. Experts in PowerCase are
familiar with this complaint. A survey of users across Ontario revealed that
only 6 percent of triggers were of investigative value or worthy of follow up. 32
It is also time-consuming to review numerous trigger notifications to
determine if they contain relevant leads. However, I conclude – as did
several experts I consulted – that some dissatisfaction about triggering and
about PowerCase generally is based on officers’ unfamiliarity with how,
properly used, PowerCase can significantly improve the efficacy and
results of their investigations.
Triggering is only one component of PowerCase’s tool kit and may, in
fact, be less important than other features I describe below. Moreover, the
senior officer who complained that triggers were unhelpful failed to appreciate
that Project Houston became aware of Mr. Faizi’s disappearance, and its
potential connection to Mr. Navaratnam’s disappearance, simply because the
Peel police had entered Mr. Faizi’s case into PowerCase (see Chapter 6).
Another issue exists that potentially limits the utility of triggering and
of objects generally. Civilian indexers are not trained investigators – there is
no reason to expect them to be. Furthermore, the Review learned that the
Service’s indexers are typically provided with relatively little information
about an investigation.33 It is, therefore, hardly surprising that they may often
be unaware of a person’s relevance to the investigation. As I state earlier,
a person may be categorized in many different ways. If indexers do not
know how a person fits into the investigation, they may not designate the
person into a specific category but as an “other.” About 600,000 of the 1.5
million people identified as objects within PowerCase are so categorized.

32
PowerCase has deactivated the use of telephone numbers as triggers owing to the virtually unmanageable
number of false positives that they generate.
33
A number of services integrate their indexers fully as part of the investigative team.
 An investigator who receives a trigger notification for a person
categorized as an “other” may place little or no value on the trigger or not even
pursue the lead. I address this issue in my recommendations. But I share the
views of one officer, highly proficient in PowerCase, who believes that some
officers incorrectly regard triggers to be a “solve button” and, as a result,
become frustrated by the number of ultimately irrelevant triggers. Instead,
officers should view triggers as a source of potentially relevant
information that, at first blush, may not be apparent, or, expressed another
way, as a “safety net for connections that may otherwise have not been
apparent.”

Object and Free-Text Searches

Triggers identify matches between different cases, not within a single case. As
well, triggers match objects only. Objects are limited to fixed categories rather
than key words, such as “landscaper” or “gay man.” This gap is where other
PowerCase tools comes into play. To look for repeated references to the same
name, address, word, or phrase, investigators can perform object searches
within their own PowerCase file as well as “free-text” searches within
either their own PowerCase file or within PowerCase at large. A free-text
search functions as a simple word search and find. PowerCase’s search
functions would easily permit investigators to answer the following types of
questions, without attempting to do so manually by poring over hundreds or
thousands of pages:

 Did three separate witnesses attend the same address at different points in
time?
 Is a particular telephone number associated with that address?
 Did the address come up in a text message or email between a suspect
and a potential witness?

Again, this is no mere theoretical observation. As I describe in Chapter

6, during Project Houston, certain email addresses and usernames, as well as
certain locations within the Village, came up repeatedly. At least one
investigator as well as the project’s analyst manually discovered some of these
connections. But investigators missed other critically important connections or
failed to discover them in a timely way. In at least one instance, an investigator
“rediscovered” a connection that had already been uncovered earlier in the
investigation. These shortcomings represented failures to upload relevant
information into PowerCase and to use it effectively – or at all.
 As I describe in Chapter 6, the police interviewed McArthur in the
course of Project Houston. However, nothing about the interview was
uploaded into PowerCase – not even McArthur’s name. As a result, when
McArthur was identified as a person of interest years later during Project
Prism, his previous interview was not immediately discovered. It was simply
fortuitous that the officer who had been involved in the earlier project
remembered that McArthur had been interviewed. In addition, McArthur was
a landscaper. A few witnesses had referred to someone who was a landscaper
and to landscaping done by Mr. Navaratnam, one of McArthur’s victims.
Although “landscaper” would not qualify as an object, an investigator
could have conducted a free-text search in PowerCase – assuming relevant
information was uploaded into the system – for references to a landscaper or
landscaping immediately before or after McArthur was interviewed.
Object and free-text searches should be one of the first steps for
investigators using PowerCase, with trigger notifications acting as a backup or
safety net.34

Link Explorer
Link Explorer is another powerful tool in PowerCase which enables
analysis of information for links and patterns and the presentation of that
information in a variety of formats.35 For example, a telephone record
uploaded into PowerCase can generate a graphic, indicating when the phone
number was used to contact another phone number. Other telephone numbers
can be added to show multiple phone numbers calling a given number and
how these calls are sequenced. This tool allows investigators to see
connections quickly between different pieces of data, connections that may
otherwise go unnoticed.
Link Explorer was available in 2012 during Project Houston. If properly
used, Link Explorer could have shown the investigators that McArthur was the
only person with potentially meaningful links to all three missing men. I am
not suggesting that Link Explorer can replace a trained, well-informed analyst.
Rather, it is an important tool that complements the work of an investigator or
analyst in ensuring that meaningful connections are identified. Unfortunately,
it was not used during Project Houston. As I explain in Chapter 6, the project’s
analyst attempted manually to chart some of the important connections in the
investigation but was not provided with up-to-date information as the

34
To be clear, the P Drive has some search capacity, but it is inferior in certain ways to PowerCase’s search
capacity.
35
For example, a “web” format can show a person of interest at the centre, with lines drawn in spider-web
fashion from the centre to connecting addresses, usernames, or persons.
investigation progressed.36 Robust use of PowerCase’s analytical tools would
likely have revealed the connections that investigators did not make in a timely
way or at all.

Action Tracking
When properly used, PowerCase also assists in the organization and
tracking of documents and assignments or tasks performed. It records
when each document was entered into the program and where the document
came from. This tracking is of obvious importance in complex investigations,
but, even more important, PowerCase also tracks “actions.” The manual
defines actions as activities or assignments that an officer must perform,
and it requires that all actions be recorded in PowerCase. Those actions
still outstanding are documented through on-screen forms that contain
instructions to an officer. Since 2012, the manual has also required that the
command triangle categorize actions to be performed as high, medium, or
low priority based on the following factors:

 risk to public safety;

 potential for loss of evidence;
 availability of the source or subject of the information;
 number of references to the same information;
 specificity of the information;
 whether the source of the information is known or anonymous;
 seriousness of the offence; and
 reliability of the source, if known.

Members of a major case command triangle have a “dashboard” within

their PowerCase accounts that lists all outstanding actions. This allows the
command triangle to quickly see any actions that have not yet been allocated
or completed. At this time, PowerCase does not issue notifications to
command triangle members about overdue actions – the command triangle is
responsible for checking their PowerCase accounts on a regular basis to ensure
actions are completed. PowerCase is currently examining how to better
manage actions.
In Chapters 6 and 7, I provide examples of critical actions that were not
recorded in PowerCase and not completed or followed-up on in a timely way.
One of the actions to be performed during Project Houston related to the
subscriber for an email address, [email protected] that was linked
to
36
The analyst did not even have access to PowerCase or the P Drive.
two of the missing men. An officer was assigned to obtain the subscriber
information. The assignment was not properly recorded in PowerCase or in the
P Drive, however, and it fell between the cracks. It took many months for the
project to identify the username’s owner – Bruce McArthur.
Similarly, in 2017, an officer was assigned to obtain several surveillance
videos, including one obtained from the building across the street from
Andrew Kinsman’s residence. A different officer viewed several other
videotapes but was unable to review all three videotapes during his shift. When
Project Prism began shortly after, an action to view the videotape from the
same building was created in PowerCase, but the action was not assigned to
any officer. It, too, fell between the cracks. The videotape was viewed
almost two months after the action to obtain it was assigned. It showed the
critical evidence of Mr. Kinsman’s departure in McArthur’s red van.

The Service’s Non-compliance with Provincial Adequacy

Standards

In this chapter, I have outlined the relevant provincial adequacy standards

respecting major case management and its case management software,
PowerCase. I have also briefly explained how PowerCase works, together with
examples of how it was not used as a case management system during the
McArthur-related investigations. These examples are but a few of the many
ways in which these investigations did not comply with provincial
adequacy standards respecting PowerCase and major case management more
generally. Some of the other ways are as follows:

 The Service repeatedly failed to recognize when the criteria had been met
to categorize a missing person investigation as a major case. This meant,
among other things, that no data were uploaded into PowerCase for
several major missing person cases.
 The Service failed to recognize when the criteria for potentially linked
cases had been met. As a result, it did not notify the serial predator
coordinator of these cases, which might have been addressed through
multi-jurisdictional major case management. The serial predator
coordinator learned about the McArthur-related investigations only when
the media reported on McArthur’s arrest for murder.
 Officers in charge of major cases, or members of the command triangle,
were not always trained, as required, in major case management or,
where applicable, in PowerCase.
 A fraction of the data collected during Project Houston was uploaded into
PowerCase. This mandatory software was not used as a case management
system but, rather, treated as a bureaucratic obligation and largely as a
data dump.
 Data were uploaded well after the fact and outside the periods set under
provincial adequacy standards.
 During Project Houston, critical connections between pieces of evidence
were overlooked – in part, because available search and linkage tools
were not used. This failure was compounded by the underuse of the
project’s assigned analyst.
 Some important actions fell between the cracks, partly because of
inadequate monitoring and supervision and partly because the action
tracking tool in PowerCase was unused. In Project Houston, the tracking
of vital assignments depended largely on human memory and handwritten
notes. This approach did not comply with the requirements for major case
management.
 The civilian indexer assigned to Project Houston, through no fault of her
own, knew little about the investigation, was largely disconnected from it,
and was provided with limited data to upload and inadequate direction on
the data’s significance. Moreover, these deficiencies became more
pronounced in the later stages of Project Houston, ultimately to the point
where the indexer was no longer assigned to the project.
 During Project Houston, no detailed chronology of investigation was
maintained,37 as required by the manual. Nor was a victim liaison
assigned, as was also required.
 A larger percentage of the data collected during Project Prism was
uploaded into PowerCase. Although Project Prism was more efficient and
effective than Project Houston, it also did not use PowerCase as a case
management system.
 Almost all the McArthur-related investigations did not comply with
provincial adequacy standards respecting ViCLAS notifications.

I elaborate on all these issues in Chapters 5, 6, and 7. They are not

confined to the McArthur-related investigations but are systemic issues that

37
Project Houston did have a daily log, although it was not entered into PowerCase; nor did the log
constitute a detailed chronology as contemplated by the manual. Different officers contributed to it on
different days, but the amount of detail they included was inconsistent. One ra tionale for a detailed
chronology involves the need for a document that is ready to be imported quickly into an urgent court
application.
 relate, more broadly, to how the Service identifies, case manages, and
ultimately investigates major cases – particularly major missing person cases.
The Service’s failure to comply with provincial adequacy standards
relating to major case management and PowerCase is not a new issue. In
February 2013, the Audit and Quality Assurance Unit issued an internal report
on the Service’s compliance with the manual (the MCM Audit Report). The
report concluded that the Service had not complied with requirements in the
manual in 50 percent of the major cases randomly selected for audit
review: 25 percent of the cases had been assigned to an investigator who
had not successfully completed the major case management course, and 14
of the 20 assigned investigators did not have any training in PowerCase. The
audit team concluded that this non-compliance represented a “significant
risk” to the Service on several levels: it exposed the Service to potential
civil liability; it could result in a public finding of non-compliance once the
ministry conducts its anticipated major case management compliance
inspection; finally, “the Service’s reputation could suffer irreparable
damage in the public eye, especially if the improperly investigated
major case involved a child or
vulnerable individual.”
I observe that although the audit examined only 20 major case
investigations, nine of the 10 non-compliant investigations were
conducted within police divisions rather than by specialty units. Moreover,
there is no indication that the audit team examined any major missing
person investigations or any such investigations that should have been treated
as major cases but were not.
The MCM Audit Report recommended that the deputy chiefs of police
responsible for divisional policing and specialized operations ensure that all
cases defined as major cases are investigated according to the Ontario Major
Case Management Manual. The response from the Service, however, can only
be described as disheartening – the report was not taken seriously. The Board,
moreover, was not even made aware of the issue, despite its systemic
implications and potential impact on the Service’s reputation.
In 2014, Detective Sergeant Stacy Gallant, 38 who headed the Service’s
Homicide Cold Case Section, drafted a proposal requesting additional
resources to ensure that the Service complied with the manual. He
recommended that five divisional Criminal Investigations Bureau (CIB) clerks
be trained to use PowerCase and that they be assigned to major case
investigations for PowerCase indexing:

38
Detective Sergeant Gallant is now retired.
 All investigative information is required to be entered into PowerCase, it
must then be researched, indexed and cross-referenced. The major case
management unit staff has been completing all of these functions, for the
entire Service. Transferring some of the responsibility to the divisional level,
to perform functions for investigations that require only tombstone data
entry, would have many beneficial effects.
…
Due to the volume of cases, and workload within the MCM office,
there are currently approximately 2500 updates outstanding. Most relate to
tombstone cases, primarily updates to or changes to supplementary reports,
or changes to the occurrence information, excluding arrests (which are
currently up to date).
Provincial legislation states that “All investigative information shall
be entered in the Ministry approved software within 30 days of receipt of
the information.” A contingent of divisional PowerCase indexers would
greatly assist with the Service’s compliancy rate and could be called upon,
when the need arises, to respond to major incidents.
Implementing divisional PowerCase indexers, would allow the highly
experienced MCM indexers the time required to become more involved in
threshold incidents (homicides and major sexual assaults) as well as
longer-term, and major case projects. Ensuring that timely and accurate
investigative material is loaded into PowerCase will assist investigators.
[Emphasis in original.]

This proposal was never acted on.

In 2016, the Major Case Management Unit issued an internal report
entitled “PowerCase – Current Status and Proposed Enhancements” (2016
MCM Report). The 2016 MCM Report stated that compliance with the manual
and with PowerCase requirements continued to pose challenges. The report
was critical of the practice of relying solely on Versadex for case management:

Relying solely on Versadex to manage a major case can present issues when
managing a chronology, preparation of search warrants, review and storage
of video (statements, seized, surveillance) and the storage of electronic
records that contain large volumes of information. Although it is possible to
manage an investigation within the limits of Versadex[,] the system does not
support compliancy with the document management requirements as set out
in the MCM Manual.
…
To achieve efficient major case management[,] the use of a
combination of the Versadex process and the electronic file system should
 be used. Versadex provides for the ease of sharing of information across the
service. The electronic file system ensures that the investigator remains
compliant with legislation. The combination of the systems is necessary as
the Versadex RMS system is not capable of allowing investigators to use the
MCM document management system (folder system). The consistent
application of the processes will ensure effective document management and
compliancy with the MCM manual including PowerCase.

I acknowledge that Project Houston and Project Prism also used the
P Drive for case management. However, as I say above, this approach remains
non-compliant with provincial adequacy standards. More significantly, the use
of the P Drive did not prevent important steps from being overlooked –
omissions that PowerCase is designed to catch. Moreover, as I demonstrate in
Chapter 5, the McArthur-related investigations that preceded Project Houston
did not employ the P Drive or any meaningful case management system.
The systemic issues around the Service’s use of PowerCase arose again
in 2017. On July 26 of that year, Detective Constable Stacey Dewsnap, a
PowerCase coordinator with the Service’s Major Case Management Unit,
emailed Inspector Bryan Bott to alert him to relevant changes to provincial
adequacy standards for missing person investigations. Specifically, Detective
Constable Dewsnap advised that tombstone data must be entered into
PowerCase when individuals remain unaccounted for 30 days after their being
reported missing. Andrew Kinsman’s disappearance was entered into
PowerCase only because the Major Case Management Unit read about his
disappearance in the media. Selim Esen’s disappearance was entered into
PowerCase because the unit developed a tracking program that identified his
case as outstanding for over 30 days.
Most recently, the ministry conducted a province-wide inspection of
major case management practices, including those at the Service, which was
completed in 2019. In important areas relevant to this Review, this inspection
was not comprehensive. It focused on major case investigations of homicides
or attempted homicides, sexual offences, and criminal harassment where the
harasser is not known to the victim. It did not address missing person
investigations, though these cases raise different considerations. For example,
the Review learned that hundreds of the Service’s missing person cases
that had been entered into PowerCase continued to show as “open,” though
they should have been appropriately updated or concluded. I raise the scope of
the ministry’s inspection not as a criticism, but simply as recognition that it
does not address a number of the issues I identify during this Review.
 The ministry’s inspection report made several relevant
recommendations. It also requested that the Board and the Service provide a
coordinated response (the Service’s improvement plan) within 90 days. The
improvement plan was publicly released at the June 3, 2020, Board meeting.
Six of the inspection report’s recommendations are relevant to this
Review:

 Number 4: The chief of police should ensure that investigative

information for threshold major cases is entered onto PowerCase in
accordance with the data entry standards set out in the manual (Ont. Reg.
354/04).
 Number 5: The chief of police should ensure that the serial predator
coordinator is notified within seven days, in accordance with the manual,
if there is a reasonable likelihood that the same person(s) has committed
the crime(s) within a single jurisdiction or a multi-jurisdiction (Ont. Reg.
354/04).
 Number 6: The chief of police should review procedures for undertaking
and managing investigations into major cases to provide further clarity
and direction on procedures and processes to support the flow of
investigative information to the Service’s Major Case Management Unit
for entry onto PowerCase.
 Number 7: The chief of police should consider linking procedures and
processes for undertaking and managing investigations prescribed as
major cases with Service procedures and processes for the use of
PowerCase.
 Number 8: The chief of police should consider revising Service
procedures for undertaking and managing major cases. This revision
would include the requirement to notify the serial predator coordinator
within seven days, in accordance with the manual, if there is a reasonable
likelihood that the same person(s) has committed the crime(s) within a
single jurisdiction or a multi-jurisdiction.
 Number 9: The chief of police should consider revising Service
procedures for undertaking major cases to require that those officers in
the command triangle be clearly identified.

The Service’s improvement plan places heavy emphasis on training. It

states that training is being developed to target “major case managers and
divisional detective sergeants in the field to include reinstalling data entry
standards.” The plan indicates that the training will include direction
respecting notifications to the serial predator coordinator and on the flow
of investigative information to PowerCase. As for the identification of the
command triangle’s members, the plan contemplates that the Service will
liaise with the Ontario Police College to ensure consistency in training. In
relation to recommendation 7, the plan reflects that the Service’s new chief
information officer has undertaken a review of the interoperability of systems
and software used by the Service. Finally, in response to several
recommendations not reproduced above, the Board has undertaken a
comprehensive review of its own policies to ensure that they have been
updated and address all provincial adequacy standards. I comment on the
ministry’s recommendations and the response to them in the Summary and
Findings section below.

The Technological Crime Unit and

Technological Tools Available to the Service

The Technological Crime Unit

The Service’s Technological Crime Unit (the Tech Crime Unit) is a unit within
the Technical Investigation Group of Intelligence Services. Rather than
conducting its own investigations, the unit provides support for other
investigative units. The unit conducts forensic analysis of electronic devices
such as computers and cell phones and provides the extracted and
analyzed information to investigators in a readable format. The Tech Crime
officers also provide advice on the contents of search warrant applications
involving electronic devices, give expert testimony, and assist with search
warrant executions and other technical aspects of investigations, including
data recovery. These officers typically have backgrounds in technology and
receive specialized training to perform their roles.
At the time of writing, Detective Sergeant John Menard leads the Tech
Crime Unit. He listed the technology-related forensic tools available to the
Service to assist in its investigations. Here, I refer only to those tools relevant
to my evaluation of the McArthur-related investigations and my
recommendations.
The Tech Crime Unit uses a case management program entitled E-
Tracker to organize and manage its own work – a program that should not be
confused with PowerCase, the case management software for an entire
investigation. E-Tracker logs the date the unit was given an electronic device,
what work was done on it, when and by whom, and what the unit found as a
result. E-Tracker also records the unit’s legal authorization to access the
contents of the device.
 During Project Houston, the unit used several forensic tools to examine
computers. At the time, one of these tools was a new program, XIRAF. This
program translates a hard drive’s content into a readable format for manual
examination. Instead of lines of illegible data, the content is viewed as a series
of files filled with searchable text. In June 2013, XIRAF was installed on
several Project Houston computers, and, three months later, in September,
using this program, Detective Constable Josh McKenzie, one of the project’s
investigators, found McArthur’s telephone number (the project had already
acquired the related email address) in Mr. Navaratnam’s computer files using
XIRAF.
During Project Houston, the Tech Crime Unit also used a similar
program, Internet Evidence Finder (IEF). The Service ultimately phased out
XIRAF in favour of IEF. AXIOM is the current iteration of IEF. All these
programs function in a similar way to XIRAF. They allow officers manually
to read, search, and analyze the content of a computer hard drive.
In addition to XIRAF and IEF, the Tech Crime Unit used forensic
software applications entitled Encase by Guidance Software (Encase) and
Forensic Toolkit (FTK) by Access Data. These tools were employed
during Project Houston and are still in use today. Encase and FTK “image” the
target media, authenticate the evidentiary forensic image, and analyze the
evidence obtained. The software enables an investigator to view all files on the
media, including deleted folders and file fragments.
As I explain in Chapter 6, during the initial investigation into Mr.
Navaratnam’s disappearance in 2010 and 2011, the Service failed to
forensically examine Mr. Navaratnam’s laptop computer. It contained valuable
evidence that ultimately implicated McArthur. In early 2013, when a Tech
Crimes officer examined the computer during Project Houston, he failed to
locate this valuable evidence because his assignment was too narrowly
defined. In February 2013, an investigator identified a link between
silverfoxx51 and two of the missing men. However, she was unable through an
“open source” search39 to ascertain that this username was one that McArthur
used. It was only in September 2013 that another investigator employed
XIRAF to connect McArthur to the silverfoxx51 email address. The
technology to make this connection was available to the Tech Crimes Unit
in February 2013. Moreover, it was only in 2017, during Project Prism,
that a forensic examination of Mr. Navaratnam’s computer uncovered
sexualized messages

39
“Open-source” searches or information gathering involves the collection of information via the internet
using sources such as search engines, chats, social networking sites, media platforms, and blogs.
between McArthur and Mr. Navaratnam that put the lie to an earlier statement
McArthur made to the police in November 2013.

The Coordinated Cyber Centre

Since 2014, the Coordinated Cyber Centre (C3) has been another support unit
of the Intelligence Services. It supports investigations of certain criteria
offences (such as homicides, cyber-bullying) that have an online component,
and it may also agree to support investigations in non-criteria matters,
depending on available resources and other priorities. The unit uses tools,
including open-source searches, scrapes, and interceptions, along with active
engagement with persons online. C3 members also support investigations
involving social media platforms and website analytics.
Internet investigations conducted by the Toronto police have, since
2014, been governed by the Service’s “Internet Facilitated Investigations”
Procedure 04-45. The procedure requires officers to have completed the
computer- and technology-facilitated investigations course, or an equivalent,
before they engage in internet investigations and/or open-source information
gathering. C3 may provide support where the online component of an
investigation is beyond an investigator’s capacity. In May 2017, for example,
the officer in charge of the investigation into the disappearance of Selim Esen
obtained the assistance of C3.

Summary and Findings

In Chapters 5, 6, and 7, I describe and evaluate the McArthur-related

investigations conducted by the Toronto police between 2010 and 2018. A
significant component of that evaluation involves how each investigation was
organized and case managed; how and what information was collected,
recorded, indexed, cross-referenced, and used; and the extent to which
investigators availed themselves of existing external and internal technological
and analytic tools and resources to advance their investigations.
The evaluation required a clear understanding of the provincial
adequacy standards and the Service’s own procedures that govern or guide
such investigations. It also required a basic understanding of the Service’s
records management and case management systems; PowerCase, the
provincially mandated case management system for major cases; and the other
technological and analytical tools and resources, both external and internal,
that existed during the relevant periods. Accordingly, this chapter provides the
necessary backdrop to my evaluation of the McArthur-related investigations,
and to the larger systemic questions those investigations raise.
My Review team and I met with Sean Ramitt at Xanalys; members
of the ministry’s Major Case Management Unit, including the provincial
software coordinator and the serial predator coordinator at the material time;
and many officers and civilian employees of the Service, including members
of the Major Case Management Unit. The Review also heard from officers of
all ranks, including senior command, who have been involved in a variety of
ways in major case investigations. The Review’s policing consultant, former
OPP chief superintendent Mark Pritchard, was seconded, during part of his
lengthy policing career, with the ministry’s Major Case Management Unit
and was well versed in these topics as well. The input of all these individuals
informed my findings and recommendations.
The evidence is indisputable that the McArthur-related
investigations did not comply in many ways with provincial adequacy
standards respecting major case management. I list the key lapses above,
though they are best elaborated on in Chapters 5, 6, and 7. Here I will address
the larger systemic issues around the Service’s use of PowerCase.
As I have repeatedly pointed out, PowerCase is the provincially
mandated case management software for major cases. It is used effectively by
other large services in Ontario to case manage major investigations. Some of
Toronto’s senior officers have expressed dissatisfaction with PowerCase – and
their dislike is manifested in the failure, in a number of major case
investigations, to use PowerCase as a case management tool. In some respects,
their dissatisfaction has become a self-fulfilling prophecy: their misuse and
underuse of PowerCase has made it ineffective. If but a fraction of data is
uploaded into PowerCase, and much of that data is uploaded well after it was
collected, it is hardly surprising that PowerCase’s search and linkage tools,
such as free-text searches and Link Explorer, are not used or of limited
assistance. If assigned indexers are largely disconnected from investigations
and are provided with inadequate information about data to be uploaded, it is
equally unsurprising that object searches have limited utility. If officers
have not received adequate training on PowerCase or do not act in accordance
with the training they receive, it is difficult to blame PowerCase for the
investigative deficiencies that result. If actions are not properly recorded in
PowerCase, it is impossible to attribute investigative omissions to the software.
In addition, I heard other complaints from Toronto police officers. Some
senior officers suggested that PowerCase may work for other police services
but not in Toronto, given the number and complexity of the Service’s
major
cases. Some officers regard the P Drive as the preferable case
management tool, and some cite weaknesses or limitations in PowerCase to
support their concerns.
I do not accept that the Service is so different from other services that it
cannot work effectively with PowerCase. Comparable police services in
Ontario and elsewhere have demonstrated otherwise. In some instances, the
position that PowerCase doesn’t work for Toronto was advanced by officers
whose understanding of PowerCase was, itself, deficient. With respect, this
position also speaks to a certain hubris or lack of introspection that the Review
observed in relation to some members of the Service.
I recognize that the Homicide Unit and others use the P Drive for some
of the case management functions PowerCase performs. I also
acknowledge that certain investigations can sometimes be, and often are,
effectively conducted without PowerCase. However, the status quo I have
described is completely unacceptable for at least five reasons.
First, several of the McArthur-related missing person investigations
were seriously flawed. Those flaws were explained, in part, by the absence of
adequate case management. Project Houston is illustrative. The P Drive did
not serve as an effective substitute for PowerCase: leads went unnoticed;
several critical assignments were missed; key analysis was not pursued,
particularly after one of the investigators left the project; supervision was, at
times, poor; technological tools were underused. In the course of conducting
this Review, I had little indication that the Service was aware of these flaws or
had adequately addressed them.
Second, the Service is undeniably pouring substantial human and
financial resources into uploading data, however imperfectly, into PowerCase.
However, this expenditure makes no sense if PowerCase is not being used
appropriately, as often happens. Moreover, Toronto investigators may create a
document in Versadex, the document may be entered into P Drive, and then it
must be uploaded into PowerCase. Other large services have demonstrated that
there is no need whatsoever for documents to exist in three different systems.
The Service’s approach reflects a lack of commitment to PowerCase.
Third, PowerCase, properly understood, can provide significant
assistance that is not otherwise available to investigators in complex cases.
Versadex is not a case management system, and the P Drive does not offer the
same assistance in facilitating the speed, flow, direction, and effectiveness of
a major investigation. The number and complexity of Toronto’s major case
investigations reinforces, rather than detracts from, the need for a robust case
management system – one, moreover, that can assist in linking major cases
within the Service’s jurisdiction.
 Fourth, the Service is not entitled to disregard provincial adequacy
standards simply because it chooses to do so. This point is applicable not only
to PowerCase but also to major case management standards generally. Officers
in charge are not entitled to ignore ViCLAS submission requirements or to fail
to notify the ministry’s serial predator coordinator of an investigation that
meets the criteria for a multi-jurisdictional investigation. If the Service wishes
to revisit existing provincial adequacy standards or their applicability to
Toronto, it has a powerful voice to raise its concerns through the ministry.
Fifth, as noted in the Service’s internal major case management audit,
non-compliance with provincial adequacy standards exposes the Service to
potential liability and the risk of reputational loss.
To be clear, this criticism is not directed at the entire Toronto Police
Service. Quite a few officers, including Acting Chief James Ramer, express
support for the Service’s adhering to provincial adequacy standards around
major case management and using PowerCase as it was designed to be used.
PowerCase is certainly not perfect and has its limitations. Uploading all
relevant data into PowerCase is time consuming and a drain on the
Service’s resources. Some types of data are particularly difficult to upload.
Trigger notifications include too many false positives, at times diverting
officers from more pressing work. As well, officers who receive trigger
notifications cannot easily access additional information about cases
potentially connected to their own and may have to contact officers in other
police services to obtain what they need. This follow-up, too, can be time-
consuming. Training on PowerCase involves some complexity, meaning that
officers must not only be trained well on its use but also have access to
refresher courses.
The answer is not to discard PowerCase (or any substituted case
management software the ministry approves), but to make needed changes to
improve its effectiveness. For example, I understand that PowerCase’s
designer is working on making the software entirely web-based, enabling it to
be accessed from any computer and automating pre-determined action lists for
particular types of investigations, such as missing person investigations. Such
lists would not bind investigators but serve as checklists for their
consideration. In Chapter 15, I make additional recommendations directly
related to major case management and PowerCase, particularly as they relate
to missing person investigations.
The issues I raise about the Service’s non-compliance with
provincial adequacy standards respecting major case management and
PowerCase are hardly new ones. It is frankly disheartening to realize that
these issues were identified by Service members some time ago but not acted
on. Most recently,
the ministry’s inspection report addressed several of these issues. Still, I must
sound a cautionary note about the ministry’s recommendations and the plan
developed in response to them. Both focus on the need to take steps, such as
training, to ensure that investigative information for threshold major cases is
uploaded into PowerCase in accordance with data entry standards. However,
if PowerCase is not used, as it was designed, to case manage threshold major
cases, the rationale for uploading the data into PowerCase is completely
undermined. Simply put, the Service, in the initial and ongoing training and
education of officers of all ranks, must address not only the data entry
requirements for PowerCase but also why it is important that it be used
consistently and properly.
The ministry’s recommendations 6, 7, and 8, reproduced above, invite
the Service to re-examine its procedures for undertaking and managing major
cases, and, more particularly, to support the flow of investigative information
to the Service’s Major Case Management Unit for entry into PowerCase.
In my view, these recommendations provide the Service with an impetus
to address, albeit belatedly, at least two key problems with the status quo. The
first problem is the siloed environment in which the Major Case Management
Unit’s indexers currently operate. I have already expressed concern over the
frequent disconnect between the investigation and both its file coordinator and
its indexers. A senior ministry representative characterized the issue this way:

One of the responsibilities of the file coordinator within the manual is to

make sure that the information that is being entered into PowerCase is
indexed, researched and cross-referenced properly. That is the part that is
getting missed out. That file coordinator’s responsibility to ensure the data
entry standard is being met. The data is going in and the investigators are
completing their investigation, but the link between the two, which is one of
the primary functions of the file coordinator, is being missed. Part of this is
the manual’s fault and part of the issue is that investigators don’t put value
on file coordination. They view the file coordinator role in relation to
disclosure, not as an integral part of the investigation.

This disconnect undermines the purpose and value of PowerCase.

The second problem relates to the number of steps and the
resources engaged in transferring data from Versadex to a P Drive to
PowerCase. My team has reviewed two internal memoranda Service
members prepared that suggest potential solutions. The Service’s chief
information officer is currently reviewing the “interoperability of systems” and
the software being used by the Service. That review should include, through
expert assistance, consideration
as to whether data must be loaded onto three separate systems in major cases,
and, in any event, whether data can be uploaded in ways that reduce the time
expended for this uploading to take place. It should also include whether some
of the current functions can be performed automatically.
The ministry’s inspection report and the Service’s improvement plan
identify the need to ensure that the serial predator coordinator receive
notifications in accordance with the applicable regulation and the manual.
Again, training on this issue will be ineffectual unless it comes with a
robust understanding of why the serial predator coordinator is to be
notified; when the criteria have been met; and, most importantly, the
Service’s commitment to multi-jurisdictional investigations in appropriate
cases.
The issues I identify in this chapter are not confined to missing person
investigations. However, these issues did figure prominently in my evaluation
of the Service’s missing person investigations, particularly those related to
McArthur’s victims. I now turn to a detailed examination and evaluation of the
McArthur-related investigations. The shortcomings in these investigations,
viewed against the backdrop of the issues explored in this chapter, inform my
ultimate recommendations.
 Chapter 5 Three Men Go Missing 115

Chapter 5

THREE MEN GO MISSING

In this chapter, I describe and evaluate the initial investigations by Toronto

police into the disappearances of Skandaraj Navaratnam and Majeed
Kayhan as well as the interplay between the Peel police and the Toronto
police respecting Abdulbasir Faizi’s disappearance. I also discuss Bruce
McArthur’s first relevant encounter with the justice system in the period 2001
to 2003 and its significance to this Review.

McArthur’s Assault Convictions Before the 2010–17

Murders

On October 31, 2001, Mark Henderson, who lived in Toronto’s Gay Village
(the Village), was preparing Halloween celebrations when McArthur showed
up at the front door of his building. McArthur was not an expected visitor, but
Mr. Henderson let him in, assuming he was there to see someone else. Without
any warning or provocation, McArthur attacked Mr. Henderson with a metal
pipe he was carrying, knocking him unconscious. McArthur then left and later
turned himself in to Toronto police.
1
He claimed he had “blacked out” and had no recollection of these events.
Purportedly, he was suggesting that his conduct was explained by a history of
seizures caused by epilepsy and/or drug consumption.
As a result of McArthur’s attack, Mr. Henderson suffered significant
physical injuries. The emotional impact on him was profound and continues to
this day. He is but one of McArthur’s survivors. He has shown courage and
resolve in the face of great adversity.
On January 29, 2003, McArthur pled guilty to two charges: assault with
a weapon and assault causing bodily harm. He continued to maintain he had
no recollection of the events, although he accepted responsibility for his
actions and waived any possible defences to them. McArthur claimed he was
carrying a metal pipe to defend himself against dangerous street people he had

1
In 2016, McArthur also turned himself in after he choked another gay man who survived the attack. Both
times, McArthur seems to have contacted the police for strategic advantage in anticipation of a criminal
complaint.
been exposed to, and not in anticipation of attacking Mr. Henderson. The
prosecutor accepted that McArthur was not a predator targeting people in the
Village and ultimately joined the defence in recommending that McArthur be
sentenced to a conditional sentence of two years less one day. 2 Once served,
the conditional sentence would be followed by a three-year probation period
that prohibited him from entering a defined geographic area of the city, an area
that included the Village. 3 On April 11, 2003, the trial judge accepted the joint
submission on sentence, ending the court proceedings against McArthur. In
2014, McArthur was granted a record suspension (formerly known as a
pardon). Nonetheless, these convictions and the circumstances
surrounding them remained accessible to the Toronto Police Service (the
Service) on its records management system / databases.
It is not within my mandate to evaluate how the justice system dealt
with McArthur back in 2003. However, I have reviewed the file relating to his
guilty plea, sentencing, and probation, including relevant psychological reports
about him and his own personal statements. The file shows, among other
things, that McArthur successfully portrayed himself as a low-risk offender
without a psychiatric or psychological disorder. In the absence of any
credible explanation offered for his violent attack on Mr. Henderson or of any
medical evidence supporting his purported blackout or lack of recollection, I
question the readiness of the justice system to evaluate him as a low-risk
offender. I do not mean this view to be a reflection on the presiding judge,
who was presented with an agreed statement of facts and a joint submission as
to sentence.
However, the more significant point for this Review is that absolutely
no attention was paid to McArthur’s 2001 violent behaviour when, in 2013, he
was interviewed during Project Houston, an investigation into allegations of
an active cannibalism ring (see Chapter 6). Project Houston examined whether
the ring explained the disappearances of three men last seen in the Village. I
will later explain how McArthur’s 2001 behaviour, and the circumstances
surrounding it, should have prompted further questioning and heightened
scrutiny of McArthur as a person of interest not only when police interviewed
him but following the interview. McArthur’s previous violent behaviour drew
investigative attention only in late 2017, after he had already been identified
as a person of interest or as a suspect during Project Prism, an investigation

2
The first third of the conditional sentence involved strict house arrest. The next third involved evening
house arrest. The remaining component involved few restrictions.
3
Both the house arrest and the probation terms specifically prohibited McArthur from being within 10
metres of Mr. Henderson’s apartment building. This address is in close proximity to Mr. Kayhan’s
residence.
prompted by Andrew Kinsman’s and Selim Esen’s disappearances (see
Chapter 7).
McArthur’s unprovoked metal pipe attack in 2001 represents his first
known criminal and violent conduct directed toward a member of Toronto’s
LGBTQ2S+ communities – or indeed, against anyone. Tragically, much more
violence was to come.
On December 2, 2005, the Toronto police stopped McArthur while he
was driving. He did not have a valid insurance card with him. This infraction,
along with his telephone number, was recorded in the Service’s electronic
database. Although the incident itself was minor, it became significant
eventually in enabling the Toronto police to connect McArthur to his email
address, [email protected].

Skandaraj (Skanda) Navaratnam: McArthur’s First

Known Murder Victim

Mr. Navaratnam was last seen alive on September 6, 2010, leaving

Zipperz nightclub in the Village. McArthur killed him that night.
A popular man, Mr. Navaratnam had many friends. He usually called
his friend Mr. AA several times a day. Mr. AA last saw Mr. Navaratnam
on the afternoon of September 5, 2010. On September 16, after not having
heard from Mr. Navaratnam in all that time, Mr. AA became concerned and
called Toronto’s 51 Division to report his friend’s disappearance. The police
went to Mr. AA’s home.
Mr. AA provided the police with information about Mr.
Navaratnam. He told them that Mr. Navaratnam worked at Ryerson
University and was scheduled to work that day. He observed that Mr.
Navaratnam had issues with drugs and alcohol and struggled with
depression. He provided an address where Mr. Navaratnam was staying and
informed them that Mr. Navaratnam’s roommate, Mr. BB, last saw him at
Zipperz on September 6, 2010.
Finally, Mr. AA speculated that Mr. Navaratnam might be visiting
Hamilton, Ontario, or even Mr. AA’s cabin in Bancroft, Ontario. In the police
Occurrence Report, Mr. AA purportedly said he did not suspect foul play but
expressed concern that Mr. Navaratnam was not in contact with him. The
police went to the address where Mr. Navaratnam had been staying, but no one
was home.
118 Independent Civilian Review into Missing Person Investigations

It was not until 2013 that the police formally interviewed Mr. AA and
Mr. BB about Mr. Navaratnam’s disappearance.4 Sergeant Douglas
Bourque, who was ultimately assigned as officer in charge5 of Mr.
Navaratnam’s investigation, told the Review it would have been “best
practice” for police to formally interview Mr. AA and Mr. BB back in
2010. To illustrate the importance of a timely, comprehensive, formal
interview, in early 2013, during Project Houston, Mr. AA told Toronto police
he had last seen Mr. Navaratnam at the Black Eagle bar in Toronto. Although
he shared that information with the media on September 20, 2010, the
Toronto police did not appear to be aware of this sighting. They did not
interview anyone at the Black Eagle during the 2010 police investigation. We
also know, based on subsequent interviews conducted by either the police or
the Review, that all or virtually all of McArthur’s murder victims frequented
the Black Eagle at various times, as did McArthur himself.
A number of officers were involved in aspects of the initial investigation
into Mr. Navaratnam’s disappearance. The Review found it difficult, however,
to determine who was directing or overseeing the investigation from the start.
Most of the police documents from the original investigation identify
Detective Debbie Harris6 as the officer in charge, but, in response to the
Review, she said that Mr. Navaratnam’s case was assigned to Detective
Barry Radford. Detective Radford in turn replied he has no recollection
whether he did any work on the original investigation following the report
of Mr. Navaratnam’s disappearance. Sergeant Bourque believes he was
assigned to the case several days after Mr. Navaratnam was reported missing.
These imprecise recollections over the officer in charge reflect at least
two systemic issues. First, the officers’ memobook notes for 2010–11 were
largely unavailable either at the Service or in the Toronto archives. They
should have been preserved and uploaded into Project Houston’s case
management database when the project began in 2012. Second, missing person
investigations at the time were typically passed from officer to officer, except
for those rare circumstances in which such investigations were designated as
“major cases,” when major case management protocols applied. Mr.
Navaratnam’s case was no exception. It followed the typical approach to
missing person cases – meaning that these investigations were often not
followed up on or appropriately and adequately supervised. It also meant that
4
I am distinguishing between cursory exchange with someone, and a comprehensive, organized “formal”
interview.
5
“Officer in charge” in this chapter is used synonymously with lead investigator.
6
Detective Harris was later promoted to the rank of detective sergeant. She is now retired. Rather than
referring to her throughout as retired Detective Sergeant Harris, I use the rank most relevant to the period
being discussed, as I do with all police officers.
 Chapter 5 Three Men Go Missing 119

those affected by the disappearances had great difficulty finding out about the
current status of the cases. In Chapters 13 and 15, I return to these systemic
issues.
By the time Sergeant Bourque became involved, he believed Detective Harris
had already completed a judicial production order to obtain Mr. Navaratnam’s
cellphone records. If this recollection is accurate, it likely places the beginning
of his involvement in late September or early October 2010. Sergeant Bourque
does not recall why he received the assignment, though it might relate to
weekend or evening shifts moving cases around among officers. Unlike a
number of other police services, Toronto had no dedicated Missing Persons
Unit at the time. Indeed, it was only after the McArthur-related and other high-
profile missing person cases that the Service moved ahead with a Missing
Persons Unit.
On September 17, 2010, Mr. AA told the police he would check his
cabin to see if Mr. Navaratnam was there. The police went to Mr.
Navaratnam’s last known address again. A neighbour told them Mr.
Navaratnam no longer lived there and that its owner, Mr. CC, was in
Europe until October 9, 2010. Approximately 10 days later, one of Mr.
Navaratnam’s friends called the police to say that Mr. CC might have contact
information for Mr. Navaratnam’s family in the United States and in Sri
Lanka.
The Toronto police did not interview Mr. CC until March 14, 2013.
During this interview, which took place as part of Project Houston, Mr. CC
said that Mr. Navaratnam had lived with him for four years and that they were
in an intimate relationship for two of those years. Most significantly, given
McArthur’s gardening and landscaping business, he stated that Mr.
Navaratnam did odd jobs and was good at landscaping. In November 2013,
when McArthur was interviewed during Project Houston, he told police he
knew Mr. Navaratnam through one of his landscaping employees.
The police never contacted Mr. Navaratnam’s family during the 2010
investigation. They made no efforts to do so until late in 2012 during Project
Houston.
On September 20, 2010, the media reported on Mr. Navaratnam’s
disappearance. The headline in the Daily Xtra read: “Toronto gay man missing
since Sept. 6.” In the article, Mr. AA was quoted as expressing fears for Mr.
Navaratnam. He mentioned that his friend had a new puppy – his pride and joy
– which he took everywhere. After Mr. Navaratnam’s disappearance, however,
the dog had been left alone in the apartment, without anyone to care for it.
This neglect was completely out of character for Mr. Navaratnam.
 Mr. AA returned to the police station on September 21 and advised the
police that Mr. Navaratnam was not at his cabin. He created a Facebook page
and missing person posters to raise awareness about Mr. Navaratnam’s
disappearance. The police sent out a Service-wide bulletin7 about Mr.
Navaratnam’s disappearance and checked local hospitals for him. They also
issued a media release.8
In addition, Mr. AA gave the police Mr. DD’s address as a possible
alternative residence for Mr. Navaratnam. The same day, the police went to
Mr. DD’s home. Mr. DD advised them that, for about nine months, Mr.
Navaratnam had been staying there two or three times per week, but he had
not seen him since September 5. The police noted that Mr. Navaratnam’s
belongings were still there. Mr. DD also told the police that Mr. Navaratnam
was seeing a therapist at the University of Toronto for post-traumatic stress
disorder.
On September 22, the police contacted Immigration Canada to learn
whether Mr. Navaratnam was a permanent resident. Koodo (Mr. Navaratnam’s
cellphone provider) advised that his cellphone last pinged off a tower on
September 6. The phone had been used extensively before that date. Mr.
Navaratnam’s cellphone was registered to a friend named Mr. EE. Mr. EE told
the police that he and Mr. Navaratnam had obtained new phones in
August 2010. He also said that Mr. Navaratnam had been in a relationship
with a man named Richard who lived in Maine. The police checked local
prisons and detention centres to see if Mr. Navaratnam was in custody,
and US immigration services to discover if he had crossed the border.
They did not uncover any leads.
On September 23, the police checked the morgue in case Mr.
Navaratnam’s body might be there. They also sent a request to Koodo for Mr.
Navaratnam’s cellphone records. On September 27, Koodo told the police that
Mr. Navaratnam’s cellphone records would not be released without a judicial
production order.
Mr. FF called Sergeant Bourque on September 23, after seeing a
missing person poster for Mr. Navaratnam. Mr. FF had seen Mr. Navaratnam
at Zipperz on September 6, where they talked about the puppy. Mr. FF
remembered that Mr. Navaratnam had left the bar with two men who
approached him. He informed Sergeant Bourque that, if necessary, he was
prepared to come in to give a statement.

7
A Service-wide bulletin is a notification to a ll members of the Service to alert them about a case.
8
The press release initially misspelled Mr. Navaratnam’s name as “Mavaratnam,” but the error was
corrected the same day.
 Sergeant Bourque told the Review that leaving the puppy behind was a
“red flag” that heightened the risk that something untoward may have
happened to Mr. Navaratnam. Unfortunately, the urgency given to the
investigation did not change because of this critical information. During this
investigation, no risk assessment was done in connection with Mr.
Navaratnam’s disappearance. I find this problematic.
Mr. FF was another person who had potentially useful information but
was never formally interviewed until 2012 during Project Houston. In 2013,
the police finally obtained a sketch by a police artist of the two men with
whom Mr. FF said he saw Mr. Navaratnam leave the bar. Although the
sketch ultimately did not prove to be a productive lead, this interview and
sketch should have been done in 2010.
On September 24, 2010, the police obtained Mr. Navaratnam’s laptop
from Mr. DD. Three days later, the police submitted a request to have the
laptop examined by the Service’s Technological Crime Forensics Laboratory
in the Intelligence Division. Despite the obvious importance of the missing
man’s laptop as a potential source of relevant information, this analysis was
not done until 2012 and, when it was finally done, it was flawed (see Chapter
6). It overlooked critically important information available through the laptop.
Indeed, it was only in 2017 that police learned from the laptop that Mr.
Navaratnam and McArthur had exchanged sexualized emails. This
correspondence demonstrated that McArthur had been dishonest about the
nature of his relationship with Mr. Navaratnam when he was questioned by the
police in November 2013.
Sergeant Bourque acknowledged to the Review that the forensic
analysis of Mr. Navaratnam’s computer was not given the same priority as it
would have been in a homicide investigation. Indeed, it was given no attention
at all.
On September 24, the police went to Zipperz to see if any surveillance
video was available from the night of Mr. Navaratnam’s disappearance. The
bar was not equipped with surveillance video, but an employee at the bar told
police he saw Mr. Navaratnam leave the bar the night he disappeared. The
police did not formally interview the Zipperz employee until February 2013.
On September 25, Mr. EE sent a fax to Sergeant Bourque saying
that Mr. GG had told him Mr. Navaratnam had been at The Cellar
bathhouse on September 6 with an unidentified male. He included the contact
information for Mr. GG. In the following days, the police attempted to contact
Mr. GG and went to The Cellar to ask for surveillance footage. An
employee said the footage would be checked.
 On September 26, the police did a walk-through of Riverdale Park with
Mr. Navaratnam’s friends because the park was said to be a meeting or pick-
up place for gay men. On the same day, Mr. Navaratnam’s ex-partner, Mr.
HH, contacted the police to tell them that Mr. Navaratnam may have left the
country with a friend who owned a float plane. The police did not formally
interview Mr. HH until 2012.
On September 27, the police put a “flag” on Mr. Navaratnam with
Canada Border Services.9 Again, the police checked the morgue and the
addresses associated with Mr. Navaratnam. They did not discover anything
new. The police also contacted TD Bank to do a “grid search” (a search to
check on bank account usage).
That same day, September 27, the police issued another media release
about the disappearance of Mr. Navaratnam, requesting the public’s assistance
and indicating their concern for his safety. The police records indicate that
Detective Radford consulted Detective Peter Code10 of the Homicide Unit
about Mr. Navaratnam’s disappearance, though Detective Radford does
not recall doing so.
Detective Harris told the Review that the Homicide Unit was notified of
Mr. Navaratnam’s disappearance in 2010 and that she believed Detective
Radford had provided this notification. According to Detective Harris,
Homicide would be notified about a missing person investigation after normal
“boots on the ground” investigative steps had been exhausted. Based on
all available evidence, it became obvious to me that this notification did
not represent an invariable or even a standard practice. Nor were existing
procedures clear as to how and when Homicide should get involved, other than
in obvious situations. In any event, the Homicide Unit did not take carriage of
Mr. Navaratnam’s case at that time. Nor did it appear to oversee the
investigation.
On September 28, the police obtained several of Mr. Navaratnam’s
personal belongings for DNA testing, including a razor and a toothbrush. They
also obtained DNA samples from Mr. EE and Mr. DD. However, Mr.
Navaratnam’s DNA was not submitted to the Office of the Chief Coroner for
Ontario or to the RCMP’s national missing person database. (I explain the
roles of the Office of the Chief Coroner and the national database in Chapter
13.) Detective Harris described this lapse as an oversight.
On September 29 and October 1, in response to a Crime Stoppers
tip, the police again checked the Riverdale Farm and Park area. On October 1,
they

9
A “flag” is a notification to Border Services to alert the police if Mr. Navaratnam crossed the border.
10
Detective Code has since been promoted to the rank of staff superintendent.
used a cadaver dog for their search. The police also contacted Durham
Regional Police to see if a helicopter could be used to search the park for Mr.
Navaratnam, but they were advised that the helicopter could not detect human
remains.
On October 5, the Toronto police obtained a judicial production
order for Mr. Navaratnam’s phone records. On the same day, the police
submitted the production order to Telus (Koodo’s parent company).
On October 17, the police made a further request for video footage from
The Cellar, as well as from a bank close to Zipperz. The Cellar advised police
on October 19 that its footage went back only 12 days, so none remained
for the night of Mr. Navaratnam’s disappearance. The video would have
been unavailable by the time police learned on September 25 that Mr.
Navaratnam had been at The Cellar. Sergeant Bourque did eventually view
surveillance footage of the alleyway next to Zipperz.
On October 21, the police contacted hospitals and jails, again with
negative results.
On October 22, Telus indicated it would be able to respond to the
production order for Mr. Navaratnam’s cellphone by November 4 or 5.
The police also contacted the University of Toronto to try to locate Mr.
Navaratnam’s psychiatrist. On October 27, the police spoke to someone at the
medical clinic and learned that Mr. Navaratnam had not been there since 2009.
On October 28, the Ministry of Health advised there was no recent activity on
his health card.
At this point, the investigation came to a standstill – one that lasted for
many months. On May 13, 2011, one of Mr. Navaratnam’s friends called the
police to let them know he had received a “spam” communication from Mr.
Navaratnam’s email account. The police replied to the address, advising Mr.
Navaratnam of the missing person investigation, but received no response. The
spam email did not represent a communication from Mr. Navaratnam.
Detective Harris told the Review that this incident was the last step the
police took on Mr. Navaratnam’s case until Project Houston began in late
2012. She acknowledged that in the original investigation, some things were
left “undone.” At the end of 2010, she indicated that she still considered Mr.
Navaratnam a missing person with no evidence of foul play, despite the
unusual red flags associated with his case (including his sudden lack of
cellphone usage and the puppy he left behind). Sergeant Bourque, in contrast,
told the Review he identified these “curious” and “suspicious” factors or “red
flags” early in the investigation.
 It is difficult to reconcile Detective Harris’s view that there was no
evidence of foul play at the end of 2010 with the October 5 application that
same year for a judicial production order for Mr. Navaratnam’s cellphone
records.11 The supporting affidavit for the application asserted that the
police had reasonable grounds to believe Mr. Navaratnam had been
“forcibly abducted” by an unknown person. The same affidavit named
Detective Harris as the lead investigator.
Detective Sergeant Hank Idsinga, 12 who became the major case
manager in late 2012 for Project Houston, agreed with Detective Harris, based
on his later review of the evidence, that, back in 2010, the police did not
have evidence of a crime. He noted that, based on the law existing at that
time, the police could not obtain a judicial production order for a missing
person’s records without reasonable grounds to believe that a crime had
been committed. In his view, this restriction may have coloured how the
affidavit was crafted. As discussed in my findings below, I disagree with
that assessment.
Sergeant Bourque felt he had no further leads to pursue. The case went
cold.

Abdulbasir (Basir) Faizi

Mr. Faizi lived with his family in Peel Region. He was last seen on December
29, 2010, leaving Steamworks bathhouse in the Village in Toronto. He spoke
to his wife shortly after, to tell her he was going to meet a friend. He bought
food at a restaurant at the corner of Church and Wellesley streets at 8:29 p.m.
He was never seen again.
On December 30, Mr. Faizi’s cousin reported him missing to 21
Division of the Peel Regional Police. The same day, Peel officers went to Mr.
Faizi’s home to speak with his wife. The Peel police immediately began
completing items on their Missing Person Task Assignment Sheet. This sheet
set out 75 general and case-specific tasks to be completed in Mr. Faizi’s
investigation, along with the name of the officer who completed each task, the
date it was assigned, and the date it was completed. No such case management
tool was used in the original investigation by Toronto police into Mr.
Navaratnam’s disappearance.
On December 31, Mr. Faizi’s brother and cousin told police they
had tried, without success, to access his bank-card and cellphone
information. On
11
A submission to the Centre of Forensic Sciences in January 2013 stated that Mr. Navaratnam’s
disappearance was deemed suspicious at the time of his original Missing Person Report.
12
Detective Sergeant Idsinga has since been promoted to the rank of inspector.
 Chapter 5 Three Men Go Missing 125

January 1, 2011, the police received information suggesting that, unbeknownst

to Mrs. Faizi, Mr. Faizi had been unhappy in his marriage and was
communicating with another woman. On January 2, his niece went to the
police station and told the police she had accessed her uncle’s email account.
Mr. Faizi was corresponding with gay men and leading what was described as
a “double life.”
At the time of Mr. Faizi’s disappearance, Peel’s 21 Division had a
missing person coordinator, Constable Marie-Catherine Marsot. 13 She was
also the domestic violence coordinator at 21 Division. At her request, she was
permitted to take over the missing person portfolio at the division. She
was deeply committed to the work and brought a fresh perspective to it. In
some instances, this interest resulted in reopening older missing person cases,
and, in a few instances, they ended in homicide charges. On January 4,
Constable Marsot took charge of the investigation into Mr. Faizi’s
disappearance.
During the week of January 3 to 8, the Peel police proceeded with their
investigation of Mr. Faizi’s disappearance. They went to his workplace. They
attempted to identify a lawyer he used. They contacted Rogers to obtain
information concerning the last known location of Mr. Faizi’s phone. Rogers
told them the phone was untraceable and was likely turned off. It had last been
used on December 29, 2010, at 8:28 p.m. when Mr. Faizi called his wife: it
had “pinged” off a cellphone tower near Mr. Faizi’s workplace. The police
also contacted Mr. Faizi’s bank and health centre.
The Peel police identified and investigated a man in Edmonton whose
name and contact information were in Mr. Faizi’s email contacts. The
individual proved to be unrelated to Mr. Faizi’s disappearance. Mr. Faizi’s last
emails also indicated he was hoping to meet up with an unknown person.
Police emailed the recipient’s account and initiated efforts to obtain the IP
address of the account. (This email account later proved to be unrelated to Mr.
Faizi’s disappearance.) The police also contacted hospitals.
On January 4, Toronto police found Mr. Faizi’s car in front of 26 Moore
Avenue in Toronto.14 Toronto police told the Peel police about the discovery.
Mr. Faizi typically did not park his car in this area while in Toronto. When the
Peel police contacted the restaurant where Mr. Faizi last bought food to ask for
surveillance footage, they were told the surveillance camera did not work.
On January 5, the Peel police issued a press release alerting the public
of Mr. Faizi’s disappearance. They received a call from one of Mr. Faizi’s

13
Constable Marsot has since retired from the police service.
14
This location was not far from the address where McArthur disposed of his victims’ bodies and also not
far from another address where he landscaped.
126 Independent Civilian Review into Missing Person
Investigations
friends, who said Mr. Faizi was not in a financial position to leave his family.
On January 6, the Brampton Guardian ran an article about Mr. Faizi’s
disappearance. Among other things, it noted that the police were particularly
concerned because Mr. Faizi’s disappearance was out of character.
On January 6, the Peel police contacted the Toronto police asking
for assistance. As a result, they were able to use cadaver dogs belonging to the
Toronto police to search the area surrounding Mr. Faizi’s abandoned car.
When the Peel police called Mr. Faizi’s family about the car, they said they
did not know anyone in the area where the car was found. The Peel police also
sent Mr. Faizi’s missing person press release and photograph to the
Salaam Queer Muslim Community Centre and distributed his missing
person information across the Peel Police Service. Mr. Faizi’s car was
towed to the Peel police station, and the Peel police completed their forensic
examination of it.
On January 7, with the family’s consent, the Peel police obtained and
searched Mr. Faizi’s computer. That same day, they sent it to their Tech
Crimes Unit. Constable Marsot began to draft an application for a judicial
production order for Mr. Faizi’s cellphone records, but never completed it. She
told the Review that obtaining a production order would have been helpful, but
police were unable to get one without proof of a criminal offence. Legislation
has since been proclaimed to make it easier for police to obtain production
orders in missing person cases.
During the week of January 9 to 15, 2011, the police updated the
photograph in Mr. Faizi’s press release. They located one of Mr. Faizi’s
friends, who last saw him on December 29, 2010, at Steamworks bathhouse.
The friend, Mr. II, told police that Mr. Faizi frequented the Black Eagle bar in
Toronto. The Peel police canvassed the area near the location where Mr.
Faizi’s car was found and went to Steamworks to check for surveillance
footage. They were told that the footage was no longer available – it was kept
for only seven days. They also flagged Mr. Faizi at the Canada–US
border, canvassed residences in the area of his disappearance, and
contacted Toronto shelters – all with no success. Mr. Faizi’s workplace
advised it had no video surveillance. The Peel police sent an emergency
request to Facebook for all Mr. Faizi’s private messages, subscriber content,
photos, and IP logs. Facebook denied the request on the grounds that a
missing person case was not considered an emergency. Forensic testing
concluded that no blood was present in Mr. Faizi’s vehicle. The Peel police
submitted Mr. Faizi’s case to the OPP Missing Person and Unidentified
Bodies Unit (see Chapter 13) – a step never taken by the Toronto police
during their investigation of Mr.
Navaratnam’s disappearance. The Peel police also notified the missing person
coordinator at their Homicide Bureau.
On January 17, Mr. II called Constable William Ramsay, one of Peel’s
assigned officers, saying he had seen posters identifying other South Asian
men missing from the Church and Wellesley streets area in Toronto. 15 This
information alerted Peel police to the possibility that similar disappearances
existed. Constable Ramsay called the owner of the Black Eagle bar and asked
about the missing men. During that conversation, he learned that the Black
Eagle had eight cameras in the bar and maintained surveillance footage for six
months. There is no explanation as to why the surveillance footage was never
obtained.
After receiving this information, Constable Ramsay reviewed the
Canadian Police Information Centre database (CPIC) 16 and identified Mr.
Navaratnam as another missing person. Constable Ramsay told Constable
Marsot about both Mr. Navaratnam and a Toronto Sun article that
discussed his disappearance.
That same day, Constable Marsot sent a CPIC message to the Toronto
police requesting a copy of Mr. Navaratnam’s Occurrence Report. When she
read the report, she was struck by the similarities between the two men: they
disappeared from the same area, they were both gay and from the Muslim
community, and they resembled each other physically in terms such as facial
hair. She suspected a connection between the cases.
Constable Marsot also spoke with a Peel police crime analyst about the
two cases. She was interested in finding information about any other
missing men from the area. She did some computer research, and her
memobook notes reflect how she learned that homosexuality appeared to be
“taboo” within the Toronto Muslim community.
Constable Marsot phoned Toronto’s 51 Division and left a message for
Sergeant Bourque, the officer in charge of Mr. Navaratnam’s investigation.
Her call was not returned. She phoned a second time, and on January 19, an
officer (not Sergeant Bourque) responded, saying the Toronto police would
“look into it.” She did not hear anything further.
In the meantime, Peel’s Tech Crime Unit made a cloned image of Mr.
Faizi’s computer.
On January 21, Constable Marsot again attempted to contact the
Toronto police. This time she emailed Sergeant Bourque to advise him she
believed

15
It is unclear what men other than Mr. Navaratnam were identified at that time.
16
CPIC is a central police database, maintained by the RCMP, that is accessible to all Canadian law
enforcement agencies.
Mr. Faizi’s and Mr. Navaratnam’s cases were possibly connected. She notified
her supervisor about her investigation. The supervisor was supportive of her
efforts and encouraged her to pursue potential connections to other cases.
Constable Marsot received no response from the Toronto police. That same
day, the Peel police added Mr. Faizi’s Occurrence Report to PowerCase –
a province-wide case management tool accessible to all Ontario police
services. As I describe in detail in Chapter 4, PowerCase automatically
generates certain “triggers.” These triggers may result in a notification to one
police service of a potential link between its investigation and another
police service’s investigation. Notably, PowerCase’s use as a case
management tool is mandatory for certain designated major cases.
The Peel police included a reference to Mr. Navaratnam in Mr. Faizi’s
PowerCase file. On January 17, Constable Ramsay had created a PowerCase
report detailing the conversation with Mr. II that led to his identifying Mr.
Navaratnam as another missing person.
The Toronto police did not upload Mr. Navaratnam’s case to
PowerCase until December 4, 2012, in the early days of Project Houston. Once
that was done, PowerCase generated a notification on December 19, 2012,
to the Toronto police about Mr. Faizi’s disappearance. The potential link
between the two disappearances had gone completely unnoticed by Toronto
investigators for almost two years after Constable Marsot tried to engage them
in discussions of what turned out to be an important link.
Constable Marsot was frustrated and angry with the Toronto Police
Service’s lack of response. She believes that these cases could have been
solved much earlier if the Service had co-operated with Peel. This view is
shared by the Toronto officer who contacted Constable Marsot in December
2012 (during Project Houston) once she discovered the potential link between
the cases.
In an interview with the Review, Constable Marsot stated that missing
person investigations are generally not a priority in policing. Working on
missing person cases was considered a low-status role. Moreover, there was
no specialized training for conducting such investigations, and officers were
left to learn on their own.
Sergeant Bourque told the Review he vaguely remembers receiving the
email from Constable Marsot. However, he does not specifically recall hearing
about Mr. Faizi’s case in early 2011 and its possible connection to Mr.
Navaratnam’s disappearance. By the time he did, he was no longer working on
the case.
During the week of January 23 to 29, Peel investigators returned to the
Moore Avenue address to canvass the owners of all the vehicles parked on the
street. They hoped to identify an address where Mr. Faizi may have gone, after
leaving his car. None of the vehicle owners were identified as being connected
to Mr. Faizi.
The following week, January 30 to February 5, the Peel police
interviewed Mr. Faizi’s wife. She told the police she did not think her husband
was alive. The Peel police continued to canvass addresses in the area of Mr.
Faizi’s disappearance.
During the weeks of February 6 to 19, the Peel police canvassed gay
establishments in Toronto’s Gay Village and interviewed Mr. Faizi’s
family members. Constable Marsot arranged for an undercover team of
officers to conduct surveillance at the Black Eagle and at Woody’s (another
bar Mr. Faizi was known to visit). An employee at the Black Eagle, as well as
an employee at Spa Excess, told the Peel officers that in January 2011, Mr.
Faizi had been seen at both establishments on several occasions. We now
know that this information was not accurate because McArthur murdered
Mr. Faizi on or around December 29, 2010.
On February 28, 2011, Constable Marsot attended an LGBTQ2S+
community meeting in Toronto to talk about Mr. Faizi’s disappearance. Her
memobook notes about the meeting indicate that the community members
were surprised to learn about Peel’s active interest in the disappearance from
the Village.
In March 2011, the Peel officers investigating Mr. Faizi’s disappearance
met with the Peel Police Diversity Relations Unit. The investigators were
advised of contacts in the gay community in Peel and they followed up, but
with no results. In June 2011, the police contacted Mr. Faizi’s family again.
No new information was available.
Mr. Faizi’s wife told the police that in the months before Mr. Faizi went
missing, he had talked about moving to Ottawa. His telephone and bank
accounts had not been used since his disappearance. The Peel investigators
forwarded information about Mr. Faizi’s case to the Montreal police, because
Montreal was known to have a large LGBTQ2S+ community presence. In
October 2011, the Peel police checked records in the provincial health system,
the Ministry of Transportation, and government assistance offices. These
efforts turned up nothing.
As indicated earlier, on December 19, 2012, the Toronto police received
a PowerCase trigger. The trigger identified a potential link between Mr.
Navaratnam’s case and Mr. Faizi’s case: the Peel police had identified Mr.
Navaratnam in the PowerCase system as a person associated with the
investigation of Mr. Faizi’s disappearance. Detective Constable Cathy Loria,
130 Independent Civilian Review into Missing Person Investigations

a member of Toronto’s Project Houston team, followed up with Constable

Marsot. I pick up this part of the narrative in Chapter 6.

Majeed Kayhan

Mr. Kayhan was last seen by his family at a wedding on October 14, 2012.
McArthur killed him on or about October 18, 2012.
Mr. Kayhan and his son talked by phone every few days, and the
younger man became concerned when, suddenly, he was unable to reach him.
On October 23, he went to his father’s apartment at 31 Alexander Street in
Toronto to look for him. A neighbour told him he had last seen Mr. Kayhan on
October 18 around 10:30 a.m. On October 25, the son reported his father’s
disappearance to Toronto’s 42 Division. Toronto police contacted all
downtown hospitals to check for Mr. Kayhan, with negative results. The
officers noted in the Occurrence Report that at this point, foul play was
not suspected.
The case was referred to 51 Division because Mr. Kayhan lived in
the Village, which was within its jurisdiction. Detective Saleem Husain, who
was assigned to the case, called Mr. Kayhan’s son to ask some questions.
Detective
Husain did not think the case “seemed very concerning.” Although this abrupt
stoppage in communication with his son was out of character for Mr. Kayhan,
and there were no apparent medical issues. At the time, Detective Husain was
not aware that Mr. Kayhan had a connection to the LGBTQ2S+ communities.
He was not aware of Mr. Navaratnam’s disappearance, nor of Mr. Faizi’s, and
did not realize that Mr. Kayhan was the third man to go missing from the
Village. This lack of information reflects a fundamental breakdown in how
missing person cases were being tracked as well as a host of systemic issues
that I address in this Report.
During the following week, the police contacted the Office of the Chief
Coroner as well as Social Services, because Mr. Kayhan received
disability payments. Social Services told Detective Husain that Mr. Kayhan’s
payments were deposited directly into his bank account at the CIBC. When
Detective Constable Guy Kama contacted the CIBC, he learned that Mr.
Kayhan’s bank card had last been used on October 11, 2012.
Surprisingly, the police did not go to Mr. Kayhan’s home until October
30. Mr. Kayhan’s much-loved birds were dead. This neglect concerned
Detective Husain: he told the Review that few people willingly let their pets
die through lack of food and water. On November 1, he arranged for the
distribution of a media release about Mr. Kayhan’s disappearance. The police
spoke to Mr. Kayhan’s family members and advised them there had been no
 Chapter 5 Three Men Go Missing 131

further activity on Mr. Kayhan’s bank cards. They again checked local
hospitals, with no results.
Between November 1 and November 13, nothing was done on Mr.
Kayhan’s investigation. Detective Husain explained he was on days off during
much of that period. Mr. Kayhan’s case was given to the next scheduled shift
at 51 Division for any necessary follow-up, but no new leads came in, and no
additional steps were taken.
On November 13, the police again interviewed Mr. Kayhan’s son. He
gave the police contact information for some of Mr. Kayhan’s friends and told
them that Mr. Kayhan was depressed about his failing marriage. He also said
he thought his father might be part of the gay community. This discussion was
the first time the police learned that Mr. Kayhan had a potential link to this
community, apart from where he lived. The police returned to Mr. Kayhan’s
apartment. They found medication bottles and contact information for Mr.
Kayhan’s doctor. The apartment security guard told police he had seen Mr.
Kayhan with members of the gay community.
While the police were at the apartment, Mr. Kayhan’s neighbour, Mr.
JJ, told them he had coffee with Mr. Kayhan almost every morning and that he
watched his apartment and looked after his birds when Mr. Kayhan went
away. He did not, however, hear from Mr. Kayhan before he disappeared. It
was not until January 2013 that the Toronto police formally interviewed Mr.
JJ. During that interview, he gave the police some additional information,
including that Mr. Kayhan went to the Black Eagle every day and that he had a
friend who was a florist or a landscaper.17 Detective Husain told the Review,
given how close Mr. JJ was with Mr. Kayhan, it would have been “best
practice” to interview him as soon as possible after Mr. Kayhan was reported
missing.
On November 25, 2012, the police checked local hospitals again, with
no results. In December 2012, the police received a call from a community
member who told them that Mr. Kayhan spent time at the Point Tent and
Trailer Resort (the Point). The police attempted to contact the Point, but the
business was closed for the season. On January 8, 2013, Detective Husain
tasked a fellow officer with checking Mr. Kayhan’s home again. That direction
was his final involvement with the case.

17
The police learned from McArthur in November 2013 that he had employed Mr. Kayhan. In 2018, a
witness recognized Mr. Ka yhan from a photograph as someone who worked for McArthur at the location
where the bodies of his victims were ultimately found.
Summary and Findings

Mc Arthur’s Assault Conviction: Before the 2010–17 Murde rs

As I state earlier, it is not within my mandate to evaluate how the justice
system dealt with McArthur’s criminal conduct from 2001 to 2003. In 2001,
McArthur committed extremely serious crimes with lasting consequences
for the survivor. Strategically, he turned himself in and successfully portrayed
himself as ignorant of what he had done – despite the absence of any
supporting medical evidence. The prosecution concluded that McArthur was
not engaged in predatory behaviour – although the available evidence
should not have inspired confidence in that conclusion. A psychiatrist
concluded that McArthur was at low risk of reoffending – although she gave
no explanation why he struck a potentially fatal blow to an unsuspecting
person. McArthur was obviously persuasive. He also disarmed others as to
his true evil. We cannot unfairly employ hindsight in evaluating what
happened in 2003. In my view, however, it appears that the justice system may
have inadequately scrutinized McArthur’s 2001 crimes.
McArthur’s survivor felt his views were discounted or ignored.
When McArthur entered a guilty plea, the prosecutor told the judge a victim
impact statement would be forthcoming. No such statement was ever filed, nor
was any explanation offered for this failure. In my view, too much attention
was given to the victim’s supposed “lifestyle” when the uncontested facts
showed an unprovoked attack on him. McArthur’s explanation, apparently
accepted at face value, that he was armed with a lead pipe to ward off violent
offenders in the Village was, as it turns out, deeply ironic.
There is one particularly troubling aspect of these 2003 convictions.
They played no part in either the Project Houston investigation from 2012 to
2014 or in the investigation into McArthur’s attempted choking of another
survivor in 2016.
In November 2013, McArthur was interviewed during Project Houston.
This interview was not preceded by any meaningful examination of his history,
including his previous criminal conduct. A Legacy Search would have
revealed McArthur’s previous convictions (see Chapter 4), but the officer did
not perform one. There is no evidence in his notes or elsewhere that he did so.
The interviewing officer believed, had he discovered this history, he would
have discounted it as dated and unhelpful. I disagree with the proposition that
this history was irrelevant to McArthur’s credibility. By the end of the
interview with McArthur, Project Houston had information that he had a
significant connection to all three missing men. This connection should
have
raised a big red flag for investigators – prompting, at the very least, focused
scrutiny on him. The fact that in 2001, he had attacked a gay man in the
Village without provocation and, for this reason, had been banned from the
Village for three years was important. In 2017, during Project Prism, the lead
investigator discovered the 2003 convictions and the underlying facts from
an electronic search of the Service’s records. He recognized their
significance.
In 2016, McArthur was accused of choking another gay man, but the
police decided not to charge him. The investigator accepted that McArthur
believed, in good faith, that the victim wanted to be choked. The 2016
investigation was flawed – and I explain why in Chapter 7 of this Report.
What is significant is that, in 2016, the investigator was also unaware of
the 2003 convictions. He said an electronic search of police records did not
disclose the previous convictions for which McArthur had been granted a
record suspension in 2014. In any event, he believed that the record suspension
precluded the police from subsequently relying on the underlying crime. It was
obvious during this Review that officers had varying views on the use that can
be made for investigative purposes of crimes for which a record
suspension has been granted. It was also obvious that the failure in 2016 to
discover McArthur’s past crimes, but the discovery in 2017 of those same
crimes through a database search, raises yet another systemic issue that I
address in my Report.

Skandaraj (Skanda) Navaratnam

On September 6, 2010, Mr. Navaratnam was last seen alive in the Village. He
was reported missing on September 16. He left behind his new puppy, a source
of pride and joy. Although he was active on social media, his participation
ended abruptly. So did his cellphone use. He appeared to have taken no
belongings with him, nor had he told anyone about plans to depart. When he
was reported missing, he had already been gone without a trace for 10 days.
His disappearance deserved to be given high priority. It wasn’t. The case
moved from investigator to investigator. Some leads were not pursued in a
timely way or at all. It wasn’t until several years later, during Project Houston,
that a number of witnesses were properly interviewed. A risk assessment was
never made. Investigators took little or no meaningful measures to engage
community organizations or leaders in the search. There is no evidence that
investigators had any true understanding of the people they should speak to
within the affected communities. They did not enlist potentially valuable
human resources within the Service, such as the LGBTQ2S+ liaison officer or
officers with close contacts with the Village, to ensure that the right people
were spoken with and that existing barriers to providing information to the
police were reduced.
One investigator found Mr. Navaratnam’s disappearance suspicious,
recognizing the existing red flags. Another investigator saw no evidence
whatsoever of foul play. The investigation simply “petered out” because, it
was said, there were no leads to pursue. But that assessment was inaccurate.
For example, Mr. Navaratnam’s computer was seized by the police, yet it was
not analyzed until 2012. Even then, its significance was not appreciated.
The computer showed Mr. Navaratnam’s access to dating websites and
included sexualized messages between him and silverfoxtoronto –
McArthur’s electronic username. These messages were not discovered until
late 2017. As well, although investigators did some social media work, they
never carried out a comprehensive search of all the potential social media
sources. Nor did they contact the OPP’s Missing Person and Unidentified
Bodies Unit. Most alarmingly, there is no evidence of a comprehensive
investigative plan for the investigation.
In fairness, the police did conduct considerable investigative work in
2010 and 2011. As well, Mr. Navaratnam’s friends speculated – sometimes
rather hopefully – that Mr. Navaratnam had merely left for parts unknown.
But, as I indicate above, the 2010–11 investigation was seriously flawed.
It was deserving of the attention ultimately given to Mr. Kinsman’s
disappearance. In Chapter 12, I discuss the reasons for the differential
treatment.
Provincial adequacy standards require that certain cases be treated as
major cases. Those same standards require threshold major cases to be
investigated through a structured major case management model that promotes
thorough, well-organized investigations with safeguards to ensure that
tasks are assigned and completed. Such cases generally attract greater
resources and must be managed through PowerCase, the provincially
mandated case management software. Ontario police services can access
entries on PowerCase, and this access in turn can trigger notifications of
potential links between cases (see Chapter 4).
In 2010 and 2012, threshold major cases included missing person cases
involving a strong possibility of foul play and non-familial abductions. As I
describe in Chapter 4, threshold major cases must be investigated, structured,
and managed in ways dictated by the provincial adequacy standards for major
case management.
There is no consistency in how Toronto investigators determine whether
a missing person case involves a strong possibility of foul play. I find it
troubling that 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. This interpretation does a disservice
to those missing, such as Mr. Navaratnam, and to their families and
friends. Mr. Navaratnam deserved better.
During the 2010–11 investigation, the police obtained court orders to
get certain records. At the time, such court orders could be obtained only when
an officer asserted, under oath, that there were reasonable grounds to believe a
crime had been committed. In the context of a missing person investigation,
this requirement meant that the police could get a court order only after
asserting, under oath, that the missing person had been the victim of foul
play.18 In this instance, an officer stated he had reasonable grounds to believe
Mr. Navaratnam had been forcibly abducted. “Reasonable grounds to believe”
is the same, in law, as “reasonable and probable grounds.” As I have already
stated, a forcible abduction investigation was also a designated threshold major
case under provincial adequacy standards.
This sworn evidence in 2010 was inconsistent with the view that there
was not even the strong possibility that Mr. Navaratnam was the victim of foul
play. Strong “possibility” falls short of reasonable and probable grounds
to believe. Simply put, the assessment that Mr. Navaratnam’s disappearance
was undeserving of major case status was inconsistent with the existing
evidence. A senior officer suggested to the Review that Mr. Navaratnam’s
disappearance did not rise to the level of a major case – instead, the
applications for court orders in 2010 reflected a “stretch” to obtain these
orders, given the inadequacies then existing in the law. I do not agree. The
application was not a “stretch.” In my view, a cumulative evaluation of the list
of red flags supports the conclusion that Mr. Navaratnam’s disappearance
qualified as a major case. The ostensible abandonment by Mr.
Navaratnam of his prized puppy headed the list. But at a minimum, those
red flags demanded that the investigation into his disappearance be given
greater priority and urgency than
it was.
Further, Ontario Regulation 550/96, “Violent Crime Linkage Analysis
System Reports,” required that the officer in charge of a missing person
investigation, where the circumstances indicate a strong possibility of foul
play, submit a ViCLAS Crime Analysis Report (see Chapter 4). No such
report was ever submitted in connection with the 2010–11 investigation
into Mr. Navaratnam’s disappearance, despite the circumstances – and
despite the investigation’s own representations to the Court.
18
Subsequent legislation has given greater latitude to police to obtain court records without such reasonable
grounds.
 Mr. Navaratnam was marginalized and vulnerable in a variety of ways
and for a variety of reasons that intersect. But his disappearance was noticed –
and reported. The Service failed him in its initial investigation. Unfortunately,
it also failed those who loved him both in how his disappearance was
originally investigated and in how little support the police gave them
during this time frame.
The response by Toronto police to the efforts by Peel police to interest
them in the potential connection between Mr. Navaratnam’s disappearance and
Mr. Faizi’s disappearance is particularly disturbing. I turn to that issue now.

Abdulbasir (Basir) Faizi

Mr. Faizi was last seen in the Village on December 29, 2010. He was reported
missing the following day. The Peel police investigated his disappearance
because he lived in Peel Region. Constable Marsot led the Peel investigation.
Although my mandate does not involve an evaluation of Peel’s work, I can say
that Constable Marsot was a dedicated investigator whose commitment to this
case impressed me. Peel’s investigation of Mr. Faizi’s disappearance was
superior to the one the Toronto police conducted in 2010 and 2011 in relation
to Mr. Navaratnam. For example, Peel reached out in a variety of ways to the
gay communities and, more specifically, to the Salaam Queer Muslim
Community Centre, attempting to enlist itsassistance in the search.
In January 2011, Constable Marsot learned through Constable Ramsay
that Mr. Navaratnam had also gone missing from the Village. This information
was purely fortuitous: the Toronto police had taken no steps to ensure that
other regional services were even aware of his disappearance. The importance
of enabling such links to be made is precisely why several tools or supports
exist, such as PowerCase, ViCLAS, and the OPP Missing Person and
Unidentified Bodies Unit. Justice Archie Campbell identified this exact
problem in his report in the aftermath of the Paul Bernardo debacle – the way
the siloing of information between police services prevents the
identification of a serial predator.
Constable Marsot quickly obtained Mr. Navaratnam’s Occurrence
Report from the Toronto police. She was immediately struck by the
similarities between the two men and the circumstances of their disappearance.
They were both gay men of colour with shared physical characteristics who
unexpectedly disappeared and were last seen in the Village. She suspected
the cases were connected. She reached out to the Toronto police on three
occasions. One message went unanswered. An officer responded to her
second message by saying the Toronto police would look into it, but there
is no evidence anyone did. Finally, she emailed Toronto’s officer in
charge to advise him that the
cases were possibly connected, and this third overture also elicited no
response.
To this day, Constable Marsot regrets she did not press the Toronto
police further to respond or ensure that her supervisors compelled Toronto to
pay attention. In my view, the failure here lies with the Toronto police.
Constable Marsot gave the Toronto police the full opportunity to pursue this
important investigative lead – and they failed to do so. As a result, the Toronto
police did not notice the potential connection between the two cases. This lead
became apparent to Toronto police only on December 19, 2012, just under two
years later. Indeed, the connection was made initially only because the Peel
police had placed the Faizi case on PowerCase. The Toronto police did not
place Mr. Navaratnam’s case on PowerCase until late 2012.
The failure of the Toronto police to identify the potential connection
between these cases – one handed to them on a platter – represents a failure of
epic proportions. It speaks to the low priority given to Mr. Navaratnam’s case.
It speaks to systemic deficiencies in how missing person cases were dealt with.
It shows an attitude inconsistent with the lessons learned from the Bernardo
tragedy when police services failed to work together to solve his crimes. The
fact that two different police services – in isolation – were investigating
the sudden disappearances of men of similar description and sexual
orientation living in or last seen in the Village represents a systemic issue.
Not surprisingly, it reinforces community perceptions, whether accurate or
not, that the Toronto police were largely indifferent to the disappearance of
gay men of colour. In Chapter 12, I explore in more detail the questions of
bias and discrimination raised during this Review.

Majeed K ayhan
Mr. Kayhan was last seen by his family on October 14, 2012. His son initially
reported him missing to Toronto’s 41 Division, but the case was referred to 51
Division because Mr. Kayhan lived and was last seen in the Village. Police did
not learn he had connections with the LGBTQ2S+ community until a month
after he disappeared.
Although some steps were taken to investigate Mr. Kayhan’s case, it
was given no priority and was not treated as a major case. The investigator did
not think his disappearance was concerning until he learned that Mr. Kayhan
left his pet birds to die, uncared for. On previous occasions when Mr. Kayhan
travelled, he had arranged for someone to take care of the birds. Despite this
red flag and others, Mr. Kayhan’s disappearance was not treated with any
sense of urgency. The investigator candidly acknowledged that nothing was
done to
advance the investigation for two weeks in November while he was on
days off. His involvement in the investigation ended in early January
2013. The investigation essentially ground to a halt ostensibly due to the
absence of any leads. Again, no ViCLAS Crime Analysis Report was ever
submitted in connection with this investigation.
Most troubling, the investigator was unaware that, in the same time
frame, two other racialized gay men had also disappeared without explanation
from the Village. This breakdown is particularly worrisome because all three
men lived in or were last seen in the Village – 51 Division’s jurisdiction – and
because two of these three investigations were being conducted by 51 Division
investigators. Together, all three cases represent a profound systemic failure.
Toronto had no Missing Persons Unit at the time and no analyst examining
incoming missing person cases across the entire Service in real time. I
acknowledge that, to its credit, the Service has since created the Missing
Persons Unit. I describe and evaluate that unit in Chapter 13.
The circumstances surrounding Mr. Kayhan’s disappearance invited
deep concern. He simply vanished. There was no evidence he had made any
plans to leave his home, nor had he exhibited any suicidal inclinations. The
fate of his uncared for yet treasured birds was a red flag that should have
alerted anyone performing a risk assessment. But again, no such assessment
was even done. No serious effort was made to engage the affected
communities in the search for him. His case was given low priority when it
should have attracted heightened resources and attention. In my view, it
qualified as a major case.
Even if one disagrees with that view based on what was known to
the investigators, the similar disappearances of Mr. Navaratnam and Mr.
Faizi should have provoked a priority response by police. That did not happen
until an informant tip almost one year later prompted the creation of
Project Houston. The sad reality is that these cases would likely have attracted
no attention until 2017 – if ever – had police not received a Swiss informant’s
tip that prompted reconsideration (see Chapter 6).
The officer assigned to investigate Mr. Kayhan’s disappearance did not
give less attention to this case because Mr. Kayhan was a person of colour.
Nor did he do so because of Mr. Kayhan’s sexual orientation. I say that not
merely because the investigator is himself a member of the racialized
community – a factor that provides no assurance of bias-free attitudes or
conduct – but because of his particular sensitivity to issues around bias. Still,
his investigation was deeply flawed. Those flaws relate largely to systemic
issues – the lack of priority given to missing person cases, the siloing of
critically important information, the failure to accurately assess risk
initially or on an ongoing
basis, the related failure to recognize when a missing person occurrence
became a major case, and the absence of true oversight and supervision.
The flaws in the investigation into Mr. Navaratnam’s disappearance
equally exposed a range of systemic issues. The investigative oversights are
explained, in part, by these systemic issues. For example, because Mr.
Navaratnam’s disappearance was not treated as a major case, despite the
evidence of a strong possibility of foul play and reasonable grounds to believe
he had been abducted, basic investigative tasks were never performed. The
failure to forensically examine Mr. Navaratnam’s computer may be explained,
we were told, by an underresourced and backlogged Technological Crime
Forensics Laboratory in the Intelligence Division. But it is also explained by
the low priority given to this investigation because it was not treated as a
major case.
What I am struck by, when comparing all three investigations, is the
randomness of what was done in each investigation. There was no consistency
among the investigations about steps taken to investigate similar
disappearances, and no consistency as to how quickly such steps were taken.
The Toronto police didn’t even have a checklist of conventional steps to be
taken in investigating such disappearances.
However, when these investigations were being conducted, the Service
did at least have in place less specific procedures for conducting missing
person investigations. Procedure 04-05 defined levels of search for missing
person cases based on urgency as well as certain investigative requirements
depending on the applicable level of search. At all levels, officers were
required to complete a Search Urgency Chart – a task never done for either of
the Toronto investigations. As the urgency of an investigation increases,
additional investigative steps are required along with heightened supervision.
I elaborate on Procedure 04-05 in Chapter 13 as part of a larger assessment of
how the Service dealt with missing person cases generally. Suffice it to say
there is no evidence that anyone considered or even monitored whether these
two investigations complied with the Service’s own procedures. Nor is there
evidence that anyone considered whether or when these investigations should
be elevated to major cases or, to use the terminology contained in
Procedure 04-05, level 2 or 3 searches. There is no point to having procedures
if they are not followed.
The question arises whether the missing person procedures that existed
at the time – or that exist even now – are adequate. Sergeant Bourque
acknowledged that low priority was generally given to missing adult cases and
contrasted it with how sexual assault cases involving children as alleged
victims were dealt with. He said the procedures required that officers
specifically justify any investigative delays in dealing with sexual assaults
involving children, but not investigative delays in dealing with adult missing
persons. He felt it important to incorporate accountability for delays in missing
person procedures.
The investigations described in this chapter represented lost
opportunities to bring McArthur to justice and end his killing spree. However,
soon after Mr. Kayhan disappeared, an informant’s tip led to renewed attention
for these cases. I now turn to an examination of the investigation that
followed.
 Chapter 6 The Project Houston 141
Investigation

Chapter 6

THE PROJECT HOUSTON INVESTIGATION

In this chapter, I describe how a tip from the Swiss police led the Toronto
Police Service (the Service) to establish Project Houston. Its purpose was to
investigate allegations that a cannibalism ring was targeting people around the
globe and that one of its members, James Brunton (alias John Jacobs), may
have killed and eaten Skandaraj (Skanda) Navaratnam and two other men
missing from Toronto’s Gay Village (the Village). Ultimately, the police
discounted Brunton’s involvement in the disappearances of thethree men and,
in July 2014, shut down Project Houston. The disappearances of the men
remained unsolved until 2018, when Bruce McArthur was charged not only
with their murders but also with the murders of five other men. McArthur
committed these additional murders during the three intervening years.
There are two reasons for chronicling Project Houston in
considerable detail in this chapter. First, the public is entitled to know
precisely what the police did or did not do to investigate the disappearances
of the three men. Information currently available to the public is both
incomplete and, in some respects, inaccurate. Second, Project Houston
resulted in the arrest and prosecution of Brunton and others for child
pornography and other crimes. However, notwithstanding the significant
resources invested in the project, the disappearances of the three missing men
were not solved. The project was flawed in many ways, impeding the ability
of the Service to investigate the disappearances properly and to end
McArthur’s killing spree at an earlier stage. These flaws are also indicative of
systemic issues I have been able to identify, thereby enabling me to make
recommendations designed to lead to better practices for future
investigations. By chronicling the story of Project Houston, I am able to
clarify what went right in the investigation and, even more important,
what went wrong.

The Swiss Informant and the Cannibal Theory

On the early morning of November 9, 2012, the Service’s International

Assistance Unit emailed Detective Debbie Harris, a 51 Division investigator,
passing on information received from the Swiss police through Interpol.
The translated email read, in part, as follows:
 The Cantonal Police of Berne received the information that in the Cannibals
forum (zambianmeat.com) possible criminal acts (consumption of human
flesh) have been communicated.
The statements came from a certain Jacobs John with the email chef-
[email protected]. He is supposed to be living near Toronto / Canada, alone
in a remote or isolated farm. He keeps animal farms and goes hunting and is
used to slaughter and evisceration. He admitted to have eaten human flesh,
could have been in the period between 2009 and 2011.
Concerning John Jacobs, he is probably a homosexual. According to
his statement he could be dating men of his age between 18 and 35.
In Internet he is cautious and very skilled in technical areas like all
kind of Skype features.
He registered himself on the 21.12.2008 at the Cannibalism forum
and has posted diverse contributions and taken part in several meetings and
discussions. His first comments and contributions in the forum he deleted
again. Currently he seems to be in the forum every day.
Requests:
According to our investigations it seems that a certain Skanda
Navaratnam, approx. 40 years old, has been missing in Toronto since
September 2010. Shortly before he disappeared, he was allegedly seen in the
nightclub Zipperz (gay club). Afterwards he was seen twice accompanied by
an unknown not identified person. Then there are no more traces of him.
Please be informed that this information was obtained from a reliable
source and are [sic] credible. For reasons of security, copies of the written
information and more details will only be transmitted to the investigating
authority and will not follow with this report. For more information and
requests please don’t hesitate to contact the responsible investigator and case
officer at the Cantonal Police of Berne: Mr. Roland Keller.

The same day, Detective Harris talked to Detective Keller of the

Cantonal Police of Berne. He spoke limited English but was able to tell her he
believed he had information about a cannibal who had eaten a missing person
from Toronto. At first, Detective Harris thought it was a joke. It wasn’t.
Detective Harris recognized Mr. Navaratnam’s name from her
involvement in the original missing person investigation into his
disappearance. She had last worked on Mr. Navaratnam’s case in September
or October 2010.
After receiving this call from the Swiss police, Detective Harris
reopened Mr. Navaratnam’s case. 1 Because of the language barrier, she

1
Theoretically the case remained open, but it had been inactive.
arranged for a German-speaking officer to join her the following Monday
morning for a second call with Detective Keller. Over the weekend, she
reviewed the file and called Mr. Navaratnam’s friends and his brother to find
out if he was still missing. In the intervening two years, no officer had
maintained contact with his loved ones. At the time, the Service often did a
poor job in monitoring and following up on unsolved missing person cases.
On November 12, 2012, the police called the coroner’s office and the
Ministry of Health to see if they had any updates on Mr. Navaratnam. They
did not. That same day, Detective Harris and her German-speaking colleague
spoke with Detective Keller again.
Detective Keller disclosed that the informant had provided reliable
information, leading to an arrest. He also sent Detective Harris emails
exchanged between the informant and the alleged cannibal. The alleged
cannibal used the alias “John Jacobs” and was active on a cannibalism website
called zambianmeat.com. According to the informant, Jacobs lived on a farm
north of Toronto. He had eaten human flesh in the past. The informant had
also mentioned the name “Skanda.” Detective Harris 2 told the Review she did
not know then whether Jacobs had used the name Skanda or the informant had
come across the name on his own.
The Service created Project Houston in response to the informant’s tip
and commenced its work in early December 2012. In my view, it was
important for the investigators to know whether Jacobs had named Skanda
as a victim, or had described his victim in a way that clearly pointed to Mr.
Navaratnam, or neither. As I explain later, for some time a disconnect
persisted within the
investigation as to what Jacobs (aka James Brunton) actually said on this
critical point.

The Lead-up to Project Houston

On November 13, 2012, Detective Harris obtained a judicial production order

for Jacobs’s email account to identify his real name. She classified the request
as “urgent.” In her view, the case involved a risk to public safety. The request
for the production order stated that Detective Harris had reasonable grounds to
believe that Mr. Navaratnam had been murdered by an unknown person. 3 The
production order led to a second production order on December 5. This one
2
Detective Harris was later promoted to the rank of detective sergeant. She is now retired. Rather than
referring to her throughout as retired Detective Sergeant Harris, I refer to the rank most relevant to the
period being discussed.
3
As reflected in Chapter 5, “reasonable grounds to believe” is synonymous with “reasonable and probable
grounds to believe.”
yielded the name James Brunton, a resident of Peterborough, Ontario. He was
the subscriber for the IP address and the owner of the Jacobs account.
Brunton had no previous contact with the police. However, the emails
Detective Harris reviewed in his account indicated that, on several occasions,
he had ostensibly arranged to meet gay men in Toronto or at Pearson
International Airport in order to kill and eat them. She read hundreds of emails
about cannibalism, kidnapping, and murder. The investigation ultimately
determined that all this content was fantasy. Initially, of course, it had to be
taken very seriously.
On November 28, 2012, Detective Harris called Detective Sheila Ogg,
a Toronto Homicide detective she had partnered with at 51 Division. Detective
Harris filled Detective Ogg in on what she had learned. If the informant’s tip
was accurate (as she then understood the tip’s content to be), Mr. Navaratnam
was a homicide victim rather than a missing person.
At that point, both detectives felt it was appropriate to bring the matter
to the Homicide Unit’s attention.4 (The unit had been notified of Mr.
Navaratnam’s disappearance in September 2010 but had not become
involved.) This time, the Homicide Unit might lead the investigation.
On November 29, Detective Harris and Detective Ogg discussed the
steps that had already been completed during the earlier investigation and the
steps that still needed to be taken. Detective Ogg assigned an officer to look
into other outstanding missing person cases involving men between the
ages of 30 and 45. She wanted to know if other gay men had gone missing.
She also recommended that the informant’s computer be forensically
examined, that the informant be interviewed, and that various witnesses from
Mr. Navaratnam’s initial investigation be interviewed (or re-interviewed),
including an individual who saw Mr. Navaratnam leave Zipperz with two
unknown men.
On December 3, Detective Ogg met with Inspector Bryan Bott, 5 a
Homicide team commander, and Staff Inspector Greg McLane, head of the
Homicide Unit.6 Inspector Bott’s role included his facilitating resources
for designated major cases and communicating up and down the chain of
command respecting such cases. The three officers discussed the needs of the
anticipated investigation, including making a request under the Mutual Legal
Assistance Treaty (MLAT) to allow Toronto police to obtain more information
from the Swiss authorities.

4
The Homicide Unit is separate and apart from the local police divisions scattered across Toronto. The
Homicide Unit is a specialty unit located at the Service’s headquarters in downtown Toronto. Each division
has its own crimina l investigative detectives.
5
Inspector Bott has since been promoted to the rank of superintendent.
6
Staff Inspector McLane has since retired.
 Later that afternoon, Detective Ogg followed up with Detective Harris.
Detective Harris advised her that Mr. Navaratnam’s computer hard drive and
the alleged cannibal’s email account would be searched first.
On December 4, the police, for the first time, uploaded Mr.
Navaratnam’s original missing person occurrence (or case) into PowerCase. 7
This posting ultimately resulted in the Abdulbasir Faizi occurrence coming to
the attention of Project Houston through a PowerCase notification.
On December 5, Detective Ogg met with Detective Harris, Inspector
Bott, Staff Inspector McLane, Detective Sergeant Mike Richmond (another
Homicide officer), and a Crown attorney. They discussed what they ostensibly
knew about the informant and the alleged cannibal. The informant had been an
informant for two years. He had turned over the password for his
“zambianmeat.com” account to police. He had experienced suicidal thoughts
and, although currently hospitalized, he was to be released the next day.
Detective Ogg told the Review that reliability is always an issue with
informants, and their mental health is an important consideration in assessing
that reliability. Ultimately, the Toronto police were satisfied (at least during
this time frame) that there were reasons why they could act on the informant’s
tip – the informant had proven reliable and had also offered access to his
computer and to his cannibal forum password.
There were some differences in how the officers described the
investigation that followed to the Review:

 Detective Sergeant Hank Idsinga8 said the investigation was treated as a

homicide case. The Homicide Unit would lead an investigation if there
was “definitive” evidence of homicide.
 Inspector Bott stated that the investigation remained a 51 Division case,
with some help from Homicide. The nature of the investigation was
beyond the scope of a divisional office, so Homicide was there to oversee
and manage it.
 Detective Sergeant Richmond said the case was being handled as a
homicide investigation. Homicide took over, but, because of space
shortages at the unit, Project Houston would be run out of 51 Division.
 Detective Harris described the case as still technically a 51 Division
investigation at this stage because the police did not have “affirmative”
evidence of a homicide.
7
PowerCase is the provincially mandated case management software used for major cases. I examine how it
functions in Chapter 4.
8
Detective Sergeant Idsinga has since been promoted to the rank of inspector.
 I respectfully disagree with Detective Harris’s characterization:
regardless of how the investigation was ultimately organized, who conducted
it, and at what location, the investigation had received affirmative evidence of
a homicide – regardless of whether such evidence ultimately proved to be
reliable. Indeed, Detective Harris’s own application for judicial production
orders relied on her belief, on reasonable grounds, that Mr. Navaratnam had
been murdered.
As I explain later, there remains uncertainty – indeed, confusion –
within the Service as to when evidence of a homicide, or “definitive” or
“affirmative” evidence of a homicide, exists. The police do not need to find a
body or obtain a confession to have “definitive” or “affirmative” evidence of
murder. The contrary view undervalues the role of circumstantial evidence.
As I say in Chapter 5, the “no body, no crime” approach that some officers
take leads to their failing to appreciate when a missing person case involves
a “strong possibility of foul play.” In cases where the police have not
discovered a body, officers also have inconsistent understandings as to when
the Homicide Unit should be notified of an investigation, and when the
Homicide Unit should assume carriage of an investigation. The Service’s
procedures are not helpful on these points. I address these issues in my
recommendations (see Chapter 15).
Despite these differences, all the officers involved agreed that the
investigation would be treated as a “major case.” Under provincial adequacy
standards, both homicide and missing person investigations involving a strong
possibility of foul play must be designated as “threshold major cases.” As I
outline in Chapter 4, such investigations must be case managed in very
specific ways set out in the adequacy standards and reflected in the
Service’s own procedures.
Project Houston was also designated as a “project.” Not every homicide
investigation becomes a project. Nor does every project involve a homicide. A
project may be created when a major case is deemed to be complex, requiring,
for instance, many warrants and many officers. It will likely attract greater
resources in terms of officers and funds, which can otherwise be difficult to
access. Yet, there is no precision as to when an investigation becomes a project
and no procedures that set out when a case should be converted to a project
and what that means.
Provincial adequacy standards require that a threshold major case be led
by a command triangle. Detective Sergeant Idsinga was assigned to serve as
the major case manager. He was a seasoned investigator who was good at
project work. Detective Harris, given her involvement in the initial
investigation into Mr. Navaratnam’s disappearance, was assigned to serve as
the primary investigator. Detective Ogg was identified as the file coordinator,
though her court obligations meant she would be unavailable for several
months at a time. Detective Constable Catarina (Cathy) Loria was selected to
serve as a second file coordinator (see Table 6.1).

Table 6.1: Project Houston’s Original Team9

Major case manager: Detective Sergeant Hank Idsinga (Homicide)

Lead investigator: Detective Debbie Harris (51 Division)

File coordinators: Detective Sheila Ogg (Homicide) and Detective Constable

Catarina Loria (42 Division)

PowerCase: Donna (Laurie) Florence (Homicide)

Affiant: Detective Constable Lindsay Gravelijn (31 Division)

(An affiant prepares applications for judicial authorizations, including search
warrants and production orders.)

Investigators

Detective Constable David Lavallee (Traffic Services): assigned to prepare a

full background on Brunton

Detective Constable Josh McKenzie (51 Division): assigned to further

investigate Mr. Navaratnam’s disappearance, including locating previous
witnesses

Police Constable Patrick Platte (12 Division), who speaks German: assigned to
contact the Swiss and German authorities

Detective Charles Coffey (Technological Crimes Unit): assigned to analyze

Brunton’s and Mr. Navaratnam’s computers.

Source: Compiled by the Independent Review.

9
There were several staffing changes to the Project Houston team before the investigative work began. This
list identifies the officers who actually worked on the project from the outset. Their work extended beyond
their initia lly assigned tasks reflected in Table 6.1. The list a lso includes Donna Florence, a civilia n
member who served as a PowerCase indexer for part of the project’s duration.
 Project Houston was resourced with a few computers and a
dedicated phone line. An internal computer hard drive, called the “P Drive,”
was set up to store everything relevant to the investigation. Access to the P
Drive was limited to the project’s members. In Chapter 4, I describe in
some detail the role of the P Drive in the Service’s major case investigations.
Although Project Houston was ostensibly being conducted under the
major case management (MCM) model, in many significant ways the project
did not comply with its mandated standards. For example, contrary to
provincial adequacy standards,10 a great deal of information collected during
the project was never uploaded into PowerCase, the mandated case
management software.11 In other words, PowerCase was not used to its full
potential and often amounted to little more than a “data dump.” A number of
assignments or actions to be performed were not recorded in PowerCase – or,
indeed, anywhere, contrary to provincial adequacy standards described in
Chapter 4.
Before serving as the file coordinator, Detective Constable Loria
received no MCM training, something that was also necessary under
provincial adequacy standards.12 Although she was one of the project’s
most dedicated and creative officer, she was obliged to “learn on the fly.”
The problem was compounded by the fact that Detective Ogg, who had
been trained in MCM, was absent for long periods. To her credit, she did read
the daily log while she was away, but she was no longer in control of the flow
of information or documents. Given that, in her words, “there was so much
happening in that room,” one had to be there to do the job, Detective
Constable Loria effectively took over the file coordinator role during
Detective Ogg’s absences. Obviously, it would have been preferable for
Detective Constable

10
See the data entry provisions in the Ontario Major Case Management Manual (MCM Manual).
11
The document log for Project Houston lists the documents that were entered into PowerCase during the
investiga tion:

49 officer’s reports;
40 civilia n statements;
approximately 200 “other documents”(including the Project Houston operational plan, emails, chat
logs, occurrence reports, media releases, reports to justices, cellphone subscriber information).

The above represents a fraction of the documents created or collected during Project Houston. For example,
approximately 85 civilian witnesses were interviewed. Moreover, in some instances, these witnesses were
interviewed more than once, but not all interviews even in relation to the same witness were entered into
PowerCase.
12
Crime Management Plan 2006. Such training was also required under the 2012 manual.
Loria to have had training in MCM before she assumed this role. 13 That said,
the project was fortunate to have her.
Detective Constable Loria understood from Detective Sergeant Idsinga
that all information relevant to the investigation would filter through her and
she would organize it into MCM computer folders. But the information
collected was, at times, incomplete, poorly summarized, and not organized in
accordance with MCM requirements. Supervision of investigative activities
was, at best, inconsistent and, especially during the latter stages of the project,
after Detective Constable Loria and others departed, virtually non-existent.
These shortcomings represented systemic failings associated with inadequate
case management.

Project Houston’s Early Work

The project’s name derived from the popular (mis)quote from the Apollo 13
mission, “Houston, we have a problem.” The initial project briefing took place
at the Homicide Unit on December 6, 2012.
The Service wanted to keep Project Houston confidential. By email
dated December 6, Detective Sergeant Richmond warned other Service
members at 51 Division to protect its secrecy:

As many of you may have already heard, this missing person investigation is
escalating significantly, with significant involvement from the Homicide
Squad and other units. It has been assigned a project name of Project
Houston. Many of you may already know some of the details of this
investigation which are quite disturbing.
It is extremely important that details of this case be kept confidential.
If the media were to become aware of it, this would have a devastating
effect on the integrity of the investigation. Please keep details of it to
yourselves. Staff Sergeants: Please address this issue on your platoons.

Unfortunately, the secrecy associated with Project Houston, while

intended to preserve the investigation’s integrity, was so pronounced that it
kept important information from others within the Service and undermined the
flow of any meaningful information from community members to the project.
The level of secrecy – some of which was unwarranted – later fuelled the

13
In fairness to both officers, the Service was not using PowerCase as it was intended to be used in any
event. In other words, PowerCase training did not guarantee its proper use.
perception of many community members that, during this time frame, the
Service had done nothing to investigate the disappearances of the missing
men. The secrecy also spilled over to the project’s failure to fully share what it
was doing with the Peel police.
Project Houston was originally created to investigate Brunton and
potential links to Mr. Navaratnam’s disappearance. After it began, the Service
identified the sudden disappearances of Mr. Faizi and Majeed Kayhan as being
similar to and therefore potentially connected to Mr. Navaratnam’s
disappearance.
There is some discrepancy among the officers’ accounts as to how
Project Houston expanded to include Mr. Faizi and Mr. Kayhan. Detective
Harris told the Review that Brunton’s emails detailed his plans to kidnap,
murder, and cannibalize gay men. This content made her concerned that more
people might be missing from the Church and Wellesley streets area. She
raised the issue with Detective Constable Saleem Husain, who had
investigated Mr. Kayhan’s disappearance, and they discussed the similarities
between Mr. Kayhan and Mr. Navaratnam. Detective Harris told Detective
Sergeant Idsinga that they really needed to look into Mr. Kayhan’s case, as
they were very similar. As a result, Detective Sergeant Idsinga directed
officers to look for other such cases. Mr. Faizi’s case was later identified.
Detective Harris’s personal recollection of the chronology does not
accord with Project Houston’s daily logs and other available evidence,
although, in fairness to her limited ability to recall what happened, many of her
memobook notes are no longer available. However, the Review was able
to reconstruct a more accurate chronology based on the totality of the
available evidence.
According to the daily logs, on December 19, 2012, Project Houston
officers first learned of Mr. Faizi’s disappearance through a PowerCase
trigger, after the Toronto police entered Mr. Navaratnam’s case into
PowerCase on December 4. Peel police had entered Mr. Faizi’s
Occurrence Report into PowerCase back on January 21, 2011 – and that entry
identified a possible connection to Mr. Navaratnam. As I describe in Chapter
5, in 2011 Constable Marie-Catherine Marsot, a Peel officer, had
unsuccessfully tried to interest the Toronto police in the connection between
the cases.
In contrast, Detective Constable Loria was very interested, and she
contacted Constable Marsot. Not surprisingly, Constable Marsot wondered
what had taken the Toronto police so long to call. Later in December 2012,
the
Toronto police picked up a copy of Mr. Faizi’s investigative file and a hard
drive that contained a partial extraction of his computer’s contents.
Mr. Kayhan’s case and its similarities to those of Mr. Navaratnam and
Mr. Faizi do not appear to have been discovered until January 3, 2013.
Detective Constable Loria also identified this potential link and brought it to
Detective Sergeant Idsinga’s attention – as he later confirmed. The discovery
of this potential link is addressed in greater detail below.

Mr. Navaratnam’s Computer Examined

Detective Constable Charles Coffey, who had a background in information

technology before he joined the Service, was the primary computer
forensic investigator on Project Houston.14 A recent addition to the
Technological Crime Unit (Tech Crimes Unit), he had recently moved there
from 51 Division. At the time, he was undergoing training to become a
certified computer forensic investigator. Ultimately, his Project Houston
commitments interfered with this training, and he was not certified.
Initially, because of commitments to his training and to other cases at
the Tech Crimes Unit, Detective Constable Coffey worked on Project Houston
only part time. He was a “forensic investigator,” not a “technical investigator.”
This distinction meant he was analyzing data extracted from electronic devices
rather than extracting the data himself. He reported primarily to Detective
Harris. Most of his Project Houston work focused on examining the contents
of Brunton’s devices. However, one of his early assignments was to search Mr.
Navaratnam’s laptop computer for potential links to Brunton or the
alleged cannibal ring – a task he approached by attempting to locate specific
keywords associated with Brunton or cannibalism in Mr. Navaratnam’s emails,
chat, and internet history. Mr. Navaratnam’s laptop had never been
examined at all during the initial investigation into his disappearance.
On December 6, 2012, the day of Project Houston’s initial briefing,
Detective Constable Coffey completed his search of Mr. Navaratnam’s
computer by using Internet Evidence Explorer, a program I describe in Chapter
4. The keyword search came back negative.
There was, however, a wealth of information in Mr. Navaratnam’s
laptop that could have tied him to McArthur and, in addition, identified dating
websites that Mr. Navaratnam visited or in which he participated. This
observation does not involve unwarranted hindsight, nor is it dependent on the
police first knowing that McArthur might be involved in the
disappearances. Rather, the evidence reveals that potentially valuable
information contained in

14
Another officer from the Tech Crimes Unit, Detective Constable Ravi Manoharan, also worked on Project
Houston from time to time. Detective Constable Manoharan was heavily involved in the covert entries into
Brunton’s home and the cloning of Brunton’s computers.
Mr. Navaratnam’s laptop was not uploaded into PowerCase or otherwise
summarized or recorded. This lapse resulted in the information being
overlooked when, later, it became relevant.
For example, in late 2017, after McArthur became a person of interest
during Project Prism (see Chapter 7), Detective Constable Coffey learned that
Mr. Navaratnam’s internet history showed he and silverfoxtoronto, one of
McArthur’s dating usernames, had exchanged sexualized messages
through the dating website www.daddyhunt.com. Even after the police learned
in 2013 that McArthur identified himself as silverfoxtoronto and silverfoxx51,
and that he denied any sexual relationship with Mr. Navaratnam, the police
were unaware of the valuable information available through Mr.
Navaratnam’s laptop as the usernames and dating websites referred to in his
computer were never uploaded into PowerCase as “objects.” 15 As I explain
in this chapter, through poor use of existing technology and case management
tools, the police lost important opportunities to discover McArthur’s crimes.
This comment is in no way intended to be a criticism of Detective
Constable Coffey – he did what he was assigned to do.

Focus on James Brunton and the Cannibal Killer Theory

From the outset, Project Houston largely focused on Brunton and, for the
remainder of 2012, conducted extensive surveillance on him. With the
assistance of the US Department of Homeland Security, the Toronto
investigators tracked his border crossings. They obtained his banking
information and cellphone history and acquired a tracking warrant for his car.
They researched his family members and went to hotels he had visited in
Toronto. Three times they planned and executed a judicially approved covert
entry into his Peterborough home to clone his computers and hard drives.
By the end of December 2012, Project Houston had acquired
approximately 2.2 terabytes of data from Brunton’s electronic devices. A
forensic examination of this data disclosed nude photographs and videos
of young men, including photographs that appeared to have been taken
surreptitiously in a locker room.
On December 12, 2012, at Detective Harris’s request, Detective Bill
McGarry from the Service’s Sex Crime Unit completed a review of Brunton’s
email contents. Detective McGarry had been told that the emails potentially
linked Brunton to cannibalism and murder. Detective Harris wanted to know
15
As I explain in Chapter 4, PowerCase recognizes 10 specific categories of objects, including persons,
telephone numbers, and e-communications such as email addresses and IP addresses. Objects are more
easily searched within PowerCase and can trigger notifications of potential linka ges.
if the location of Brunton’s reported farm could be identified from the
photographs attached to the emails.
Detective McGarry was unable to identify a farm location, but he did
find evidence of child pornography. Brunton had been discussing cannibalism
with a young person who sent him several nude photographs of himself
and offered to meet him. During these conversations, the young person
told Brunton that the talk of cannibalism was mere fantasy.

Contact with the OPP ViCLAS Unit

In Chapter 4, I describe how the Violent Crime Linkage Analysis System

(ViCLAS) supports the identification of crime patterns and serial or predatory
behaviour. According to provincial adequacy standards, police investigators
across Ontario are required to submit ViCLAS Crime Analysis Reports (also
referred to as “booklets” or “submissions”) to the Ontario Provincial Police
(OPP) ViCLAS Unit when certain criteria have been met. Of relevance to this
Review, these booklets, which contain detailed responses to standardized
questions, must be submitted in relation to missing person occurrences where
the circumstances indicate a strong possibility of foul play and the person
remains missing.
In Chapter 5, I point out that the Toronto police did not submit ViCLAS
booklets – though they should have – in relation to the initial investigations
into the disappearances of Mr. Navaratnam and Mr. Kayhan. Once
Toronto investigators believed, on reasonable grounds, that Brunton, or a
person unknown, had killed Mr. Navaratnam and perhaps others as well in
connection with a cannibalism ring, a ViCLAS booklet or booklets should
have been submitted to the OPP. The strong possibility that one or more of the
missing men had met with foul play undoubtedly existed. But no ViCLAS
booklets were submitted in relation to these disappearances until years later.
Project Houston investigators were certainly aware of ViCLAS. Indeed,
on December 6, 2012, the ViCLAS Unit received a query from Project
Houston to check for any instances of cannibalism-related activity in the OPP
database. As well, in June 2013, Project Houston did submit ViCLAS booklets
in relation to the victims of Brunton’s child pornography activities.
There was no valid excuse for the Service’s failure to submit ViCLAS
booklets in relation to the missing men. In fact, they had an added impetus for
doing so. David Moore, a civilian analyst with the OPP ViCLAS Unit, told the
Review that the issue of the missing men first came to his attention in late
2012 or early 2013. He had read media reports about several deceased men
being
 found in Lake Ontario. No signs of foul play were reported, and there was no
known cause of death. All the men were approximately the same age, in the
19–25 age span. The combination of all these factors struck Mr. Moore as odd.
Mr. Moore contacted the Service’s ViCLAS coordinator to ask for
Occurrence reports for the men. Over the next few months, the Service sent
him more than 60 reports of bodies found in Lake Ontario. Mr. Moore was
interested in looking for similarities among the men. Did any of them know
one another, for example, or were they from the same area of town? Many of
the bodies had no connection to Toronto and appeared to have been washed up
onto the Toronto shore, carried by Lake Ontario’s currents from
Hamilton,
Oakville, and even New York State.
As part of his research into those bodies, Mr. Moore read in the media
about the disappearances of Mr. Navaratnam, Mr. Faizi, and, in 2013, Mr.
Kayhan. All three were gay, of somewhat similar physical appearance, and had
last been seen in the Village. Mr. Moore contacted the Toronto police and the
Peel police to ask for the Occurrence reports. He reviewed them and told both
the Toronto and the Peel police forces that the cases might be connected. He
specifically asked them to submit ViCLAS booklets for the missing men.
Both services declined, on the grounds that there was no evidence of
foul play in any of these cases. Mr. Moore understandably turned his attention
back to the men whose bodies had been found in the lake. In summary, the
police chose not to submit booklets even after the OPP ViCLAS Unit
requested they do so and during the Service’s own Project Houston murder
investigation relating to these same missing men. As I explain in Chapter 7,
the Toronto police submitted ViCLAS booklets in relation to McArthur’s
victims only after McArthur was arrested and the OPP ViCLAS Unit again
requested them.

Clarifying the Informant’s Tip

As I mention above, there was initial uncertainty as to what Brunton had told
the informant, in particular whether he even mentioned “Skanda” or someone
meeting Mr. Navaratnam’s description as a victim.
On December 6, 2012, the date of Project Houston’s first team briefing,
Detective Sergeant Idsinga recorded in his memobook that the alleged cannibal
told the “CI [the confidential informant] that he had sex with male
‘Skanda’ two years ago and engages in cannibalism. CI believes that Brunton
killed Skanda.” This note accords with Detective Sergeant Idsinga’s
recollection that Detective Harris had conveyed her understanding that the
alleged cannibal had identified Skanda as his victim.
However, on December 12, Police Constable Patrick Platte spoke with
Detective Keller, who clarified that Brunton had never mentioned the name
Skanda or Mr. Navaratnam to the informant. Rather, Brunton described his
victim as active in the Toronto gay community, 18 to 35 years old, with a slim
or athletic build. He claimed the crime had been committed between 2009 and
2011. Any purported connection between Jacobs and Mr. Navaratnam was
merely the informant’s speculation based on his having read in the media
about Mr. Navaratnam’s disappearance.
Police Constable Platte emailed this information to Detective Harris. It
was also captured in Project Houston’s briefing notes for December 12, 2012:

CI told handler about “Zambian Meats” website being a cannibalism website

and that he had spoken with a “Chef Master” who told him that he had
partially ate [sic] a person. The Chef Master did not provide a name for the
person he ate but indicated that the person lived in Toronto, was
homosexual, 18–35 years old, slim and athletic. This person was partially
eaten between 2008 and 2011.

Although Detective Keller cleared up the confusion over what Brunton had
told the informant, some Project Houston documents, including its operational
plan and some reports forwarded up the chain of command, continued to state
that the cannibal had confessed to kidnapping and murdering one of the three
missing men. The operational plan stated that the cannibal’s confession
included information about the victim being a “homosexual, East Indian male”
from the Church and Wellesley streets area of Toronto.
Detective Sergeant Idsinga told the Review that it remained
“ambiguous” whether Brunton had named Skanda as his victim until April
2013, when the Toronto police interviewed the informant in Switzerland. With
respect, there was no basis for any ambiguity or confusion on this fundamental
point. Simply put, there was no basis for the claim that the alleged cannibal
confessed to victimizing an East Indian male from the Church and Wellesley
streets area. Nor could Mr. Navaratnam be described as being between 18 and
35 years old, slim, and athletic.
Clearly, there was a serious breakdown in communication among
the project team members. Inspector Bott believed he became aware of
this clarification in December 2012 – a timing that is consistent with the
briefing notes and Police Constable Platte’s disclosure of the December 12
call. However, some of the other officers involved in Project Houston,
besides Detective Sergeant Idsinga, told the Review that they too had been
unaware of this clarification until the interview with the informant in April
2013.
Decisions made about how this investigation should be conducted, what
direction it should take, what resources should be allocated to it, and the role
of other police services in it should have been based on an accurate
understanding of the tip that prompted the investigation in the first place. I
revisit the significance of this confusion in the Summary and Findings at the
end of this chapter.
There was also some early internal skepticism in Project Houston about
Brunton’s role in Mr. Navaratnam’s disappearance, primarily from
Detective Constable Loria. Although officially assigned to be file
coordinator, she quickly took on other tasks as well. Within the first weeks of
Project Houston, she was tasked with going through approximately 10
binders of emails extracted from Brunton’s computer. In her view, the emails
demonstrated that Brunton had a sexual interest in young white men. She
felt it significant that Mr. Navaratnam, an older brown man, did not fit this
profile.
Detective Constable Loria approached Detective Harris and Detective
Sergeant Idsinga to voice her concerns. She told them she did not think the
project was on the right track. Detective Harris suggested that perhaps Brunton
liked to have sexual encounters with young white men, but preferred “brown
meat” when it came to cannibalism. Detective Constable Loria agreed to keep
an open mind about the cannibal theory. Detective Sergeant Idsinga did not
recall this conversation. However, I observe that Detective Constable
Loria was not critical of Detective Sergeant Idsinga: he gave her scope to
investigate other potential leads.

Involvement of the Peterborough Police Service

On December 13, 2012, Detective Sergeant Idsinga and Detective Harris

visited the Peterborough Police Service. They showed Peterborough Detective
Debbie Gillis a nude “locker room” photo taken from Brunton’s computer.
Detective Gillis believed the photo may have been of a Peterborough hockey
player. She also recognized a photo of Brunton as someone active in local
hockey. She was assigned to be the liaison for the covert entries planned for
Brunton’s home.

Reinvestigation of Mr. Navaratnam’s Disappearance

The Project Houston officers reinvestigated Mr. Navaratnam’s disappearance

in a variety of ways. They canvassed other police services for outstanding
missing person reports. They looked for additional witnesses relating to Mr.
Navaratnam, went to Zipperz nightclub and The Cellar bathhouse, and began
to set up interviews with Mr. Navaratnam’s friends. Some of these people had
been identified during the initial 2010 investigation but not interviewed. For
example, on December 12, 2012, the police contacted Mr. BB who, in 2010,
had reported Mr. Navaratnam’s disappearance but had never been formally
interviewed.
Mr. FF is another example. On December 14, 2012, Detective Constable
Josh McKenzie and Police Constable Platte interviewed Mr. FF – one of the
last people to see Mr. Navaratnam alive. He had called the police on
September 23, 2010, to tell them that on September 6, he had seen Mr.
Navaratnam leave Zipperz with two men, but he had not been formally
interviewed. During his December 14, 2012, interview, he described the two
men, but it was only in June 2013 that he was asked to provide a composite
sketch of them. The officers also contacted Mr. Navaratnam’s ex-partner Mr.
HH for an interview. He, too, had not been interviewed during the 2010
investigation.
On December 17, 2012, the project obtained a judicial production order
for Mr. Navaratnam’s Yahoo email account. Detective Constable Lindsay
Riddell (now Gravelijn) sent the production order to Yahoo Canada the same
day. Yahoo told her, however, that the email account was a US account, so
Yahoo was unable to assist. Two months later, in February 2013, the Project
Houston officers sought the assistance of American authorities to preserve Mr.
Navaratnam’s email account.16
On December 18, Detective Constable McKenzie and Police Constable
Platte interviewed Mr. GG, who saw Mr. Navaratnam at the Black Eagle bar
the day before his disappearance. Mr. GG gave the police the names of several
other friends who had never been interviewed.
On December 27, Detective Ogg spoke with the Berne police. They told
her they required an MLAT request before the Project Houston officers could
interview the informant. Police Constable Platte began translating the
document from German to English, while Detective Ogg discussed the
required legalities with a Crown attorney.
On December 28, Detective Constable Loria discovered that both Mr.
Navaratnam and Mr. Faizi were members of the gay dating website
www.silverdaddies.com. This discovery provided the first potential link
between the two men. On January 9, 2013, Detective Harris told the Project
Houston affiant that Brunton was also a member of this website.
Although the project team did not know it at the time, McArthur was
also a member of this website.

16
Although the project’s files reflect an understanding that a judicial production order was sought during the
original investigation to obtain Mr. Navaratnam’s email contents, there is no indication it was ever done.
Expansion to Include Mr. Kayhan’s Disappearance

On January 3, 2013, Detective Constable Loria told Detective Sergeant Idsinga

that, given the many similarities between Mr. Navaratnam and Mr. Faizi, she
worried about the prospect of a serial killer in the community. In response,
Detective Sergeant Idsinga told her not to jump to conclusions and instructed
her, rather, to see if she could find another possible victim. Detective
Constable McKenzie mentioned Mr. Kayhan to her. Detective Constable Loria
thought the three cases might be related. The men were similar in appearance
in some respects as were the circumstances surrounding their disappearance.
Both Mr. Navaratnam and Mr. Kayhan, for example, had ostensibly abandoned
their pets. When she brought these parallels to Detective Sergeant
Idsinga’s attention, he encouraged her to “go with it.”
The Project Houston officers sought a judicial production order for Mr.
Kayhan’s OHIP records – something that had not been done before. They
spoke with Mr. Kayhan’s son, who told them he had hired a private
investigator to attempt to locate his father. When the son later gave the
investigators a copy of the report, they saw that the private investigator was
attempting to identify a friend of Mr. Kayhan who was a “florist /
gardener.” McArthur was a gardener / landscaper.
Project Houston contacted the Peel police to ask for a DNA sample for
Mr. Faizi. They obtained production orders for his OHIP records and banking
records as well as his telephone and email information. The Peel police
had not obtained this information during their original investigation. As I
indicate in Chapter 5, Peel police were not convinced they could obtain such
records, based on the legislation then in existence, without proof of a crime. In
any event, the various production orders yielded nothing of note.
Throughout January 2013, Project Houston continued to focus on
Brunton. In the meantime, Detective Constable McKenzie completed the
MLAT request relating to the Swiss informant for Detective Harris to review.
By January 11, the police had reviewed approximately 1,200 videos and
photos obtained from Brunton’s computer. Three days later, they discovered a
chat from 2007 during which Brunton indicated he had access to a cabin near
Bancroft. The police questioned whether it might be the same cabin that Mr.
Navaratnam sometimes visited. They also noted that Mr. Navaratnam and
Brunton were both members of the www.silverdaddies.com and the
www.daddyhunt.com sites. In late January 2013, the police learned through
surveillance that Brunton had another computer (a personal laptop) he carried
with him. They continued to review the material extracted from his home
computer. A search of Brunton’s email and chat history yielded information
about people associated with him. The police expanded their investigation to
include them.
At the same time, Detective Constable Loria went to Mr. Kayhan’s
apartment, took photos, and seized a variety of documents and personal
belongings. She was frustrated at the lack of progress in the investigation
involving Brunton. As the file coordinator, she saw no indication that the
Brunton angle was leading anywhere. Instead of focusing on Brunton, she
concentrated on the missing men. Again, Detective Sergeant Idsinga, to his
credit, granted her permission to take this approach.
The police submitted the items seized in 2010 from Mr. Navaratnam’s
apartment to the Centre of Forensic Sciences for DNA testing. They contacted
the RMCP National Centre for Missing Persons and Unidentified Remains
(see Chapter 13), which offered to place Mr. Navaratnam’s information on its
open- source public website.
On January 10, Detective Constable David Lavallee asked Detective
Sergeant Stacy Gallant, who oversaw the Service’s Major Case Management
Unit, for permission to install a software program, IEF Report Viewer, on a
number of computers. The program was designed to review and analyze
extracted electronic data. By June 2013, this program plus another forensic
search program, XIRAF, were installed. I describe both programs in Chapter
4. On January 16, the Project Houston officers located an image in
Brunton’s computer files that resembled Mr. Kayhan. Mr. Kayhan’s son could
not ascertain whether the photo was indeed of his father.
On the same day, Detective Harris forwarded a “deputies briefing” that
contained an investigative overview of Project Houston. It identified the
original occurrences for the missing person cases of Mr. Navaratnam, Mr.
Faizi, Mr. Kayhan, and another man, Mr. Jiwani.17 The investigative overview
indicated that the informant’s identification of Mr. Navaratnam as Brunton’s
potential victim was based on the informant’s own research and a description
Brunton provided.18 It also indicated that 27 judicial authorizations had
been obtained to that point. These authorizations attempted to establish
a link between Brunton and any of the potential victims. No direct links were
found.
Despite the absence of any demonstrable links between the missing men
and Brunton, the project continued to focus largely on Brunton. In late January
2013, the Project Houston team expanded to include two more officers. That

17
Mr. Jiwani was ultimately found to have no link to the other disappearances or to McArthur.
18
This document, unlike some others, accurately reflected that Brunton had not named Mr. Navaratnam. His
description was different, in some respects, from Mr. Navaratnam’s in age and physical characteristics.
month, the team met with several Peterborough officers to discuss the
investigation. Detective Gillis reviewed the videos and photos seized from
Brunton’s computers.

An Operational Plan and the Role of Other Police

Services

On January 29, 2013, Detective Sergeant Idsinga emailed Detective Sergeant

Kenneth Reimer,19 the head of the Service’s Intelligence Division (copying
Detective Harris, Inspector Bott, and a Peterborough police officer), to report
that he had submitted an Operational Plan for Project Houston. He indicated
that the team might apply for Criminal Intelligence Service Ontario (CISO)
funding to support the project. He also inquired as to whether the Operational
Plan would be uploaded to the Automated Criminal Intelligence
Information System (ACIIS)20 automatically and whether a lead analyst had
been assigned to the project.
An analyst in this context referred to an intelligence analyst with access
to ACIIS and other intelligence databases. Detective Sergeant Idsinga told the
Review that filing an Operational Plan and requesting an analyst were pre-
requisites to obtaining CISO funding. Detective Sergeant Reimer assigned
Jonathan Retchford, a senior intelligence analyst at the Service’s Intelligence
Services Unit, to assist with Project Houston. I describe Mr. Retchford’s
involvement in Project Houston below.
On January 30, Detective Sergeant Idsinga spoke with Detective
Sergeant Randy Cowan,21 the Homicide Major Case Manager of the Peel
police about the investigation into Mr. Faizi’s disappearance. The purpose of
his call, after he provided an overview of Project Houston, was to request that
one investigator be assigned to assist with the project. Acting Inspector Cowan
said he would discuss this request with his supervisors.
On the same date, Detective Sergeant Idsinga emailed Inspector Bott to
tell him that, given the potential link between Mr. Faizi’s case and the Project
Houston investigation, he felt it prudent to bring a Peel investigator on board
to represent Peel’s interests. He explained he had spoken with Detective
Sergeant Cowan and made an informal request. Detective Sergeant Idsinga
proposed that they treat Peel’s involvement in the same way they handled
Peterborough’s: having an investigator come to 51 Division to review the
19
Detective Sergeant Reimer was subsequently promoted to the rank of staff sergeant. He is now retired.
20
ACIIS is Canada’s only national criminal intelligence database. Managed by the Criminal Intelligence
Service Canada (CISC), it contains criminal information and intelligence on organized and serious crime in
or affecting Canada, including data on criminals or suspected criminals and businesses or organizations if
they are involved in organized crime or serious crime that may affect more than one jurisdiction.
21
Detective Sergeant Cowan is now retired.
material collected to date, so the other force could then decide whether it
wanted to be involved.
Detective Sergeant Idsinga prepared an Operational Plan and
funding request for Project Houston dated January 30, 2013. 22 The funding
proposal indicated that Toronto would be the lead agency in the
investigation and, overseen by a joint management team, would work in
partnership with CISO, the Peterborough Police Service, and the Peel
Regional Police. The funding proposal requested an equal splitting of costs
among all the agencies. Project Houston was described as follows:

Project “Houston” involves sexual assaults, the making / importing /

exporting of child pornography, and the trafficking of human victims for the
purposes of cannibalistic rituals by members of criminal organizations who
reside in and frequent the area of Ontario. It is anticipated that as the
investigation unfolds that other jurisdictions will be impacted.

According to the funding request, oversight for Project Houston would be

provided by members of a joint management team: Detective Sergeant Idsinga
for the Toronto police; Detective Sergeant Larry Charmley of the
Peterborough police; and the director of CISO.23
However, the funding request was never submitted. Project Houston
never became a multi-jurisdictional major case with a joint management team.
Acting Inspector Cowan declined to assign an investigator from Peel to the
project – a decision I explain below. Instead, the project was funded internally.
Toronto’s decision not to apply for CISO funding was tied to its decision not
to structure the project as a multi-jurisdictional major case with a joint
management team.
Inspector Bott told the Review that the CISO application did not move
forward because Staff Inspector McLane felt it should not proceed unless a
link was established between Brunton and the missing men. Until that time,
the project would be funded internally. If a link were established, the project
would submit the CISO application and transition the investigation into a
multi-jurisdictional major case. But no link was ever established.
Instead, the Review was told that Project Houston operated as an
“informal” multi-jurisdictional team investigation. Detective Constable Dave

22
This date may have been in error: Detective Sergeant Idsinga’s January 29, 2012, email indicated that the
Operational Plan had already been submitted.
23
Of interest, although it was proposed that Mr. Faizi’s disappearance form part of the investigation, an
officer from the Peel Regional Police had not been named asa member of the proposed joint management
tea m.
Rughoo, for example, told the Review that he acted as an international liaison
for the informal multi-jurisdictional team: he dealt with police and security
agencies in the United States, Germany, Australia, and New Zealand as the
investigation into the alleged international cannibal ring continued. This
international portion of the investigation, he explained, was separate from the
investigation into the disappearances of Mr. Navaratnam, Mr. Kayhan, and Mr.
Faizi. Detective Constable Gravelijn, the designated affiant for Project
Houston, similarly described an informal investigative arrangement with the
Peel and Peterborough police.
Deputy Chief James Ramer, now the Service’s acting chief, told the
Review that most of the investigations he oversaw were funded by CISO and
operated as multi-jurisdictional joint-force operations. It was common for the
Service to work with the Peel police in that way. In this case, it never got off
the ground. It was obvious from the email exchanges I reviewed that at
least one senior officer was “not excited” about involving other
jurisdictions and about Detective Sergeant Idsinga’s CISO proposal,
while Deputy Chief Ramer, in contrast, seemed very positive. One officer
indicated that he was probably going to hear about speaking out of turn in
supporting the proposal. However, as I explain in my findings below,
provincial adequacy standards required that this investigation be run as a
multi-jurisdictional major case or that, at a minimum, a discussion about that
issue take place with the province’s serial predator crime investigations
coordinator (the serial predator coordinator) and with command-
level officers or their designees in Peterborough and Peel. Although I
accept that Detective Sergeant Idsinga and others were prepared to involve
other services informally in the investigation, the particular approach that
was adopted was counterproductive and defeated
the underlying rationale for the provincial adequacy standards.
The Toronto police were convinced that reasonable grounds existed for
believing that an international cannibal ring existed with tentacles around the
world and that Brunton was possibly at the centre of the ring. They believed
Brunton lived in Peterborough and, apparently, was committing criminal
offences unrelated to why Project Houston was created. They also believed
those offences were being committed outside Toronto.
The Toronto police also sought judicial authorizations on the basis that
Brunton abducted and ate Mr. Navaratnam. They were also investigating
whether the disappearances of Mr. Faizi and Mr. Kayhan were related. Peel
was conducting a separate investigation of Mr. Faizi’s disappearance. Acting
Inspector Cowan declined to assign an officer to Project Houston in large part
because he questioned the whole cannibalism theory and Toronto’s focus on
it.
 These circumstances represented precisely the kind of situation
contemplated by the provincial adequacy standards respecting a multi-
jurisdictional major investigation. Ontario’s serial predator coordinator was,
however, kept in the dark about the entire investigation. Decisions as to the
involvement of other police services were not made at the command level. If
Brunton was not involved in Mr. Navaratnam’s disappearance, there was
nothing connecting this investigation to Toronto. The “informal” arrangement
reduced or eliminated altogether any meaningful provincial oversight of what
the Toronto police were doing. It is telling that even after Project Prism
identified McArthur as a suspect or person of interest in multiple
disappearances, the serial predator coordinator was not informed of the
investigation. He learned about it by reading of McArthur’s arrest in the
media.
A senior officer from another Ontario police service who had direct
knowledge of the project told the Review:

If they had followed the multijurisdictional protocol, it probably would have

worked a lot better … if they had, that would have triggered a Major Case
Management supervisor assigned, it probably would have been left with
[Idsinga] at the time, you would have had the resources and funding put in
place … And all it would be … [Idsinga] would come and report on the case
and say[,] “Here’s where we are, here’s where we’re going, here’s the funds
I need, is everyone in agreement?” And it would be managed like a board of
directors … So that’s the right way to do it. It’s a bit difficult. The
bureaucracy’s difficult but it would have been a joint management team, a
JMT, and run as a multijurisdictional project …That way when you get
something like this, the European angle and the cannibalism, you have some
competent people sitting across from you giving you a chat like, “Really, is
that where you want to go with this? Have you spoken to those two other
managers?” Do that first. Then talk to me about Sweden [sic].

Acting Chief Ramer candidly acknowledged to the Review that, in his view,
the serial predator coordinator should have been notified about Project
Houston while it was taking place. He also observed that the Service has not
always complied with this requirement.

Project Houston Discovers silv erfox x 51 and

newy ork boy 21 in Mr. Faizi’s Notepad

On January 31, 2013, Detective Constable Loria found a reference to

silverfoxx51 in Mr. Faizi’s notepad. Although she did not know it at the time,
this was a reference to McArthur’s email address and/or his username on the
dating website www.silverdaddies.com. She ran the name through Twitter and
online search engines but could not identify its owner. That same day, she also
found the name newyorkboy2124 in Mr. Faizi’s notes, but, again, she was
unable to identify its owner. Although tools were available to make those
identifications, they were not used in this case at the time.

Further Investigation into Brunton

In February 2013, Project Houston continued to review the electronic data

recovered from Brunton’s computers. The officers investigated Brunton’s
known associates and worked with the Swiss police to attempt to arrange an
interview with the informant. They discussed posing as a fellow cannibal
online or befriending Brunton at a hockey tournament, given his involvement
in the Peterborough minor league hockey community.
On February 4, Detective Sergeant Idsinga submitted an Organized
Crime and Intelligence Investigations Tracking Template form to the Canadian
Integrated Response to Organized Crime. It listed the primary base of
operation for the investigation as Peterborough, with Toronto as the secondary
area, and described the scope of the investigation as “international,” with co-
conspirators suspected in Vancouver, Sault Ste. Marie, the United States, the
United Kingdom, Germany, the Netherlands, and Switzerland. Detective
Sergeant Idsinga told the Review that submitting this form was a required
preliminary step before making an application for CISO funding. As I indicate
above, the CISO application was ultimately abandoned.
On February 5, Project Houston received information from the FBI
about a potential kidnapping plot. A resident of Peel Region, John
Orfanogiannis, was intercepted communicating about a plot to kidnap and
murder a woman with ties to one of Brunton’s contacts. Ultimately, the
investigation was turned over to Peel, with some continuing involvement by a
Project Houston officer.
On February 6, Detective Constable McKenzie obtained guest lists for
a number of hotels in the Church Street area of Toronto for the periods
coinciding with the disappearances of the three missing men. He was looking
for evidence that Brunton had stayed in the Church Street area of Toronto.
None was found.
On the same day, Detective Constable Loria spoke to Detective Sergeant

24
Both newyorkboy21 and n ewyorkboy21@y ahoo.com are aliases. The real username and email address
discovered by Project Houston have been omitted in this Report to protect the privacy of the owner.
Idsinga about compiling a spreadsheet with the usernames and websites
the missing men had contacted before their disappearances.
On February 7, Detective Constable Doug McCaw joined the
Project Houston team. He was tasked with trying to find Brunton’s cabin
in the Bancroft area. Although Bancroft is within the OPP’s jurisdiction, the
OPP was not approached to assist in this search.
On February 9, Project Houston officers located Mr. AA’s cabin in
Gilmour, Ontario. The officers had previously been told that Mr. Navaratnam
occasionally spent time at the cabin.
On February 11, Project Houston officers interviewed an employee
from Zipperz who had seen Mr. Navaratnam leaving the bar on September 6,
2010. He had not been formally interviewed at the time Mr. Navaratnam
disappeared. In 2013, he could not remember anything unusual.
On February 12, the undercover officer attended another hockey game
in Peterborough to observe Brunton. Other officers went again to Mr. AA’s
cabin in Gilmour. Project Houston officers continued to review Mr.
Navaratnam’s phone records as well as Brunton’s electronic communications.
On February 13, Detective Sergeant Cowan emailed Detective Sergeant
Idsinga to advise that, although Peel would not be assigning an investigator to
Project Houston, it was willing to support the investigation. Detective Sergeant
Cowan wrote:

Inspector Koekkoek and I addressed the issue of assigning an investigator

from Peel to this project with our administration. It was decided that it
would not be possible at this time. We would however be willing to support
you with whatever you may need otherwise. This would include expedited
occurrences, address checks, interviews in our jurisdiction, following up on
the seized computer from our missing person or any other detail deemed
appropriate. I will remain your contact for this matter should you need
anything. In regards to CISO, I think you can consider us assisting and we
would be willing to confirm that involvement as it relates to our missing
party. If things progress we would readdress the issue should an official
Joint Task Force be created and a Joint Management Team implemented.

In explaining this decision to the Review, Detective Sergeant

Cowan said the Toronto police were extremely secretive about the Project
Houston investigation. At an earlier stage, Toronto officers asked Peel
whether it had any missing person cases that fit a certain age group and a
certain ethnicity. The Toronto police would not tell Peel the reason for the
request. Detective Sergeant Cowan thought the Toronto police were
investigating a potential
serial killer and were trying to keep the information “locked down.” The Peel
police gave the Toronto police Mr. Faizi’s evidence file for copying.
Later, Detective Sergeant Idsinga approached Detective Sergeant
Cowan for assistance in Project Houston. Detective Sergeant Cowan was
briefed on the Project Houston investigation but was not impressed. In his
view, the investigation lacked direction. The focus on Brunton and the
cannibalism theory appeared to be an instance of “tunnel vision” premised on
an exotic theory rather than sound investigatory basics. Peel decided to offer
co-operation but not resources. The Peel police would continue to investigate
Mr. Faizi’s missing person case on their own.
For the remainder of February 2013, Project Houston obtained a judicial
authorization to record, by Skype, the undercover officer’s conversations with
Brunton; a tracking warrant for his car; and judicial production orders for two
additional email addresses associated with him. The amount of work and
ingenuity that went into this element of the investigation is to be commended:
the Project Houston affiant, Detective Constable Gravelijn, told the
Review that she understood the Skype recording order to be the first of its
kind for the Service.
In late February 2013, US and UK investigators came to Toronto to
meet with Project Houston investigators. The United Kingdom’s Serious
Organized Crime Agency was to determine the appropriate course of
action relating to several email addresses associated with Brunton’s contacts
there, and the FBI to disseminate information on persons of interest in the
United States to its field officers. Undercover officers were to coordinate
globally in efforts to infiltrate cannibal fetish websites.

Mr. Navaratnam Linked to silv erfox x 51 and newy ork boy 21

On February 22, 2013, Detective Constable Loria received from Detective

Constable Coffey a hard copy and, later, an electronic version of the deleted
email contacts from Mr. Navaratnam’s computer. She noticed a common email
address contact between Mr. Navaratnam and Mr. Faizi:
[email protected], the address she had previously seen in Mr. Faizi’s
notebook. On February 25, Detective Constable Rughoo sent a subpoena to the
FBI to obtain subscriber information for this email address.
On February 26, Detective Constable Loria identified another common
email address between Mr. Navaratnam’s deleted computer files and Mr.
Faizi’s notebook: [email protected]. The next day, Detective
Sergeant Idsinga assigned Detective Constable Rughoo to pursue subscriber
information for this address.
 Detective Constable Rughoo sent a request to the American Department
of Homeland Security to serve a subpoena on Hotmail to identify the account’s
owner. Despite this request, Project Houston did not receive any subscriber
information for the account. Detective Constable Rughoo told the Review that
at some point after making this request, an agent from Homeland Security told
him that an MLAT request was required because Microsoft, which operates
Hotmail, is an American company. Detective Constable Rughoo could not
make an MLAT request – this task was the responsibility of the lead
investigator. Detective Constable Rughoo advised Detective Constable Loria
of the needed MLAT request because she was making a list of the outstanding
tasks in advance of her upcoming maternity leave.
On April 24, Detective Constable Loria emailed Detective Harris,
asking her to add the [email protected] email address to an MLAT
request. The following day, Detective Harris contacted a Crown attorney to
discuss an MLAT request to the United States for several email addresses, but
[email protected] was not included on the list.
[email protected] was McArthur’s email address. However,
the Project Houston officers did not discover the connection until September
15, 2013 – approximately seven months following the February 26
identification.
To understand what went wrong, I must briefly address the assignment,
or “actioning,” component of Project Houston. Detective Sergeant Idsinga told
the Review that assignments, or actions, should be tracked in an action log in
the P Drive as well as in PowerCase. In addition, he also relied on the Project
Houston daily logs and team briefings to stay on top of assignments. During
Project Houston, however, items were often assigned orally and not recorded
or tracked in a formalized format. The Review substantiated this flawed
method when it examined the contents of the P Drive and PowerCase file.
Very few assignments were recorded as either assigned or completed. It is
apparent that, contrary to the 2012 Major Case Management Manual, the
Project Houston team was relying largely on memory and a manual system
(such as officer memobook notes) to keep track of assignments. Such
reliance is precisely what provincial adequacy standards respecting the use of
PowerCase are designed to avoid. Otherwise, things are missed, sometimes
of critical importance. That is exactly what happened here.
An oversight of particular consequence was the fact that no assignments
involving [email protected] were recorded in either PowerCase or
the P Drive action log. As a result, no steps were taken to identify the owner
of this email address for many months – even though both Detective
Constable
Loria and Detective Sergeant Idsinga appreciated the need to identify the
owner. This significant omission simply went unnoticed.
Project Houston also asked US authorities to serve a subpoena on
Yahoo.com for Mr. Navaratnam’s email address – to allow the team to
determine the last login to Mr. Navaratnam’s account and to preserve Mr.
Navaratnam’s emails if extraction from Mr. Navaratnam’s hard drive was
unsuccessful. Yahoo replied to the subpoena on April 17, 2013, with a list of
the last logins to Mr. Navaratnam’s email account. The final login was on
November 3, 2012. With the assistance of Interpol, Project Houston was able
to determine that this login took place from Aruba. Mr. Navaratnam’s
email account had been accessed several times internationally since his
disappearance, including from the Netherlands, Vietnam, and Turkey. Project
Houston analyzed the logins but was unable to explain them.
On February 27, 2013, Detective Constable Loria reviewed the list
of Brunton’s usernames against the list of Mr. Navaratnam’s deleted
usernames. There were no matches.

Investigation of Orfanogiannis and Brunton

At the end of February 2013, Project Houston began a parallel file for the
suspected kidnapping plot involving Orfanogiannis. On February 28, Project
Houston officers received a call from the FBI. The undercover agent there was
concerned about Orfanogiannis’s intentions: he was becoming more resolute
in his kidnapping plans and talked about buying a van to facilitate them.
The investigation into Orfanogiannis became a “side project” for
Detective Constable Rughoo. He worked co-operatively with the FBI and the
UK authorities because Project Houston was a hub of information about
Brunton and the cannibal ring. Once Orfanogiannis was arrested,
Detective Constable Rughoo’s involvement with the FBI tapered off.
In the meantime, Detective Harris and Detective Lori Haggett
interviewed Mr. HH, Mr. Navaratnam’s ex-partner. He had last spoken with
Mr. Navaratnam on September 4, 2010. During the initial investigation, he had
not been interviewed, and he was now able to provide the police with
significant background about Mr. Navaratnam’s friends and other ex-partners.
The undercover operation also continued in Peterborough. In March
2013, the Project Houston officers tracked and surveilled Brunton. They
placed a tracking device on his vehicle and reviewed his online activity. In
early March, an undercover officer met Brunton at a Peterborough restaurant
for dinner and arranged a second meeting in mid-March, also in Peterborough.
At the same time, Detective Constable Coffey located a contact by the
name of “Mr. KK” on Mr. Navaratnam’s computer. Detective Constable
Coffey found a similar name when he searched Brunton’s computer in
connection with the website www.justhookup.com. He could not determine
whether Brunton had contacted Mr. KK or even checked his profile, but he
started a working file for background information on Mr. KK. Detective
Constable Coffey also learned that both Mr. Navaratnam and Brunton used the
www.silverdaddies.com website, although this information had already been
discovered earlier in the investigation.
On March 4, Detective Constable Rughoo contacted the German
Federal Criminal Police Office (BKA). He spoke with Officer Patrick
Schuh, the BKA’s police liaison officer responsible for Canada and the
United States. Officer Schuh agreed to act as Project Houston’s point of
contact and began to pursue subscriber information for Brunton’s German
email contacts.
On March 5, officers sent out grid alerts 25 to the Canadian Bankers
Association and Interpol for the missing men: in the event they were still alive,
these listings might allow the officers to track them. The officers also
interviewed others connected to the three missing men. None of these people
had been interviewed in the Service’s initial investigations.

 Mr. II: Mr. II had been involved in intimate relationships with both Mr.
Faizi and Mr. Navaratnam. He told the police an attendant at The Cellar
bathhouse had said that people from the Middle East appeared to be
targeted (in reference to Mr. Navaratnam, Mr. Faizi, and a man in his
twenties from western Ontario who had gone missing in 2009). Detective
Constable Loria went to The Cellar to try to find out more about this third
man.
 A professor at the University of Toronto who taught Mr. Navaratnam in
2005 and 2006: the professor and his wife last had contact with Mr.
Navaratnam in 2008. The professor’s wife told the officers that Mr.
Navaratnam had a friend in Rosedale with a big house who hired him to
do yard work. It is not clear who this friend was, but 53 Mallory Crescent
– the property where McArthur worked as a gardener / landscaper,
employed others (including some of his murder victims), and ultimately
hid the bodies of his murder victims – is near Rosedale.
 Mr. BB and Mr. AA: Mr. BB and Mr. AA had originally reported Mr.
Navaratnam’s disappearance. Mr. BB told police he found it odd that the

25
A “grid alert” is a request for an alert should any of the missing men come to the attention of these
services. A grid alert for a bank, for example, would give rise to the bank’s notifying the police if one of the
missing men used a debit card at a bank location.
 police had not interviewed either him or Mr. AA when they first reported
Mr. Navaratnam missing. Their memories would have been fresh back
then. Mr. BB told the police that Mr. Navaratnam liked dating older men,
or “silver daddies.” Mr. Navaratnam was very private about his personal
life, and Mr. BB had never met any of his other partners. Mr. Navaratnam
was street smart and would not have left the bar with a person he didn’t
know.
 Mr. LL: Mr. LL met Mr. Kayhan at the Black Eagle bar sometime in
2012. He told the officers he had a few beers and cigarettes with Mr.
Kayhan, they exchanged phone numbers, but neither of them contacted
the other again. However, the police had found Mr. LL’s business card in
Mr. Kayhan’s apartment and recognized his voice from a voicemail
message on Mr. Kayhan’s answering machine. There is no suggestion
that Mr. LL had anything to do with Mr. Kayhan’s disappearance.
However, the interview illustrates the importance of pre-interview
preparation to allow investigators to assess the credibility of a witness’s
account. It also illustrates the reticence of community members, at times,
to share information with the police;
 Mr. CC: Mr. CC met Mr. Navaratnam in 2000. The two men lived
together for approximately four years. Mr. CC told the officers that Mr.
Navaratnam did odd jobs and was good at landscaping. He also described
him as very private about his life. After Mr. Navaratnam moved out of his
home, Mr. CC did not have much contact with him. Mr. CC told the
police that, in the past, Mr. Navaratnam had twice gone missing for a few
days but was very smart and would not put himself into a dangerous
situation. In his view, Mr. Navaratnam had simply left to start a new life.
 The owner of the Black Eagle bar: during the interview, the officers
identified employees who had worked at the bar at the time Mr.
Navaratnam disappeared. The owner said that Mr. Navaratnam, Mr.
Faizi, and Mr. Kayhan were regular customers.
 Mr. MM: Mr. MM had been sexually intimate with Mr. Navaratnam and
Mr. Faizi. He knew them both from the Black Eagle bar. Mr. Navaratnam
told Mr. MM he was a landscaper.
 Mr. KK: Mr. KK met Mr. Navaratnam on www.squirt.org and had one
sexual encounter with him in the summer of 2009. Mr. KK told the
officers that in July 2010, he bought a trailer in Peterborough and went
there every summer weekend. As indicated earlier, the Project Houston
officers had found a reference to “KK” in Brunton’s computer search
history. Despite this potential link between Brunton and Mr. Navaratnam,
 the officers never asked Mr. KK if he knew Brunton. One of the
interviewers told the Review he may have been aware of the reference to
“Mr. KK” in Brunton’s computer but could not recall one way or the
other. He was not able to provide an explanation as to why he and the
other interviewing officer did not ask Mr. KK about Brunton if they were
aware of that fact. This lapse reflects a common theme throughout this
Report – the failure to use case management tools effectively to
understand and benefit from information that had been collected.
 Mr. NN, a friend of Mr. Navaratnam: Mr. NN told police about Mr.
Navaratnam’s life, including his trips to a cabin up north.

The officers did not turn up any leads from these interviews. On March
11, 2013, the Project Houston team obtained 12 judicial production orders for
the telephone and tower records of the last people to speak to Mr. Navaratnam
before his disappearance.
On March 19, Project Houston followed up with the FBI, which
reported that it was in the process of winding down the second tier of its
cannibal investigation. Once the operation concluded and the agents
assessed the intelligence gathered, the FBI would change its focus to
investigating the persons of interest forwarded to them by the Project
Houston.
Detective Constable Loria continued to search through Mr.
Navaratnam’s online activity and identified multiple dating websites he had
used between 2000 and 2010, including www.silverdaddies.com,
www.squirt.org, and www.daddyhunt.com (www.silverdaddies.com and
www.daddyhunt.com had already been identified earlier in the investigation).
She also emailed the Montreal police to see if they had any active or cold
missing person cases similar to the three missing men. Because of the yearlong
gap between the first two disappearances and the third, Detective Constable
Loria was concerned that a perpetrator might be moving around.
On March 26, Detective Constable Loria emailed Detective Constable
Coffey to remind him to download the hard-drive extraction that the Peel
police provided from Mr. Faizi’s computer. She had asked about the hard drive
back in February. Detective Constable Coffey emailed Detective Constable
Loria on March 28 to say he had the imaged copy of the hard drive from Peel.
He had not been able to do much investigating on the case but had run some
keywords and had not found anything.
In April 2013, Project Houston continued to track Brunton and
engage with him online through the undercover officer. Detective
Constable Rughoo consulted with officers from the United States,
Australia, and New Zealand
about attempts to identify the owners of usernames associated with
cannibalism messages. Detective Constable Rughoo lined up a special agent
with the FBI Denver Field Office in Colorado as a point of contact with
respect to one individual, Mr. OO. Mr. OO and Brunton had exchanged emails
that were classified as child pornography.
On April 2, the Peel police told Detective Constable Loria that a DNA
sample from Mr. Faizi’s daughter, along with the hair and fibre collected from
Mr. Faizi’s car, had been submitted to the Centre of Forensic Sciences for
comparisons.

Plans to Wind Down Project Houston

On April 2, 2013, because the Project Houston team was thought to be nearing
the end of its investigation, Detective Harris requested a meeting with the
Crown attorney. The discussion took place the next day and focused on the
potential charges to be laid against Brunton.
That same day, Detective Constable Rughoo spoke with the FBI, which
had received the results of the search warrants executed on
Orfanogiannis’s email accounts. Orfanogiannis was heavily involved in child
pornography. The FBI identified several persons of interest in their
investigation, including one in Toronto.
Throughout April, the Project Houston officers consulted with
authorities from the United States, Australia, and New Zealand about
Brunton’s potential contacts. They also continued to interview people who had
known the missing men. On April 4, they interviewed Mr. PP. He told them he
did not recognize photos of any of the missing men. That turned out to be a lie.
Although the officers did not know it at the time of the interview, Mr. PP was
the owner of the newyorkboy21 email address found in Mr. Navaratnam’s
computer and on Mr. Faizi’s notepad. He had also spoken to Mr. Faizi on the
phone shortly before his disappearance.
On April 5, Detective Constable Loria went to the Tech Unit to meet
with Detective Constable Coffey about Mr. Faizi’s computer files. She learned
that no files had been extracted for her. She left a message for Detective
Constable Coffey asking him to extract any information regarding Mr. Faizi’s
email contacts, websites, anything to do with suicide, or any places to which
he may have considered running away. On April 9, Detective Constable
Coffey gave her photos from Mr. Faizi’s computer on DVDs, and on April 10,
the extracted data from Mr. Faizi’s computer. She reviewed the data and
identified www.bearforest.com as the last website Mr. Faizi visited on the
morning of his disappearance. She found that in the previous days, he was
also active on
various sites, including www.silverdaddies.com.
On April 10, Detective Constable Gravelijn emailed Detective Harris
the contents of a document to be submitted to the court. It set out details of the
investigation to date, including an accurate summary of what the confidential
informant had told the police and the child pornography–related photos in
Brunton’s possession.26 Of significance, the document also reflected that the
investigation had located two email addresses that were in the contact books
of Mr. Navaratnam and Mr. Faizi: [email protected] and
[email protected]. The document did not contain any evidence
linking Brunton to any of the missing men. This document was, however, yet
another indication that the project recognized the potential significance of
[email protected].
On April 11, undercover officers went with Brunton to the Black Eagle
and to other bars and strip clubs. Brunton indicated he had never been to the
Black Eagle before. The undercover officers noted that Brunton did not appear
to like the dancers who had beards. Each of the three missing men had a
beard. On April 16, Detective Constable Loria continued reviewing the files
extracted from Mr. Faizi’s computer. She found several Google map images,
including an area about two kilometres from where Mr. Faizi’s car had been
found. Detective Constable Loria checked to see if any of Mr. Faizi’s contacts
were associated with addresses in this area, and she ran a Unified Search for
any incidents involving gay men in the area. 27 Her searches came back
negative.
Detective Constable Rughoo continued to review the Yahoo Instant
Messenger chats extracted from Brunton’s computer. On the same day,
Mr. Retchford completed his Telephone Toll Analysis report for Project
Houston. The report analyzed data from the cellphones used by Mr.
Navaratnam and Mr. Faizi. No direct or indirect connections were found
between the two phones.

Project Houston’s Analyst

When Mr. Retchford joined Project Houston as a civilian analyst in February

2013, his point of contact was with Detective Constable Loria. He was not
assigned full time to the project, nor did he work out of the project room at 51
Division with the investigators. He stayed at Intelligence Services and worked
26
Contrary to at least one media account, photographs of Mr. Faizi or Mr. Navaratnam were not found on
Brunton’s computer.
27
The Unified Search tool was a one-stop search feature that allowed officers to access several databases.
These databases included eCOPS and its predecessor COPS as well as CIPS, RICI, MANIX, CPIC, and
MTO. For greater detail, see Chapter 4.
on the project in conjunction with his other assignments.
All the information Mr. Retchford received about Project Houston came
from Detective Constable Loria. She gave him a number of documents from
the investigative file, including telephone records, banking records,
information from Brunton’s computer and chats, and summaries of
information relating to the three missing men. He never had access to Project
Houston’s P Drive.
Mr. Retchford recalls his initial focus being on the cellphone records of
Mr. Navaratnam and Mr. Faizi. Detective Constable Loria wanted to know if
there was any connection between the two phones or any similarities between
their contacts. As I indicate above, his Telephone Toll Analysis report
identified no connection between the phones.
After that task was completed, Detective Constable Loria asked Mr.
Retchford to see if he could find any other connections between the missing
men. He was not asked to review any information relating to Brunton: rather,
he focused exclusively on the missing men and whether they might be
connected to one another. In Mr. Retchford’s view, this limitation made sense:
the Brunton / cannibalism angle seemed far-fetched to him.
In April 2013, Mr. Retchford created several analytical charts to set out
the known connections that linked the three missing men. All three were
known to have attended the Steamworks bathhouse, The Cellar bathhouse, and
the Black Eagle bar in Toronto. Mr. MM and Mr. II had relationships with
both Mr. Faizi and Mr. Navaratnam. Mr. QQ was Mr. Kayhan’s neighbour and
had also had a sexual encounter with Mr. Faizi. Finally, Mr. Faizi and Mr.
Navaratnam had two email contacts in common: [email protected]
and [email protected]. Both men had used www.silverdaddies.com
and www.daddyhunt.com. Significantly, the chart demonstrated no known
connection to Brunton. No one interviewed by the police or otherwise referred
to during the investigation had a meaningful connection to all three missing
men.
When Mr. Retchford created the analytical linkage charts in April 2013,
silverfoxx51 had not yet been identified as McArthur. Nor had McArthur been
connected to Mr. Kayhan.
Mr. Retchford recalls that even after his April 2013 analysis, the
investigation seemed to focus heavily on Brunton. Detective Constable Loria
went on maternity leave. Mr. Retchford’s involvement decreased and no
further information was shared with him. In September 2013, he was not told
that silverfoxx51 had been identified as McArthur’s username. When, in
November 2013, McArthur acknowledged a sexual relationship with Mr.
Kayhan, Mr. Retchford was not told. He learned about McArthur’s connection
to silverfoxx51 in 2018 through media reports of McArthur’s arrest.
As I explain below, when Project Houston interviewed McArthur in
November 2013, no one paid any attention to his meaningful connection to all
three missing men. The underuse of the project’s own analyst – a systemic
flaw I identify in my later findings – represented yet another lost
opportunity to connect the dots that were there for investigators to see.
On April 17, 2013, Detective Constable McKenzie and Detective
Constable Lavallee interviewed Mr. QQ, who was referenced in Mr.
Retchford’s analytical chart. He was Mr. Kayhan’s neighbour and had also
been involved in a sexual encounter with Mr. Faizi. He recognized Mr.
Navaratnam from a missing person poster but had never met him.

Interview with the Informant in Switzerland

On April 18, Detective Harris and Police Constable Platte went to Switzerland
to interview the confidential informant. The interview transcript shows that the
Toronto police said they were investigating allegations of murder, conspiracy
to commit murder, kidnapping, and possession of child pornography.
During the interview, the confidential informant told the police that
since February 2012, he had been a member of the website “Zambian Meat,”
a cannibal forum where cannibal fantasies were exchanged. The confidential
informant met “John Jacobs” (whose real identity was now known to be
Brunton) on the website. Jacobs lived near Toronto and used the username
“chefmate” on the zambianmeat.com website. The confidential informant said
that Jacobs did not talk about previous victims but had “experience.” He did
not say much – just that he lived on a farm and had slaughtered animals.
Jacobs did not directly say he had murdered a human being.
The informant and Jacobs discussed how Jacobs would kill the
informant by putting a bullet in his head. In April 2012, the informant asked
Jacobs if he had experience with human meat. Jacobs said yes, but the
informant did not know if this reply represented Jacobs’s own experience or
something he had read. Jacobs did not talk about how many people he may
have murdered, where or how he killed previous victims, or how he met his
victims.
When asked what Jacobs said about the person the informant believed
to be Mr. Navaratnam, the informant said that Jacobs never mentioned a
particular person. The informant concluded that Jacobs was a homosexual, was
looking for younger victims, and liked “muscle meat” best.
The informant was also asked why he thought Jacobs’s victim was from
the Toronto gay scene. The informant only presumed that if Jacobs were gay,
he would need a trick to “lure his victim into a trap.” The informant was also
uncertain that the offence being discussed would have taken place between
2009 and 2011.
The informant had come to his own conclusion that Mr. Navaratnam
was one of Jacobs’s victims. As he said:

I started to search on Google. I searched for “Toronto man missing.” I found

Skanda pretty fast. Then I researched if he is homosexual and how he
disappeared, etc. He could be gone or he could be a victim of a crime. He
could be a victim which would fit into the profile. There are others but he
would fit the profile. His age is a bit high. I think that Skanda could be a
victim of a crime due to the fact that he bought a dog shortly before he
disappeared. The dog was by himself at his home. If he had committed
suicide he would not have bought a dog beforehand. An accident would be
possible as well. For example[,] if he would have gone on a day trip he
would have left the dog at home. And they did not find a corpse.

This rationale supported the possibility that Mr. Navaratnam had been the
victim of foul play, but it provided no support for Brunton’s involvement.
On April 26, Detective Sergeant Idsinga reviewed the transcript of the
confidential informant’s interview. He recorded in his notes that it disclosed
“no specific link from Brunton to any of our victims.”
By April or May 2013, Detective Sergeant Idsinga was “pretty satisfied”
that Brunton was “full of crap” and was merely expressing cannibal fantasies.
The Project Houston officers had also found a chat in Brunton’s internet
history from 2009 where Brunton arranged to pick up a willing male victim to
be killed and eaten. Brunton did not follow through with the plan: he brushed
the man off, and later posed online as his own wife to explain his absence.
On April 22, 2013, Inspector Bott emailed Staff Inspector McLane to
provide an update about Project Houston:

Investigators traveled to Switzerland to speak to the witness. I am told that

nothing earth shattering came from the interview that will allow us to make
the link between our target and the missing males. The witness was adamant
and indicated that he has been involved in the lifestyle for 10 years and he
has only ever called the police twice, and indicated that our target is the
“Real Deal.”
There will be another live UC [undercover] play this week after the
successful meet in Toronto.
The online UC plays continue.
 Investigators are focused [on] having the target commit to an overt
act related to his fetish.
Investigative team would like to be in a position to make an arrest by
the end of May. The reason for arrest and subsequent charges will depend on
the success of the UC plays.

Inspector Bott told the Review that after the trip to Switzerland, Project
Houston’s focus shifted to getting Brunton off the street while also seeing if
the team could substantiate any of the informant’s information. Inspector Bott
was concerned about the missing men but felt the team did not have any
additional leads to investigate. As he put it:

We had no information that there was any criminality involved in any of the
missing persons, which left us in a void. We sort of had really no direction.
There was nothing to suggest there was criminality except that they all were
active in the community and were no longer active in their banking, with
family, with friends and had potentially just disappeared.

As I later explain, I disagree with this view.

The Project Houston officers continued to work with the FBI and
Australian authorities to attempt to locate a missing Australian youth they
believed might be part of the cannibal ring. They also continued to review
Brunton’s extracted chat messages.

Owner of newy o r k b o y 2 1 @ y ahoo.com Identified

On April 22, Detective Constable Rughoo obtained and reviewed the results
of the subpoena he had submitted on February 25, 2013, for
[email protected]. The email address was associated with Mr.
PP. As I indicate above, according to Mr. Faizi’s telephone records, Mr. Faizi
had also called Mr. PP on December 10, 2010, a few weeks before he
disappeared. Mr. PP had lied to police by saying he did not know either Mr.
Navaratnam or Mr. Faizi. The police also noted that Mr. PP’s previous address
was close to where Mr. Faizi’s car had been found.
Interest in Mr. PP increased. Detective Sergeant Idsinga assigned
Detective Constable Loria to do a complete background workup on Mr. PP.
On April 24, Detective Harris applied for visual and photographic surveillance
of Mr. PP, identifying him as a possible “person of interest” in the murders of
the two missing men from 2010. The next day, she submitted an official
request for a “lifestyle” report on Mr. PP. These reports are prepared by
having a
plainclothes team of five or six officers follow a person of interest, taking
photographs, examining patterns of behaviour, and generating a report about
the person’s lifestyle.
I observe that Project Houston officers never requested or completed a
similar background workup on McArthur before or after his November 11,
2013, interview. Detective Harris was unable to explain why one was not
done.

Investigation of Email Addresses, but Not

silv erfox x [email protected]

On April 24, 2013, Detective Constable Loria emailed Detective Harris to

advise her that Mr. Faizi had last sent an email to [email protected] As I state
earlier, Detective Constable Loria also noted that [email protected]
was a connection between Mr. Faizi and Mr. Navaratnam. She asked Detective
Harris to include the [email protected] address in an MLAT request.
The next day, on April 25, Detective Harris contacted the Crown Law
Office2 9 regarding an MLAT request to the United States for several email
addresses, including [email protected] and [email protected]. The
[email protected] address was not included in this list. On April
26, Detective Harris emailed Microsoft to request that it preserve several
email addresses in anticipation of an MLAT request. The requested emails
included [email protected]. Detective Harris also emailed
Yahoo to request
that it preserve [email protected] and [email protected].
There is no evidence in the Project Houston file, however, that an
MLAT request pertaining to [email protected] was ever made. If it
was, there is no evidence that it resulted in obtaining the desired information.
There is no record in the file that anybody noticed the omission. Some of
Detective Harris’s notes are no longer available, though they should have been
retained in the file as required by provincial adequacy standards. In any event,
these are precisely the types of tasks or actions that should be documented,
listed on PowerCase, and followed up on in a timely way if not completed.
The connection between [email protected] and McArthur was not
discovered until September 2013, about five months later. And that connection
was established without resort to an MLAT request.
28
[email protected] is an a lia s. The actual email address has been omitted from this Report.
29
The Crown Law Office – Criminal at the Ontario Ministry of the Attorney General.
Arrest of Orfanogiannis

On April 25, Detective Constable Rughoo went to Orfanogiannis’s home with

members of the Peel Regional Police Special Victims Unit. The Peel police
arrested Orfanogiannis on child pornography and conspiracy to commit sexual
assault charges.

Planned Arrest of Brunton

Through April 2013, the Project Houston team continued to monitor Brunton
online. On April 28, Brunton responded to a message from the undercover
officer, arranging to meet at Pearson International Airport. The undercover
officer posed as a willing cannibalism victim for Brunton. The Project
Houston team also continued to work with the FBI and with Australian and
New Zealand police, attempting to set up an interview with one of
Brunton’s associates.
On April 30, Detective Sergeant Idsinga emailed Inspector Bott and
Staff Inspector McLane to provide an update on Project Houston:

As you are aware, the online undercover operation is progressing well, and
we are now anticipating an arrest date of May 11th, 2013 of Brunton.
There are numerous charges that are going to be laid against Brunton,
regardless of the outcome of the undercover operation. Should the operation
succeed, these charges will be laid on May 11th. Should the operation not
succeed, it is proposed that charges be laid and warrants executed on May
13th.

The email outlined the charges to be laid against Brunton (including

various child pornography offences) 30 pertaining to two young victims, one in
Colorado and one in California. Detective Sergeant Idsinga anticipated that,
with the FBI’s assistance, the project’s investigators would interview these
victims in the United States. The costs for the trips are outlined in the same
email. (The Peterborough Police Service agreed to pay one-third of these
costs.) Detective Constable Rughoo ultimately went to Colorado, and
Detective Constable Lavallee to California.
On May 1, 2013, Detective Harris distributed an email to the effect that
30
I note that several charges were under customs and immigration legislation. These seemingly fall within
the jurisdiction of Canada Border Services, though the project’s files do not reflect any involvement by the
Canada Border Services Agency.
on May 11, Project Houston would be “taken down” and Brunton arrested.
On May 7, a Department of Homeland Security investigator in the
United States told Detective Constable Rughoo they had made an arrest in
Boston with regard to a cannibal ring focused on sexually assaulting and
eating children. Homeland Security had identified several networks and
would disseminate the information. Brunton had been in contact with
persons of interest who were connected to Boston.
On May 8, Detective Sergeant Richmond emailed the 51 Division
Detective Office and the members of Project Houston to advise that
Project Houston would soon be concluding. A press conference was
tentatively scheduled for May 13, presumably to follow Brunton’s arrest, and
a telephone tip line would be set up to receive information from the public.
On the same date, Superintendent Jason Tanouye31 emailed
Detective Harris to advise that the investigative fund at 51 Division had been
exhausted. Eighty percent of the fund had been spent on Project Houston.
Superintendent Tanouye stated that no further investigation expenditures
would come from this account.
On May 9, the Project Houston team obtained search warrants for
Brunton’s home and vehicles. They also got a warrant for a “limiter” device 32
for Brunton’s car. Toronto officers met with the Peterborough police to discuss
Brunton’s anticipated takedown. The undercover officer had lunch with
Brunton in Peterborough. Officers continued to monitor Brunton and installed
the limiter device onto his car.
The supporting documents for the warrants reflected that Detective
Constable Coffey had identified two email addresses in common between Mr.
Navaratnam and Mr. Faizi: [email protected] and
[email protected]. The documents also reflected that the
[email protected] email address belonged to Mr. PP, who had earlier
told police he did not know either Mr. Navaratnam or Mr. Faizi. A judicial
production order was still being sought for Mr. PP’s phone records to identify
any further possible links between Mr. PP and the missing parties.
In other words, Project Houston was ostensibly winding down without
having identified the owner of [email protected] and without solving
the disappearances of the three missing men.
By May 11, an undercover officer had been conversing online with
Brunton for two months – a different officer from those who had met
with
31
Superintendent Tanouye has since retired.
32
A limiter device a llows the police to remotely slow down a vehicle. This device was to be installed to
provide some measure of control because it was anticipated that the undercover officer would be in
Brunton’s vehicle.
Brunton earlier. This undercover officer had offered himself up as a
willing victim to be killed and eaten. He and Brunton planned to meet at
Pearson International Airport that day. Twenty-one officers from Toronto
and Peterborough were mobilized to support the operation. Inspector Bott
and Detective Sergeant Idsinga were to direct it. The Peterborough police were
to arrest Brunton if he returned to his Peterborough home after going to the
airport. He would then be turned over to 51 Division officers for transport to
Toronto. The Toronto officers would execute the search warrant for Brunton’s
home. Detective Sergeant Idsinga told the Review that the plan to take down
Brunton was unprecedented. The logistics of the operation were massive.
However, Brunton did not show up. Project Houston surveilled Brunton
drive in the direction of the airport, but then, not far from Peterborough,
he pulled over, did some shopping, and went home. He later emailed the
undercover officer to say he had suffered a heart attack and was in the
hospital. Project Houston decided to proceed on the child pornography and
other charges described earlier against Brunton. On May 13, he was
arrested, and search warrants were executed on his house and car. After his
arrest, Brunton
acknowledged he might have met Mr. Navaratnam 15 years earlier.
Project Houston never found any evidence linking Brunton to Mr.
Navaratnam, Mr. Faizi, or Mr. Kayhan.

After Brunton’s Arrest

Throughout mid to late May 2013, members of Project Houston contacted

individuals in Germany who had chatted with Brunton online. They extracted
and reviewed the contents of Brunton’s cellphone. They found many photos of
young men changing in a hockey locker room. They cross-referenced the
usernames Brunton had contacted online with information provided by US and
UK agencies.
The officers continued to take some investigative steps in Toronto. They
went to Remington’s Men of Steel strip club and were told that Mr.
Navaratnam had been there shortly before he went missing. They interviewed
employees of Remington’s and Zipperz as well as patrons of the Black Eagle.
Nothing came of the interviews.
The Project Houston team got smaller. Detective Ogg left the team
within days of Brunton’s arrest. By that point, Detective Constable Loria had
been acting as the primary file coordinator for many months.
On May 21, Detective Constable Loria contacted Peel Detective
Sergeant Cowan. He approved the release of a media bulletin about all
three
missing men and agreed to have a Peel officer contact Mr. Faizi’s family to
inform them of the multiple missing person cases that might be related.
Detective Constable Loria told him that Project Houston remained
ongoing, though its length depended on how much information the team
would now receive from the public. If it appeared that the case involved a
serial killer, the team would be moved from 51 Division to the Homicide Unit.
Around May 24, Detective Constable Loria left the Project Houston
team to begin her maternity leave. The investigation no longer had a file
coordinator.
On May 31, Detective Constable McKenzie attended training for
XIRAF – a new software for accessing evidence from computers. On June 6,
Staff Inspector McLane emailed the Homicide Unit to confirm the installation
of XIRAF on several computers at Homicide. He explained that XIRAF
allowed the focus of computer investigation to shift back to the primary police
investigator, rather than a forensic technology team, to use the investigator’s
knowledge more efficiently. The XIRAF program allowed the investigator to
search the computer through keywords. By using the program, the investigator
could read emails, view photo and chat logs, and create reports. XIRAF could
also aggregate extracted searches from multiple devices to allow investigators
to search content across those devices. Staff Inspector McLane said that
Project Houston was being used as a test case for the XIRAF program.

Project Houston No Longer a Homicide Investigation

On June 5, Police Constable Platte emailed Detective Harris an update,

outlining the status of the investigations into the missing men. The update
noted that interviews were ongoing. Detective Harris forwarded the update to
Detective Sergeant Richmond. She advised him that she would receive any
tips that came in through the tip line.
Detective Sergeant Idsinga told the Review that as of June 6, 2013, the
Project Houston officers had determined that Brunton was not linked to the
missing men. Although they were still concerned about the missing men, the
police no longer classified the investigation into their disappearances as a
homicide investigation. As a result, Detective Sergeant Idsinga would no
longer be involved. Carriage of the investigation was transferred back to 51
Division, and the Homicide officers would return to their unit.
Inspector Bott’s involvement with Project Houston ended when
Detective Sergeant Idsinga left the investigation. He exchanged occasional
emails with Detective Harris about the project, but his focus shifted to the
Homicide Unit’s other ongoing work. Inspector Bott thought there was no
evidence to suggest that the missing men were the victims of a homicide
or that foul play was involved. Other than the fact that they had been missing
for a long time, there was no evidence the missing men were even dead. He
said the Homicide officers would have remained at 51 Division as part of the
project team if there had been evidence of foul play. Without this evidence, the
cases reverted to missing person investigations. On June 6, after consultation
with the Peel officers, the Service issued the media release about the
disappearance of the three men. Detective Sergeant Idsinga’s notes
described it as the project’s final media release.
The media release said that investigators “researched the missing
persons databases for missing persons who were similar to Skandaraj
“Skanda” Navaratnam, specifically individuals with similar ethnicity, similar
lifestyle33 and associated to the area of Church Street and Wellesley
Street.” Mr. Faizi and Mr. Kayhan “fit the same profile” and “there are a
number of similarities between the three men.” Constable Tony Valla of
Corporate Communications spoke to the media. He said that while the
disappearances were “highly
unusual,” each was still considered a missing person case and would remain
so unless evidence was found to suggest something more sinister. The police
handed out missing person flyers in the Church and Wellesley streets area.
On June 8, Xtra published an article about the missing men, quoting
Detective Harris:

Toronto Police Service investigators say the three missing-persons cases are
connected through “similar ethnicities.” Detective Deb Harris, who is
leading the investigation, says the three men were not all openly gay. “They
frequented the Church and Wellesley area and lived similar lifestyles.”
…
Harris says the three missing men have probably never met, but she
can’t say for sure. “There is nothing that links the three men to each other.”
…
Harris says police have done an extensive background search on
Navaratnam, including accessing “numerous judicial authorizations” to try
to determine his whereabouts, such as immigration, but have discovered no
leads from that.
“The key connection for us is that all three disappeared from the
Church and Wellesley area, they have family and friends who are concerned
about them, and everything that we’ve done from the onset, there is nothing
that tells us where these three people are,” she says.
She says it’s unusual for missing-persons cases to be outstanding for

33
In Chapter 8, I comment on the “lifestyle” characterization.
 this long. “We have also been looking at missing-person cases across
Canada.”
…
Some media outlets have been reporting that police are investigating
a connection to the recent arrest of a man in Peterborough who is facing
dozens of charges in child porn. But Harris says that is not accurate.
“I can certainly tell you that I have found no links between
[Peterborough’s] Alex Brunton 34 and these three missing males,” she says.
“Peterborough police are not working with us in regards to this missing-
persons case.”

On June 7, Mr. RR called the Service’s tip line. He indicated that he had
known Mr. Kayhan for about eight or nine years. He last spoke to him by
telephone on the Saturday of the 2012 Pride Parade. Mr. RR added that
Mr. Kayhan frequented the Black Eagle bar as well as Zipperz and bathhouses.
Mr. RR described Mr. Kayhan as someone who bonded quickly with anyone
who spoke Farsi, and he preferred slightly older men. The content of Mr. RR’s
tip, and his subsequent interview with the Service, are significant, given his
contact with the media after McArthur’s arrest in 2018.
On June 12, Detective Constable McKenzie and Police Constable Platte
interviewed Mr. RR. The interview was recorded. Mr. RR provided the
following additional information to the police. He had dated Mr. Kayhan for a
while. Mr. Kayhan was depressed and spoke often of suicide: he had to hide
his sexuality from his family and felt isolated from his community. When Mr.
RR first met him, Mr. Kayhan had a loving relationship with a partner (Mr.
SS, who had since died), but he could not tell his family about it.
The police asked Mr. RR if Mr. Kayhan ever talked about a friend who
was a florist. (Although the project’s records do not disclose why this question
was asked, and the questioner could not recall, it appears it may have been
prompted by information the police received in January 2013 that the Faizi
family’s private investigator was looking for Mr. Kayhan’s friend who was a
florist / gardener.) According to Mr. RR, the few friends Mr. Kayhan had
included Mr. RR; Mr. SS; a friend who had given Mr. Kayhan an air
conditioner and with whom Mr. Kayhan sometimes went camping; and
someone named Bruce. The police showed Mr. RR a photo of Brunton. Mr.
RR indicated that Brunton might be the friend who had given Mr. Kayhan the
air conditioner, but that he believed the man’s name was Paul.
Mr. RR did not know Bruce’s last name. He said Bruce was on the
internet. When Mr. Kayhan went missing, Mr. RR tried to find Bruce online.
34
Brunton is referred to both as James Brunton and Alex Brunton. His full name is James Alex Brunton.
Mr. RR believed that Bruce might know the identity of the person with whom
Mr. Kayhan went camping.
This interview marks the first time the name “Bruce” came up in the
Project Houston investigation, yet the officers appear not to have made
any efforts to identify who he was. Similarly, they had an opportunity
months earlier to identify McArthur as silverfoxtoronto and silverfoxx51.
Detective Constable McKenzie told the Review that Mr. RR was going
to try to reach out to Bruce to tell him to contact the police, but Bruce never
did. In effect, the police placed the onus on Mr. RR to get Bruce to contact
them. There is no evidence that the police followed up on this lead.
Well after McArthur was charged, Mr. RR participated in the CBC
Podcast “Uncover: The Village.” In the first episode, Mr. RR told the CBC
that McArthur and Mr. Kayhan were in a sexual relationship. The last time Mr.
RR saw Mr. Kayhan, he also saw McArthur. Mr. RR and Mr. Kayhan were on
a date at Mr. Kayhan’s apartment, and McArthur showed up. McArthur was
upset that Mr. RR was there, and he left.
Mr. RR did not tell the police about this incident when he was
interviewed on June 12, 2013. Following McArthur’s eventual arrest in 2018,
the police interviewed Mr. RR again. He told the police he had participated in
a threesome with Mr. Kayhan and McArthur. He also told the police he had
called the tip line to provide McArthur’s name.
Mr. RR told the Review that on January 28, 2016, he had messaged
McArthur on the Scruff dating app to say hello. McArthur did not respond.
Mr. RR believed he called the tip line sometime after he sent the message
to McArthur. He may have talked to an officer or he may have left a
voicemail. He could not recall.
The Review has not found any evidence of this tip. However, not all the
tips from Project Houston have been located. No log or register was kept of
the tips received in the P Drive or in PowerCase. 35 The Major Case
Management Manual (MCM Manual) requires that a register of such tips be
kept in a specific file for that purpose.
Mr. RR also told the CBC that when he mentioned the name “Bruce” to
the police during the June 12, 2013, interview, the police appeared to be
familiar with the name and asked if “Bruce” worked in landscaping or as a
gardener, or if he worked outside or mowed lawns. This recollection was
35
The Review examined the folder, Tip Reports and Register, contained in the P Drive, but it contained no
tips. Another file, Tips for Inquiry, contained a few.
inaccurate, although the inaccuracy was understandable. The police had asked
him whether Mr. Kayhan had a friend who was a florist, but he had not
connected this friend to the name “Bruce” at that point.
Mr. RR made various inconsistent statements. I am satisfied that he
never intended to mislead the police but conflated what he told the police
at times with what he subsequently heard or what he knew that he did not
share with police. Clarifying this point is important only because one narrative
in the public discourse is that the police were specifically warned about
McArthur, yet did nothing about it. Although I identify serious flaws in how
the police squandered opportunities to focus on McArthur, the evidence does
not support a finding that the police ignored specific warnings about him.
Throughout June 2013, the Project Houston investigators continued
to interview friends and acquaintances of the missing men. They also
continued
to investigate and interview Brunton’s contacts and reviewed the material from
his computers. They kept on this tack even though, by then, the police did not
think Brunton was connected to the disappearances of the three men.

Project Houston Reduced to Three Investigators

On June 10, 2013, in an email Detective Sergeant Richmond sent to Detective

Harris and various other officers, he indicated that, because Detective Harris
was still completing Project Houston, her Criminal Investigations Branch
(CIB) platoon at 51 Division would be without a detective for some time.
Then, on June 28, he stated, again in an email, that Detective Harris would
simultaneously cover CIB while completing her work on Project Houston.
On June 18, Detective Harris emailed Inspector Gary Meissner and
Detective Sergeant Richmond to say that Project Houston was being
downsized to a smaller room at 51 Division. On June 24, in an email to
Inspector Bott, she indicated that only three officers remained on Project
Houston: Detective Constable McKenzie, Police Constable Platte, and herself.
Project Houston no longer had a major case manager or a file
coordinator. As I explain more fully below, it was not being run in any
meaningful way according to MCM procedures.
In July 2013, the remaining officers obtained a judicial production order
for Brunton’s credit card account. They also followed up on Crime Stoppers
tips and sent the composite sketches of the two men who had been seen
leaving the bar with Mr. Navaratnam for facial recognition analysis.
By July 31, Police Constable Platte and Detective Constable McKenzie
finished their review of the approximately three hundred CDs and DVDs
seized from Brunton’s home. They found more child pornography and videos
taken in a hockey locker room of naked young men. Detective Constable
McKenzie found one photo of a man whose skin tone resembled Mr.
Navaratnam’s. He found another photo of a man with a beard who looked
“similar” to Mr. Kayhan.
Through August 2013, they continued reviewing Brunton’s computer
files and interviewed friends and acquaintances of the missing men. The police
identified one of the men in Mr. FF’s composite sketch as Mr. TT.

Investigation of Luka Magnotta

In late August 2013, the Project Houston officers began looking into Luka
Magnotta, already a notorious killer, to determine if he was involved in the
missing men’s disappearances or was connected to Brunton.36
On September 12, Detective Harris emailed Detective Sergeant
Richmond to provide a working copy of a draft warrant for the investigation
into Magnotta. The draft of the supporting affidavit for this warrant
included reference to an associate of Brunton named “Nathan,” who went to
Brunton’s farm with him. Magnotta sometimes used the alias Nathan. The
draft also noted that Detective Constable Coffey had identified one of
Magnotta’s online usernames: canadianluka. This username appeared on
various gay dating sites and was linked to posts seeking Middle Eastern men.
The appendix to the draft affidavit outlined several circumstantial links
between Brunton and Magnotta, including that, as a teenager, Magnotta had
lived close to Brunton in Peterborough.
On September 13, Detective Harris emailed the draft to Detective
Constable Coffey. She asked him to compare the names, usernames, and
websites in the document with those in Mr. Navaratnam’s and Magnotta’s
computers as well as with usernames and passwords for Brunton.

McArthur Identified by Name for the First Time

On September 14, Detective Constable McKenzie’s notes read: “production

order for Microsoft, [email protected], Faizi and Skanda
connection.” However, it does not appear that a judicial production order was
applied for or obtained for the email address, nor would such an
application

36
In 2012, Luka Magnotta murdered and dismembered a man in Montreal, Quebec. Mr. Magnotta posted a
video depicting the murder online and fled the country. The case attracted significant national and
international attention. Mr. Magnotta was arrested in June 2012 and was convicted of first-degree murder in
December 2014.
make sense. Months earlier, Detective Constable Rughoo had noted that an
MLAT request would be required to access the American Hotmail account.
The next day, September 15, Detective Constable McKenzie, using
XIRAF, found McArthur’s telephone number in Mr. Navaratnam’s
extracted computer files by doing a keyword search for
[email protected]. The telephone number was associated with the
email address in Mr. Navaratnam’s deleted computer files.
Detective Constable McKenzie told the Review that he was able to find
the telephone number because he was searching through the imaged data
copied from Mr. Navaratnam’s computer. Back in February 2012, Detective
Constable Loria, in contrast, did not have the imaged data: it appears she was
working from a Word document or Excel spreadsheet that Detective Constable
Coffey had prepared. The evidence indicates, however, that Detective
Constable Coffey, if asked, could have extracted McArthur’s telephone
number back in February 2013.
Having found McArthur’s telephone number, Detective Constable
McKenzie performed a Unified Search on it – a Toronto police database search
(see Chapter 4). By inputting the telephone number, he was able to check
whether the number had come up in any earlier investigations. An officer had
recorded McArthur’s telephone number in 2005, when McArthur was stopped
while driving without a valid insurance card.
Detective Constable McKenzie’s memobook notes from September 15
reflect that “United search of phone # comes back to Bruce McArthur.” He
also noted that the website silverdaddies.com listed silverfoxx51 as
“Bruce” with the email address [email protected]. And Mr.
Navaratnam’s Facebook page listed McArthur as a friend, with a similar
photo to the one used on www.silverdaddies.com.

Mr. PP Interviewed a Second Time

On September 16, 2013, the police interviewed Mr. PP a second time: they had
discovered through Mr. Faizi’s phone records that Mr. PP exchanged 41
text messages with Mr. Faizi before Mr. Faizi disappeared and had spoken
with him on the telephone. This information contradicted his earlier claim that
he did not know Mr. Faizi. Mr. PP explained he had met Mr. Faizi on
www.bearforest.com, a dating site, and they exchanged text messages about
the printing company Mr. Faizi worked for. The police never found a link
between Mr. PP and Brunton.
 On September 23, Detective Harris obtained a general warrant 37 for
Magnotta. On October 3, Detective Harris, Detective Constable McKenzie,
Detective Constable Coffey, and a detective from Montreal executed a warrant
in Montreal on a computer seized from Magnotta. Detective Constable Coffey
discovered that Magnotta was a member of www.daddyhunt.com, a dating
website on which Mr. Navaratnam and Mr. Faizi had also been members. He
attempted to find any email link between Magnotta and the missing men
by cross-referencing Magnotta’s email address and online usernames with
the contents of Mr. Navaratnam’s and Mr. Faizi’s computers.
Through October 2013, the police continued to investigate the
possibility of a link between Magnotta and the missing men and/or Brunton.
Among other investigative steps, they again reviewed the photos obtained
from Brunton’s computer to compare them against the content of
Magnotta’s computer.
On October 4, Peel Detective Sergeant Cowan emailed Detective Harris
to ask for an update on Project Houston. Detective Harris replied the same day,
advising there were no further updates on the three missing men. She said that
Project Houston was working on an “angle” with the Montreal police but did
not disclose what it was.
On October 17, Detective Constable McKenzie found five photographs
of a teenaged boy on Magnotta’s computer. The boy was clothed, but appeared
to Detective Constable McKenzie to be the type of male in whom Brunton had
been interested. The police reviewed Brunton’s computer again to see if
images of the same boy were in the files. The young male Brunton was
ostensibly “interested in” did not fit the profile of the three missing men.

McArthur Interviewed

On November 7, 2013, Detective Constable McKenzie scheduled an interview

with McArthur for the following week. The Project Houston daily log for
November 7 reflected that “Bruce knew Skanda and Basir from
Silverdaddies.com.” It is unclear whether Detective Constable McKenzie
learned of this connection from McArthur while scheduling the interview or if
it was intended to convey that the police knew they all had profiles on this
website. We know that before the interview, Project Houston had learned that
McArthur’s username, silverfoxx51, was on Mr. Faizi’s notepad.

37
A general warrant is a judicial authorization for the exercise of powers other than those associated with a
conventional warrant to search property; for example, permitting covert entry into the homes of suspects or
installing a video surveillance camera in a hotel room.
 In preparation for the interview, Detective Constable McKenzie
assembled some photographs to show McArthur, including those of the
missing men, Brunton, and Brunton’s associate(s). He did not have an
interview plan or questions prepared. Nor did he do a Canadian Police
Information Centre (CPIC) database search relating to McArthur – one that
would have revealed McArthur’s 2003 convictions. As well, at the time, the
Service had just switched over to using the Versadex record management
system from the previous in-house occurrence database called “eCOPS” A
component of eCOPS was the Unified Search tool, which allowed access
to eCOPS’s predecessor, CIPS. Versadex replaced the Unified Search tool
with a Legacy Search tool (described in greater detail in Chapter 4). An
officer, seeing McArthur’s 2003 convictions on CPIC, could obtain the
underlying synopsis of McArthur’s 2001 pipe attack through the Unified
Search or the Legacy Search. By using the Legacy Search, the Project
Prism officers discovered all this information in 2017, once McArthur became
a person of interest (see Chapter 7).
Detective Constable McKenzie told the Review he thought he did a
Unified Search. However, there is no reference whatsoever in his memobook
notes to either the 2003 convictions or the underlying facts. Nor did he
mention them during his interview of McArthur or in any post-interview
documents.
I conclude that Detective Constable McKenzie is mistaken in his
recollection of his preparation for the interview with McArthur. He did not
know that McArthur had been convicted in 2003 for an unprovoked attack on
a gay man in the Village or that he had been prohibited for three years from
entering into an area that included an address next door to where Mr. Kayhan
lived.
I also note that, in preparing for his interview of McArthur, Detective
Constable McKenzie did not search Project Houston’s files to see whether
“Bruce” or “Bruce McArthur” or a “florist, gardener, or landscaper” had been
referred to in earlier interviews. The project was not using PowerCase in the
way it was intended, making it impossible to use its search functions to find
out such information. However, there was search capacity, although less
extensive, in the P Drive.
Furthermore, before the interview, Detective Constable McKenzie
failed to do any background workup of any kind on McArthur. Detective
Sergeant Idsinga told the Review that a full background workup should be
done for every witness in a homicide investigation, either before or after the
witness is interviewed. This preparation was not done for McArthur. Nor was
it done for many of the other individuals Project Houston officers interviewed.
As I indicate earlier, when Detective Sergeant Idsinga was still the major case
manager, he ordered a complete background workup, and Detective Harris
requested a lifestyle report (involving a surveillance team), on Mr. PP, who
had a connection to two of the missing men and had lied about that connection.
Detective Sergeant Idsinga told the Review that, if he had remained involved
in the investigation in November 2013, a background check on McArthur
would “absolutely” have been done.
I note that Detective Constable McKenzie was, at the time, a relatively
junior officer. As he told the Review, he did what he was told to do. Had he
been asked to do a background workup on McArthur, he would have done so.
It appears that a Homicide investigator may well have known to do this check
independently of any direction. However, by the time McArthur was
interviewed, no Homicide investigators were still involved with Project
Houston. As I say earlier, the Service no longer regarded this project as a
homicide investigation.
On November 13, Detective Constable McKenzie interviewed
McArthur. Another officer took notes. The entire interview lasted about 16
minutes.
It would be unfair to base my description or evaluation of how this
interview was conducted on what we now know about McArthur. Detective
Constable McKenzie was eager to solve the disappearances of the missing men
and did some valuable work during Project Houston and later during Project
Prism. He was the officer who discovered the identity behind the
username silverfoxx51. However, even without the benefit of hindsight, I find
that the interview was inadequately prepared for and conducted. It is important
for this Report to identify the serious deficiencies in this interview, and the
opportunity lost as a result.

 Detective Constable McKenzie told McArthur he was investigating the

disappearance of Mr. Navaratnam. He was, in fact, investigating the
disappearances of all three men.
 When Detective Constable McKenzie produced a photograph of Mr.
Faizi, McArthur denied knowing him. Detective Constable McKenzie
never asked him about the reference to silverfoxx51 on Mr. Faizi’s
notepad or the information contained in the daily log that McArthur knew
Mr. Faizi through the silverdaddies.com website. Detective Constable
McKenzie appeared to overlook that evidence.
 Although McArthur acknowledged he had a sexual relationship with Mr.
Kayhan, Detective Constable McKenzie asked no questions about the
duration and nature of that relationship or other things that McArthur
 might have known as a result of it. As one example, he did not ask about
Mr. RR’s comment that Mr. Kayhan had a friend named “Bruce” who
might know with whom he went camping. Detective Constable
McKenzie acknowledged he had not made the connection between the
“Bruce” in Mr. RR’s interview and McArthur.
 McArthur indicated he had a non-sexual relationship with Mr.
Navaratnam. Detective Constable McKenzie asked somewhat superficial
questions about that relationship as well. He did not explore the nature of
the relationship, given the known connection between them through a
dating website. Although he asked McArthur about his whereabouts on
certain dates years earlier, such questions are not useful, given the
passage of time and the absence of any discussion about
contemporaneous aids McArthur might have (emails, diaries, etc.) to
enable him to answer the questions.
 Detective Constable McKenzie did not explore the possible connection
between McArthur and Mr. Navaratnam based on McArthur’s work as a
gardener / landscaper. The project had collected evidence that Mr.
Navaratnam was involved or interested in landscaping. The police
learned nothing during this interview about where McArthur worked, the
proximity of his residence or work locations to other important locations,
or even the nature of his landscaping work.
 For the reasons already given, McArthur was not asked about his
previous convictions for an unprovoked attack with a pipe on a man in
the Village or the terms of his sentence, which prohibited him from
entering an area that included the Village.

Despite the flaws in the interview, the police now possessed evidence
that McArthur had a potentially meaningful connection to all three of the
missing men. However, this important fact went unnoticed: Detective
Constable McKenzie’s summary of the interview failed to include it.
Moreover, although fundamental to major case management, no supervisor
appeared to review the interview or instruct any follow-up action because of
it. Neither the interview nor its summary was entered in PowerCase or even
recorded in Versadex. 38 I explain in Chapter 7 the significance of these
omissions. For example, an officer who investigated McArthur in 2016 for
choking a man did not know that McArthur had been interviewed during
Project Houston. Nor would Project Prism officers necessarily have
discovered

38
The summary of the interview was contained in the P Drive, although as already indicated, the summary
failed to refer to the connection McArthur had to all three of the missing men.
that McArthur had been interviewed during Project Houston if Detective
Constable McKenzie hadn’t remembered it.
One investigator summarized – accurately, in my view – the
implications of the information obtained during the McArthur interview:

He [McArthur] would have been the one and only person who was linked to
all three disappearances at that point from all the information we had, and
we went through so much information. We finally found one person who
was connected to all three of them. That would be a huge red flag as to who
this person might be. And I would have conducted some searches for sure on
his background. And we would have been able to see that in [2003] that he
was involved and convicted … for a violent crime. So for an investigator he
looks like a pretty good person to approach and not only just interview but
maybe do some follow up on or some more research regarding him. He was
connected to all three guys. He was the only one who was connected to all
three guys that we could get.
He would be on the top of the list of finding out what more is he
capable of and what he does. The prime suspect, if you will.

November and December 2013

On November 7, 2013, the MLAT request for Mr. Navaratnam’s email

account was completed and submitted to the Crown attorney’s office for
review. It must be remembered that it was now three years since Mr.
Navaratnam had been reported missing.
Throughout November 2013, the police continued to search for
links between Magnotta, Brunton, and the missing men. They canvassed
homes in the neighbourhood of 26 Moore Avenue, where Mr. Faizi’s car
had been found. They left posters about Mr. Faizi’s disappearance with the
staff at a church located in an area marked on a map on his computer. They
also investigated what was described as a “sex club” that Magnotta and Mr.
UU, a Brunton associate, had possibly frequented.
On November 29, 18 days after his interview with the police, McArthur
purchased and registered a 2001 silver Dodge Caravan.
On the same day, Detective Constable McKenzie had a meeting with a
Crown attorney about the MLAT request, where they agreed they did not have
sufficient information to link Mr. Navaratnam to either Magnotta or Mr. UU.
They decided to focus first on obtaining Magnotta’s and Mr. UU’s email
content, before attempting to obtain the content for Mr. Navaratnam. Through
December 2013, the police continued searching for a link to Magnotta.
 In January 2014, the officers prepared an application for a judicial
production order for Mr. Faizi’s health records from the Sherbourne Health
Centre. Detective Constable McKenzie revisited the area where Mr. Faizi’s car
had been found in 2012. He followed the route set out in the Google maps
found on Mr. Faizi’s computer and formulated a search area with the Service’s
Mounted Unit.
Detective Constable McKenzie and Detective Constable Coffey
interviewed Mr. Faizi’s wife. She had not heard from her husband since
his disappearance and believed he may have started a new life elsewhere.
On January 7, 2014, Detective Constable McKenzie interviewed Mr.
Faizi’s brother. He told the police that Mr. Faizi was a happy person who
wanted to leave his marriage to pursue his gay lifestyle but had been
planning to wait until his daughters were adults.
In addition, Detective Constable McKenzie contacted the webmaster at
www.bearforest.com about Mr. Faizi’s account. The webmaster advised that
he was concerned for the safety of the missing men and agreed to compile the
messages on file. There were approximately five thousand messages in Mr.
Faizi’s account. Detective Constable McKenzie combed the messages to
attempt to see who Mr. Faizi may have been in contact with before he
went missing.
The Service activated a Facebook page for the missing men and also
placed more posters in the Village.
On January 8, Detective Harris emailed Detective Brad Hoover of the
Service’s Major Case Management Unit about PowerCase. She advised him
that although Project Houston had once had a PowerCase clerk, she had
not received any PowerCase linkage reports for some time and assumed
that the project no longer had anyone assisting it. Indeed, Project Houston had
not had a file coordinator or a PowerCase indexer since May 2013.
Superintendent Elizabeth Byrnes at 51 Division suggested having
one or two of the three officers still assigned to Project Houston trained on
PowerCase so they could do the uploading themselves. She also indicated that
she wanted to give the Project Houston officers access to the search function
in PowerCase so that they could conduct Freetext searches.39
On January 16, arrangements were made for Detective Hoover to train
the investigators on certain aspects of the PowerCase program. Ultimately,
PowerCase was installed on several of the project’s computers.
The investigators contacted CIBC Corporate Security to inquire about a
safety deposit box belonging to Magnotta that had been opened by authorities

39
A Freetext search functions as a simple word search and find. See Chapter 4.
in July 2012. For the next several weeks, until March 2014, the police
continued to investigate any potential links to Magnotta. None were
discovered.
In mid-January 2014, the Project Houston officers contacted many
individuals for interviews relating to the disappearance of Mr. Navaratnam,
including a security guard and other employees who were at Zipperz the night
he went missing as well as friends who frequented the Black Eagle.
On January 21, Detective Constable McKenzie met with Police
Constable Danielle Bottineau, the LGBTQ2S+ liaison officer, to discuss how
to get information about the missing men to that community. She said she
would reach out to community leaders and would also ask contacts she had in
the Vancouver, Montreal, and Ottawa police forces to distribute the missing
person posters in those cities as well.
On January 28, Detective Sergeant Idsinga emailed Inspector Bott, Staff
Superintendent McLane, and Detective Harris to say he had some great news
from the Project Houston “windfall.” Orfanogiannis, whose communications
were intercepted by the FBI when investigating some of the Project Houston
targets, had been arrested for plotting to drug and sexually assault a woman.
The arrest followed an investigation conducted co-operatively among the FBI,
the Service, and the Peel police. Detective Sergeant Idsinga noted it was “a bit
of a distraction from Brunton, but well worth the effort.”
In February 2014, Brunton was sentenced to a suspended sentence and
probation on the child pornography charges, based on his 10 months of pre-
trial custody that were equivalent to a 15-month sentence.40
The officers continued their attempts to locate Brunton’s cabin. On
February 20, the police went to a cabin close to Mr. AA’s cabin, where
Mr. Navaratnam spent time before his disappearance. The cabin belonged to a
man, Mr. VV, whose brother had helped Brunton with his taxes in 2013.
Sadly, Mr. VV had died in a house fire several days before the police arrived.
On February 24, the police interviewed Mr. VV’s brother. He did not
recognize Mr. Navaratnam’s photo but did recognize Brunton. He stated that
although he did Brunton’s taxes, Brunton had never mentioned hunting or
having a cabin property.
In March 2014, the Project Houston team continued to try to locate
Brunton’s cabin. They located and interviewed more friends and acquaintances
of the missing men and attempted to identify an individual named “Richard”

40
Convicted individuals are often given enhanced credit for time spent in custody awaiting trial, based on
pre-tria l conditions in custody and the fact that such time is not counted for purposes of parole or early
relea se eligibility.
from Maine whose name had come up in another interview. They also
attempted to locate Mr. TT and Mr. WW (the two individuals identified in the
police sketches prepared by Mr. FF).
On March 18, Detective Constable McKenzie interviewed one of Mr.
Kayhan’s brothers for the first time. Mr. Kayhan’s brother told him that Mr.
Kayhan was a happy man who loved his pet birds and would never leave them
for an extended period without arranging for someone to care for them.
At the end of March 2014, Detective Constable McKenzie located and
attempted to identify several more telephone numbers from Mr. Kayhan’s
notebook. On March 29, the officers interviewed Mr. TT. He indicated he used
to work at Zipperz but had not been to Toronto since 2008. The officers went
to Zipperz that day to try to obtain employment records for Mr. TT. While
there, they met Mr. XX, who was Zipperz’s head of security. Mr. XX had
never been interviewed by police, although he was working the night
Mr. Navaratnam went missing. They scheduled an interview with him for
April 2. On March 31, the officers conducted their second interview with Mr.
BB. Mr. BB told the police that the sketch of the blond man who was allegedly
with Mr. Navaratnam the night he disappeared looked like Mr. YY, who
moved to Winnipeg shortly after. Mr. BB also told the police that a man
named Mr. ZZ told him that Mr. Navaratnam had been murdered. According
to Mr. ZZ, someone in the gay community knew who murdered Mr.
Navaratnam but
was not talking. The police reached out to Mr. BB for an interview.
Through April 2014, the police continued to interview people associated
with Brunton and friends and acquaintances of the missing men. On April 2,
the officers interviewed Mr. XX, who remembered seeing Mr. Navaratnam at
Zipperz the night he went missing but did not recall the people with whom he
left the bar. Mr. XX also remembered Mr. Faizi and Mr. Kayhan from the bar.
On April 13, Detective Constable McKenzie interviewed Mr. AA for a
second time. Mr. AA remembered Mr. Kayhan from the Black Eagle. He gave
Detective Constable McKenzie a portable hard drive that had belonged to Mr.
Navaratnam. Detective Constable McKenzie reviewed the contents of the drive
and determined it did not contain any new information.

The End of Project Houston

On April 13, Detective Constable McKenzie emailed Detective Harris to

say he had met with Detective Sergeant Richmond, who told him that
Project Houston had five weeks to wrap everything up. In the meantime,
Detective Constable McKenzie planned to fly to Winnipeg to conduct several
interviews. He would also ask the police in British Columbia to conduct an
interview with
Mr. TT, who lived there. Detective Constable McKenzie concluded the
message: “[W]e brought up the additional work that still needed to be done
and it didn’t seem to matter anymore. I’ll let you know when the MLAT
stuff comes back, but other than that, we will be shutting things down over
here by the end of May.”
On April 23, Detective Constable McKenzie interviewed Mr. ZZ
who had seen Mr. Navaratnam the night he went missing. He said that Mr.
Navaratnam was with Mr. BB in a group of people in the parking lot. Mr.
Navaratnam said loudly to someone in the group: “[W]hat, you’re going to
take me home, fuck me and then kill me?” April 23 was the last date recorded
in the Project Houston daily log.
On July 9, the police interviewed Mr. AB. He was a bartender at
Zipperz at the time Mr. Navaratnam went missing but had been in Manitoba
the week of his disappearance. Mr. AB told police that his old roommate, Mr.
YY, was very close to Mr. Navaratnam and would have more information.
According to Mr. AB, Mr. YY said he had seen Mr. Navaratnam the day
before he disappeared.
Mr. AB told the Review he had reached out to the police shortly after
Mr. Navaratnam went missing in 2010. He asked for information about the
investigation, but the police would not tell him anything. They advised him to
speak to a family member. Mr. AB told the Review: “Well, you know what,
we are family. We are his family members. We don’t need to share biological
blood to get this information. We know more about where Skanda may or may
not be than his family right now because we are the ones who know him.” He
did not reach out to the police again for several reasons: he was in Manitoba,
he explained; the police had brushed him off when he called the first time; and
he had heard stories of police misconduct from others.
On July 28, 2014, the Winnipeg police interviewed Mr. YY on behalf of
Project Houston. Mr. YY told the police he last saw Mr. Navaratnam at
Zipperz, though he was unsure of the actual day. Mr. Navaratnam left in a
hurry without saying goodbye. Later, Mr. YY helped put up missing person
posters for Mr. Navaratnam. He said Mr. Navaratnam was into “silver
daddies” (older men) and could get aggressive with the men he dated. He
wondered whether Mr. Navaratnam had pushed one of these men too far, to
the point of retaliation. Mr. YY told the police he did not know who Mr.
Navaratnam was living with at the time he disappeared.
This interview was recorded, and it is of note because Mr. YY was later
interviewed by the CBC for the podcast “Uncover: The Village.” Mr. YY said
in the podcast that Mr. Navaratnam had been in a relationship with McArthur
at the time of his disappearance. McArthur was jealous and controlling and
would become angry if he felt Mr. Navaratnam was not paying enough
attention to him. According to Mr. YY, he and Mr. Navaratnam were playing
pool the Sunday before the disappearance when Mr. Navaratnam got a call and
left abruptly. Mr. YY believed the call was from McArthur. We have no
evidence that any of this information was ever provided to the police.
There is no evidence that any further work was done on the project. In
2015, McArthur killed again.

Summary and Findings

Overview
Project Houston occurred only because the Swiss authorities shared an
informant’s tip with Toronto police. The tip suggested that a cannibal ring was
targeting victims around the globe and that one of its members, soon to be
identified as James Brunton from the Peterborough area, killed Skandaraj
(Skanda) Navaratnam.
The tip could not be ignored – and it wasn’t. Project Houston
investigators spent countless hours investigating Brunton and his associates.
Were they killing and eating people or were they engaged in pure fantasy?
They also looked into whether Brunton or his associates were involved in the
disappearances of Mr. Navaratnam, Mr. Faizi, or Mr. Kayhan. They found
nothing to substantiate any such involvement.
Project Houston ended without solving the disappearances of the three
men. Only several years later when Mr. Kinsman was reported missing was
the investigation into the disappearances of these first three missing men
reactivated.
There is no question that Toronto police thoroughly investigated the
alleged cannibal ring. Their work with other police agencies ultimately
resulted in child pornography–related and other charges being brought against
Brunton and a man from Peel Region, John Orfanogiannis. They also
conducted many interviews of individuals who potentially had relevant
information about the three missing men.
These interviews highlighted shortcomings in the investigations
Toronto police had conducted when Mr. Navaratnam and Mr. Kayhan were
initially reported missing. They added to the information that had been
accumulated about Mr. Navaratnam, Mr. Faizi (although Peel police continued
to retain the investigation into his disappearance), and Mr. Kayhan. That said,
Project Houston was seriously flawed. These flaws meant that the Service lost
valuable opportunities to identify Bruce McArthur as a serial killer much
earlier. They also exposed systemic issues to be addressed.
What were the serious flaws in how Project Houston was organized and
conducted?

Major Case Management

When Project Houston commenced its work, Mr. Navaratnam had been
missing for more than two years. Provincial adequacy standards mandated that
any disappearance unsolved for more than 30 days from when someone had
been reported missing was to be treated as a major case. Further, as I explain
in Chapter 5, although the evidence had not yet established that Mr.
Navaratnam was the victim of foul play, that outcome was, at a minimum, a
strong possibility given the circumstances around his disappearance. This
strong possibility also required that any investigation into his disappearance be
treated as a threshold major case. In any event, the informant’s tip in
November 2012 was regarded as sufficiently reliable to characterize the
ensuing investigation as a homicide case and to seek judicial production
orders based on reasonable grounds that Mr. Navaratnam had been murdered.
Both these developments reinforced the point that, under provincial adequacy
standards, the investigation had to be treated as a threshold major case.
This categorization meant, among other things, that the investigation
into Mr. Navaratnam’s disappearance, whether viewed in isolation or as part
of a larger investigation, had to be conducted in accordance with major case
management standards, as set out in Ontario Regulation 354/04 and in the
province’s MCM Manual. It also meant that the investigation was required to
use PowerCase as its case management software program.
Moreover, even before the Toronto police received the informant’s tip,
there were sufficient similarities among the three missing men and the
circumstances of their disappearances to treat them as “linked.” Contrary to
the views of several senior Toronto officers, the evidence does not need to
establish definitively that the same person is responsible for all three
disappearances before the cases can be treated as “linked” for the purposes of
major case management. Unfortunately, on a systemic level, the Toronto
police did interpret the requirement that way, thereby avoiding the applicable
major case management standards.

The Serial Predator Coordinator

Even leaving that error aside, once the informant’s tip led to the establishment
of Project Houston, the Toronto police were investigating an international
cannibal ring with alleged involvement in serious crimes, including murder,
around the globe. From the outset of Project Houston, again contrary to the
views of several senior Toronto officers, the available evidence required that
the serial predator coordinator within the Ministry of Community Safety and
Correctional Services be notified of this investigation and that the issue of a
multi-jurisdictional joint investigation be addressed. This decision should not
have been made by the Toronto police alone. Nor was it a decision to be
informally discussed only with Peel or Peterborough officers.
There are compelling policy and public safety reasons for the provincial
protocols to be followed, including appropriate oversight, accountability,
effective use of and access to resources, and the appropriate sharing and
allocation of responsibilities. The mere fact that Project Houston officers
believed, on reasonable grounds, that Mr. Navaratnam had been murdered and
that his probable death was tied to an international cannibal ring involving
Brunton and others in and outside Canada made it not just important but
necessary for the Toronto police to comply with provincial adequacy standards
for multi-jurisdictional investigations.
Alarmingly, they didn’t. The serial predator coordinator knew nothing
about Project Houston – or even about the later Project Prism (see Chapter 7).
In both cases, the Toronto police did not follow basic standards for multi-
jurisdictional investigations.
I fully recognize that there was extensive informal co-operation among
the Toronto police, international law enforcement agencies, and both Peel and
Peterborough police officers in the investigation. But these efforts were no
substitute for a strict adherence to provincial adequacy standards. It is obvious
to me that several senior Toronto officers still do not accept that this approach
was problematic. They still believe that the informal co-operation among
agencies worked just fine, and that the involvement of the serial predator
coordinator or a formal multi-jurisdictional joint investigation was
unwarranted, unnecessary, and too bureaucratic.
This attitude presumes that the Toronto police were best situated to
direct this investigation, although at least one internal document described
Toronto as the “secondary area of operation” and the scope of the investigation
as “international.” It presumes that the Toronto police could learn nothing
or benefit little from a true multi-jurisdictional joint investigation. It
presumes that Toronto taxpayers, more particularly 51 Division’s investigative
reserves, should assume most of the significant costs associated with an
investigation that had, at best, an uncertain connection to Toronto. It presumes
that a multi- jurisdictional joint investigation would have given the same
priority or credibility to the cannibal theory that figured so prominently in
how Toronto conducted its investigation. Or that a multi-jurisdictional joint
investigation
would have continued to devote significant resources to Brunton’s alleged
involvement in the disappearances of the three men well after his arrest and
after that involvement had effectively been discounted.
There were internal discussions – indeed, Detective Sergeant Idsinga
proposed a plan for a true multi-jurisdictional joint investigation with
CISO funding support. But it was apparent to me from the Review’s
interviews and from documents generated during the project that, with some
exceptions, the Toronto police were reluctant to involve other services as true
partners in this investigation. It was also apparent to me that at least some Peel
officers were reluctant to be involved in the joint investigation, even if the
Toronto police welcomed it, both because some Toronto officers were
secretive about their own investigation and because the Peel police regarded
the cannibal theory as dubious at best.
Equally important, because this investigation was not treated as a multi-
jurisdictional joint investigation, both the Peel and the Toronto police were
investigating Mr. Faizi’s disappearance. Peel repeatedly asked for updates on
Project Houston. Information was sometimes withheld from Peel, either
deliberately or inadvertently. At an earlier stage of the investigation, at least
one Toronto investigator was not prepared to tell the Peel police why the
Toronto police were looking for missing person cases that fit a certain age
group and ethnicity. In October 2013, when Peel Detective Sergeant Cowan
asked for an update on Project Houston, he was told there were no further
updates on the missing men, though the project was working on an undisclosed
“angle.” That angle was the Luka Magnotta component of the investigation.
Of considerable significance is the fact that in September 2013, the
Toronto police learned that silverfoxx51, a username found on Mr. Faizi’s
notepad, was McArthur. There is no evidence that anyone shared that
information with the Peel police. There is no evidence that anyone told
Peel that McArthur was being interviewed or that, at the conclusion of the
interview, the Toronto police had learned he was connected to all three
missing men, including Mr. Faizi. I characterize this lapse as inadvertent
non- disclosure to Peel because its significance was also lost on the Toronto
police. But it illustrates the very danger Judge Archie Campbell identified
in the aftermath of Paul Bernardo’s undetected crime spree – siloed policing.
I also observe that the Toronto police searched for Brunton’s cabin in
the Bancroft area. Bancroft is within the OPP’s jurisdiction, and the OPP local
officers might be expected to have greater knowledge than the Service about
the community they serve. But the Service never approached the OPP to assist
in this search.
 One rationale I was given for why this investigation was not structured
as a multi-jurisdictional major case and why no application was made for
CISO funding was because it was premature to do so until a link was
established between Brunton and the missing men. I do not accept this
rationale: it seriously undermines the reason why we have a multi-
jurisdictional major case regime. So far as the Service was concerned, the
evidence was sufficient to vigorously investigate an international cannibal
ring, to obtain judicial orders to advance the investigation, and, informally,
to engage other police services in Ontario as well as international law
enforcement agencies. None of these initiatives was dependent on any
connection between Brunton and the missing men, although, again, the
Service had no hesitation in investigating the potential connection between
Brunton and the missing men based on the available evidence. It is circular
reasoning to suggest, in effect, that the police must affirmatively prove the
linked crimes before they should investigate them within a multi-jurisdictional
major case framework.
Even if Project Houston had not contained a multi-jurisdictional
component – which it most certainly did – it was still mandatory for it to be
conducted in accordance with major case management standards for homicide
cases as well as missing person cases involving disappearances over 30
days or the strong possibility of foul play.

Powe rCa se
In Chapter 4, I describe, in detail, how PowerCase is designed to work, and the
systemic issues around its use by the Service in its McArthur-related
investigations and more generally. PowerCase was intended to be used as the
project’s case management tool, but it wasn’t. Instead, it was used largely as a
“data dump.” Information was sporadically uploaded into PowerCase, often
well after it had been obtained. Actions or assignments were not placed in
PowerCase. The PowerCase indexer, who was well qualified for her job, had
insufficient information about the investigation to meaningfully index
incoming information. She, like the analyst for the project, was not working at
51 Division and was not integrated into its work. Once Brunton was arrested,
little or nothing was uploaded into PowerCase. The indexer was no longer
assigned to the project, and PowerCase’s search and trigger capacities were
not used as intended. The file coordinator trained in PowerCase had relatively
little to do with the project, and the other file coordinator was untrained in
PowerCase. Neither file coordinator was at fault for these difficulties. The
skeletal remainder of the Project Houston team after Brunton’s arrest received
some training on PowerCase, but it proved to be of limited assistance.
Several senior officers, including the former police chief, Mark
Saunders, told me that PowerCase might work for other services, but not for
Toronto, given the nature and number of its cases. There are at least three
problems with that perspective:

 first, PowerCase is provincially mandated – if there are larger issues with

its use for Toronto, they should have been addressed at the ministry level
rather than by ignoring provincial standards;
 second, it became obvious to me after extensive evidence on point,
including PowerCase experts, that many Toronto officers are unfamiliar
with how PowerCase can be used effectively – thereby raising doubts
about their criticisms; and
 third, major police services in Ontario do use PowerCase in complex
investigations. And they use it effectively.

As I explain in Chapter 4, this criticism has significant practical

implications. I would still have been concerned about the project’s non-
compliance with provincial adequacy standards if adequate proxies had been
in place to ensure that the investigation did not suffer because of it. But
such proxies were not in place. The investigation did suffer as a result of the
non- compliance in at least the following ways:

 On January 31, 2013, Detective Constable Loria had identified the

reference to silverfoxx51 on Mr. Faizi’s notepad but had been unable,
through her own efforts, to determine the identity of the owner of this
username. On February 26, she identified an email address or username
common to Mr. Navaratnam’s computer and Mr. Faizi’s notepad:
silverfoxx51. The next day, Detective Sergeant Idsinga requested that an
officer obtain the subscriber information for [email protected].
It was determined that this task could be accomplished only through an
MLAT request to Microsoft.
However, there is no evidence that anyone followed up in a timely
way to make an MLAT request to identify the subscriber for this
username, silverfoxx51. The assignment should have been recorded on
PowerCase, together with the completion date and its priority, so as to
allow members of the project’s command triangle to monitor its status. In
fact, the assignment was not even listed on the action log contained in the
P Drive. As a result, the investigation completely overlooked the fact that
the assignment was never completed. This example is no isolated event.
Assignments, or actions, were often assigned verbally and not recorded or
 tracked in a formalized way.
 The Review’s examination of the P Drive and the PowerCase file
contents revealed that very few actions were recorded as either assigned
or completed. The project was relying largely on memory and a manual
tracking system (such as officer notes or the contents of daily logs) to
keep track of assignments. This uncertainty is precisely what provincial
adequacy standards around PowerCase are designed to avoid. Otherwise,
actions fall between the cracks.
 Further, as I state earlier, both Detective Constable Loria and Detective
Sergeant Idsinga appreciated the need to identify the subscriber
associated with [email protected]. The potential significance of
this contact address was highlighted in documents prepared by the project
for the court and in a flowchart dated April 18, 2013, which set out the
known connections that linked the missing men. Nonetheless, the need to
identify who silverfoxx51 was remained unaddressed for many months –
and was addressed only after both Detective Constable Loria and
Detective Sergeant Idsinga had left the project.
 Neither the McArthur interview nor the summary of the interview was
uploaded into PowerCase. As a result, McArthur was not identified as an
“object” or “person of interest”41 for others, including Project Prism
officers, several years later. It was purely fortuitous that Detective
Constable McKenzie subsequently remembered he had interviewed
McArthur in November 2013.
 The Project Houston files were not set up to permit easy searches for
keywords such as “Bruce,” “Bruce McArthur,” “landscaper,”
“landscaping,” or “gardener.” The failure to upload relevant information
into PowerCase meant that the extensive information collected by officers
was often never used. For example, the police interviewed Mr. KK about
his relationship with Mr. Navaratnam, not realizing that Mr. KK’s name
had already been found in Brunton’s computer search history. It meant
that Mr. KK was not asked about this connection, although the police
were investigating Brunton and any connection he had with the missing
men. It is astonishing that a project of this complexity relied so heavily
on its investigators, in preparation for their interviews, both to know and
to remember what information had been collected throughout the
investigation.
 Usernames and dating websites referred to in Mr. Navaratnam’s

41
This point is not dependent on a determination that McArthur was a “person of interest” in November
2013. At the very least, he should have been identified as an “object” in PowerCase.
 computer were not uploaded into PowerCase as “objects.” This omission
meant, among other things, that in 2013, after the police learned that
McArthur identified himself as silverfoxtoronto and silverfoxx51 and that
he denied any sexual relationship with or interest in Mr. Navaratnam,
they remained unaware that Mr. Navaratnam’s internet history showed
that he and silverfoxtoronto exchanged sexualized messages through the
dating website www.daddyhunt.com.

The OPP Violent Crime Linkage Analysis System

Earlier, I point out that the Toronto police did not submit ViCLAS reports, or
booklets – though they should have – in relation to the initial investigations
into the disappearances of Mr. Navaratnam and Mr. Kayhan. Once
Toronto investigators believed, on reasonable grounds, that Brunton or a
person unknown had killed Mr. Navaratnam, and potentially others as
well, in connection with a cannibalism ring, a ViCLAS booklet or ViCLAS
booklets should have been submitted to the OPP, as required. The strong
possibility that one or more of the missing men had met with foul play
undoubtedly existed during Project Houston. But it was not until years later
that any ViCLAS booklets were submitted in relation to these disappearances.
As I state above, there was no valid excuse for the Service’s failure to
submit ViCLAS booklets in relation to the missing men. In fact, the failure
was aggravated because David Moore, the ViCLAS civilian analyst,
specifically asked the Toronto police to submit ViCLAS booklets for the
missing men. The police chose not to submit booklets even in the face of the
ViCLAS Unit’s request and the Service’s own treatment of Project Houston as
a murder investigation relating to these same missing men. This decision
showed, at a minimum, a lack of commitment to ViCLAS, provincial
adequacy standards, and, unfortunately, an unwarranted “We know better”
attitude.

Technical Support
The project failed to take a coordinated approach to technical support. For
example, Detective Constable Loria, to her credit, found the reference to
silverfoxx51 in Mr. Faizi’s notepad. She was unable to figure out, through
Twitter or online open sources, the identity of its owner. There is no evidence
that the Tech Crimes Unit was consulted on this issue or that this unit would
have been unable to determine who silverfoxx51 was in a timely way.
Eventually, seven months later, Detective Constable McKenzie used XIRAF
to find out the answer to that question. The combination of the failure to make
a timely MLAT request and the failure to use all available technological
support meant that McArthur, as the owner of silverfoxx51, went undetected
for many months.
The approach to the internet and social media was also deficient in ways
other than those I have already described. It should have been obvious to the
Project Houston officers that this investigation relied heavily on electronic and
internet searches. Indeed, the officers spent an extraordinary number of hours
examining Brunton’s computer, including emails, his online search history,
websites he visited, and his chat messages. Yet no one systematically and
comprehensively examined each missing man’s involvement in social media
and the internet. If McArthur had been appropriately scrutinized as a person of
interest once his connection to all three men (and his previous history) was
known or available to the police, his involvement in social media and the
internet could have and should have been comprehensively examined as well.
I also observe that Detective Constable Coffey, who was able to work
only part time on the project. It was obvious that, in several instances, his
other commitments prevented a timely response to Detective Constable
Loria’s requests.

Underuse of the Project’s Analyst

When Project Houston began in late 2012, Toronto’s Intelligence Services
Unit had relatively little involvement with individual investigations. One
analyst told the Review that this avoidance stemmed from a culture of siloed
information within the Service and the attitude of some officers that, rather
than rely on a civilian analyst, they would try to perform analytical work
themselves.
Given the sheer volume of collected information, it was commendable
that an analyst was assigned to Project Houston. Quite simply, the vast
quantity assembled cried out for analytical assistance. However, the project
failed to use Mr. Retchford’s skills to the full.
Detective Constable Loria may have been regarded informally as the
project’s analyst – Detective Sergeant Idsinga referred to her as such at a
police conference much later. Through perseverance and hard work, often
through manual searches only, she did some laudable analytical work and
created spreadsheets to track information about relevant usernames and
websites. But this project could have greatly benefited from a well-informed,
professionally trained analyst such as Mr. Retchford. Analysts of his calibre
serve a critical role in investigations of this kind, bringing an objectivity or a
fresh perspective that might otherwise be lacking in the investigators. This
statement may be especially true for civilian analysts.
In this case, Mr. Retchford’s only point of contact with the Project
Houston investigation was Detective Constable Loria. He did not work
alongside the investigators at 51 Division and did not have access to the
P Drive. He had only the information that Detective Constable Loria gave
him. Once she left the project on maternity leave in May 2013, Mr.
Retchford received no information whatsoever. He was not told that
silverfoxx51 had been identified as McArthur or that McArthur had
acknowledged having a relationship with Mr. Kayhan. Given his earlier
work in identifying potential connections on the file, this lapse represented
another lost opportunity – this time through analytics – to discover and
examine McArthur’s links to the missing men.

Need for a Coordinated Investigation

I acknowledge that the Toronto police interviewed a number of
individuals who, potentially, had relevant information about the three
missing men. However, there were significant shortcomings in how they
collected information about these men.
No true investigative plan was devised regarding what information
to collect and from whom – particularly as Project Houston was winding
down. Many people were interviewed, but not in any methodical way.
Officers did not necessarily know what information had already been collected
relevant to these interviews. Often, interviewers did not ask basic questions
that might have elicited relevant information. Supervisors engaged in little or
no quality control over these interviews. For example, there is no evidence that
anybody reviewed the contents of the McArthur interview until years later.
Robust case management requires an ongoing assessment of the work being
done.
Such supervision and oversight were particularly important in this
project for several reasons. First, it was a serious and complex investigation,
whether it was characterized as a homicide case or not. But the officers
conducting the investigations were not members of the Homicide Unit. Once
Brunton was arrested, the few members from the Homicide Unit left the team.
Their departure created an urgent need for supervision of how the remaining
investigative tasks would be performed, yet there was none.
In the aftermath of the arrest of McArthur in 2018, witnesses came
forward or were identified who had important information about his
relationship with some of the missing men and his abusive conduct toward
others. There are a variety of reasons why the police were unaware of this
information, but some of it could certainly have been obtained through a
methodical questioning of witnesses and a detailed investigative plan years
earlier.
The LGBTQ2S+ Liaison Officer
The LGBTQ2S+ liaison officer had little to do with Project Houston. In
January 2014, she was asked how to get information about the missing men to
the LGBTQ2S+ communities. She told the investigators she would reach out
to leaders in the communities and also forward contacts she had for the
Vancouver, Montreal, and Ottawa police to help get the missing persons
posters distributed in those cities as well.
Project Houston was an investigation into the disappearances of
three men from the Village. It became obvious to me that the Toronto
investigators undervalued the importance of using officers closely
connected to the LGBTQ2S+ communities – whether that be the liaison
officer or others – in order to facilitate information coming forward, create a
safe and welcoming environment for potential witnesses, dispel existing
mistrust and provide needed assurances, familiarize investigators with the
significance of information they were being provided, correct stereotypical
assumptions or preconceptions that could infect the investigation, and
access street-level community members better situated to assist the
investigation. A number of investigators acknowledged that the project
underused existing human resources within the Service, including the
LGBTQ2S+ liaison officer, to advance the investigation.
I say above that not all the relevant information came forward
during the period in which Project Houston was active. There are myriad
reasons for that delay, including barriers to reporting for members of
vulnerable and marginalized community members. LGBTQ2S+ officers, if
properly used, can bridge some of these barriers. In this case, though, there
appeared to be little appreciation that these officers could provide such
assistance.

Support for Those Affected

When people go missing, their disappearances deeply affect their loved ones –
their families and their friends. The justice system recognizes and provides
support for victims of crime and their loved ones and families. However, the
support given to those affected by the disappearances of these three men was,
at best, uneven. Such support should have been available, it should have been
provided, and it should have been consistent and ongoing – but it wasn’t,
neither in the interval between the initial investigations and Project
Houston nor during the project itself. I heard the same complaint in relation to
missing person cases generally. That said, I note there were loved ones who
described acts of kindness by individual officers.
One problem is that those affected by the disappearances of their loved
ones or family members are not seen as victims when those cases remain
unsolved. Another problem is a failure to recognize, within the context of
LGBTQ2S+ missing persons, who the affected loved ones and family
members are who need support. All missing persons’ situations are different –
for example, they may be members of a heteronormative family while also
self-identifying as LGBTQ2S+ with friends and loved ones existing in
different circles.
The MCM Manual requires that a victim liaison officer be selected and
assigned by the major case manager. There was no victim liaison officer for
Project Houston.

Police Transparency and Communicating with the Public

Understandably, the police are reluctant to discuss active investigations with
members of the public because it is important that they avoid jeopardizing an
ongoing investigation. But most officers acknowledged to the Review that the
Service did a poor job in communicating with the public about Project
Houston. Many community members did not know that the police were
vigorously investigating the disappearances of the three men. They believed
the police were not devoting adequate attention and sufficient resources to the
investigations. Moreover, on a systemic level, the Toronto police have
undervalued the affected communities’ role in advancing many investigations:
in order to partner with the communities in solving cases, they must rethink
how to communicate more regularly and in a more transparent way about their
plans and actions.
The police were anxious to keep Project Houston secret on the
theory that transparency would harm the investigation. However, I am
satisfied that the secrecy around Project Houston transcended anything needed
to preserve the investigation’s integrity. That excessive secrecy set the
Service up for heightened mistrust when community members later learned
they were misled (as many expressed following Project Prism) or, at a
minimum, shut out. Inaccurate or unnecessarily censored statements by the
Service and/or its senior command undermine respect for the Service and,
ultimately, future investigations. This lesson is best illustrated in Chapter
7, when I examine Project Prism. Although Project Prism was considerably
more transparent than Project Houston, Chief Saunders’s public statements
were ill-advised and damaged the already frayed relationship with many
members of the LGBTQ2S+ communities.
How Project Houston Was Wound Down and How It Ended
From the outset of Project Houston and into April 2013, the police devoted a
tremendous amount of time to investigating Brunton. Despite an intensive and
elaborate effort, including presenting an undercover officer as though he was
prepared to be eaten, they found nothing to substantiate Brunton’s
involvement, or that of a cannibal ring, in the disappearances of the three men.
In early April 2013, Detective Harris contemplated that the team was nearing
the end of its investigation and consulted with the Crown attorney about the
unrelated charges to be laid against Brunton. As I explain above, the April 18,
2013, informant interview made Brunton’s connection to the missing men
even more doubtful. Detective Sergeant Idsinga recorded that the
interview disclosed “no specific link from Brunton to any of our victims.”
He told the Review that by April or May 2013, he was pretty satisfied that
Brunton was “full of crap” and merely engaged in fantasy. On May 1,
Detective Harris advised the project team as well as senior officers that
Brunton would be arrested on charges related to child pornography and
Project Houston would be “taken down.”
In the sections above, I fully document the work done by Project
Houston after Brunton’s arrest. Suffice it to say here that, following Brunton’s
arrest, a much-reduced police team continued to investigate Brunton’s
activities, some of which related to child pornography, while they also
continued to look for any connection to the missing men. At one point, they
examined the possibility that Magnotta was connected with Brunton and was
involved in the disappearances of the missing men. They also conducted
investigative tasks relating directly to the missing men. Project Houston was
scaled down to three officers.
So where did that leave the investigation into the missing men?
Inspector Bott felt there was no evidence to suggest that the missing men were
the victims of a homicide or that foul play was involved. Similarly, he said
there was no evidence that the missing men were dead except that they had
been missing for a long time. In his view, and that of Detective Sergeant
Idsinga, Project Houston reverted to simply a missing person investigation.
The Homicide Unit’s involvement was no longer warranted.
In my opinion, this position is problematic for several reasons. On any
interpretation, the disappearances of the three missing men constituted major
cases – either because there was circumstantial evidence that raised a strong
possibility of foul play or because the men had gone missing for over 30 days
– indeed, several years. No serious effort appeared to have been made to
assess in a comprehensive way what investigative steps might be pursued
and how
the disappearances should be characterized. Indeed, some investigators were
quite troubled that the project was winding down while certain identified tasks
remained unperformed.
Equally important, the fact that the investigation reverted to a missing
person case undervalued the circumstantial evidence that these three men had
met with foul play. Several senior officers involved in Project Houston
appeared to take the view that might be expressed as “no body, no crime” or
“no confession, no crime.” I revisit this theme when I discuss the December 8,
2017, statement Chief Saunders made to the public that the evidence did
not point to a serial killer (see Chapter 7).
The lack of introspection over how the police should treat these
disappearances is also reflected in the inconsistency between the view
expressed by Inspector Bott and the few officers who remained on the Project
Houston team and their actions. In an attempt to gather evidence about the
missing men’s disappearances, they obtained several judicial authorizations
after Brunton’s arrest which indicated they believed, on reasonable grounds,
that one or more of the men had met with foul play. On July 4, 2013, for
example, Police Constable Platte obtained a judicial production order for
Brunton’s bank records. The materials in support of the order reflected the
officers’ belief that Mr. Navaratnam had been kidnapped by an unknown
person.
In my view, the way in which this project ended raises two
additional related systemic issues.

The Absence of an Internal Review

Project Houston was active for about 17 months. The Service invested
substantial human and financial resources to advance the investigation: 80
percent of 51 Division’s investigative fund was spent on the project.
Equally important, it was a Toronto project only because of the purported
connection between 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. Despite all this effort, no case
review or case conference was convened, as contemplated by the MCM
Manual, to evaluate the investigation objectively and thoroughly,
including the many deficiencies and shortcomings I have identified, or to
consider the lessons to be learned from it and the possible next steps. The
question of what to do next was of particular importance because these missing
person cases still qualified as major cases, and they remained unsolved and
deeply troubling. Some officers are still concerned that there has been
little introspection into the
lessons to be learned from the operation.
The MCM Manual specifically contemplates an introspective,
comprehensive case conference or case review in these kinds of situations.
Such a review was particularly necessary after Project Houston because it was
shut down even though identified work was left undone.

Notification to the Board

Project Houston easily transcended the “critical point” at which it should have
been disclosed to the Toronto Police Services Board, either while it was active
or, at the very least, once it ended without successfully solving the
disappearances of the missing men (see Chapter 3, where I identify this second
systemic issue). This operation was likely to have an impact on the Service’s
reputation and on its relationship with the LGBTQ2S+ communities. It raised
important issues about the Service’s role in carrying out this investigation and
about the resources devoted to it. The range of systemic issues I have
identified respecting the project reinforces why it should have been discussed
with the Board, without the Board purporting to direct the day-to-day
investigative steps. But no one told the Board about Project Houston,
either during its operation or after it ended.
I found it problematic that Mark Saunders, then the deputy chief whose
portfolio included this project, knew relatively little about the investigation.
Curiously, he did not have adequate information about the project to brief the
chief of police or the Board itself.

Misinformation About the Case

On December 12, 2012, near the beginning of Project Houston, the Toronto
police learned that Brunton had not identified Mr. Navaratnam as his
victim. He had said nothing about killing a man of colour. The description of
his victim as 18 to 35 years old with a slim, athletic build did not match Mr.
Navaratnam. Nonetheless, some operational plans and other documents that
went up the chain of command still stated that Brunton had confessed to
killing one of the missing men. The purported confession by Brunton that
he had killed Mr. Navaratnam figured prominently in the decision to create
Project Houston. I would have expected that every team member would have
known early on that Brunton had not confessed to killing Mr. Navaratnam. For
several reasons, I would also have expected, that this information would have
influenced how the investigation was conducted thereafter:

 the evidence that Brunton had really committed a crime in Toronto was
more questionable;
 Brunton lived in Peterborough and apparently had committed or was
committing crimes in Peterborough; and
 there was some evidence that Brunton’s alleged activities took place, in
whole or in part, on a farm in rural Ontario where he slaughtered
animals, again making his connection to Toronto more questionable.

In my view, the clarification that Brunton had not confessed to

killing Mr. Navaratnam or provided a description that matched Mr.
Navaratnam, taken together with the above points, did not mean that law
enforcement agencies should no longer investigate Brunton and his associates.
It did mean, however, that Toronto’s senior management should have
considered, in consultation with the team, whether these facts should
change the Service’s role in this investigation or strengthen the need for a
multi-jurisdictional joint investigative team to be created. Similarly, the
information was also relevant to the ongoing evaluation as to whether Brunton
was likely responsible for the disappearances of the three missing men from
the Village.
The fact that the project was so heavily dependent on the informant’s tip
created another problem. The informant was not interviewed until April 18,
2013, more than five months after the original tip and after the Service
was already deeply involved in the investigation. It was obvious from the
outset that the informant would have to be interviewed and that the
interview could be done only through an MLAT request. I am told that the
MLAT process is a slow one. However, it does not appear that the MLAT
application itself was completed or pursued with a sense of urgency. Without
question, it should have been.
The April 18, 2013, interview with the informant not only reinforced
what was already known or suspected – that Brunton never mentioned a
particular victim and, in fact, was looking for younger “muscle meat” – but
also that he never said he had victimized someone active in the Toronto
gay scene. The informant came up with that association on his own.
Indeed, Brunton had not even confessed to killing anybody. Detective
Sergeant Idsinga recognized that the interview showed no connection between
Brunton and the missing men. It followed that the premise on which the
project was conceived and on which formidable resources were expended was
seriously eroded.
This evidence leads me to question how Project Houston evaluated the
informant’s tip and its limitations.
Tunnel Vision
The informant’s tip, some of Brunton’s email exchanges, and various potential
connections to the missing men through dating websites certainly compelled
close scrutiny of whether Brunton had any involvement in the disappearances
of the three men. Without applying, in hindsight, what we now know, I
understand why Brunton was, for some time, a person of interest in their
disappearances. But the investigation quickly yielded evidence that pointed in
another direction. Brunton expressed interest in younger “white meat,” rather
than “dark meat,” to use the language contained in cannibal-related
conversations. Relatively early in the investigation, the police found no
communications between Brunton and any of the three men, although that
forensic work was ongoing. Brunton’s connection to Toronto was marginal at
best. Shortly after Project Houston started, some members of the team were
already skeptical about the relevance of the cannibalism theory to the missing
men.
Detective Sergeant Idsinga encouraged Detective Constable Loria to
pursue other leads, including a detailed examination of the lives of the missing
men, and she followed through. Still, it was obvious when the Review
examined Project Houston’s work product that an inordinate emphasis had
been placed on the cannibalism theory, to the exclusion of alternative
scenarios. While the project, to its credit, interviewed or re-interviewed people
who knew or might be associated with the three missing men, the
interviews were somewhat skewed by the prevailing investigative theory
about Brunton and the cannibal ring. When someone excited interest as
being potentially involved in the disappearances, the focus most often was
on whether that person was connected to Brunton. Mr. Navaratnam’s
computer was examined forensically not in a general sense but through the
lens of finding evidence of his connection to Brunton. Detective Harris
speculated that Brunton may have been sexually interested in young white
men, but preferred men of colour when it came to cannibalism. Although
possible, that suggestion also speaks to an unconscious focus on the
investigative theory that prompted and then animated the entire project, rather
than where the evidence appeared to lead.
The focus on Brunton continued well after Brunton’s involvement
was
largely dismissed by Detective Sergeant Idsinga and even after Brunton’s
arrest in May 2013. When Magnotta developed as a potential person of
interest, the police focused on his connection, if any, to Brunton. When the
Toronto police erected a logistically intensive, expensive undercover
operation to see if Brunton would take the bait, his involvement had already
been significantly discounted.
My point is that this investigation, despite best intentions, suffered from
tunnel vision. Commissioner Fred Kaufman, in his recommendations from the
Inquiry into Proceedings Involving Guy Paul Morin, described tunnel vision
has been defined as “the single-minded and overly narrow focus on an
investigation or prosecutorial theory so as to unreasonably colour the
evaluation of information received and one’s conduct in response to the
information.”42 Tunnel vision has also been described as “a trap that can
capture even the best police officer or prosecutor.” It must therefore “be
guarded against vigilantly.”43
The tunnel vision exhibited during Project Houston may have been less
pronounced than that described by Commissioner Kaufman respecting the
investigation by Durham police into nine-year-old Christine Jessop’s
abduction and murder. For example, Detective Sergeant Idsinga did support
Detective Constable Loria’s work when it pointed in another direction. But I
have no doubt that the collection of evidence during Project Houston was
significantly infected by the cannibalism theory, and that the importance of
interviews and the information collected during those interviews was
inordinately affected by whether they advanced the theory that Brunton
was involved. In fairness to the project officers, they appeared to recognize
when the evidence did not advance that investigative theory, rather than
attempt to shape the evidence unreasonably. For that reason, I distinguish
their tunnel vision, to some extent, from that exhibited during the Jessop
investigation. The bottom line, however, is that the cannibal theory distracted
the project from equal consideration of alternative theories.
The McArthur interview is one notable example. It didn’t occur to
Detective Constable McKenzie that a person with McArthur’s connections to
the missing men – more substantial than any connection they had to Brunton –
should have attracted attention. But McArthur was unable to provide any
evidence relevant to Brunton or his associates, so its significance was missed.

The Mc Arthur Interv iew

I outline in some detail above why the McArthur interview was deeply flawed.
It was inadequately prepared for and poorly conducted. Its significance was
lost on the officers. No meaningful supervision of the interview or what was
learned from it took place. It was not uploaded into PowerCase, and it was
not

42
Ontario, Commission on Proceedings Involving Guy Paul Morin, Report, 2 vols, and Executive Summary
(Toronto: Ontario Ministry of the Attorney General, 1998) (Commissioner Fred Kaufman),
Recommendation 74.
43
FPT[WU1] [Federal / Provincial / Territorial] Heads of Prosecutions Committee Working Group, “Report
on the Prevention of Miscarriages of Justice, Chapter 4, Tunnel Vision” [2004], online at:
http://www.justice.gc.ca/eng/rp-pr/cj-jp/ccr-rc/pmj-pej/p4.html.
communicated to the Project Houston analyst, so its significance was
effectively buried. But these flaws are more reflective of systemic issues
around the conduct of the investigation than personal criticism of the
interviewer. He was entitled to greater guidance, oversight, and supervision.
Robust supervision could have ensured that the interview covered all relevant
topics and was adequately prepared for. Robust case management should have
identified the importance of the interview after it was completed along with its
shortcomings.44 Its significance should not have been tethered to Brunton or
the cannibal theory, especially at that stage in the investigation. Detective
Constable McKenzie was a caring and dedicated officer – and, by all accounts,
remains so today. This Report should provide him and others with guidance on
better practices rather than be treated as an indictment of his work.
It is important to be crystal clear about one aspect of the findings in this
chapter. Members of the LGBTQ2S+ communities do not become persons of
interest merely because of who they love, how they love, or how many people
they love. The police must also be vigilant not to fall into that trap. The point
here is that full preparation for the McArthur interview, an understanding of
his criminal history, and his connection to all three missing men should
have resulted in heightened scrutiny of his conduct. Such scrutiny should
have carefully examined his whereabouts at the material times (questions that
were only superficially addressed during his interview); revealed, through
proper forensic examination of Mr. Navaratnam’s computer, that he lied about
his relationship with Mr. Navaratnam; and, ultimately, resulted in
additional investigative work.
I cannot say that McArthur would necessarily have been apprehended
earlier if these investigative steps had been taken. He was a true psychopath.
He disarmed others, including Detective Constable McKenzie, with his calm
and ostensibly helpful approach to the interview. Possibly with the exception
of Mr. Kinsman, McArthur carefully selected his victims. But the Toronto
police did lose important opportunities to identify him as the killer until they
examined the videotape of Mr. Kinsman’s departure from his home in
McArthur’s van in August 2017.
In 2015, McArthur killed again. In Chapter 7, I examine and evaluate
the investigations that ultimately ended with McArthur’s arrest and
prosecution.

44
The MCM Manual provides that, in every threshold major case, an interviewer shall undertake duties that
include, in consultation with the primary investigator and the file coordinator, developing appropriate
interviewing strategies and, where practicable, reviewing a ll documentation relevant to the interview in
prepa ration for the interview. As I explain above, in my view, in November 2013, this investigation should
still have been treated as a threshold major case.
 Chapter 7 The Project Prism 217
Investigation

Chapter 7

THE PROJECT PRISM INVESTIGATION

As set out in Chapter 6, Project Houston ended in 2014 without the police
being any closer to solving the disappearances of Skandaraj (Skanda)
Navaratnam, Majeed Kayhan, or Abdulbasir Faizi – Bruce McArthur’s first
three murder victims. In 2015, McArthur killed again. His victim was Soroush
Mahmudi. Like the others, Mr. Mahmudi disappeared without a trace. In 2016,
McArthur was arrested for choking a man during a sexual encounter.
Fortuitously, the man survived the attack. However, McArthur persuaded the
police to drop the case on the basis that he purportedly believed the
complainant had consented to rough sex.
McArthur’s crime spree continued. He killed four more men. The
disappearances of two of them – Selim Esen and Andrew Kinsman – were
reported to the police. It was only after Mr. Kinsman’s disappearance that the
Toronto Police Service (the Service) initiated Project Prism, an investigation
focused primarily on Mr. Kinsman’s disappearance with a potential link to Mr.
Esen’s disappearance.
Project Prism ultimately led to McArthur’s arrest and prosecution on
murder charges relating to all eight of his known murder victims. This chapter
documents and evaluates the Service’s McArthur-related investigations from
2015 to 2018.

Events Leading Up to Project Prism

The Investigation into Soroush Mahmudi’s Disappearance

On or about August 15, 2015, McArthur murdered Mr. Mahmudi.
Mr. Mahmudi lived with his family in Scarborough, Ontario. On August
22, 2015, his stepson1 called Toronto’s 43 Division to report his stepfather’s
disappearance. (At the time, Mr. Mahmudi’s wife and daughter were in Sri
Lanka.) His stepson told the police he had last seen Mr. Mahmudi on August
15, that Mr. Mahmudi’s black bag was missing from his home, and that Mr.
Mahmudi often took this bag when he planned to be away for a few days. Mr.
Mahmudi’s stepson gave the police Mr. Mahmudi’s photo. The police

1
Mr. Mahmudi’s stepson is erroneously identified as his son-in-law in the initia l missing person occurrence.
218 Independent Civilian Review into Missing Person Investigations

contacted local hospitals and the Centre for Addiction and Mental Health to
see if Mr. Mahmudi could be located, as well as a pub in Scarborough he was
known to frequent. The results were all negative.
The police Search Urgency Chart prepared by the officer who originally
responded to the reported disappearance reflected no foul play or criminal
concerns. Indeed, the chart identified the urgency rating as “low.”
Detective Constable Matthew Tim was the officer in charge of Mr.
Mahmudi’s investigation. From 2015 to 2017, Detective Constable Tim was
the “informal” missing person coordinator for 43 Division. This role was
created for him in 2015. It was a good fit, as investigative work appealed
to him. He did not receive any formal training in missing person
investigations before he took on the role, but, during his tenure as missing
person coordinator, he did attend a symposium the Ontario Provincial
Police (OPP) hosted concerning such investigations. Every week, he followed
up on missing person cases and reported to his supervisor about the status
of those cases. He investigated Mr. Mahmudi’s case while he was
investigating many other missing person cases.
At the time, Detective Constable Tim was not aware of Project Houston
or the disappearances of Mr. Navaratnam, Mr. Kayhan, or Mr. Faizi. There
was no Missing Persons Unit or a missing person coordinator for the entire
Service. Indeed, divisions did not necessarily have an officer assigned to be a
missing person coordinator.
On August 27, 2015, Detective Constable Tim spoke to Mr. Mahmudi’s
stepson, who had noticed that some clothing was missing from Mr.
Mahmudi’s closet.
On or about October 1, Detective Constable Tim learned that, at 11:02
p.m. on August 15, 2015, Mr. Mahmudi had last used his debit card to
purchase food from a pizza place in East York. Detective Constable Tim did
not know why the bank was not contacted earlier and agreed it should have
been.
I also observe that by late September 2015, more than 30 days had
passed since Mr. Mahmudi’s stepson had reported the disappearance. As of
November 2013, the definition of “major cases” had been changed to include
missing person cases “where police have yet to ascertain whether foul play is
involved when the individual remains outstanding and unaccounted for 30
days after being reported missing.” The 30-day anniversary apparently
passed unrecognized by the police. Mr. Mahmudi’s case was not converted to
a major
 Chapter 7 The Project Prism 219
Investigation

case, and even basic information about the case was not entered into
PowerCase, the mandatory case management software for major cases.2
On October 2, 2015, Detective Constable Tim contacted several
hospitals to try to locate Mr. Mahmudi. The results were negative.
On October 14, Detective Constable Tim called Mr. Mahmudi’s stepson
again. He requested more photos of Mr. Mahmudi and asked if the family
would consent to a media release about Mr. Mahmudi’s disappearance. Mr.
Mahmudi’s stepson asked Detective Constable Tim to wait until October 23,
when Mr. Mahmudi’s wife was scheduled to return from abroad. On October
21, Mr. Mahmudi’s stepson told Detective Constable Tim that he had been
receiving strange, anonymous telephone calls from someone who said nothing.
He believed it could be Mr. Mahmudi who was making the calls.
On October 30, an officer was dispatched to look for Mr. Mahmudi in
the area around a community housing building frequented by Mr. Mahmudi in
downtown Toronto, just east of Toronto’s Gay Village (the Village). This
search yielded no results. The officer left Mr. Mahmudi’s photo with Toronto
Community Housing.
On November 3, Mr. Mahmudi’s stepson told Detective Constable Tim
that Mr. Mahmudi’s cellphone account was registered in the stepson’s
name. He would try to get information from the cellphone provider about
the cellphone’s use.
On November 6, Detective Constable Tim learned from Mr. Mahmudi’s
employer that Mr. Mahmudi last showed up for work on August 15, 2015.
Significantly, he had not picked up his most recent paycheque. Detective
Constable Tim checked local hospitals again and the coroner’s office for Mr.
Mahmudi or any unidentified men. He did not turn up anything helpful.
On November 27, Detective Constable Tim met with Mr.
Mahmudi’s wife and stepson. He learned that Mr. Mahmudi’s bank
balance was over
$8,000. He also learned that Mr. Mahmudi’s passport had expired. He asked
Mr. Mahmudi’s stepson to check Mr. Mahmudi’s cellphone account for text
messages on Mr. Mahmudi’s cellphone. On November 29, Mr. Mahmudi’s
stepson called Detective Constable Tim to give him the telephone number of
the last text message sent from the cellphone. Detective Constable Tim
discovered the number was not in service.
On December 3, 2015, Detective Constable Tim went to the pizza place
where Mr. Mahmudi last used his debit card. He asked for the relevant

2
As I explain in Chapter 4, for non-threshold major cases, such as missing person cases outstanding for
more than 30 days, “tombstone” information had to be entered, indexed, researched, and cross-referenced
into PowerCase.
220 Independent Civilian Review into Missing Person Investigations

surveillance video footage. Four weeks later, he learned that the footage was
no longer available. Detective Constable Tim told the Review that it would
have represented better practice to have obtained the video footage earlier.
No canvassing was ever done in the vicinity of the pizza place.
Canvassing was perhaps unlikely to produce any evidence unless the pizza
location had been identified much earlier in the investigation. I observe,
however, that the pizza place is located approximately 800 metres from
McArthur’s apartment building in East York.
During this same time frame, the Peel police issued another media
release about Mr. Faizi’s disappearance. The release sought new information
about the disappearance, reflecting that, two years earlier, the Toronto police
had said his disappearance could be connected to two other men who had
disappeared from the Village.
On January 6, 2016, Detective Constable Tim learned from Mr.
Mahmudi’s wife that her son was still trying to obtain information about Mr.
Mahmudi’s phone use. On January 13 and January 26, Detective
Constable Tim followed up again. On February 4, Mr. Mahmudi’s wife
told Detective Constable Tim that a log for Mr. Mahmudi’s phone use was
available from Mobilicity. She later emailed the log to him.
In February 2016 and again in May, Detective Constable Tim took
initial steps to obtain Mr. Mahmudi’s dental records. In June, they were
finally obtained.
On March 4, 2016, Detective Constable Tim contacted several
telephone numbers from Mr. Mahmudi’s cellphone log. Some of the
numbers were associated with businesses. All the individuals Detective
Constable Tim spoke with denied knowing Mr. Mahmudi or his stepson,
although one individual said he recalled receiving multiple calls from a
person speaking broken English. Another said Mr. Mahmudi may have called
him in response to a flyer he had posted in the community. Many of the
calls had a “00:00” time allotment associated with them in the log, indicating
the calls had not been completed. Detective Constable Tim did not find it
unusual that the individuals associated with the numbers in the log denied
knowing Mr. Mahmudi. (McArthur’s telephone number was not in the phone
log.)
On April 1, Detective Constable Tim learned that Mr. Mahmudi had
significant outstanding debts and had not shown up for an August 21,
2015, meeting to discuss them. On the same day, Detective Constable Tim did
a records check on Mr. Mahmudi. He found no activity since Mr. Mahmudi’s
disappearance. Detective Constable Tim sent Mr. Mahmudi’s name to
www.hostels.ca to see if that site had any information about him.
 Chapter 7 The Project Prism 221
Investigation

On May 20, Detective Constable Tim conducted follow-up checks in

relation to several numbers that Mr. Mahmudi had contacted. Detective
Constable Tim again spoke to Mr. Mahmudi’s wife and stepson, who advised
him that Mr. Mahmudi may have been attempting tochange his identity. In the
past, Mr. Mahmudi had talked about changing his name. Detective Constable
Tim thought this possibility might be related to his debts.
On November 24, 2016, Detective Constable Tim checked with Canada
Border Services Agency to see if it had any record of Mr. Mahmudi’s having
crossed the border. It didn’t. On the following day, and again on March 30,
2017, Detective Constable Tim conducted a query with the Canadian
Police Information Centre (CPIC)3 for Mr. Mahmudi. The results were
negative.
Mr. Mahmudi’s disappearance did not form part of the Project
Prism investigation until January 2018, when his photo was identified on
McArthur’s computer. This date was after McArthur’s arrest in relation to
other victims.
Detective Dave Dickinson,4 Project Prism’s primary investigator,
said this delay was explained by the absence of any evidence that Mr.
Mahmudi was connected to the LGTBQ2S+ communities or to the Village.
Detective Constable Tim saw no evidence of such a connection during his
investigation
– it was only through media reports after McArthur’s arrest that he learned
about this potential link.
In his recent book Missing from the Village (September 2020), Justin
Ling described Ms. AC’s history with Mr. Mahmudi. Ms. AC, a trans woman,
met Mr. Mahmudi in 1997 at Woody’s bar on Church Street in the Village.
She was Mr. Mahmudi’s former romantic partner and the victim of an assault
for which Mr. Mahmudi was convicted in Lefroy, Ontario, in Bradford West
Gwillimbury, in 2001. During the 2015 investigation into Mr. Mahmudi’s
disappearance, the police were unaware of the conviction and did not interview
Ms. AC.
Had the police looked into Mr. Mahmudi’s 2001 conviction and read
the related synopsis or Occurrence Report, or interviewed Ms. AC, they
might have learned that Mr. Mahmudi, like Mr. Navaratnam, Mr. Faizi,
and Mr. Kayhan, was a Church Street regular. But they did not.
Detective Constable Tim learned about Mr. Mahmudi’s prior conviction
only when he was interviewed for the Review. He pointed out that he had
checked out Mr. Mahmudi on CPIC several times but saw no indication of a
prior record. He said he believed that, had he seen the prior record, despite its

3
CPIC is a central police database maintained by the RCMP that is accessible to all of Canada’s law
enforcement agencies.
4
Detective Dickinson is now a sergeant.
222 Independent Civilian Review into Missing Person Investigations

age, he would have obtained and read the underlying synopsis or Occurrence
Report and attempted to interview Ms. AC to see if she had any relevant
information to provide. It is unclear why Detective Constable Tim’s CPIC
searches did not yield information about Mr. Mahmudi’s prior record.5

The Murders of Kirushna Kumar Kanagaratnam and Dean Lisowick

In January 2016, McArthur murdered Kumar Kanagaratnam. He was never
reported missing.
Sometime between April 2016 and July 2017, McArthur murdered Dean
Lisowick. After the fact, there was speculation in the community that Mr.
Lisowick had been reported missing, but not recorded as missing. The
evidence is compelling that he was never reported missing.
The fact that both Mr. Kanagaratnam and Mr. Lisowick were never
reported missing raises systemic issues this Review addresses. It is not always
obvious when a marginalized and vulnerable person goes missing. As
well, barriers exist that inhibit people from reporting someone missing, even if
the disappearance is noticed. It is also no crime to choose to disappear, to go
off the grid. The challenge is to ensure that a person’s disappearance is noticed
and that, when circumstances warrant, the disappearance is promptly reported
and investigated.

The 2016 Investigation into McArthur’s Choking of a Man

On June 20, 2016, Toronto Police received a 911 call from a man (described
here as Mr. AD) who said that during a sexual encounter a person named
Bruce attempted to choke him. This encounter took place in the back of the
assailant’s red van in a parking lot at the corner of Bathurst Street and Finch
Avenue West. Mr. AD provided the assailant’s licence plate number to police,
and initially attempted to follow the assailant’s van while on the telephone to
police. The police advised Mr. AD to stop pursuing the van.
McArthur knew Mr. AD was in the process of contacting the police
when he (McArthur) fled the scene. A dash cam on Mr. AD’s vehicle captured
McArthur’s quick departure on video. It shows that McArthur, in his haste to
get away, briefly drove southbound in Bathurst Street’s northbound lane
before he continued in the southbound lane. Although Mr. AD told the officers
who initially responded to his 911 call that the video was available, the police
never examined it.
McArthur anticipated the police would get involved. He therefore came
in on his own to 32 Division. In the meantime, two officers met Mr. AD close

5
The Review obtained the relevant CPIC record from the Service. It shows the prior conviction.
 Chapter 7 The Project Prism 223
Investigation

to the scene of the encounter and recorded his narrative in their memobooks.
They learned McArthur was at 32 Division and returned to the station to arrest
him for assault. They held him in custody, pending investigation. From the
outset, McArthur made it clear that he wanted to tell his side of the story. He
provided a brief account to the arresting officers and then provided a
videotaped statement to the assigned investigator, Sergeant Paul Gauthier, who
was accompanied by one of the arresting officers.
Back in 2001, McArthur had, without provocation, injured another man
by hitting him over the head with a pipe. In 2003, McArthur was convicted of
assault with a weapon and assault causing bodily harm. He received a
conditional sentence. The conditional sentence was followed by a three-year
probation that prohibited him from, among other things, being within certain
geographical boundaries, including the Village (see Chapter 5).
In June 2014, McArthur was granted a record suspension
(previously known as a “pardon”) in relation to these offences. As described
below in more detail, the officers involved in the 2016 incident were unaware
of McArthur’s prior violent history. They were also unaware that McArthur
had used the same proactive strategy in 2001 – that is, coming to the police
before he was being sought. He knew his 2001 victim although, immediately
before the attack, he showed up at the victim’s home unannounced. I will soon
say more about the significance of McArthur’s earlier violent history.
In 2016, when Mr. AD first spoke to the officers dispatched to the scene
about being choked, he advised them that, in the past, he and McArthur (whom
he knew only as Bruce) had had casual sex. His previous relations with
McArthur had given him no cause for concern. This time, McArthur came to
see him unannounced. They decided to meet for dinner and ultimately agreed
to engage in sex in McArthur’s van. Although at the time it had no importance
to those involved, the interior of McArthur’s van was covered in plastic and
the items in the van included a fur coat. These items figured prominently in
McArthur’s killings.
The attending officers took what was described as a verbatim statement
from Mr. AD. He signed the statement as recorded in the memobook of one of
the officers.
Mr. AD told the police that “Bruce” had just tried to strangle him.
Mr. AD started “freaking out” when McArthur didn’t say anything, but just
grabbed Mr. AD by the throat and started squeezing his neck. Mr. AD said
something like, “What the fuck, what do you want, are you trying to kill me?”
Mr. AD could barely get the words out. McArthur just wouldn’t let go.
Mr. AD rolled over, breaking McArthur’s grip, and pushed McArthur off him.
Mr.
AD then grabbed McArthur by the throat in a straight-arm fashion to
create distance from him and show he wasn’t going to allow this to take place.
Mr. AD got out of McArthur’s van and into his own car, as McArthur fled
the scene. As already indicated, Mr. AD contacted 911, while attempting to
track McArthur’s van.
As a result of McArthur’s attack, Mr. AD’s throat was sore. It hurt him
to swallow, and he felt his voice was hoarse. He declined medical treatment at
the time, although he told the police he would follow up with his family
doctor if it got worse. He did go to the hospital the following day to have his
condition checked out.
Sergeant Gauthier, the assigned investigator, was an experienced
officer, had worked in the sex crimes unit, and had been trained in domestic
and sexual offence occurrences. He had trained other officers as well. Before
interviewing McArthur, Sergeant Gauthier briefly reviewed McArthur’s
statement that had been recorded in the arresting officer’s memobook. He also
recalled reviewing the notes again after he met with McArthur. He would have
checked (or delegated others to check) whether McArthur had any relevant
entries on Versadex, the Service’s records management system, and on CPIC.
According to Sergeant Gauthier, no relevant history, including the 2001 attack
or the 2003 convictions, was found. Nor did Sergeant Gauthier find any
reference to McArthur being interviewed during Project Houston. (In the latter
case, the Review confirmed that McArthur’s interview in November 2013 was
never entered into Versadex.) I discuss below whether that relevant history
should have been discoverable in 2016.
In the interview with Sergeant Gauthier, McArthur repeated the
explanation he initially gave to the arresting officers. He claimed he believed,
during his sexual encounter with Mr. AD, that he had Mr. AD’s consent to
choke him. According to McArthur, during the encounter Mr. AD told
McArthur to pinch his penis harder to arouse him. McArthur took this to mean
that Mr. AD liked it rough, so he squeezed Mr. AD around the neck, thinking
it was welcome. He said Mr. AD became upset and, in response, grabbed
McArthur around the neck. McArthur said Mr. AD then departed.
Sergeant Gauthier found McArthur to be “credible, truthful and
believable.” He accepted that McArthur mistakenly believed he had consent to
choke Mr. AD. In his view, this conclusion was fortified by several
factors. McArthur, a 64-year-old man, appeared to have no prior record. He
voluntarily came forward to tell his story. Based on his professional
experience, Sergeant Gauthier understood that rough sex, including
autoerotic asphyxiation by strangling, was quite common. Because Mr. AD
declined medical treatment, Sergeant Gauthier concluded that Mr. AD had not
suffered the kind of injuries
Sergeant Gauthier would have expected if McArthur had been attempting to
inflict injury. Sergeant Gauthier also relied on his statement analysis training
in evaluating McArthur’s truthfulness based on how McArthur answered
questions. Sergeant Gauthier regarded it to be significant that McArthur’s and
Mr. AD’s accounts were consistent with each other. Sergeant Gauthier
believed both Mr. AD and McArthur. As a result, he did not believe a crime
had been committed.
Sergeant Gauthier advised his supervisor of the circumstances. The
supervisor approved of Sergeant Gauthier’s assessment. McArthur was
therefore released unconditionally. This meant that no charges would be
pursued. Sergeant Gauthier directed one of the arresting officers to so
advise Mr. AD since that officer had met with Mr. AD. That officer left a
message for Mr. AD, who, according to the police, did not return her call. As
a result, no police officer ever spoke to Mr. AD after the initial police
response to his call. In late 2017, following the disappearances of Mr.
Esen and Mr.
Kinsman, Project Prism began its work. Once the project focused on
McArthur, its primary investigator, Detective Dickinson, conducted a database
search. The Versadex search revealed that McArthur had been granted a record
suspension. A Legacy Search6 of prior databases provided the investigator
with the underlying Occurrence Report pertaining to those 2001 offences.
Project Prism also learned that McArthur had been accused of choking
someone in 2016, but that no charges were pursued. Detective Sergeant
Hank Idsinga requested that the Service’s Professional Standards Unit
examine how the 2016 complaint had been dealt with. He expressed
concern that police procedures had not been followed. This point also raises
an issue for me about whether another opportunity to identify McArthur as a
person of interest in the missing person cases had been lost.
After the Professional Standards Unit conducted an investigation,
Sergeant Gauthier was charged under the Police Services Act with
insubordination and neglect of duty. In essence, the Service alleges that, as a
domestic violence investigator, Sergeant Gauthier failed to act in accordance
with the Service’s Domestic Violence Procedure. The procedure states that
“the domestic violence investigator shall be responsible for ensuring the needs
of the victim are met, effective management of the crime scene, including the
gathering of evidence, and ensure that a thorough and comprehensive
investigation is conducted.” The procedure further provides that, “when

6
A “Legacy Search” incorporates queries for the Service’s historical records management systems. I explain
this term more fully in Chapter 4.
investigating a person who is in custody for an offence resulting from a
domestic violence situation, the investigator shall:

 conduct a thorough and complete investigation;

 whenever possible, obtain an electronically recorded statement from the
victim, using the R. v. B (K.G.) guidelines and comply with procedures
04-32 and 12-08, as applicable; and
 where possible, ensure that injuries sustained by the victim are
photographed a second time 48–72 hours after the initial incident.”

Sergeant Gauthier’s disciplinary hearing has not yet been conducted: the
charges against him therefore remain outstanding. Sergeant Gauthier disputes
the allegations against him. He maintains the Service is using him as a
scapegoat for the deficiencies in how it investigated the McArthur killings, and
how it reported on its investigation to the public. He also relies on the fact that
his supervisor vetted and agreed with his decision to unconditionally
release McArthur.
My mandate does not permit me to decide whether Sergeant Gauthier or
anyone else engaged in professional misconduct. Both Sergeant Gauthier and
the Service are entitled to advance their respective cases at a hearing based on
sworn evidence. More importantly, it is unnecessary for me to decide whether
Sergeant Gauthier’s conduct amounted to misconduct. I can fully address
whether his investigation fell short of best practices. Not every investigation
that fails to comply with best practices amounts to misconduct. Few
investigations adhere, in every way, to best practices. Having said that, I do
conclude that the 2016 investigation should have been done differently in
some important ways. I explain the basis of this conclusion in my findings at
the end of this chapter. However, that does not constitute any finding of
misconduct.
The scope of my mandate also means that, in examining the 2016
investigation, I am not confined to the issues raised in Sergeant Gauthier’s
discipline proceedings. The goal here is to identify best practices, whether
relied on by the Service in the prosecution of Sergeant Gauthier or not. I must
also do so without the impermissible use of hindsight. McArthur’s subsequent
exposure as a serial killer cannot skew my analysis of the 2016 investigation.
It does explain why the identification of best practices is so important. I
also consider, near the end of this chapter, whether and how the 2016
events affected the Service’s ability to discover that McArthur was a serial
killer.
The Investigation into Selim Esen’s Disappearance
On or about April 16, 2017, McArthur murdered Selim Esen. On April 30, Mr.
AE, Mr. Esen’s ex-partner, reported Mr. Esen missing. Sergeant Henry Dyck
was assigned to investigate the case. Sergeant Dyck was – and remains – a
high-profile member of the gay communities with a significant community
following. He played an important role in the creation of the Service’s
Neighbourhood Community Officer Program and is active in community
outreach.
On April 30, following an initial meeting with Mr. AE, the police
looked for Mr. Esen at St. Stephen’s Community House on Augusta Avenue,
where Mr. Esen picked up his Ontario Disability Support Program cheques
weekly. Mr. Esen had not been there since April 12.
The officers noted a domestic incident on record between Mr. Esen and
Mr. AE but did not identify any current risks to which Mr. Esen was exposed.
On May 1, Detective Constable Guy Kama, Sergeant Dyck’s partner in the
investigation, called the community house to determine that Mr. Esen had not
returned.
On May 9, Detective Constable Kama investigated Mr. Esen’s bank
account. The account’s last activity was shown as April 24, 2017. Detective
Constable Kama was contacted by another acquaintance who worried that Mr.
Esen had been killed by someone he knew only by a first name (not “Bruce”).
Detective Constable Kama requested that the Intelligence Unit obtain the name
of Mr. Esen’s cellphone provider.
On May 12, Sergeant Dyck filed a C3 Intake Form. This form is a
request for the Computer Cyber Crime Unit (C3) to see if it could find any
instances on the internet or social media where Mr. Esen was active or had
been discussed. Sergeant Dyck told the Review that a C3 request is not a
standard part of investigative procedures, but he wanted to cast the net as
widely as possible. Through the request, Sergeant Dyck learned that Mr. Esen
had an inactive Facebook profile. On the same date, Sergeant Dyck received a
call from Mr. AE. Mr. Esen had not shown up for a court hearing the day
before. Mr. Esen had mentioned a “bad guy” named “Jimmy.” Mr. AE had no
other information about “Jimmy.” (In 2018, after McArthur’s arrest for
murdering Mr. Esen and Mr. Kinsman, the Toronto police interviewed Mr. AE
again. He recognized McArthur’s photo, as being “Jimmy.” He met “Jimmy”
only once. Mr. Esen was fearful of “Jimmy,” Mr. AE said, and believed
“Jimmy” was going to kill him.)
By the end of May 2017, 30 days had passed since Mr. Esen had been
reported missing. Yet again, this anniversary appeared to have been
228 Independent Civilian Review into Missing Person Investigations

overlooked despite the requirement that the case now be treated as a major
case.7
As a next step, Sergeant Dyck contacted Mr. Esen’s lawyer. Mr. Esen
had not spoken to her for about two months. This was out of character for him,
and she was concerned for his safety. Sergeant Dyck made inquiries with the
City of Toronto, the Canadian Air Transport Security Authority, Facebook, the
Centre for Addiction and Mental Health, various hospitals, and the Office of
the Chief Coroner. He did not turn up any leads. Sergeant Dyck called Mr. AE
again. He asked for more photos of Mr. Esen and any additional details about
his life. Mr. AE told Sergeant Dyck that Mr. Esen liked to hang out in the
Church and Wellesley area. Mr. Esen had been upset the last evening Mr. AE
saw him, and left Mr. AE’s home with a grey suitcase.
On May 16, the Service issued a media release about Mr. Esen’s
disappearance and expressed concern for his safety. Sergeant Dyck
tweeted Mr. Esen’s photo to many of the local Church and Wellesley
streets organizations, including bars and the neighbourhood association. This
tweet represented one of the few times that any Toronto officer
investigating the disappearances of McArthur’s victims had directly
sought to enlist LGBTQ2S+ and neighbourhood organizations to assist in
their work.
In May 2017, Sergeant Dyck spoke with retired superintendent
Elizabeth Byrnes. She told him that the disappearance of Mr. Esen sounded a
lot like the disappearances of the missing men from Project Houston (see
Chapter 6). Superintendent Byrnes urged Sergeant Dyck to speak to Detective
Constable Josh McKenzie about the potential similarities in the cases.
Sergeant Dyck was not working at 51 Division when Project Houston
was underway. His knowledge of the investigation and of the earlier missing
men was limited to discussions with members of the LGBTQ2S+ communities
and to media reports. As we know, the communities and media received little
information about Project Houston and the investigative steps taken.
On May 23, Sergeant Dyck emailed Detective Constable McKenzie,
Detective Sergeant Michael Richmond, and Detective Constable Charles
Coffey, writing:

Former Supt. BYRNES saw my tweet on this and suggested that I ask you
about project Houston. This pre-dates my time here so I don’t have any
knowledge of it. I understand my missing person fits the profile of some of
the people who had previously gone missing.

7
As set out in Chapter 4, this requirement was reflected in the November 14, 2013, All Chiefs
Memorandum.
 Chapter 7 The Project Prism 229
Investigation

I have some more work to do on this file, namely, I want to fully

interview the complainant and do a production order on the phone to see if
there is anyone besides the complainant he was talking to before he went
missing, but it’s disturbing that literally any footprint of him has gone silent.
Could you have a cursory look at the above GO # [the occurrence file
number] and let me know if there is something with regard to that prior
investigation I should know about with regard to this one.

The same day, Detective Constable McKenzie replied to Sergeant Dyck.

He did not think Mr. Esen’s case was related: none of the men from Project
Houston was addicted to hard drugs or appeared to suffer from depression.
(Mr. AE had indicated that Mr. Esen struggled with drug addiction.) Detective
Constable McKenzie suggested several potential investigative steps and noted:

Looking at it at this stage of the game, the only similarity is that they have
all dropped off the map without a trace. I personally feel that The Toronto
Police Service needs a Missing Persons Unit. These investigations are
usually never taken as seriously as they should be at the beginning stages,
and it’s not until they get more interesting which is usually when some time
has passed that we start working them harder. I personally would throw your
investigative net out as far as it will go, with what you have until you find
out that he is ok. That way if it does become a homicide or something like
that later, you’ve done almost all of the required footwork that will help you
move forward faster. With the previous three missing men, the only
similarities with them was that they all used to frequent The Black Eagle on
a regular basis and that they were mainly East Indian background. We didn’t
have any information that they went to the bar together, but I’m sure there
may have been times when their paths crossed.
Skanda NAVARATNAM was very outgoing and loved to party. He
bounced around to various friend’s [sic] houses as places to sleep and was
always meeting and going out with new people. He was last seen leaving
Zippers [sic] with two men and was never seen or heard from again.
Majeed KAYHAN was openly gay with his family and children and
lived in an apartment on Alexander alone with his two birds. He always had
coffee with a friend in the building every day. He had recently come back
from a family wedding and when he met with this coffee friend, he said he
had to leave early because he was receiving a very important phone call at
home. That was the last time anyone saw him.
Abdulbasir FAIZI lived and worked in Mississauga and was married
with two kids. He was not openly gay and his wife had no idea. He would
get off work early, tell his wife he was working overtime, and come down to
 the Church and Wellesley area. His car was last seen parked on Moore
Avenue in Toronto and he was never seen or heard from again.
All very strange, and to this day, almost seven years later, all still
missing.

In my view, the similarities among all these men and the circumstances
surrounding their disappearances were much more significant than Detective
Constable McKenzie believed them to be. Even a cursory examination of their
photographs (below), taken together with their disappearances without a trace
and the risk factors associated with each, should have prompted the police to
treat their cases as if they were potentially related.

Left to right: Mr. Navaratnam, Mr. Esen, Mr. Faizi, and Mr. Kayhan.

Indeed, as I explain in Chapter 4, six years earlier, Constable Marie-

Catherine Marsot, a Peel officer, had been struck by the obvious similarity
between Mr. Navaratnam’s and Mr. Faizi’s physical presentation and the
circumstances of their disappearances.
That said, to Detective Constable McKenzie’s credit, he did
accurately identify to his superiors some of the systemic issues around
how missing person investigations were being conducted and urged
Sergeant Dyck to conduct as broad an investigation as possible.
However, for the time being, the investigation into Mr. Esen’s
disappearance continued, but on its own. The Toronto police were not actively
investigating the other disappearances.
Throughout June 2017, Sergeant Dyck attempted to persuade Mr. AE to
give a video or audio statement. Mr. AE refused to do so. The officers
considered his refusal suspicious. Given the history of domestic assault
between Mr. Esen and Mr. AE, the police were becoming increasingly
concerned that foul play was involved in Mr. Esen’s disappearance. On June
15, Detective Constable Kama asked Mr. AE for any items belonging to Mr.
Esen that he had in his possession. Detective Constable Kama hoped to obtain
a DNA sample.
On June 9, about three weeks before Mr. Kinsman’s disappearance, the
Vice media website published an article titled “The mysterious, unsolved, case
of three men who went missing from Toronto’s Gay Village.” The article
outlined the investigation into the disappearances of Mr. Navaratnam, Mr.
Faizi, and Mr. Kayhan. (Later, the police found a copy of this article on
McArthur’s computer.)
On June 21, Detective Constable Kama interviewed Mr. Esen’s social
worker. He also tried to call Mr. Esen’s family in Turkey but was unable
to speak to them because they did not speak English or French.
On June 26, Andrew Kinsman went missing. His disappearance was
reported to the police two days later. Later in this chapter, I pick up the
narrative relating to the investigation into Mr. Kinsman’s disappearance. But I
observe here that, although Mr. Kinsman was white, there were, again,
important similarities between his disappearance and the disappearances of the
other reported men. They all vanished without a trace and without explanation.
Moreover, it arguably defied coincidence to conclude that these cases were
unrelated or that three gay / bisexual men associated with the Village just
voluntarily chose to leave prized pets behind, unattended. The cases cried out
for a single, coordinated investigation into their disappearances.
The Esen investigation continued. On July 17, a Turkish-speaking
officer spoke with Mr. Esen’s brother, who lived in Turkey. His brother had
not heard from Mr. Esen in about eight months. According to the brother, Mr.
Esen had family in London, England, who had not heard from Mr. Esen for
more than a year.
Mr. AE finally agreed to be interviewed by police. On July 20, Sergeant
Dyck and Detective Constable Robert Chevalier spoke with him for three
hours. At the end of the interview, Sergeant Dyck prepared a Supplementary
Report, noting that he had “far greater” concerns about Mr. Esen’s safety: Mr.
Esen had no electronic footprint and no access to funds, and no one had seen
him since his disappearance.
On July 21, officers searched several parks with cadaver dogs to try to
locate Mr. Esen. On July 24, officers interviewed Mr. Esen’s social worker
again. She told them that Mr. Esen had a new cellphone and Metropass
waiting for him that he never picked up. He also missed a doctor’s
appointment on April 26, 2017. On the same day, a friend of Mr. Esen told
police that Mr. Esen used the Grindr and GROWLr social-networking
apps, and frequented
Woody’s and the Black Eagle bars. Like Mr. Navaratnam, Mr. Faizi, Mr.
Kayhan, and Mr. Mahmudi, Mr. Esen was a Church Street regular.
Sergeant Dyck’s July 22, 2017, memobook notes reflect that he was
familiar with Mr. Kinsman’s case and could not rule out a link between the
disappearances of Mr. Kinsman and Mr. Esen, given the many similarities
between their disappearances and demographics.
On July 24, Sergeant Dyck and Detective Constable Chevalier went to
Mr. AE’s former condo to see if they could find Mr. Esen’s property. The
condo had a new tenant, and the property was gone. On July 25, Sergeant
Dyck conducted a 300 metre radius search and checked with local hospitals
and the Office of the Chief Coroner for Mr. Esen. All the searches were
negative.
Sometime between July 22 and July 27, Sergeant Dyck met with
Detective Sergeant Richmond and Detective Constable McKenzie to discuss
the case. He urged Detective Sergeant Richmond to include Mr. Esen’s
disappearance in the anticipated Project Prism investigation. He wrote a
Supplementary Report for Inspector Peter Code8 identifying similarities
between Mr. Esen and Mr. Kinsman, including their sexual orientation, the
bars they frequented, the area they went missing from, dating applications they
used, and their physical appearances. But Sergeant Dyck told the Review that
the Service responded differently to Mr. Esen’s disappearance than it did to
Mr. Kinsman’s case: unlike Mr. Kinsman, Mr. Esen was born outside of
Canada, had no family in Canada, had fewer close ties to members of the
LGBTQ2S+ communities, had addictions, and was underhoused. In Sergeant
Dyck’s opinion, these circumstances made it difficult to bring both police
attention and media attention to Mr. Esen’s case. However, Sergeant Dyck
adamantly rejected the theory that Mr. Kinsman’s case received greater
attention from the police because he was white. Rather, in his view, the
significant difference was that Mr. Kinsman was considerably more connected
to the local LGBTQ2S+ communities. His disappearance was reported
quickly, and there was a great deal of community attention to it as well as
pressure to find him. I revisit this issue later in this chapter.
I turn now to a more detailed discussion about Mr. Kinsman’s
disappearance and the investigation that followed.

The Investigation into Mr. Kinsman’s Disappearance

On June 26, 2017, McArthur picked Andrew Kinsman up from Mr. Kinsman’s
apartment building at 71 Winchester Street in downtown Toronto, about two

8
Inspector Code is now a staff superintendent.
kilometres from Church and Wellesley streets. Mr. Kinsman left in
McArthur’s 2004 red Dodge Caravan. He was never seen again.
On June 28, Ms. AF called 911 twice to report Mr. Kinsman
missing. She was Mr. Kinsman’s neighbour and friend. She waited five
hours for a response. When the police did not return her calls or come to
her apartment building, she walked to 51 Division late that evening to report
Mr. Kinsman’s disappearance, in person. The officer at the front desk told her
to go home and wait for an officer to be dispatched to meet with her. (As I
discuss in Chapter 13, it does not represent good practice to send anyone
home in these circumstances without taking a missing person report.) Ms. AF
told the officer she would wait outside of her building until an officer arrived.
An officer did arrive within 45 minutes. That was early on the morning of
June 29.9
Ms. AG was another neighbour and friend who reported Mr.
Kinsman missing. She was concerned when Mr. Kinsman stopped responding
to her text messages and phone calls. This was out of character for him. She
called 911 at about 5:00 p.m. Later that night, Ms. AG (separately from Ms.
AF) drove to 51 Division to report Mr. Kinsman missing. The officer at the
front desk told her that the division was handling a lot of calls that night, and
an officer would come by when one was available.
At about 1:30 a.m., two officers came to Mr. Kinsman’s apartment
building to speak with Ms. AF and Ms. AG. Ms. AF told the officers that
another tenant had last seen Mr. Kinsman on June 26, 2017, at about 2:00
p.m. Ms. AF received a final text message from Mr. Kinsman around the same
time. Ms. AF described Mr. Kinsman as a very detail-oriented and responsible
person. He was the building superintendent, and it was unlike him to disappear
without having assigned his tasks to someone. Mr. Kinsman’s cat had been left
without food or water. Ms. AF had contacted Mr. Kinsman’s ex-boyfriend,
who usually cared for Mr. Kinsman’s cat when Mr. Kinsman was out of town.
His ex-boyfriend had not heard anything from Mr. Kinsman.
Ms. AF had also contacted Mr. Kinsman’s workplace, the Toronto
People with AIDS Foundation. She learned that he had not shown up for work.
Ms. AF also told the officers that Mr. Kinsman depended on his HIV
medication. The officers searched Mr. Kinsman’s apartment. It was neat, and
they could not find his medication. Their calls to local hospitals yielded no
information.
The police completed a Search Urgency Chart for Mr. Kinsman at 1:29
a.m. and marked his disappearance as “low” urgency. I simply do not
9
Many of the documents in the police file indicate that Mr. Kinsman was reported missing on June 29,
2017. This date is inaccurate.
234 Independent Civilian Review into Missing Person Investigations

understand how the circumstances surrounding Mr. Kinsman’s disappearance

would justify a “low” urgency designation. It speaks to the low priority
systemically being given to missing person cases. But it also speaks to how
information was quite remarkably siloed within the Service – and even within
51 Division. No officer could reasonably have designated this disappearance
as “low urgency” based on Mr. Kinsman’s circumstances in isolation, let alone
if the officer had been fully and accurately informed of the history of unsolved
disappearances of gay men within 51 Division’s boundaries. Fortunately, in
relation to Mr. Kinsman’s disappearance, the police recognized the heightened
concerns about him the day after he went missing. His disappearance was
assigned to Detective Barry Radford at 51 Division. Detective Radford
immediately thought something was amiss: Mr. Kinsman had a regular
schedule, was responsible, and was typically in frequent communication with
friends. Plus, he had seemingly abandoned his beloved cat.
The same day, officers contacted local hospitals, with negative results.
The Toronto police issued a media release with Mr. Kinsman’s photo, stating
that police were concerned for his safety. They contacted Mr. Kinsman’s
doctor, cellphone provider, and bank. The police also searched Mr. Kinsman’s
apartment. They found his iPad, a phone bill, and a chequebook. Police
canvassed the area around Mr. Kinsman’s apartment building. They found
video cameras across the street, at 72 Winchester Street. They spoke with the
building superintendent, who told them that the video footage for the building
would be kept for 30 days. The superintendent did not know how to download
it. Police arranged to follow up. Mr. Kinsman’s iPad was given to the
Tech Crimes Unit for investigation.
On June 30, the police checked Mr. Kinsman’s banking activity and
attempted to obtain video footage from a Tim Hortons close to Mr. Kinsman’s
home. They were told that the footage could not be accessed until the manager
returned on July 3. The police contacted Rogers Communications to learn that
Mr. Kinsman’s cellphone was not responding to pings. This meant the phone
was turned off or out of range, or that its battery was dead. One of Mr.
Kinsman’s friends told the police that Mr. Kinsman had said he would be
going to the “Point” campground in Turkey Point, on Lake Erie, for most of
the summer. That friend believed Mr. Kinsman was most likely there. The
police went back to Mr. Kinsman’s apartment and seized his desktop
computer. Mr. Kinsman’s physiotherapist called the police to tell them Mr.
Kinsman had mentioned a heated argument with another tenant during his last
appointment on June 21, 2017. A tenant in Mr. Kinsman’s building gave the
police emails she had received from Mr. Kinsman. On June 26, Mr. Kinsman
let her know that he would be away for work between June 29 and July 3.
 Chapter 7 The Project Prism 235
Investigation

On June 30, Detective Constable Philip Wong was assigned to go to 72

Winchester Street to retrieve video footage to capture Mr. Kinsman leaving his
residence. Detective Radford directed him to obtain footage for June 26, 2017,
from 1:00 to 4:00 p.m. Detective Constable Wong was also told to canvass for
any video on Winchester Street that may have captured Mr. Kinsman’s
comings and goings on June 26.
Detective Constable Wong obtained the video footage from 72
Winchester Street. He also obtained footage from a nearby restaurant and a
Tim Hortons. Once he returned to 51 Division, he copied the files to his
computer for safekeeping. He consulted with Detective Constable Michael
Agostinho about his results and allowed Detective Constable Agostinho access
to the files for viewing.
On July 4, after returning from his days off, Detective Constable Wong
made DVDs of the videos from each location and submitted them to the
Service’s Video Evidence Section of the Property and Video Evidence
Management Unit.10
Detective Constable Agostinho’s memobook notes reflect that, on June
30, 2017, he reviewed the video footage from the restaurant and the Tim
Hortons. His notes make no reference to the footage from 72 Winchester
Street. He advised the Review that he did not review the footage from 72
Winchester Street. Based on the length of the other videos, he assumed he was
unable to get to the third video before he went off-shift. He did not know if
another officer was assigned to review the third video. In any event, the
evidence discloses that the 72 Winchester Street footage was not reviewed
until August 23, 2017. The footage showed Mr. Kinsman getting into
McArthur’s red van on June 26, 2017, at 3:07 p.m. (within the time parameters
specified by Detective Radford back on June 30). I elaborate on this delay later
in this chapter.
In early July 2017, officers interviewed a number of Mr. Kinsman’s
friends and colleagues. On July 1, the police formally interviewed Ms. AF and
Ms. AG. The police learned that Mr. Kinsman used online dating apps,
and that he had a troubled relationship with an ex-partner. They also learned
that, as of June 25, Mr. Kinsman had appeared happy and upbeat. A friend saw
him walking home from Pride, excited about possible permanent
employment at the food bank where he volunteered. In the early morning
hours of June 25,

10
The Property and Video Evidence Management Unit is a support unit of the Service that is responsible for
the processing, tracking, storage, maintenance, and disposal of all evidence. The Video Evidence Section of
this unit is a centralized area for the intake and management of video within the Service.
Ms. AF had seen Mr. Kinsman at their apartment building with a white-haired
man who appeared to be in his late 50s.
On July 2, 2017, Detective Corey Crawford emailed Ontario’s Missing
Adults website, a civilian-run informational website about missing persons in
the province, to ask that Mr. Kinsman be added to the registry. Detective
Crawford noted that the circumstances of Mr. Kinsman’s disappearance were
considered suspicious, and there was growing concern for his safety. The
police sent a similar email to Crime Stoppers. The officers also conducted a
300 metre radius check of parks, laneways, and rear lots in Mr. Kinsman’s
neighbourhood.
On July 3, the police issued a second media release about Mr.
Kinsman’s disappearance, alerting the public that the disappearance was being
treated as suspicious. One of the factors concerning the police was that Mr.
Kinsman had
left behind his pet cat. As I reflect in Chapter 5, for reasons that I simply do
not understand, Mr. Navaratnam’s and Mr. Kayhan’s ostensible abandonment
of their pets did not prompt a heightened investigative priority or urgency
when their disappearances were initially investigated.
On July 4, the police went back to Mr. Kinsman’s apartment to take
photographs and seize Mr. Kinsman’s toothbrushes and razor for DNA
collection. On July 5, the police went to the Turkey Point campground. Mr.
Kinsman was not there. Members of the Marine Unit did a shoreline search in
Toronto and searched the Don River Valley.
On July 6, CTV News, along with several other outlets, published a
story about Mr. Kinsman’s disappearance. The article highlighted his
disappearance as one of five men from the LGBTQ2S+ communities who had
gone missing since 2010.11 The article specifically referred to Mr. Faizi, Mr.
Kayhan, and Mr. Navaratnam. It noted that the police would not say whether
the cases were connected.
On July 7, Sergeant Dyck and Detective Constable Adrian Piccolo
responded to a Crime Stoppers tip regarding Mr. Kinsman. The tipster
indicated that on June 26, at about 3 p.m., he had purportedly seen Mr.
Kinsman on Wellesley Street, near Jarvis Street. Police officers went to the
A&W restaurant at the corner of Wellesley and Jarvis to request the external
video footage from that date. Sergeant Dyck watched the video but did not see
Mr. Kinsman on it.
On July 8, an anonymous tipster called the police to tell them that Mr.
Kinsman had been a bartender at the Black Eagle bar about 10 years
earlier. The police also learned that Mr. Kinsman may have spent time with
two men

11
The fifth man mentioned in the article, Zhu Jian “Frank” Wa ng, was never connected to McArthur.
from Australia over the Pride weekend. The police located the two men and
interviewed them. They recognized Mr. Kinsman’s photograph, but did not
know him personally.
On July 11, Detective Sergeant Richmond spoke to Constable Caroline
de Kloet, a Toronto police media relations officer, about the advisability of a
public safety media release in relation to gay men using social media dating
sites such as Grindr to arrange sexual liaisons. The discussion focused on
community members pursuing sexual relationships with strangers through
these types of sites and the inherent safety concerns.
However, there was concern that a media release could cause the public
to relate Mr. Kinsman’s disappearance to his use of social media. It was
pointed out that there was no evidence to establish such a connection.
Detective Sergeant Richmond followed up with Director Mark Pugash of the
Corporate Communications Unit. Director Pugash advised that since there
was no established connection to either the earlier Project Houston
investigation or Mr. Kinsman’s use of social media sites for arranging sexual
encounters, such a media release / public warning would not be appropriate at
this time.
On July 14, Constable Danielle Bottineau, the Service’s LGBTQ2S+
liaison officer, emailed a list of men who had gone missing to Deputy
Chief Barbara McLean. Deputy Chief McLean forwarded the list to
Superintendent Tony Riviere, 51 Division’s unit commander. Deputy Chief
McLean noted that she had been speaking with the owner of the Pegasus
bar on Church Street. Superintendent Riviere responded the same day:

As mentioned, earlier this week, I did asked [sic] D/Sgt Richmond to

consider a press release to alert members of the community (based on a few
similar criteria that raises [sic] some cause for concern), however Pugash
declined to support that notion.
I wasn’t aware of the cases provided by PC Bottineau (thank you)
and so I can’t speak to any similarities, suffice to say that they all meet the
criteria for MCM [major case management] and hopefully any similarities
would have hopefully surfaced and [been] considered.
By way of next course of action, I will be suggesting that a “war
room” approach be considered where all the relevant cases be reviewed for
patterns and similarities. It might be that a mini taskforce be established
with that sole purpose.
I will raise again the notion of a public alert, learning from the Jane
Doe investigation, aimed at potential victims.
Thank you for providing Mr. Hudspeth’s contact info, like I said
earlier, I see merit in meeting with him and/or other prominent members of
the LBGTQ community to share exactly what we know, to date, about the
 investigations. We also have an embedded Crown at D51, I will ensure that
his input be sought and considered.

Superintendent Riviere’s perspective was a welcome one. He supported

the creation of a task force to examine these similar disappearances, presumed
that these cases should be treated as major cases, and promoted a public alert
about dating websites and the sharing of information with the LBGTQ2S+
communities.
On July 14, a forensics officer went to Mr. Kinsman’s apartment.
The officer took photographs. There were no signs of a confrontation in
the apartment. The officer could hear sound from other units, making it
unlikely that an altercation in the unit would have gone unnoticed. DNA
samples were taken.
On the same day, the police interviewed one of Mr. Kinsman’s
neighbours, who was one of the last people to see Mr. Kinsman alive. She told
the police that she saw Mr. Kinsman at his apartment building on June 26,
between 1:00 and 2:00 p.m. Mr. Kinsman told her that he was going to meet
friends for coffee.
On July 17, a witness told police that he had seen Mr. Kinsman in a
heated discussion with several Middle Eastern men sometime before his
disappearance.
On July 19, Superintendent Riviere emailed Staff Superintendent Mario
Di Tommaso12 about Mr. Kinsman’s disappearance, noting:

As you may be aware, there has been a tremendous amount of public interest
in this case as it represents one of many outstanding missing cases, over the
years, involving males belonging to the LGBTQ community.
Although there is no tangible evidence of foul play or criminality
these disappearances are tremendously suspicious and concerning.
I have recommended that a mini Task Force be comprised to provide
a holistic overview of all the related cases to ensure all the due diligence has
been afforded to the investigations.

On July 21, Detective Constable Kama went to Mr. Kinsman’s

apartment to see if he could find a copy of a will or other relevant
documentation. Detective Constable Kama did not find a will but did find two
boxes containing large amounts of cash in Mr. Kinsman’s bedroom closet.
This discovery, of course, made it even less likely that Mr. Kinsman had
chosen to leave voluntarily.
12
Staff Superintendent Di Tommaso is now the deputy solicitor general, communitysafety.
 On July 23, Detective Radford and Police Constable Patrick Platte
interviewed another one of Mr. Kinsman’s friends. The friend told them that
Mr. Kinsman regularly engaged in outreach for safe sex practices in local
parks. Mr. Kinsman never mentioned any bad experiences in the parks, but his
friend told police that the parks were known to be dangerous: sometimes
straight men would wait to beat up gay men. On July 26, the police located
another surveillance camera in the vicinity of the site of Mr. Kinsman’s
disappearance. The owners of the camera told police that the video had since
been “written over,” but after Mr. Kinsman’s disappearance they had checked
the footage for June 26, in its entirety. Mr. Kinsman did not appear on it. The
friend also told the police that Mr. Kinsman often walked along Carlton Street
to get to Parliament Street. The police checked for other video cameras along
Carlton Street, with no success.
Detective Constable Cathy Loria learned of Mr. Kinsman’s
disappearance through the media. She had suspected, during Project Houston,
that a serial killer was targeting the Village. She immediately suspected that
the serial killer was responsible for this disappearance as well. Although
Mr. Kinsman was not Middle Eastern or dark skinned, unlike the missing men
from Project Houston, he had facial hair and was an older man. He appeared to
be a member of the “bear” community (that is, an older, hairy, heavy-set man).
Like the men who had disappeared earlier, his disappearance was out of
character. Detective Constable Loria sent a text message to Detective
Sergeant Idsinga. “It’s happening again.” Detective Sergeant Idsinga
texted back: “Yup, it’s happening again.”

A Narrow Escape: McArthur Assaults Sean Cribbin

Sean Cribbin is a retired preschool teacher and a gay man. He and his life-long
partner have spent the better part of their adult lives in the Village. Mr. Cribbin
and his partner have an open relationship. Mr. Cribbin and McArthur had
communicated on the dating app GROWLr (McArthur used the username
silverfoxx) for several months.
On July 26, 2017, McArthur picked up Mr. Cribbin in his truck a few
blocks from Mr. Cribbin’s apartment in the Village. McArthur’s truck smelled
like landscaping materials and was filled with tools. During the ride, McArthur
remained silent as Mr. Cribbin commented on the recent disappearances in the
area and the possibility of a serial killer. Mr. Cribbin was referring to Mr.
Esen and Mr. Kinsman. Mr. Cribbin recalled that McArthur asked him if
anyone knew that he (Mr. Cribbin) was with McArthur. No one did. At
McArthur’s apartment, McArthur mixed a drink laced with GHB for Mr.
Cribbin. GHB is
commonly known as the “date-rape drug.” Mr. Cribbin recalled panicking as
McArthur choked him during their sexual encounter. He may have temporarily
lost consciousness. Later, Mr. Cribbin would learn that McArthur had
taken photos of him when he was unconscious. Fortunately, McArthur’s
roommate came home earlier than expected, enabling Mr. Cribbin to “cut the
date short.” He was “uncomfortable and wanted to leave.” He considered the
experience to be a bad date and did not think of it again until McArthur’s
arrest was publicized in the media in January 2018.
When Mr. Cribbin saw McArthur’s photo in the media, all he could say
was “Oh, my God.” A day later, the Toronto police contacted him for an
interview. The police had found chats between Mr. Cribbin and McArthur as
well as photographs of Mr. Cribbin on McArthur’s computer. He met with the
police on January 23, 2018. This is when he learned that McArthur had taken
photos of him. McArthur had taken similar pictures of his murder victims, and
seemingly kept them as “trophies.” Mr. Cribbin knew he had come close to
becoming McArthur’s next murder victim.
Mr. Cribbin was understandably traumatized by his experience. In my
meeting with him and his partner, I learned about what happened during his
experience with McArthur and about the great bravery Mr. Cribbin has
demonstrated in the years since. After McArthur’s arrest, Mr. Cribbin
considered himself a spokesperson for the murdered men. I commend him for
his willingness to share his personal story.
Mr. Cribbin and his partner also shared with me how they have enjoyed
a positive relationship with the police, both before and after Mr. Cribbin’s
encounter with McArthur. Mr. Cribbin did not report the incident to the police
at the time because he considered it a bad date and chose simply to move on;
however, he told me he would have felt comfortable doing so. His experience
with the police during the McArthur investigation and more generally was
positive and supportive. (Mr. Cribbin particularly appreciated Detective Keri
Fernandes’s kindness and compassion toward him during his interview with
the police after McArthur’s arrest. Mr. Cribbin also contacted Detective
Dickinson after McArthur’s guilty plea to thank him for his hard work.)
I observe that, by July 26, 2017, the Toronto police had obtained
surveillance footage showing Mr. Kinsman getting into McArthur’s van (likely
the same van McArthur used to pick up Mr. Cribbin), but the police had not
yet watched it. I explain in this chapter why this footage should have been
viewed much earlier than it was, even without my applying impermissible
hindsight. Mr. Cribbin’s escape might ultimately be attributable to good
fortune – namely, the early return of McArthur’s roommate – as well as to Mr.
Cribbin’s quick thinking. Tragedy was averted, but this incident reinforces the
importance of timely investigative steps, including the review of relevant
surveillance videos.

Project Prism – Official Launch to Aftermath

The Task Force

In late July 2017, news outlets reported on an upcoming task force to be set up
by the Service to investigate the disappearances of Mr. Esen and Mr.
Kinsman. This task force would become Project Prism. The media reported
that police indicated that the investigation and evidence collected to that point
did not lead them to believe the disappearances of Mr. Esen and Mr. Kinsman
were linked to the missing men from Project Houston.
Several people called the police after seeing the articles. One of Mr.
Esen’s friends told the police he had last seen Mr. Esen about six months
earlier. Mr. Esen was an addict in recovery, and he had spoken about suicidal
thoughts, an abusive relationship he was in, and a desire to go home to Turkey.
On August 1, 2017, the Toronto Star ran an article about the attendance
of Toronto police at a town hall meeting at The 519 Community Centre that
evening:

Worried friends, families and co-workers of two missing men in Toronto’s

LGBTQ community received few answers from police at a Tuesday night
meeting at the 519 Community Centre, raising concerns over the pair’s
whereabouts.
Officers from a Toronto police team tasked with finding Andrew
Kinsman, 49, and Selim Esen, 44, met an overflowing crowd of more than
200 people in the Church and Wellesley neighbourhood.
Toronto police say they have yet to find any criminality in the pair’s
disappearances, or connection to three other missing persons cases from 2010–
2012.
…
“We do not have a lot of information for you. I understand how frustrating
that must be,” said Peter Code, the Toronto police inspector tasked with
leading the investigation, who credited the community for sending an
abundance of information.
“The police want to know everything. All information is important
because we just don’t know what the next piece will lead us to.”

One of the officers who attended the meeting told the Review that the
political pressure from the LGBTQ2S+ communities about Mr.
Kinsman’s
disappearance was very powerful. That pressure was why Mr. Kinsman’s case
moved over to the Homicide Unit to become a project investigation. This
officer indicated that there was “no way Homicide would have taken this on
without some sort of clout.” In fairness, Detective Sergeant Idsinga had served
as major case manager of Project Houston. As well, the Homicide Unit did not
assume carriage of Project Prism from the outset although the project’s
primary investigator, Detective Dickinson, was a Homicide Unit officer.

The Operational Plan

Project Prism officially started on August 14, 2017. The project’s Operational
Plan that Inspector Peter Code prepared listed Detective Sergeant Richmond
as the major case manager, Detective Dickinson as the primary investigator,
and Detective Constable Jeff Weatherbee as the file coordinator. The
Operational Plan focused primarily on Mr. Kinsman’s disappearance and listed
Mr. Esen’s disappearance as a potential linked case.
The Operational Plan noted:

In addition to the ESEN case, a TPS investigation into three missing men
was also investigated jointly by TPS D51 and TPS Homicide Squad in 2012.
This case involved the disappearance of the following three males:

 Skanda Navaratnam (Toronto Police Service)

 Majeed Kayhan (Toronto Police Service)
 Abdulbasir Faizi 11 Division (Peel Regional Police)

These three males also disappeared from the same geographical area as
Mr. Kinsman and Mr. Esen, and to date these occurrences still remain open
without any information as to the whereabouts of these individuals.
At this time the similarities between these cases has [sic] not met the
threshold for the cases to be linked as defined by OMCM [Ontario major
case management]. However, these cases need to be investigated in totality
as part of a prudent investigation to ensure that there is not one offender
responsible.

I later address (and disagree with) the conclusion that these cases had
not met the threshold for linked cases under provincial adequacy standards for
major case management.
Detective Dickinson was Detective Sergeant Idsinga’s partner in the
Homicide Unit. His appointment as primary investigator facilitated his ability
to consult with Detective Sergeant Idsinga about the Project Houston
investigation so he could get up to speed. Because he had previous experience
at 51 Division, he knew most of the Project Houston officers and had a good
working relationship with them.
A joint management team provided general oversight of Project
Prism. The team was made up of Inspector Bryan Bott of the Homicide Unit,
Inspector Peter Code of 51 Division, and Inspector Pauline Gray of the Sex
Crimes Unit. The first Project Prism meeting took place on August 14,
2017.
Detective Constable McKenzie and Detective Constable Coffey provided an
overview to the other officers of the Project Houston investigations and the
ongoing Kinsman and Esen investigations. The disappearances of Mr.
Kinsman and Mr. Esen were to be investigated separately because, according
to police, nothing linked them or connected them to the missing men from
Project Houston. There were no known persons of interest.
Officers who worked on both projects told the Review that Project
Prism had a more formal structure. At their first team meeting, officers learned
the project would be run according to the major case management model.
For example, officer assignments would be formally submitted and tracked
throughout Project Prism as required by the Major Case Management Manual.
Officers were required to submit reports on completing assignments,
something the Review discovered did not generally happen during Project
Houston. One officer told the Review this requirement made a huge
difference; during Project Houston, he had not even been aware that major
case management existed.
Detective Dickinson told the Review that the Project Prism team
understood that links between the Project Houston missing men and the
Project Prism missing men may be discovered down the road.
The officers continued to review the data extracted from Mr. Kinsman’s
iPad. They looked at locations he had Googled shortly before his
disappearance and at people he looked up on Facebook. On August 16,
the police obtained a judicial production order for Mr. Kinsman’s
cellphone records. They sent a subpoena to Grindr for Mr. Kinsman’s
messages, but were told that all messages were deleted from the Grindr system
within 15 minutes.
On the same day, August 16, officers found Mr. Kinsman’s calendar in
his apartment. Detective Dickinson noticed the name “Bruce” or “Bryce”
recorded in the calendar for June 26 at 3:00 p.m. (the day of Mr.
Kinsman’s disappearance).
Detective Dickinson told the Review that, in hindsight, the calendar
entry turned out to be an important clue. However, according to him, at the
time, the officers did not know what time Mr. Kinsman had gone missing.
Discovering the identity of “Bruce” was actioned, but it was not considered a
priority. “Bruce” was not considered to be a suspect. According to the police,
until the investigators narrowed down the time of Mr. Kinsman’s
disappearance and ultimately watched the surveillance footage showing Mr.
Kinsman getting into McArthur’s van, “Bruce” was just another lead.
Detective Dickinson was unaware that McArthur had been interviewed during
Project Houston. Throughout August 2017, the officers continued to interview
friends, colleagues, and neighbours of Mr. Kinsman. After discovering the
calendar, they asked interviewees if they knew a “Bruce,” but did not get any
leads.
On August 17, shortly after the public announcement of the Project
Prism task force, McArthur took possession of a new 2017 van. (The Project
Prism team eventually located the van McArthur used to pick up Mr. Kinsman.
They found it in a wrecking yard.)
On August 23, Detective Constable Coffey and Detective Constable
Weatherbee watched the video footage from 72 Winchester Street. They saw
an individual who appeared to be Mr. Kinsman getting into a red Dodge van
at 3:07 p.m. On August 24, Detective Constable Coffey went to a Dodge
dealership to show the manager a screen capture from the surveillance video.
The manager identified the van as a 2004 Dodge Caravan 20th-
anniversary edition. The police continued to canvass the area around Mr.
Kinsman’s apartment building for further video footage.
On August 24, Detective Sergeant Richmond emailed the Project Prism
team, telling them that his bosses had told him

they want to have some consistent updates provided to the community,

rather than letting this project run it’s [sic] 60/90/120 course, and then
releasing information at the end. I realize that we have to be careful what is
released, but there is no harm in advising them generally about what we
have done such as searching specific areas and following up on social media
or phone records.

The same day, Detective Sergeant Richmond emailed Constable

Bottineau to tell her about Project Prism. He indicated that the project team
would like to bring Constable Bottineau onboard to disseminate updates to the
LGBTQ2S+ communities. The Review did see several emails from Constable
Bottineau to the civilian co-chair of the Chief’s Consultative Committee
and to some community members.
On August 30, Sergeant Dyck and Detective Radford interviewed one
of Mr. Kinsman’s friends with the first name “Bryce.” They showed Bryce
Mr. Kinsman’s calendar. The “Bruce” or “Bryce” entry for June 26 was
not a
reference to him. He believed he was working that day. There was an
earlier reference to “Bruce” on June 15, 2017. Bryce had driven Mr. Kinsman
to the Turkey Point campground on that date.
On August 31, 2017, Detective Constable Coffey gave the Project Prism
team an update about the video surveillance footage from the day of Mr.
Kinsman’s disappearance: the video cameras from 72 Winchester Street
showed a man who appeared to be Mr. Kinsman getting into a red van at about
3:07 p.m. The van was a fourth-generation Dodge Caravan with a roof rack, a
blown-out headlight on the passenger side, and rain guards on the doors.
Detective Dickinson told the team that he was waiting for an engineer from
Dodge to narrow down the year of the van. He requested Ministry of
Transportation records for all red Dodge Caravans and Grand Caravans
from 2003 to 2006. Members of the Computer Cyber Crime Unit (C3) had
looked at the videos but were not able to identify the licence plate.
Detective Sergeant Richmond reflected in his notes that he wanted the
community to be suitably updated though he was not referring to the van in
particular. Up until that point, Project Prism had issued no media releases. A
media release went out in October 2017.

Mc Arthur Is Identified
On August 31 and September 1, 2017, Sergeant Dyck cross-referenced Mr.
Kinsman’s Facebook friends against a list from Detective Dickinson of all the
people in the Greater Toronto Area owning early-model red Dodge Caravans.
One of the people was McArthur. Detective Dickinson ran the names of the
identified people and learned that only McArthur had recent contact with the
police (regarding the June 20, 2016, choking incident). He still didn’t know
that McArthur had been interviewed during Project Houston. That information
should have been easily accessible – and it would have been if PowerCase had
been properly used or if the interview had been placed in Versadex. (As I note
earlier, PowerCase is the mandatory case management software for major
cases.)
On September 1, Detective Dickinson and Detective Constable Coffey
went to McArthur’s apartment building. They obtained a list of the key
fobs assigned to residents and what they revealed about McArthur’s access to
the building from June 14 to September 1, 2017. They also learned that
McArthur had a roommate. Detective Constable Coffey tried to obtain video
footage from the apartment building, but the footage from June 26, 2017,
had been overwritten. The officers reviewed footage from July 27, 2017,
onward and
observed McArthur driving what appeared to be the same red van that picked
up Mr. Kinsman.
On September 5, based on the identification of McArthur as owner of a
red Dodge Caravan, Detective Constable McKenzie pulled a copy of his
Project Houston interview with McArthur from November 2013. He realized
McArthur was the same person. Detective Dickinson requested immediate
Mobile Support Services surveillance on McArthur and directed Mobile
Support to obtain lifestyle and background information on him and his
discarded DNA. (Police have greater latitude in obtaining DNA without a
judicial order when that DNA is on a discarded item.) The surveillance
team conducted surveillance on 15 separate days between September 5 and
November 7, 2017. On September 6, it saw McArthur doing landscaping work
at several addresses, including 53 Mallory Crescent.
Detective Dickinson watched McArthur’s videotaped statement from
Project Houston. His main takeaway from the interview was that McArthur
had connections to the three missing men from Project Houston. At that point,
McArthur was not a “suspect” in all the disappearances, but the connections
heightened Detective Dickinson’s concern and his sense that the investigation
was going down the right path. Detective Dickinson contacted Sergeant
Gauthier. Detective Dickinson had located the 2016 occurrence
investigated by Sergeant Gauthier and wanted to know if any photos had been
taken of McArthur’s van.
On September 6, 2017, Detective Radford interviewed the
salesperson who had sold the red van to McArthur. Detective Sergeant
Idsinga’s notes of that same date indicate that McArthur was believed to
have picked up Mr. Kinsman on June 26, 2017. He noted that McArthur had
not come forward despite numerous media appeals about Mr. Kinsman, and
that McArthur had been arrested in 2016 for choking a man in his van.
Officers reviewed and made a copy of McArthur’s Facebook page.
On September 7, Sergeant Dyck interviewed one of Mr. Kinsman’s
neighbours. The neighbour recalled that, in the month before Mr. Kinsman’s
disappearance, she had seen a man with Mr. Kinsman at the building. The man
fit McArthur’s physical description.
On September 8, Detective Constable McKenzie contacted Peel police
to ask them to hold the property and DNA obtained during the investigation
into Mr. Faizi’s disappearance, in the event that Project Prism were to find a
link to Mr. Faizi’s disappearance. Detective Constable McKenzie noted in his
memobook that the disappearances of Mr. Navaratnam, Mr. Kayhan, Mr.
Kinsman, and the choking victim in 2016 all occurred on a Monday. (Mr. Faizi
was last seen on a Wednesday.)
 On September 10, Mobile Support continued surveillance on McArthur.
The team followed him to a coffee shop in the Church and Wellesley
streets area and seized a discarded plate and fork for DNA testing. The plate
and fork were ultimately submitted to the Centre of Forensic Sciences on
October 25, 2017, to generate a DNA profile.
On September 11, McArthur was formally identified as a “person of
interest” in Mr. Kinsman’s disappearance. Detective Radford told the Review
that this designation was based on a number of factors, including McArthur’s
link to the red Dodge Caravan and to the Project Houston missing men. As
well, Detective Dickinson had conducted a search of McArthur’s record to
learn he had been convicted of assaulting a man with a pipe in the Village.
Ministry of Transportation records had also revealed that McArthur purchased
a new van shortly after his Project Houston interview. This information was
all suspicious to Detective Radford. In his view, there was a definite possibility
that McArthur and the missing men from Project Houston could be linked. But
the police did not have evidence of “definitive” ties.
Detective Constable Coffey searched Mr. Kinsman’s desktop computer
and cellphone for any reference to McArthur. He found a telephone number
for McArthur in a backup of Mr. Kinsman’s cellphone. On September 12, the
officers obtained a copy of McArthur’s van purchase from the dealership.
They also obtained McArthur’s cellphone records, including text messages,
calls, and tower usage. They saw no contact with Mr. Kinsman or Mr.
Esen. McArthur’s telephone number was also not in the cellphone records for
Mr. Kinsman. Nor was it in Mr. Esen’s cellphone records.
On September 14, the police obtained a tracking warrant for McArthur’s
vehicles, enabling them to track the whereabouts of McArthur’s two vans (the
2004 Dodge Caravan that had picked up Mr. Kinsman, and a 2017 Dodge
Caravan). However, on September 16, before the police installed the tracking
device, McArthur’s son-in-law sold the 2004 Dodge Caravan.
Throughout the rest of September 2017, Project Prism focused
exclusively on McArthur. The officers continued to interview witnesses and
conduct surveillance on him. They investigated people close to McArthur and
evaluated whether they could be involved in the disappearances. At a
September 21 project-briefing meeting, the investigative team discussed
whether any follow-up was required or if the investigation into Mr. Kinsman’s
disappearance could take a direction that was not related to McArthur.
They concluded that no leads pointed anywhere else.
On September 25, Detective Dickinson sought an extension to Project
Prism. In doing so, he identified McArthur as a “person of interest” in the
disappearances of Mr. Kinsman and Mr. Esen and noted that he was linked to
the three missing men from Project Houston. Detective Dickinson told the
Review that at that point, McArthur was a “person of interest” only in the
Kinsman and Esen disappearances but “could not be excluded” with respect to
the disappearances of the Project Houston men.
On September 27, Detective Constable Joel Manherz contacted
www.silverdaddies.com to request that certain accounts be preserved until a
subpoena could be issued. A representative from the silverdaddies website
advised that messages are automatically deleted after 30 days. Detective
Constable Coffey found several photographs of McArthur in Mr. Kinsman’s
computer hard drive. The photos had been taken in September 2011.
On October 3, the officers found McArthur’s previously owned 2004
red van at an auto-wrecking shop. McArthur had last been seen in the van on
September 11. Forensics officers began examining the van.
On October 11, officers went back to Mr. Kinsman’s apartment to see if
they could find any other information about McArthur. They found a piece of
paper with the name “Bruce” on it.
On October 16, Detective Constable McKenzie began looking
through Mr. Kayhan’s property for possible connections between Project
Houston and Project Prism. Forensics officers requested comparison DNA
samples from Mr. Navaratnam, Mr. Faizi, Mr. Kayhan, Mr. Kinsman, and
McArthur. On the same day, the officers sent to Apple a Mutual Legal
Assistance Treaty request (a request for international assistance through US
channels), seeking subscriber information for Mr. Kinsman’s and McArthur’s
accounts.
On October 17, Detective Constable Kama asked Police Constable
Burak Inal (a Turkish-speaking officer) to contact Mr. Esen’s brother to
ask for Mr. Esen’s hairbrush or toothbrush, as well as DNA samples from
family members.
On October 16, 17, and 18, Detective Constable Coffey analyzed the
forensic image of Mr. Navaratnam’s computer that had been created
during Project Houston. He used Internet Evidence Finder, X-Ways Forensics,
and Encase 6.5 to perform keyword searches of the computer’s contents. (I
discuss relevant search programs in Chapter 4.) He searched for various
terms, including “Bruce,” “McArthur,” “silverfoxx,”13 and McArthur’s
telephone number.
Constable Coffey found evidence of contact between McArthur and Mr.
Navaratnam on Mr. Navaratnam’s computer:

13
The police already knew that “silverfoxx” was referenced in Mr. Navaratnam’s computer.
 On April 21, 2010, the user of Mr. Navaratnam’s computer appears to
have viewed McArthur’s account profile photo on the gay dating website
www.daddyhunt.com.
 A copy of McArthur’s dating profile from www.silverdaddies.com was
located in deleted file space on Mr. Navaratnam’s computer. The profile
contained the email address [email protected], and described
how the profile owner had his own landscaping business. The user of Mr.
Navaratnam’s computer appears to have viewed the photo associated with
the silverfoxx51 dating profile.
 A Yahoo messenger chat username appeared for a “Brucem.”
 McArthur’s telephone number was located in deleted file space on the
computer; it was associated with McArthur’s dating profile on
www.daddyhunt.com.
 A partially deleted message from McArthur’s dating profile on
www.daddyhunt.com to Mr. Navaratnam was found, reading “hey
sexy did you get my [sic].”

Detective Constable Coffey also logged into Mr. Navaratnam’s

Facebook account. He determined that Mr. Navaratnam had “friended” and
“unfriended” McArthur several times in 2009 and 2010. Most recently, on
February 1, 2010, Mr. Navaratnam had added McArthur as a friend. Finally,
Detective Constable Coffey used the forensic software program Axiom to
review the entirety of image files within the computer. The findings appeared
to indicate that Mr. Navaratnam had been in contact with McArthur through
daddyhunt.com’s private messaging system as well as through Yahoo
Messenger. The partially recovered messages were intimate in nature.
This finding undermined McArthur’s claim during his November 2013
interview that he and Mr. Navaratnam were only friends and did not have
a sexual relationship.
Detective Dickinson received an email from a forensics officer. The
police had found blood in several areas of McArthur’s van. The source of the
blood was not yet identified.
Through to the end of October 2017, the Project Prism team reviewed
the Project Houston files. Detective Dickinson was granted access to
Peel’s PowerCase file for Mr. Faizi. 1 4 Detective Dickinson told the
Review that

14
Information contained in PowerCase is not automatically accessible to all police officers, even when there
is a trigger notification potentially linking two cases. To ensure the confidentiality of investigative
information entered into the software system, officers who are not associated with the original investigation
must be granted access to the investigation in order to view its contents.
Project Prism did not officially take carriage of Mr. Faizi’s case until after
McArthur’s arrest, when Mr. Faizi’s remains were found. There was some
confusion over which service had carriage of the case, and Detective
Dickinson recalled receiving a call from the Peel police about it on the second
day of the Project Prism investigation. It was agreed that Peel officers
would gather evidence and complete certain tasks, which included locating
Mr. Faizi’s dental records.
On October 16, the Service issued a media release to update the public
about the Project Prism investigation. The release indicated that the task force
had been investigating the disappearances of Mr. Kinsman and Mr. Esen
for 60 days, and, to date, the disappearances had not been linked.
However, investigators were continuing to keep an open mind about any
possible links to Project Houston. Constable Bottineau emailed the release
to various community members and groups, including The 519 and the
Pegasus bar.
On October 24, officers obtained a judicial production order for another
gay dating website (www.squirt.org) in an attempt to find information
regarding the dating profiles belonging to Mr. Navaratnam, Mr. Esen, and
McArthur, but found no relevant evidence.
On October 25, Ms. AF participated in a photo lineup. She picked out a
photo of McArthur that was similar to the man she saw with Mr. Kinsman the
night before he went missing. On the same day, officers submitted the
toothbrushes and razor from Mr. Kinsman’s apartment and McArthur’s
discarded fork and plate to the Centre of Forensic Sciences to generate
DNA profiles.
On October 31, Police Constable Inal advised Detective Constable
Kama that Mr. Esen’s family did not have any items containing Mr. Esen’s
DNA. Mr. Esen’s parents were deceased, and Mr. Esen’s brother lived in
Turkey. Detective Constable Kama requested assistance from Interpol to
collect a DNA sample from Mr. Esen’s brother.
On November 2, the Project Prism team obtained a forensic copy of Mr.
Faizi’s computer from the Peel police. On the same date, a transmission data
recorder15 was authorized for McArthur’s cellphone. Surveillance of McArthur
continued throughout the month. The officers looked through Mr. Kayhan’s
property and Mr. Faizi’s computer for a possible connection to McArthur. On
November 7, Project Prism reviewed McArthur’s cellphone records for June
24 and 25, 2017, dates when Ms. AF saw Mr. Kinsman with an older man who

15
A transmission data recorder is a device that allows the police to collect information relating to cellphone
or computer transmissions, such as the location, duration and destination of calls.
resembled McArthur. The records showed that McArthur had been downtown
the night of June 24, 2017.

Mc Arthur Officially Becomes a Murder Suspect

On November 8, 2017, the Centre of Forensic Sciences reported back to
Project Prism: Mr. Kinsman’s blood was found in three separate locations in
McArthur’s van. His semen was also in the van. McArthur officially became a
suspect in Mr. Kinsman’s murder.
On November 12, Detective Dickinson emailed Detective Sergeant
Idsinga and Inspector Bott to tell them that McArthur was a suspect in Mr.
Kinsman’s murder. He wrote:

Based on these CFS [Centre of Forensic Science] results and evidence to

date, I believe that MCARTHUR is a suspect in the disappearance of
KINSMAN. Additionally, based on the totality of the investigation to date
as it relates to Andrew KINSMAN and the linkages and evidence made
between Bruce MCARTHUR, Skanda Navaratnam, Majeed Kayhan and
Abdulbasir Faizi, I have RG [reasonable grounds] to believe that Bruce
MCARTHUR is a suspect in their murders. Direct linkages have not yet
been made between ESEN and MCARTHUR.

Detective Dickinson requested Homicide to take over the major

case management role and that the investigation team be moved to
Intelligence. He wrote that 51 Division, specifically Detective Sergeant
Richmond, should continue to be a front for Project Prism. Detective Sergeant
Richmond had, to that point, been the main liaison for communication to the
media. Detective Dickinson proposed that Detective Sergeant Richmond
continue to liaise with the media, suggesting that, at the appropriate time, the
media could be updated that Homicide had taken over the investigation.
Detective Dickinson met with Inspector Bott the same day to discuss steps
moving forward. He also asked Meaghan Gray, the head of the Service’s
Media and Issues Management Unit within Corporate Communications, to
draft a communication to the public about safe dating. The media release
was circulated on December 5.
On November 13, Detective Dickinson emailed a PowerPoint
presentation for a “Command” presentation about Project Prism to
Inspector Bott and Detective Sergeant Idsinga. The PowerPoint
presentation summarized the potential connections between McArthur and
Mr. Kinsman and Mr. Esen, as well as McArthur’s links to the missing men
from Project Houston. Regarding Project Houston, it indicated:
 McARTHUR was interviewed on November 11, 2013
 Admitted to knowing Skanda NAVARTHAM [sic] and Majeed
KAYNAN [sic] but denied knowing Abdulbasir FAIZI
 FAIZI’s car was located abandoned on Moore Avenue. This location is
close to Thorncliffe Park Drive and only metres away from an address
that McARTHUR landscapes.
 McARTHUR’S contact (silverfoxx51) located in deleted e-mails of
Skanda NAVARATNAM
 [email protected] located on notepad at the residence of
Abdulbasir FAIZI

According to the Project Prism meeting minutes, as of November 14,

2017, McArthur was formally considered a “person of interest” in the
disappearances of Mr. Navaratnam, Mr. Kayhan, and Mr. Faizi. Detective
Dickinson told the Review that the minutes were in error: McArthur was not
elevated to a person of interest in the Project Houston disappearances. Rather,
the proper phrasing should have been that “McArthur cannot be excluded as
being involved in their disappearances.” Detective Dickinson told the Review
that there cannot be a person of interest in a missing person investigation
without indication that a crime was committed.
An officer who participated in Project Prism told the Review that
McArthur was a “person of interest” at this stage. In that officer’s view,
McArthur’s 2013 interview during Project Houston formed the basis for
the police to consider McArthur as a “person of interest” in the disappearances
of Mr. Navaratnam, Mr. Kayhan, and Mr. Faizi. The officer also explained the
rationale for keeping 51 Division, and specifically Detective Sergeant
Richmond, as the “front” for Project Prism even as the investigation moved to
Homicide:

Richmond was still kind of like the central contact point for the community
because the gay community is in 51 Division and he was their primary
contact. So, they didn’t want it to get out right away that it was a Homicide
investigation because that would have opened up another whole can of
worms with the community. So, they try and keep it on the QT … There
would have been just a political explosion.

Detective Dickinson’s assertion to the Review that McArthur was not

even a “person of interest” as of November 14, 2017, appears to be
inconsistent with his November 12 email. McArthur’s designation as a
“suspect” or a “person of interest” in the Project Houston disappearances
as of November
2017 became particularly significant when viewed in the light of Chief of
Police Mark Saunders’s comments during a December 8 press conference
about Project Prism. Chief Saunders told the public that “the evidence today
tells us there is not a serial killer based on the evidence involved.” This press
conference is addressed in greater detail below.
A follow-up Operational Plan for Project Prism dated November 17,
2017, focused on conducting surveillance of McArthur. McArthur was
identified as a suspect in Mr. Kinsman’s murder, and a person of interest in the
disappearances of Mr. Navaratnam, Mr. Faizi, and Mr. Kayhan. The officer in
charge of the investigation was now Detective Sergeant Hank Idsinga. The
plan noted:

On August 14, 2017 Project “PRISM” commenced as a 51 Division

project investigating the uncharacteristic disappearance of two men from the
Church Street and Wellesley Street area in Toronto. Assistance for Project
“PRISM” was provided by members from SCI [special criminal
investigators] Homicide and SCI-Sex Crime Unit. The recommendation was
made that moving forward, SCI-Homicide take carriage of Project “PRISM”
and that the Major Case Manager change to a member of the SCI-Homicide.
The objective is to thoroughly investigate the disappearance of two
men as well as continue to identify linkages and associates to three other
men who went missing between 2010 and 2012. It is being proposed that
this be accomplished in two phases.
Phase one will consist of continued traditional investigative
techniques with the assistance of members from Intelligence Services to
covertly gain entry into locations and premises associated to Bruce
McArthur to gather evidence.
Phase two will consist of a full Part VI authorization to intercept
communications. The goal of the Part VI authorization will be to gather
additional evidence into the disappearances of the missing men.

The Operational Plan outlined the background to the investigation as

follows:

Project “Houston” was created in 2012 to investigate the disappearances of

three (3) men who were last seen in the Church Street and Wellesley Street
area in 51 Division. The disappearances occurred between 2010 and 2012.
The project was jointly investigated by members of 51 Division and the
Homicide Squad. The project focused on attempting to identify linkages
between the three missing men to that of a person of interest. After a
thorough investigation, that person of interest was excluded and eventually
 the taskforce was disbanded. To date, these three missing men, Skanda
Navaratnam, Majeed Kayhan and Abdulbasir Faizi had not been located.
On August 14, 2017 Project “PRISM” was created to investigate the
disappearances of two (2) men who disappeared in the spring / summer of
2017 and were last seen in the Church Street and Wellesley Street area, in
51 Division.
Andrew Kinsman was last seen by neighbours and friends in the early
afternoon of Monday, June 26, 2017. Kinsman had set routines and
schedules and his disappearance was quickly identified as being
uncharacteristic. A review of Kinsman’s electronic devices corroborated the
belief that something untoward had happened to him in the early afternoon
on June 26, 2017.
A van owned by Bruce McArthur was observed on surveillance
picking up a person, believed to be Kinsman, at his home address on June
26, 2017 at approximately 3:00 pm. Kinsman has not been seen since this
time. An examination of the van owned by McArthur identified blood and
semen belonging to Kinsman in several locations within the van. On
November 8, 2017, Bruce McArthur was identified as a suspect in the
murder of Andrew Kinsman.
Selim Esen was last seen on April 16, 2017 but was not reported
missing for several weeks. Esen was living at various residences and at the
time of his disappearance could be said to have no fixed address. Third party
linkages and associations have been established between Esen and Bruce
McArthur and a review of both of their cellular telephones put them in the
same general area when Esen was last seen.
In 2013 Bruce McArthur was interviewed by members of Project
Houston as physical and forensic evidence was identified associating him to
all three of the missing men. During his interview, McArthur admitted to
knowing two of the missing men but denied knowing Abdulbasir Faizi.
Bruce McArthur has been identified as a suspect in relation to the
murder of Andrew Kinsman. To date, Skanda Navaratnam, Majeed Kayhan
and Abdulbasir Faizi have not been located and a criminal offence in
relation to their disappearances has yet to be established. Bruce McArthur
and his relationship to these missing men will continue to be investigated to
either include or exclude him as being involved in their disappearances.

The threat level of the investigation was identified as “medium to high,”

and the Operational Plan stated:

To minimize the risk to the public, MSS [Mobile Support Services] is

currently providing heightened surveillance on McArthur where reasonably
practicable. Additionally, trackers have been placed on his cellular
telephone and vehicle. Alerts are provided 24/7 to the investigative team
 whenever McArthur’s vehicle stops / starts or enters predetermined
locations.

Detective Dickinson told the Review that, up until this point, McArthur
had been surveilled for fact finding. Now, surveillance was also being
conducted to preserve public safety. Surveillance continued throughout
November 2017. Detective Constable McKenzie continued reviewing the
Project Houston investigation to determine if there was a connection to
McArthur.
On November 27, Detective Constable Manherz wrote an application
for a judicial production order for Blizzard Media Technologies for the data
relating to usernames “silverfoxtoronto,” “thirstybear,” and “hairserviceman,”
the usernames associated with McArthur and Mr. Kinsman. The application
listed the similarities among Mr. Kinsman, Mr. Esen, and the missing men
from Project Houston:

In August 2017 I was assigned to Project Prism, a task force set up to find
several missing gay males from Toronto’s Church-Wellesley Village
including Andrew KINSMAN, Selim ESEN, Majeed KAYHAN, Skandaraj
NAVARATNAM and Abdulbasir FAIZI.
…

On August 8th 2017 I was assigned to the Project Prism task force. It is a
temporary unit set up to investigate the mysterious disappearances of
Andrew KINSMAN, Selim ESSEN [sic] and, by extension, Skandaraj
NAVARATNAM, Abdulbasir FAIZI and Majeed KAYHAN. Although
there are similarities between the missing males, there is nothing to
definitively tie them together at this point.
…

16. I know from being briefed as a member of Project Prism that KINSMAN
is not the first person to go missing from Toronto’s village. In fact, he is the
5th gay male to have vanished without a trace since 2010. Although, at this
time we have not yet discovered a concrete connection between the men,
they do share some similarities which suggest they may be related:

a. The other missing men are Selim ESSEN [sic] (missing since April
2017), Skandaraj NAVARATNAM (missing since September 2010),
Abdulbasir FAIZI (missing since December 2010) and Majeed
KAYHAN (missing since October 2012).
 b. All of the missing men, including KINSMAN, had facial hair and
would be considered ‘bears’ in the gay community.
c. All of the men, except KINSMAN, have brown skin (3 of them are
from South Asia and ESSEN [sic] is from Turkey).
d. All of the men spent a good deal of time at The Black Eagle bar at
one time or another.
e. All of the men went missing over holidays – NAVARATNAM
over Labour Day weekend, FAIZI over the Christmas holidays,
KAYHAN over Thanksgiving weekend, ESSEN [sic] over an Easter
weekend and KINSMAN over a PRIDE weekend.
f. All of the men lived in or frequented Toronto’s Village.
g. All of the men were middle-aged (40s and 50s).

The Project Prism team reviewed McArthur’s and Mr. Kinsman’s

cellphone records. The officers installed a covert camera to survey McArthur
and continued to track him.
On December 1, Detective Radford met with Crown attorneys and a
polygraph technician. Detective Radford told the Review that, by this point, it
was only a matter of time before McArthur was arrested. Detective Radford
provided an update on the investigation to the polygraph technician and the
Crown attorneys to allow them to begin preparing for a potential interview
with McArthur.
Surveillance continued throughout December 2017. The Project Prism
team noted that McArthur acted as a volunteer Santa Claus at a local mall. One
officer prepared a workup on the missing men from Project Houston.
On December 4, Inspector Bott emailed a copy of a media release about
Project Prism to Superintendent Myron Demkiw 16 of the Intelligence Services
Unit. Inspector Bott stated:

We have officially taken the case over as the lead Detective has moved our
POI [person of interest] to the status of suspect based [on] recent evidence.
Our carriage of the case has not been made public at this time as we
were hoping to use that to our investigative advantage down the road.
What did occur to me with the change in status was[f]or Corporate
responsibility to issue a public warning, which prompted discussions with
Corp Comm and our LGBTQ2 liaison.

On December 5, the Service issued the media release about Project

Prism, and recommended safe online dating practices:

16
Superintendent Demkiw is now an acting deputy chief.
 Get to know the person you are connecting with by asking for additional
photos and social media profiles or speaking on the phone before meeting.
 When you decide to meet someone, do so in a safe space.
 Consider telling a friend or family member where you are going, or leave
a note behind with details of who and where you are meeting.
 At any time, if a situation leaves you feeling suspicious or uncomfortable,
consider reporting it to police or Crime Stoppers.

On December 6, Detective Constable Manherz obtained a general

warrant to covertly enter McArthur’s apartment. That same day, officers
entered McArthur’s apartment and found a computer and external hard drive.
The next day, they entered the apartment again to clone the computer and take
DNA swabs from a stained pillow, leather gloves, and a metal bar. Detective
Constable Coffey began analyzing the forensic data from McArthur’s
computer. Surveillance and tracking of McArthur continued.

The December 8, 2017, Press Conference

On December 8, 2017, Detective Sergeant Richmond and Chief of Police
Saunders conducted a press conference to update the media and public about
the status of the Project Prism investigation. The chief had just recently
returned from medical leave. Detective Sergeant Richmond commented on the
connection between the various disappearances and the possibility of a serial
killer in the following way:

There is no evidence at this point in time which in any way establishes the
disappearance of Selim Esen and Andrew Kinsman are linked to the
disappearance of the males from the Project Houston investigation. There is
also no evidence to support that the disappearance of Selim Esen or Andrew
Kinsman are linked; it simply makes sense to have the same dedicated team
investigate these occurrences in parallel. There is no conclusive evidence
that establishes any of these males were the victim of foul play, although
this cannot be ruled out.
There is no evidence that a serial killer is responsible for the
disappearance of any of the missing males. There is no evidence that social
media or dating applications played a role in the disappearances of any of
the missing males, although all five of the males who disappeared, whose
disappearances are investigated under the auspices of both Projects were
active on social media.
 Near the end of the press conference, members of the media asked
Chief Saunders if there was a serial killer. In response, Chief Saunders said:

We follow the evidence, [reporter’s name], and the evidence is telling us

that that’s not the case right now. So, if the evidence changes, if the
evidence changes, that’s another day. But the evidence today tells us there is
not a serial killer based on the evidence involved.

Many community members were outraged by Chief Saunders’s

statement when McArthur was charged shortly after this press conference.
They regarded the statement as demonstrably false. They felt betrayed. Many
believed, and continue to believe, the police failed to take seriously the
affected communities’ concern that a serial killer was targeting them and that,
at best, this failure showed indifference. Their anger was compounded by the
lack of meaningful communication from police about the ongoing
investigation and then by Chief Saunders’s later reported comments to the
Globe and Mail. These later comments were widely condemned as blaming
the community for the failure to capture McArthur. I address his comments to
the Globe and Mail later in this chapter.
The perspectives of officers within the Service about Chief Saunders’s
public comments, especially those he made on December 8, 2017, varied
greatly. Some, including those who were privy to the status of the
investigation, were shocked or dismayed by Chief Saunders’s statement.
Others supported his statement, believing that it accurately captured – at least
from a legal perspective – the state of the investigation. They believed, at that
point in time, that police did not have concrete evidence of McArthur’s
involvement in the disappearances or deaths of anyone other than Mr.
Kinsman. Others acknowledged that the statement was, at best, unskilful. In
their view, it would have been preferable simply to leave all theories open, as
Detective Sergeant Richmond did, rather than express the view that the
evidence did not suggest the presence of a serial killer. One officer was
astonished by Chief Saunders’s statement, but attributed it to an effort to
mislead or disarm the suspected killer.
Chief Saunders told the Review that, at the time of the press conference,
he did not know the Project Prism officers had evidence that gave them cause
for concern about McArthur’s involvement in the disappearances of Mr.
Navaratnam, Mr. Faizi, and Mr. Kayhan. He was told only that Mr. Kinsman’s
DNA had been found in McArthur’s van. Had he been told about the
information potentially linking McArthur to the other missing men, he would
not have made the comments he did.
 On completion of this narrative, I explain why Chief Saunders’s
comments on December 8, 2017, were unfortunately both inaccurate and
corrosive of the relationship between the Service and Toronto’s LGBTQ2S+
communities and the public in general. I also explain why, in my opinion, the
Globe and Mail article did accurately capture what Chief Saunders said,
and why some of his comments in the Globe and Mail were ill advised
and unfortunate.

The Events Leading to Mc Arthur’s Arrest

Throughout December 2017, Project Prism continued to track McArthur and
review his computer files. On December 11, Detective Dickinson installed
a covert video camera at 53 Mallory Crescent, a property where McArthur did
gardening and landscaping work and at which he was observed. On December
19, Detective Dickinson emailed Detective Sergeant Idsinga and
Superintendent Bott, providing an update on the Project Prism investigation
and McArthur’s behaviour:

McArthur appears to also creep men, taking surreptitious photographs of

them from the back of his van and then finding open source photographs of
the same men from the internet …
The established pattern that McArthur once had has totally changed
and is very unpredictable. It would appear however, that he is playing Santa
Claus at the Agincourt mall all week.

On the same date, the police sent the leather gloves, stained pillow, and
metal bar to the Centre of Forensic Sciences for DNA testing. The Project
Prism team used cadaver dogs to search another property McArthur
frequented. Nothing was discovered.
On December 23, Detective Constable Coffey found a file in
McArthur’s computer relating to his 2016 choking victim. Detective Constable
McKenzie continued looking for connections between McArthur and Project
Houston. On December 27, Detective Dickinson reviewed photographs of
a previously unidentified man from McArthur’s computer. The man was
an acquaintance of Mr. Esen.
On December 28, Detective Constable McKenzie began preparing a
workup on another individual whose photograph was found on McArthur’s
computer. After McArthur’s arrest, the police interviewed this man. He told
them that McArthur and Mr. Navaratnam had been in an abusive relationship.
Project Prism continued to monitor McArthur throughout the first half
of January 2018. On January 16, the Project Prism team discussed installing
probes in McArthur’s vehicle, as well as in vehicles belonging to his friends
and family members.
On January 17, the Project Prism team found photographs of a deceased
Mr. Esen on McArthur’s computer. His body was photographed in McArthur’s
bed and van. McArthur officially became arrestable for the murder of Mr.
Esen and Mr. Kinsman.
Detective Dickinson told the Review that the project planned to prepare
search warrants on McArthur’s home and then execute the warrants and arrest
him on January 20. The search warrants would relate to four separate
addresses and four vehicles associated with McArthur. By this point,
Detective Dickinson felt that McArthur must be involved in the murders
of Mr. Navaratnam, Mr. Faizi, and Mr. Kayhan. A contingency plan was
developed for an earlier arrest if McArthur was seen alone with someone, or if
someone got into his van or entered his apartment.
On January 18, the Project Prism team observed McArthur going to his
apartment with an unknown man. They decided to arrest McArthur
immediately. The time lag between McArthur’s entering his underground
parking garage and his arrest was approximately 15 minutes. Officers
described the experience as nerve-wracking.
The Project Prism officers knocked on McArthur’s apartment door.
They found the previously unknown man tied to McArthur’s bed. McArthur
was arrested and charged with the murders of Mr. Kinsman and Mr. Esen.
Later that day, the police held a press conference to announce McArthur’s
arrest.

The Events Leading to More Charges

In the weeks that followed, the Project Prism team interviewed associates of
McArthur, including neighbours, friends, and family. The police received
numerous tips about McArthur. Witnesses identified Mr. Navaratnam as
having been one of McArthur’s landscaping employees.
On January 19, 2018, Mr. RR called the Toronto police tip line to
indicate that he had last seen Mr. Kayhan with McArthur. On the same day,
the team executed a search warrant at 53 Mallory Crescent. Cadaver dogs
indicated a “positive hit” on the planters at the back of the property. On
January 22, the team interviewed the victim of McArthur’s 2016 choking and
learned that he had met McArthur on the silverdaddies website.
On January 22, the police identified photographs of Mr. Mahmudi on
McArthur’s computer. On January 24, 2018, the coroner opened up the
planters from 53 Mallory Crescent and found human remains. Dr. Kathy
Gruspier, a forensic anthropologist, examined the remains and drafted a report
 Chapter 7 The Project Prism Investigation 261

about the scene and the state of the bodies. On January 28, McArthur was
charged with three additional counts of first-degree murder, in relation to Mr.
Kayhan, Mr. Mahmudi, and Mr. Lisowick. On February 6, Project Prism
received the DNA swab via mail from Mr. Esen’s brother. It also obtained
a DNA sample from Mr. Kayhan’s son. Fingerprints from the remains in one
of the planters were matched to Mr. Kinsman.
As of February 15, based on the identified remains, the Project Prism
team had reasonable grounds to believe that McArthur had committed
seven murders: Mr. Kinsman, Mr. Esen, Mr. Kayhan, Mr. Mahmudi, Mr.
Lisowick, Mr. Navaratnam, and an unknown person. On February 22,
McArthur was charged with Mr. Navaratnam’s murder. In early March
2018, the Project Prism team found a photo of a deceased Mr. Lisowick in
McArthur’s email account. Detective Constable Coffey also found emails
between Mr. Kinsman and McArthur.
On March 23, 2018, Detective Constable McKenzie re-interviewed Mr.
RR. Mr. RR had originally been interviewed during Project Houston and had
recently given a media interview to CTV’s W5. Mr. RR told Detective
Constable McKenzie that he had been mistaken during his W5 interview about
what he had told the police during Project Houston. Mr. RR told Detective
Constable McKenzie he was unsure whether he had indeed called the Toronto
tip line or sent an email with McArthur’s online usernames. Neither the tip nor
an email has been located. Mr. RR also told Detective Constable
McKenzie that he had participated in a threesome with Mr. Kayhan and
McArthur shortly before Mr. Kayhan went missing. He had not shared this
information with Project Houston.
At the end of March, Mr. Faizi’s remains were identified. McArthur
was formally charged with his murder on April 11, 2018. On April 12, Mr.
Kanagaratnam’s remains were identified through fingerprints. McArthur
was charged with Mr. Kanagaratnam’s murder. Between April and October
2018, Project Prism continued to conduct interviews with witnesses and
associates of McArthur and the missing men.
Once McArthur was charged with murder, Toronto police learned about
others who had survived being victimized by McArthur. They also learned
more about the connection between McArthur and some of his murder victims.
I have set out only some of this information in this Report. In particular, I have
chosen to protect the privacy of his survivors whose identities are not
generally known. I have also attempted, however difficult, to tell this
important story without further traumatizing those affected. But the fact that
information came
262 Independent Civilian Review into Missing Person
Investigations
forward during Project Prism that was not known during Project Houston
raises an important systemic issue.

The Se ria l P re dator Crim inal Investigations Coordinator

In Chapter 4, I explain the role of the serial predator criminal investigations
coordinator (serial predator coordinator) of the Ministry of the Solicitor
General (formerly the Ministry of Community Safety and Correctional
Services) and the Service’s obligation to notify him or her if an investigation
meets certain criteria. These criteria (discussed in detail in Chapter 4) were
met during Project Houston and during Project Prism. However, the serial
predator coordinator learned about any investigation relating to the
disappearances of McArthur’s victims only when he read in the media about
McArthur’s arrest.

The Violent Crime Linkage Analysis System

In Chapter 4, I also explain the role of the OPP Violent Crime Linkage
Analysis System (ViCLAS) and the Service’s obligation to submit
ViCLAS booklets to the OPP ViCLAS Unit when certain criteria have
been met, including for missing person investigations where the
circumstances indicate a strong possibility of foul play and the person
remains missing. This submission must be made within 30 days of the
start of an investigation. In addition, the investigators must update these
booklets within 30 days of a material change or of their acquiring
information that is significant to the investigation.
As I discuss in Chapter 6, the issue of missing men in Toronto first
came to the attention of David Moore, a ViCLAS civilian analyst, in late
2012 or
early 2013. He had asked the Toronto and Peel police services for
ViCLAS submissions for Mr. Navaratnam, Mr. Faizi, and Mr. Kayhan in
2013. Both services declined: they told Mr. Moore that there was no evidence
of foul play in any of the cases. This explanation was both inaccurate and
inconsistent with Toronto’s applications for judicial production orders before
and during Project Houston.
In 2017, Mr. Moore read media reports about the disappearances of Mr.
Esen and Mr. Kinsman from the Village. They reminded him of the
missing men from 2013. He contacted the Toronto police several times to
ask for ViCLAS submissions for all five men. First, he contacted Detective
Sergeant Richmond, then he contacted the Service’s ViCLAS coordinator, and
finally he contacted Detective Sergeant Stacy Gallant. He also again contacted
the Peel police to request a ViCLAS booklet for Mr. Faizi.
The ViCLAS Centre ultimately received booklets for the five missing men:
 Mr. Esen’s booklet was received on July 31, 2017.
 Mr. Kinsman’s booklet was received on August 9, 2017.
 Mr. Faizi’s booklet was received on August 25, 2017.
 Mr. Kayhan’s booklet was received on September 13, 2017.
 Mr. Navaratnam’s booklet was also received sometime in 2017,
during Project Prism.

No explanation was provided to the ViCLAS Centre about why the

booklets had not been submitted earlier. There is no question they should have
been. There is also no question that, years before the booklets were submitted,
there was a strong possibility of foul play in relation to the disappearances of
Mr. Navaratnam, Mr. Faizi, and Mr. Kayhan.
On December 12, another ViCLAS civilian analyst, Les Show, began
an analysis into the five missing men. The ViCLAS Unit decided this analysis
was warranted – there was no indication in the media of any viable explanation
for why five men would go missing from one small geographical area.
ViCLAS had no information from the Toronto police about whether they knew
what had happened or whether there were other – potentially related – missing
men. Mr. Show contacted the Service’s ViCLAS coordinator and asked her to
forward his contact information to the Project Prism investigative team
because he was interested in receiving any new information about the
investigation that could assist in his analysis. He did not receive a reply.
The OPP ViCLAS Unit continued to look for potentially related cases,
and analysts identified eight cases of possible interest. All the cases involved
missing men, although not all were connected to the Village. ViCLAS
forwarded the cases to the Toronto police for further investigation to see if any
were linked to McArthur. On January 14, the Toronto police sent ViCLAS
information regarding interviews it had conducted with additional victims who
had survived their encounters with McArthur.
Mr. Show continued his analysis. On January 18, 2018, he learned
through the media that McArthur had been arrested. Mr. Show immediately
checked to see if McArthur was in the national ViCLAS database. He was not.
The same day, Mr. Show emailed Detective Sergeant Idsinga to tell him
ViCLAS was monitoring the media releases and continuing its analysis. Mr.
Show offered ViCLAS’s assistance regarding the missing men and any found
human remains. Detective Sergeant Idsinga replied to Mr. Show’s email the
same day to confirm he had received it but did not request any assistance or
analysis.
Chief Saunders’s Globe and Mail Interv iew
Excerpts from the Globe and Mail article dated February 27, 2018,
entitled “Toronto police chief says civilians failed to help Investigation
into alleged serial killer,” appear below.

Toronto police might have identified a suspected serial killer in the city’s
gay village earlier if people who had crossed his path had been more
forthcoming with investigators in the past, Chief Mark Saunders says.
“We knew something was up … We did not have the evidence,”
Chief Saunders said in an interview with The Globe and Mail, noting that
Bruce McArthur, who was recently charged with the deaths of six men, was
a well-known member of the community. “If anyone knew before us, it’s
people who knew him very, very well. And so that did not come out.”
The chief defended his service’s handling of a two-year investigation
called Project Houston launched in 2012, into the disappearances of three
men of similar ages and physical appearance who had ties to the village.
Members of the LGBTQ community have criticized the service for not
recognizing a potential serial killer sooner. Chief Saunders said he is
confident his officers did all they could based on the information they had at
the time.
“I’ve heard a lot of sources say certain things, and had those sources
said those things when we had Project Houston, I think there is a very strong
potential that the outcome could have been different,” Chief Saunders said.
He later added: “We knew that people were missing and we knew we
didn’t have the right answers. But nobody was coming to us with anything.”
Chief Saunders noted that the way the force handles missing-persons
cases is under review, but said he thinks his officers did the best they could
with Project Houston. Relations have been strained between police and the
local LGBTQ community going back decades, to the controversial
bathhouse raids, and again last summer, when officers were excluded from
the Toronto Pride parade.
“If there are things that we can do to increase relationship [sic], if
there are things to be operationally better, I’m willing to hear that,” Chief
Saunders said.
“But I don’t mind speaking on what we did. Was I satisfied with what
we did? At the time, with the information that we had, the answer is yes,”
Chief Saunders said.
…
Since Mr. McArthur’s arrest, new information has been brought forward that
could have helped investigators years ago, he said, comparing the situation
to investigations into sex assaults or street gangs in which detectives do not
have the co-operation of people with key knowledge.
 “If things are not reported, it emboldens the suspect.”

Chief Saunders thought the article unfairly depicted what he had said in
the interview, and he chose to release the full audiotaped interview to the
public. Given its impact on community members and the disagreement over
what Chief Saunders said or intended to say, I have reproduced much of the
transcript at the end of this chapter.

The Guilty Plea

On January 29, 2019, just over one year after his arrest, McArthur pled guilty
to eight counts of first-degree murder. On February 8, 2019, McArthur was
sentenced to life in prison with no eligibility for parole for 25 years.
McArthur declined my request to be interviewed by the Review.

Summary and Findings

The Investigation into Mr. Mahmudi’s Disappearance

Detective Constable Tim, the assigned investigator, was a dedicated officer.
He did a considerable amount of work to solve Mr. Mahmudi’s disappearance.
However, there were deficiencies in the investigation – steps left undone and,
perhaps, more importantly, steps not taken in a timely way. For example, there
were delays in learning where Mr. Mahmudi banked, in finding out when and
where he last used his debit card, and in seeking to obtain video footage from
the location where he last used that card. No canvassing was done in the area.
To the detriment of the McArthur-related investigations, the Toronto
police were very slow in identifying links among the missing person cases.
There were lost opportunities to learn that a serial killer was on the loose, as
many community members feared, and that McArthur was that killer.
But I understand why the connection between Mr. Mahmudi’s
disappearance and the disappearances of the other men was much less obvious.
The police were unaware of his connection to the LGBTQ2S+ communities.
There was no evidence known to police that he disappeared from the Village.
He lived in Scarborough, and his disappearance was being investigated by a
Scarborough-based officer. He was not active on social media. He had
apparently talked about assuming a different identity and was in debt. As a
result, his case was not treated with any urgency.
There were some circumstantial signs that he might be the victim of foul
play, but these were less pronounced than the red flags associated with
the
other disappearances. Notwithstanding all that, the system did fail Mr.
Mahmudi and his loved ones as well. I say that for several reasons.
First, once a person had been missing without a trace for more than 30
days, provincial adequacy standards required that the investigation be treated
as a major case. It is obvious to me that Toronto investigators were either
unaware of or failed to act on the 2013 change in the definition of a major
case
– investigators certainly did not initiate major case management on multiple
occasions, when it should have been begun.
Second, the low priority and diminished urgency associated with this
investigation meant that certain investigative steps were not taken. For
example, because this case was not designated as a major case, it was not
entered into the PowerCase software system.
This failure represented another lost opportunity to potentially link Mr.
Mahmudi’s case to the others.
The failure to recognize when cases should be designated as major cases
is a recurrent theme in my Report. To be clear, the designation does not
necessarily mean that the investigation must be led by three separate
officers (the command triangle) or that every major case attracts endless
resources. Indeed, the days of endless resources are gone – if they ever
existed. But the major case designation does impose certain obligations on
the Service, obligations designed to recognize the priority to be given to
cases, to promote a more thorough investigation, and to make it more likely
that linked cases will be swiftly identified.
Third, the Service had no centralized unit to examine all missing person
cases, a Service-wide missing person coordinator, or even an analyst dedicated
to reviewing unsolved missing person cases. A Service-wide, comprehensive
approach to missing person cases, with analytical support, would have
increased the likelihood that Mr. Mahmudi’s disappearance was not viewed in
isolation.
Fourth, the investigator did not contact the OPP’s Missing Persons and
Unidentified Bodies Unit about the case (see Chapter 13). However, I cannot
say that this omission features as prominently in my analysis.
Finally, Detective Constable Tim indicated that he would have looked
into Mr. Mahmudi’s prior assault conviction if he had been aware of it.
Although the conviction was in 2001, it was worthwhile at least to read about
the underlying facts to provide background information and perhaps some
insight about where Mr. Mahmudi might have gone. Detective Constable Tim
advised the Review that he would have also attempted to contact Ms. AC. (As
I note earlier, Ms. AC was Mr. Mahmudi’s former romantic partner and
the victim of an assault for which Mr. Mahmudi was convicted.)
 Such an approach could have provided clues that may have linked Mr.
Mahmudi to the Village and, thus, to the other cases. However, in fairness, this
potential investigative lead would have been far less obvious than others I have
described in this Report. As well, I accept that Detective Constable Tim did
make several Canadian Police Information Centre (CPIC) queries
pertaining to Mr. Mahmudi. It remains unclear why those queries did not
reveal the prior conviction.
In summary, the combination of at least some of these systemic
deficiencies, and some shortcomings in the investigation itself,
represented another lost opportunity – though less pronounced than others ––
to identify a serial killer when lives could have been saved.

The 2016 Investigation into Mc Arthur’s Choking of a Man (Mr. AD)

Mr. AD did not consent to being choked. That is crystal clear. There was no
evidence that he did consent. In fact, there was evidence to the contrary. He
did not invite McArthur to choke him, he objected immediately, he took
forceful steps to stop the choking, and he courageously reported the events to
police.
Sergeant Gauthier accepted that Mr. AD did not consent to being
choked. Instead, he concluded that McArthur honestly, though mistakenly,
believed Mr. AD was consenting. In 2018, when Mr. AD was re-
interviewed by homicide officers, he also acknowledged that, at one point, he
questioned himself about whether McArthur mistakenly believed Mr. AD
wanted to be choked. To be clear, Mr. AD has nothing to answer for. He
bears no responsibility for McArthur’s behaviour. His quick response to
McArthur’s unsolicited choking probably saved his life. His immediate call to
911 enabled the police to investigate McArthur’s conduct.
In my view, it was, at best, premature for Sergeant Gauthier to
conclude, based on McArthur’s purported mistaken belief in consent, that no
offence had been committed. Indeed, it is well arguable, in any event, that the
evidence did
not support this conclusion.
Re-interviewing Mr. AD
Sergeant Gauthier decided not to interview Mr. AD before deciding McArthur
would be unconditionally released. In Sergeant Gauthier’s view, the Service’s
Domestic Violence Procedure did not mandate taking a second statement from
Mr. AD. The lead arresting officer, also trained in domestic violence
investigations, had taken a satisfactory, verbatim statement signed by Mr. AD.
That officer was also present for McArthur’s interview in order to identify any
inconsistencies to be explored. She raised none. Generally, it is undesirable to
compel a domestic complainant to provide multiple statements. Furthermore,
Sergeant Gauthier saw no need to do so here once he decided that charges
were unwarranted – an electronically recorded statement is of importance
only where a matter is likely to proceed to court. As well, he questioned
whether the procedure even applied here, based on his conclusion that this
event did not involve domestic “violence” and on the limited relationship
between Mr. AD and McArthur. Nonetheless, out of caution, he treated it as a
domestic occurrence.
I need not decide whether existing procedures mandated an
electronically recorded statement. I can contemplate circumstances in which
such a statement may be unnecessary or counterproductive. However, in my
view, Sergeant Gauthier should have interviewed Mr. AD. I do not agree that
McArthur’s and Mr. AD’s statements were largely consistent. McArthur
described how Mr. AD asked him to pinch his penis harder. This statement
may have been accurate, as it turned out, but Mr. AD did not mention it to the
police at the time. More importantly, McArthur said he briefly placed his hand
around Mr. AD’s neck and that Mr. AD reciprocated. He presented the event
as if they simply choked each other for a few seconds before parting company.
But Mr. AD was unequivocal in saying that without warning McArthur
grabbed him by the throat and started squeezing and wouldn’t let go, despite
Mr. AD’s protestations. McArthur’s narrative gave scant attention to or
emphasis on his own actions but emphasized Mr. AD’s action in grabbing
McArthur by the throat, and his purported statement to McArthur (a statement
never raised with Mr. AD) that “now I am going to show you what I am going
to do to you.”
Sergeant Gauthier should have put these differences to McArthur during
McArthur’s interview, and he should have tested what McArthur said by re-
interviewing Mr. AD. Detective Andrew Taylor recalled that Sergeant
Gauthier told him there were conflicting versions of events, but Sergeant
Gauthier didn’t believe he had grounds to lay a criminal charge. Sergeant
Gauthier told the Review that Detective Taylor’s recollection was inaccurate.
Sergeant Gauthier did not regard the versions of events to be conflicting. That
may have been his perception. But I see things differently. There were
materially conflicting accounts, and they needed to be addressed.

The Availability of a Defence to the Allegation

Not every asserted mistaken belief in consent affords a defence. Even
McArthur did not claim that Mr. AD asked him to choke him. Sergeant
Gauthier observed that, contrary to conventional views, strangulation fetishes
and autoerotic asphyxiation are quite common. But Mr. AD gave no indication
that these practices were acceptable to him, and the police never asked
McArthur whether his prior sexual encounters with Mr. AD. ever involved
consensual choking, rather than merely Mr. AD’s willingness to be touched
roughly on his private parts. Sergeant Gauthier did not regard this allegation
as one of sexual assault because Mr. AD consented to the sex, not to the
choking. He acknowledged that it might have been characterized as a
sexual assault if he disbelieved McArthur, but he never reached the point
of identifying charges. In my view, the jurisprudence does not support
compartmentalizing McArthur’s conduct in the way Sergeant Gauthier
described. Based on Mr. AD’s allegation, McArthur’s conduct was potentially
a sexual assault or an aggravated sexual assault (since choking could place Mr.
AD’s life at risk). In other words, the choking potentially formed part of an
assault committed in circumstances of sexuality.
If understood in this way, even an honestly held belief on McArthur’s
part that Mr. AD consented to being choked would not have afforded him a
defence. It cannot be said that, before choking Mr. AD, McArthur took
reasonable steps, as required under the Criminal Code, to ascertain whether
Mr. AD consented to being choked. And it would be difficult to see Mr. AD’s
request as licence to choke him. (Of course, there is something surrealistic
about this legal analysis since, based on what we now know, I have little doubt
that McArthur intended to kill Mr. AD, but was thwarted in his efforts. But
that hindsight has no place in this analysis.)
Although I understand Sergeant Gauthier’s concern that this encounter
may not have evidenced a crime, it would have been best practice to question
McArthur on the version of events Mr. AD presented and to explore with Mr.
AD the plausibility of the account McArthur provided. It also would have
constituted best practice to explore whether McArthur’s mistaken belief in
consent, even if genuine, would have afforded him any defence.

The Photographing of Injuries

In Sergeant Gauthier’s statement to the Professional Standards Unit, he said he
would have expected observable swelling if the choking had been intense. He
corrected this statement at his interview with the Review because swelling may
not appear immediately. His point was that the absence of any observable
injuries, and Mr. AD’s decision to decline immediate medical attention,
supported McArthur’s lack of intent to injure Mr. AD. I take Sergeant
Gauthier’s point that it is difficult to criticize him for failing to photograph
injuries several days later when there were no observable injuries on initial
observation. But in my view, the decision not to photograph Mr. AD’s injuries
was also connected to the decision not to charge McArthur. If Sergeant
Gauthier had decided that further investigation was warranted, including an
interview with Mr. AD, it might well have led to further inquiries about
Mr. AD’s hospital visit and more detailed information about what, if any,
injuries had been sustained. We also know that some injuries become more
observable with the passage of time.

McArthur’s 2003 Convictions

Project Prism’s primary investigator, Detective Dickinson, was able to find,
based on Versadex and Legacy searches, that McArthur had previously
assaulted another male with a lead pipe. Sergeant Gauthier told the
Review that a 2016 search of CPIC and Versadex yielded no such
information. He also questioned the relevance of the prior occurrence, noting
that it was dated and that he must evaluate the merits of a potential charge
based on the evidence pertaining to that charge, untainted by a suspect’s
history. During questioning by my counsel, he acknowledged that, for
investigative purposes, the prior history may well have relevance in assessing
credibility, although it should not overwhelm an investigator’s analysis. I
accept the accuracy of that acknowledgement. Sergeant Gauthier also felt
that offences for which McArthur was granted a record suspension could play
no role whatsoever in his investigation. A record suspension reflects official
acceptance that an offender has been rehabilitated and that prior conduct
should no longer be used against him or her. As I discuss immediately below, I
disagree with Sergeant Gauthier, as does the Ministry of the Attorney
General, that McArthur’s prior conduct could play no role in a subsequent
investigation into his conduct because he had been granted a record
suspension. Equally important, the inconsistent understandings held by
Toronto officers surrounding this issue must be resolved.
McArthur’s 2003 convictions and the subsequent record suspension
raise several systemic issues.
First, to what extent does a record suspension prevent the subsequent
use by the police of the underlying conduct for investigative purposes?
Second, if police are entitled to use the underlying conduct for
investigative purposes, to what extent are the police aware of its permitted
use? Similarly, to what extent do the police fully use existing databases to
access relevant historical information?
 Third, leaving aside the issues around a record suspension for a
moment, to what extent is prior conduct such as that engaged in by
McArthur in 2001 relevant to subsequent investigations?

The Use of Underlying Conduct Relating to a Record Suspension

Sergeant Gauthier was correct that, once McArthur had been granted a record
suspension, the use of McArthur’s prior underlying conduct in or related to
court was necessarily circumscribed in law. However, I am not convinced that
its use for investigative purposes only is similarly circumscribed.
The Criminal Records Act (CRA)17 is the governing federal
legislation for record suspensions. It was amended in 2012 to substitute the
term “record suspension” for “pardon.” Record suspensions are designed to
assist offenders in their rehabilitation and reintegration into society by
reducing the social barriers and stigma a criminal record creates. Record
suspensions constitute evidence that the Parole Board of Canada is satisfied
that a successful applicant is of good conduct and that the conviction should no
longer reflect adversely on the applicant’s character.18 However, a record
suspension does not “retroactively wipe out” a conviction. Instead, it is
intended to minimize the future consequences of a conviction in a variety of
ways.
Under s. 6(1) of the CRA, the minister of public safety and emergency
preparedness may require a person having the custody or control of a judicial
record of a conviction that is the subject of a record suspension to deliver it to
the commissioner of the Royal Canadian Mounted Police. The RCMP is
responsible for CPIC. Such a record in the custody of the commissioner or any
federal department or agency shall be kept separate and apart from other
criminal records; and the record, its existence, or the fact of the
conviction cannot be disclosed to anyone without the minister’s approval. The
legislation creates certain exceptions to non-disclosure that are not relevant
here. Record suspensions may cease to have effect if, for example, their
beneficiaries are subsequently convicted of certain offences. Record
suspensions may also be revoked by the Parole Board of Canada in its
discretion.19
Nothing in the legislation requires that municipal or provincial police
services purge their own databases of records, such as Occurrence reports or
transcripts relating to convictions that are the subject of record
suspensions. The legislation primarily regulates disclosure by the federal
government and access to its records. The RCMP purges CPIC of entries
from individuals’

17
Criminal Records Act (CRA), RSC 1985, c C-47, as amended.
18
CRA, s. 2.3
19
CRA, ss. 6, 6.2, 6.3, 7, 7.2.
criminal records that have been the subject of record suspensions, thus
affecting what municipal or provincial police officers see when they conduct
CPIC checks. However, this purge does not mean that the same officers cannot
access, through their services’ own databases, information about prior
convictions that have been the subject of record suspensions, including
summaries of the related underlying conduct.20
Simply put, there were restrictions on the use of McArthur’s prior
convictions in any subsequent court proceedings because they no longer
formed part of his criminal record. 21 However, there was no legal impediment
to the use of the underlying prior conduct by the police, if relevant, for
investigative purposes. Moreover, although a record suspension reflects the
view that the prior offender should be treated for certain purposes as untainted
by the prior convictions, this view does not preclude the use of the prior
conduct, again if relevant, in subsequent investigations. To take an obvious
example, the prior conduct may be so strikingly similar to the criminal conduct
in a currently unsolved investigation to invite consideration as to whether the
same person is involved.
Such investigative use comes with a cautionary note – the
indiscriminate or unbridled use of such information could undermine the
rationale of record suspensions by preventing rehabilitated individuals from
escaping the stigma of their past.
I am advised that my view of the law in this regard is shared by
Ontario’s Ministry of the Attorney General. I also understand that the Ministry
of the Attorney General is unaware of any existing policies it has that
prohibit a municipal police officer from accessing such information for
investigative purposes. I also find support for this position in how the
Supreme Court of Canada, in Re Therrien,22 described the legal effect of
pardons, as they were then called.

Police Access to Relevant Information

Sergeant Gauthier delegated the responsibility to check McArthur’s history to
another officer. We do not know whether that officer conducted an adequate
search for this history. But we do know this information, which turned out to

20
As stated above, s. 6(1) of the CRA confers discretion on the minister of public safety and emergency
preparedness to direct any person having custody or control of any judicial record of a conviction in respect
of which a record suspension has been granted to deliver that record into the custody of the commissioner.
Although unnecessary for the purposes of this Report, I do not regard this subsection as addressing the types
of records held by municipal or provincial police services at issue here.
21
This observation is subject to McArthur’s record suspension’s ceasing to have effect or being revoked
based on the homicides he committed.
22
[2001] 2 SCR 3.
be relevant, was easily discovered during Project Prism. Sergeant Gauthier did
point out that there are inconsistencies in the ways in which the Service’s
database searches yield such information, especially as the Service repeatedly
transitions from one record management system to another. I am unable to say
whether those inconsistencies explain why McArthur’s prior history went
undiscovered in 2016.
What became obvious to me during this Review is that officers have
varying (and sometimes inaccurate) understandings of what is available to
them on their own databases. They have equally varying understandings of
whether they can or cannot use underlying conduct relating to a record
suspension for investigative purposes. There is a need for clarity in these
areas.

The Relevance of the Prior Conduct

Leaving aside the record suspension McArthur was granted, the 2001 events,
had they been known, would have been useful to Project Houston and to the
2016 investigation.
As I stated earlier, in November 2013, Project Houston should have
recognized the connection between McArthur and all three missing
persons. This connection should have led the police to closely scrutinize
McArthur, scrutiny that would have intensified as a result of his crimes in
2001. Someone with a connection with all three missing persons who had
attacked another member of the LGBTQ2S+ communities and been banned
from the Village for a period should undoubtedly have qualified as a person of
interest. Plus, no record suspension had been granted back then.
Similarly, McArthur’s crimes in 2001 were logically relevant to his
credibility in responding to the 2016 complaint. Absent information about the
2001 offences, he presented as a 64-year-old man with no prior violent history.
As well, McArthur’s credibility was supposedly enhanced because he came
forward to police on his own initiative. (However, he employed the same
strategy in 2001 in anticipation of his arrest.) Finally, Mr. AD told the officers
who first interviewed him that his assailant might have been stalking him or
engaged in obsessive behaviour. He noted that the assailant always showed up
unannounced. Sergeant Gauthier could not remember this entry in the officers’
notes, but he pointed out that Mr. AD also told the officers he did not fear
McArthur – in Sergeant Gauthier’s view, a statement that was inconsistent
with a continuing concern about being stalked. A review of McArthur’s
2001 offences reveal he arrived unannounced at the victim’s residence, as he
did in 2016.
 Admittedly, some of these points are more significant than others. I also
accept that Sergeant Gauthier identified the danger of misusing or giving
undue prominence to prior misconduct. Surely, however, the prior history
invited closer scrutiny of what McArthur had to say.

The Dash Cam

The dash cam on Mr. AD’s vehicle captured McArthur’s quick departure on
video and showed that McArthur fled the scene so hastily that he initially
proceeded southbound in the northbound lane of Bathurst Street. Sergeant
Gauthier never viewed the dash cam. He said he would have asked to see it if
he had noticed the relevant entry in the officers’ memobooks. When the dash
cam’s contents were outlined to him, he reflected that someone can flee the
scene for reasons unrelated to guilt. That is true but, in my view, the way in
which McArthur fled the scene was another reason heightened scrutiny was
called for.

Follow-up with Complainant

Sergeant Gauthier directed one of the arresting officers who interviewed Mr.
AD to contact Mr. AD to advise him that the case would not proceed to trial.
The arresting officer left a message on Mr. AD’s voicemail, but said that Mr.
AD never responded. During the investigation by Professional Standards, the
issue was raised about whether the complainant’s “needs were met” in
accordance with the Domestic Violence Procedure.
I cannot say that Sergeant Gauthier should have personally contacted
the complainant, based on the arresting officer’s prior interaction with the
complainant. That, of course, assumes the decision not to proceed on charges
against McArthur was the correct one. Ideally, there should have been further
follow-up to ensure that the complainant had received the voicemail message
and received an explanation for the decision made. But the real issue here is
the decision itself, which, as I have said, was at best premature and at worst
unsupported even by the evidence available to Sergeant Gauthier.

Implications of Siloed Information

If McArthur had been charged with sexual assault or aggravated sexual
assault,23 the following procedures would have been mandatory. The
investigation would have been subject to major case management, requiring
that information about the offender and the offence be placed on PowerCase.

23
Sexual assault under the circumstances outlined was a non-threshold major case. Aggra vated sexual
assault was a threshold major case. Even if McArthur was charged only with sexual assault, basic
information (otherwise known as “tombstone information”) should have been entered into PowerCase.
 If Project Houston had earlier entered McArthur’s name into PowerCase
as an “object 24” or “a person of interest” (as it should have been, based on the
complete facts available to the project), then in 2016, the entry of McArthur’s
name in PowerCase by Sergeant Gauthier would have caused Project
Houston’s primary investigator or the file coordinator to be notified of the link
between the cases – even after the project had wound down.
Sergeant Gauthier had a valid related point. Apart from entering
McArthur’s name into PowerCase, Project Houston should have recorded the
McArthur interview in Versadex. It didn’t.
Sergeant Gauthier said that, had McArthur even been identified as
someone who had contact with three missing persons connected to a lengthy
Toronto project, then, before making his decision in relation to the 2016
occurrence, he would have contacted those involved in that project to see if
there was something more he should know about McArthur. As well, the
Project Houston investigators could have determined if the 2016 incident was
potentially relevant to their project. It disturbed Sergeant Gauthier that he was
not even aware of Project Houston, despite its length and the resources
devoted to it. He saw this situation as a counterproductive siloing of
relevant information. I agree with him.

Gender, Sexual Orientation, and Sex

My counsel asked Sergeant Gauthier whether the result would have been the
same if this incident had taken place during a heteronormative encounter
between a male suspect and a female complainant. Sergeant Gauthier said that
the result would have been exactly the same, unless other factors (such as a
weight or height differential or other indications of a power imbalance)
existed. That said, I can understand why an objective observer might
conclude otherwise: based on the ready acceptance or assumption that Mr. AD
might be expected to be involved in autoerotic asphyxiation. Some might
regard Sergeant Gauthier’s approach as based on a stereotypical view of how
gay men interrelate. There is no basis on which to conclude that Sergeant
Gauthier consciously treated the case differently based on bias. But that is not
the sole litmus test to avoid discrimination-free policing. The point must be
made, an important point, that officers have to be vigilant in ensuring that their
work is not inadvertently infected by bias or stereotypical thinking.

24
The use of “objects” in PowerCase is explained in Chapter 4.
The Investigation into Mr. Esen’s Disappearance
Sergeant Dyck and Detective Constable Kama showed a shared
commitment to solving Mr. Esen’s disappearance. Certain steps were taken
in this investigation that were not taken in earlier Toronto investigations.
As I mentioned earlier, Sergeant Dyck drew on his contacts in the
LGBTQ2S+ communities, tweeted about the case, and reached out to
community organizations and the neighbourhood association. All this should
be standard- fare, rather than exceptional.
Sergeant Dyck also requested that the Cyber Crimes Unit examine, in a
comprehensive way, Mr. Esen’sinternet and social media profile. As it turned
out, Mr. Esen made limited use of the internet and social media. But I
have compared Sergeant Dyck’s approach to the approaches in other
investigations. For example, Mr. Navaratnam’s computer went unexamined
during the original investigation into his disappearance. His social media
and internet activity were too narrowly examined during Project Houston.
The Review met with many officers who did not have a full
understanding of how to obtain a comprehensive internet and social media
profile of missing people: whether it involves forensic searches of computers,
iPads and 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. But the information available to this
Review disclosed a lack of a uniform approach to this work. It also revealed
an incomplete understanding of resources available to investigators to assist
them in obtaining relevant evidence from the internet and social media.
The Esen investigation highlighted several systemic issues of
importance.
First, Sergeant Dyck cannot be criticized for knowing little about
Project Houston. He was conducting a missing person investigation into
the disappearance from the Village of one gay man. He knew virtually nothing
about the other men who had gone missing from the Village and remained
unaccounted for. This was not his fault. It reflected the absence, in Toronto, of
any centralized oversight of missing person investigations. It reflected
inadequate communication with affected communities and even within the
Service itself in relation to Project Houston. And it reflected a failure to
employ major case management tools, internal and external, to ensure that
investigations did not operate in silos. Let’s face it: it was largely
fortuitous that Sergeant Dyck found out about the earlier missing men and the
similarities among all these cases. By “fortuitous” I mean, for example, that
retired superintendent Byrnes happened to see his Esen-related tweet
and
commendably wrote to him to ensure that he knew about the other
disappearances. Others within the Service, though not active on these cases,
told Sergeant Dyck about the other cases as well. The police cannot count on
these fortuitous interventions to advance their investigations.
Second, by the end of May 2017, 30 days after Mr. Esen was
reported missing, provincial adequacy standards required that the Esen
investigation be designated as a major case. Plus, in June 2017, even the police
were concerned that foul play was involved in Mr. Esen’s disappearance. In
my view, the circumstances of his disappearance, taken together with the
similar cases, did raise a strong possibility of foul play. But the Esen
investigation was not designated as a major case until it was incorporated
into Project Prism.25 Nor did there appear to be any systemic consideration
within the Service about whether it or other missing person cases should be so
designated.
A major case designation is not the answer to all shortcomings of an
investigation. That is clear. But, as I have repeatedly explained, such a
designation facilitates a more thorough, properly resourced investigation and
increases the likelihood that links to other major cases will be established.
Third, there was institutional resistance to the notion that these cases
might be linked and that a serial killer might be preying on Toronto’s
LGBTQ2S+ communities. This systemic failure is perhaps the most troubling.
Some officers understood fully why the disappearances of four gay / bisexual
men might well be related. Several officers reached out to Sergeant Dyck to
ensure that he was aware of these other cases. But it took several months
for the Service to decide to initiate Project Prism – and that took place
only because Mr. Kinsman went missing. I am unconvinced that the decision
would have been made to have a task force or project investigate all these
disappearances if Mr. Kinsman had not gone missing. Indeed, even after Mr.
Kinsman disappeared under suspicious circumstances, it took the Service
unwarranted time for that decision to be made. In my view, this decision was
made primarily as a result of pressure from the public and those close to Mr.
Kinsman, media coverage, and advocacy within the Service.
Some officers told the Review that the police must make decisions –
including the decision to launch an investigation into multiple disappearances
– based on evidence, not speculation, and that they must not jump to the
conclusion that disappearances are attributable to foul play or to a serial killer.
I understand, all too well, that, as evidence is collected, police cannot
jump to conclusions, too quickly presume what happened, or prematurely
25
In fairness, the tracker programof the Service’s MCM Unit did enter Mr. Esen’s disappearance into
PowerCase when it identified Mr. Esen as having been missing for more than 30 days.
narrow their investigative perspective. But that misses the point here. There
was ample circumstantial evidence that indicated a strong possibility that these
cases were connected and deserved a high-priority, coordinated investigative
response. There was ample community concern about the possibility of a serial
killer to investigate that concern properly and without delay.

Public Warning
In mid-July 2017, Superintendent Riviere raised with Detective Sergeant
Richmond, who in turn advocated to Corporate Communications, that the
Service issue a public safety media release in relation to gay men using social
media dating sites to arrange sexual liaisons. It appears the release was vetoed
by the director of corporate communications 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. It was pointed
out that there was no evidence to establish such a connection. No such release
was issued until December 2017.
In the Jane Doe case, the Service was soundly criticized for failing to
warn women about a sexual predator operating in the community.26 It was
commendable that Superintendent Riviere and Detective Sergeant
Richmond
were alive to the issue.
The Service does have a procedure governing community and public
safety notifications.27
During the Review, I did not fully explore the decision-making process
around whether a warning should or should not be issued. I frankly see no
impediment to issuing such a warning regardless of whether the evidence has
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, I believe that such a release was
unlikely to jeopardize the ongoing investigation in any meaningful way.
I also question whether decisions around the propriety of a public
warning should be made or vetoed by Corporate Communications, as opposed
26
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 la ter appointed an independent auditor, Jeffrey Griffiths, to examine the Service’s sexual
assault investigations. His report is summarized in Chapter 11.
27
Ontario Regulation 265/98, entitled Disclosureof Personal Information and issued under the Police
Services Act, permits the disclosure of personal information, subject to certain conditions. During Project
Prism, Community / Public Safety Notifications RO 2016.02.08–0158, made pursuant to Ontario Regulation
265/98, was in force.
to the investigators directly involved. I address this point in my
recommendations.
Regardless of the merits of issuing or not issuing a public warning at
that time, the systemic issue of importance is the need to make these kinds of
decisions in partnership or consultation with community leaders. The leaders
of affected communities are well situated to advise the police on whether a
warning should be issued, how it could most effectively be worded, and how
to avoid language that would appear to delegitimize how members of the
LGBTQ2S+ communities may connect, particularly when certain avenues may
be unavailable or less available to them because of their marginalization. But
trust must exist between communities and the Toronto police in order to have
those kinds of important conversations.
There are other indications that members of the Toronto police do not
entirely trust all the communities they serve. The affected communities
remained largely uninformed about Project Houston. The police did not want
to tell the affected communities that Project Prism was being taken over by the
Homicide Unit, anticipating “political explosion” if this information came out.
These decisions are often cloaked in concerns about maintaining the
integrity of ongoing investigations. In my view, however, overemphasis is
placed on this concern.
Equally important, the Service generally and many officers in particular
fail to appreciate that 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 because they feel the police do not trust them, investigations
will inevitably suffer, and public confidence and support for the police will be
eroded. Indeed, that is precisely what has happened in Toronto, especially in
traditionally marginalized and vulnerable communities. My recommendations
suggest a fundamental shift in how the police share information with
communities.

The Investigation into Mr. K insman’s Disappearance

Detective Radford led the initial investigation into Mr. Kinsman’s
disappearance. He showed dedication and skill in the interval between his
initial involvement and the launch of Project Prism. It was appropriate that, as
a member of Project Prism, he continued to investigate the other
disappearances as well.
Overall, I was impressed with the quality of the Project Prism
investigation, particularly once the police discovered that Mr. Kinsman left his
home on June 26, 2017, in a red van. The investigators showed commitment
and skill in identifying McArthur as a killer and ultimately, together with the
Office of the Chief Coroner, in identifying McArthur’s eight homicide
victims. During this same period, and extending to McArthur’s guilty
pleas, Project Prism officers showed sensitivity and compassion in dealing
with affected loved ones and communities, including McArthur’s survivors;
that is, others who had been victimized by McArthur, but lived to tell about it.
In its outreach, the project also involved the LGBTQ2S+ liaison officer. I
have criticized Toronto police when they got it wrong. It is no less important
to acknowledge them when they got it right. I am also mindful of
conscientious officers such as Detective Dickinson, who built respectful
relationships with vulnerable witnesses and loved ones of those who were
murdered and continues to take steps to prevent unnecessary intrusions into
their privacy.
Having said that, I do wish to highlight some systemic issues manifested
shortly before and during Project Prism.

Case Management and PowerCase

In Chapters 4 and 6, I explain how Project Houston failed to meet provincial
adequacy standards relating to major case management and to its use of
PowerCase, the provincially mandated case management system.
As I indicate earlier, officers who worked on both Project Houston and
Project Prism described greater structure to Project Prism’s investigation and
greater adherence to major case management principles. More data was
entered into PowerCase during Project Prism, 28 and greater use was made of
the software.
That said, during Project Prism, actions were still largely managed
manually through the P Drive29 rather than through PowerCase, contrary to
directives in the existing Major Case Management Manual. The lead
investigator managed tasks through an Excel spreadsheet he created in the P
Drive.
It is important to manage tasks and monitor their completion during
complex investigations and avoid allowing them to fall between the
cracks. This point is best illustrated by an example of a shortcoming both in
the initial investigation into Mr. Kinsman’s disappearance and in Project
Prism.

28
During Project Prism, about 200 officer reports or notes, 155 witness statements, and about 800 other
documents (including media reports, search warrants, emails, pathologist’s reports, financial records, tracker
summaries, and internet-based information), were entered into PowerCase.
29
An internal computer hard drive set up to store everything relevant to the investigation. In Chapter 4, I
describe in some detail the role of the P Drive in the Service’s major case investigations.
 Almost immediately after Mr. Kinsman went missing, the police
obtained evidence that he was last seen on June 26, 2017. Several witnesses
appeared to narrow the time he was last seen, although, of course, the police
had to keep an open mind on the precise time he disappeared.
As early as June 30, 2017, Detective Radford gave instructions to an
officer to obtain the video footage from 72 Winchester Street for June 26,
2017, between 1:00 p.m. and 4:00 p.m. The video footage was obtained the
same day. However, there is no evidence that it was viewed until August 23,
2017, almost two months later. Of course, as we now know, it proved to be the
most important lead obtained in the case. It showed Mr. Kinsman’s departure
at 3:07
p.m. on June 26, 2017, in a red van later connected to McArthur.
During Project Prism, a number of actions were entered into PowerCase.
For example, the Incident Log for PowerCase shows that an action to “Follow
up with Service Canada” (Action 56) was created on August 15, 2017. The
associated Action Form shows that this action was completed on September
27, 2017, and marked “concluded.” Action forms show the date of a given
assignment, details about the assignment, the priority to be given to the
assignment, and, on completion, the date the assignment was completed and
whether any follow-up investigation is required.
Many of the actions in the Project Prism PowerCase file do not
have associated Action forms. The Review was told that some actions do not
have Action forms because some actions were assigned and completed
before Project Prism officially began. For example, on June 30, 2017,
Detective Constable Wong had been assigned to obtain the video from 72
Winchester Street. He completed the assignment on the same day, and
prepared a Supplementary Report dated July 4, 2017, to record that he had
completed the assignment.
Detective Constable Wong’s assignment was retroactively entered into
PowerCase as Action 49 on August 15, 2017. However, the
Supplementary Report, to the effect that the assignment had been completed,
was not entered into PowerCase until March 16, 2018 30 (after McArthur’s
arrest), and no Action Form was completed.
On the same date as Action 49 was retroactively entered into
PowerCase (August 15, 2017), an action was also created in PowerCase to
review the video from 72 Winchester Street (Action 59). The action was
marked as “unallocated” in the PowerCase file, meaning it was not
assigned to anyone. No Action form was completed for this action.
Detective Constable
30
Data are required to be entered into PowerCase within 30 days. Neither Project Houston nor Project Prism
complied with this requirement.
Weatherbee, who ultimately reviewed the footage with Detective Constable
Coffey, told the Review that he believes he was given his assignment orally.
On August 23, 2017, Detective Constable Coffey watched the video and
recorded in his memobook notes that Mr. Kinsman could be seen getting into
the van. Detective Constable Coffey’s notes were entered into PowerCase as a
report on February 8, 2018, well after McArthur’s arrest and the end of the
project.
The key question that remains is why it took approximately two months
for Project Prism to review the surveillance footage obtained from the building
across the road from Mr. Kinsman’s apartment building. The Review was told
the police did not know precisely when Mr. Kinsman went missing until the
end of August, when they pinpointed the time he sent his last email. Detective
Constable Coffey did not watch the surveillance footage until after that
determination had taken place.
I am not satisfied with this explanation. Investigators knew as of June
30, 2017, that Mr. Kinsman’s cellphone had last been used on June 26, 2017.
As already indicated, several witnesses described when Mr. Kinsman was last
seen on June 26, 2017. Based on those interviews, Detective Radford sought
the video footage for June 26, 2017, between 1:00 p.m. and 4:00 p.m. On July
4, 2017, a witness told Project Prism that he believed he was the last person to
see Mr. Kinsman alive – on June 26, 2017, at about noon. Media reports at
least as early as July 4, 2017, also reflected that Mr. Kinsman disappeared on
June 26, 2017.
In my view, the potential significance of video footage at 72 Winchester
Street for the afternoon of June 26, 2017, was high. Viewing that video should
have been given top priority. But it appears to have fallen between the cracks.
It had not been done when Project Prism formally took over the investigation.
The officer who obtained the video viewed two other videos, but not this one.
It is clear that no one tracked completion of this task in a sufficiently prompt
manner.
Although many actions did not have associated Action forms, the
Project Prism P Drive did contain detailed information about many of the
actions listed in an Excel spreadsheet.
Action 49 reads, “obtain video from 72 Winchester Street,” with the
note, “attempt to locate MP [missing person] on surveillance video – retained
for 30 days.” The priority is categorized as “high,” and the date assigned is
June 30, 2017. The date completed is reflected as July 4, 2017. (Detective
Constable Wong gathered the footage on June 30, 2017, but completed his
supplemental report on July 4, 2017.)
 Action 59 in the Excel spreadsheet reads, “Review video from 72
Winchester, 51B Winchester Street and 537 Parliament Street looking for
MP.” No priority was assigned to this task, nor is there any indication of the
date it would have been assigned or the officer to whom it would have been
assigned. No Action form for this task was found in the P Drive. In other
words, there is no documentation that the task was assigned, if it was; when it
was assigned; or to whom and what priority it was to be given.
There is no evidence that anyone noticed this omission in a timely way.
It is hardly surprising that no one reviewed the video until August 23, 2017. In
my view, and without the benefit of hindsight, given what was known at the
time, this task should have been a priority item.
The cascading effect of such an omission is obvious. On August 16,
2017, officers found Mr. Kinsman’s calendar in his apartment. Detective
Dickinson noticed the name “Bruce” or “Bryce” recorded on the calendar for
June 26 at 3:00 p.m. Detective Dickinson advised the Review that, at that
point in time, the identification of “Bruce” was not a priority, nor was
“Bruce” considered a suspect. But if investigators had watched the video
footage before August 23, 2017, the identification of “Bruce” would have been
a priority, and Bruce McArthur may well have been categorized as a
suspect. He would certainly have been a person of interest.
Further, the police potentially missed an opportunity to obtain
surveillance footage from McArthur’s apartment building. On September 1,
2017, Detective Constable Coffey tried to get video footage from McArthur’s
apartment building for June 26, 2017, the date of Mr. Kinsman’s
disappearance. The footage was accessible only for 30 days and had been
overwritten. Had the officers reviewed the footage from 72 Winchester Street
sooner, they may have connected McArthur to the van and sought the footage
from McArthur’s apartment building sooner.
Fortunately, there is no evidence that the delay in viewing the video
resulted in any loss of life. However, as referenced above, Mr. Cribbin was
attacked by McArthur at McArthur’s apartment in July 2017, about one month
after the police obtained the surveillance footage from 72 Winchester Street.
Mr. Cribbin escaped by virtue of the fortuitous return of McArthur’s
roommate and his own decision to leave. Had Mr. Cribbin not been able to do
so, he could have been McArthur’s next murder victim.
On August 31, 2017, and September 1, 2017, excellent police work
connected one of the people in Toronto who owned an early-model red Dodge
Caravan, McArthur, to one of Mr. Kinsman’s Facebook friends. The evidence
accumulated in relation to McArthur. But it was only on September 5, 2017,
that Detective Constable McKenzie realized he had interviewed McArthur.
Detective Dickinson immediately saw the significance of the earlier McArthur
interview – it connected McArthur to all missing men from Project Houston.
The point here is not to criticize Detective Constable McKenzie for not
remembering the earlier interview sooner. That is understandable, given the
low level of importance assigned to the interview at the time. But case
management tools are supposed to prevent investigators from relying on
memory alone and allow them to search easily for relevant information.
Surely, once McArthur was connected to the red van, the police should have
been able to search the Project Houston records to see whether anyone named
Bruce came up in that investigation. That search was never carried out. It could
have been done more easily, of course, if work product had been uploaded
consistently into PowerCase or even the P Drive, for that matter. Indeed,
proper use of PowerCase could have triggered McArthur’s name in 2017, once
he was entered as a person of interest in 2017.
It is also unclear to me whether Project Prism notified the Peel
police that McArthur was connected to multiple missing men, including Mr.
Faizi, immediately on learning about that connection. This notification
obviously did not take place in November 2013 because the connection to Mr.
Faizi and the others went unnoticed at that time. As I observe in Chapter 6,
during Project Houston, the Toronto police did not even notify the Peel
police that silverfoxx51 was McArthur, despite their knowledge that this
username was found on Mr. Faizi’s notepad.

The Serial Predator Coordinator

As I previously indicated, the serial predator coordinator learned about any
investigation relating to the disappearances of McArthur’s victims only when
he read in the media about McArthur’s arrest. This lack of notification did not
represent an isolated failing, but a systemic issue for the Service. It became
obvious to me that a number of senior officers failed to appreciate when their
obligation to notify the serial predator coordinator arose.

The Violent Crime Linkage Analysis System

The OPP ViCLAS Unit recognized that something potentially significant was
taking place in Toronto involving multiple missing persons but received little
co-operation from the Toronto police in conducting its analyses. Only the
OPP’s perseverance resulted in Toronto’s preparation of ViCLAS
submissions, well after they were required. As it turned out, McArthur’s
victims, as far as we know, had a connection to Toronto, either based on their
residence or other links to the Village. But what if that were not the situation?
Or what if unidentified bodies reported to the ViCLAS Unit had represented
additional McArthur victims? The point here is that, 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 unidentified bodies. Unfortunately, this
approach represented another instance in which the Toronto police preferred
not to avail themselves of provincially mandated tools and supports. The
status quo is quite unacceptable.

The December 8, 2017, Press Conference

At the December 8, 2017, press conference, Chief Saunders advised the public
that “the evidence today tells us there is not a serial killer based on the
evidence involved.”
At that point in time, the Project Prism documentation reflected that

 By September 2017, McArthur had already been identified as a person of

interest in the disappearances of Mr. Kinsman and Mr. Esen and could
not be excluded with respect to the disappearances of the Project Houston
men;
 according to a November 12, 2017, email from Detective Dickinson to
Detective Sergeant Idsinga and Inspector Bott, McArthur was then a
suspect in the murders of Mr. Kinsman, Mr. Navaratnam, Mr. Kayhan,
and Mr. Faizi; and
 according to the Project Prism meeting minutes, as of November 14,
2017, McArthur was formally considered a person of interest in the
disappearances of Mr. Navaratnam, Mr. Kayhan, and Mr. Faizi.

As previously indicated, Detective Dickinson told the Review that the

meeting minutes were in error. According to him, McArthur was not elevated
to a person of interest in the Project Houston disappearances, and there cannot
be a person of interest in a missing person investigation without indication of
a crime’s having been committed. I disagree.

Ontario’s Major Case Manual defines a person of interest as follows:

A person whose background, relationship to the victim or the opportunity to

commit the offence(s) warrants further investigation but no evidence
currently exists to suggest culpability in the commission of the offence.
By contrast, the manual defines a suspect as follows:

A suspect is a person(s) of interest whom investigators believe had culpabilit

y in the commission of the offence(s) based on the evidence.

Evidence of the commission of an offence can be, and often is,

circumstantial. In the context of a missing person, there can be compelling
evidence that a missing person has been the victim of foul play, including
murder, based on circumstantial evidence.
The characterization of someone as a “person of interest” or as a
“suspect” is not dependent on whether “reasonable grounds” exist of that
person’s culpability or that a crime has been committed.
Unfortunately, the characterization of someone as a person of interest or
a suspect may be influenced, unintentionally or otherwise, by the purpose for
which the characterization is or is not being made. For example, although the
police may characterize someone as a person of interest or a suspect to support
the issuance of a judicial order, the police may be more reluctant to describe
someone as a person of interest or a suspect, or even to state that a person of
interest or a suspect exists, in communications with the public.
Viewed objectively, there is no doubt that, as of December 8, 2017,
there was circumstantial evidence that McArthur may have been or was
likely involved in the crimes relating to the disappearances of all five of
the men connected to the Village who were then known to be missing.
Indeed, by December 8, 2017, the circumstantial evidence of his
involvement was compelling, if not yet overwhelming.
Regardless of these characterizations, it was inaccurate, and
unfortunately misleading, to say that the existing evidence told police
affirmatively that there was not a serial killer in Toronto. In my opinion, the
evidence simply did not support that conclusion. To the contrary, even if the
evidence was not conclusive at that point, the police were intently focused on
McArthur because it appeared that all roads led to him.
I do not believe that Chief Saunders deliberately misled the public. I
accept that he may have had an imperfect understanding of the state of the
investigation and may have failed to ensure he was fully briefed on it when he
returned to duty. He may also have been much less careful than the
circumstances required in how he conveyed his understanding.
Although I do not attribute malevolence to these statements, as some in
the communities do, these statements had the effect of further rupturing an
already precarious relationship with the LGBTQ2S+ communities. When
McArthur was identified as a serial killer shortly after the press conference,
community members felt betrayed. Although the evidence grew stronger
between the press conference and McArthur’s arrest, the statements were
misleading when made.
Nor was it necessary to mislead the public to preserve the integrity of
the ongoing investigation. McArthur was under surveillance. The chief of
police could candidly have indicated that investigators were carefully
considering whether the disappearances were explained by a serial killer or
could have conveyed, in some other way, that the investigation was
progressing but that he was unable to share more information at the time so as
to not jeopardize the work being done.
Chief Saunders’s statement was unfortunate because it reinforced the
views of some community members that the Service and its chief of police
were indifferent to their fears and concerns and too willing to discount
prevalent views that a serial killer was at large.

Chief Saunders’s Globe and Mail Interv iew

Many members of the public, most particularly in the LGBTQ2S+
communities, were deeply offended by Chief Saunders’s later statements to
the Globe and Mail. These statements were summarized earlier in this chapter.
Chief Saunders felt he was misquoted or that his comments were taken
out of context. He publicly released an audiotape of his interview to support
his position. (See the partial transcript reproduced at the end of this chapter.)
Although, again, I do not attribute malevolence, as some do, to Chief
Saunders’s comments, they were poorly worded and, in some important
respects, unfortunate. I cannot find that the Globe and Mail misquoted him or
even took his comments out of context. The Globe and Mail did place
particular emphasis on the more controversial feature of the interview in its
headline and in the content of the article.
I say that the chief’s comments were unfortunate and poorly worded for
several reasons.
First, he said several times that nobody came forward to assist the
police, and that the police did everything they could do with the evidence they
were given but could not act without evidence.
There can be no question that it was inaccurate to say that nobody came
forward to assist the police. Many people came forward to assist and are to be
commended for it. Indeed, at a meeting on August 1, 2017, Inspector Code
credited the community for providing an abundance of information to the
police.
 Understandably, those who did so were disheartened by the chief’s
blanket statements that nobody came forward. They and others believed the
chief was blaming the public for the Service’s failure to apprehend McArthur.
In fairness, Chief Saunders made these statements in the context of
public revelations about what people were now saying about McArthur –
revelations that police were previously unaware of. This prompted him to say
that people were self-vetting out of concern about falsely implicating someone.
But Chief Saunders failed to acknowledge that reluctance to come
forward may also be rooted in concern over how information is likely to be
used by police; by the legacy of mistrust toward the police based on prior and
ongoing interactions; and by the lack of information provided to the public
about the focus of the investigation and what kinds of information police were
looking for. As stated earlier, with limited exceptions, the police did not
effectively use its officers closely connected to the affected communities
or community organizations, neighbourhood associations, and community
leaders to build trust and encourage people to come forward. Simply put, the
emphasis on the community’s responsibility for the inability of the police
to
solve the disappearances was misplaced.
Equally problematic, Chief Saunders was unequivocal in saying the
investigation was well executed without any internal or external review’s
having even taken place at that point in time. He qualified his comment only
when pressed by the questioner. It did not inspire confidence – at least, in any
internal review process – when it sounded as if the issue had been prejudged.
And, as we now know, he was wrong. It would have assisted in repairing the
relationship with affected communities if Chief Saunders had reserved
judgment on the Service’s performance.
Finally, Chief Saunders reiterated the accuracy of what he had said at
the December 8, 2017, press conference about the presence of a serial killer in
the community. As he acknowledged during the Review, the chief would have
said something different had he known the state of the investigation at that
point in time. It would have been preferable if he had properly informed
himself of the accuracy of his earlier statement before reasserting its accuracy
several months later.
Words matter. However inadvertent, Chief Saunders 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.
Bias, Discrimination, and Differential Treatment
A number of community members believe the police truly investigated the
disappearances from the Village only when Mr. Kinsman, a white man, was
reported missing. Some community members focus on the fact that the other
missing individuals were racialized; some focus on the fact that they were gay
or bisexual; some focus on other demographics or circumstances or the
intersection of these circumstances that made each vulnerable and
marginalized. Other community members discount the fact that these were gay
men, noting that this demographic was shared with Mr. Kinsman. They
observe, as a point of differentiation, that Mr. Kinsman was a well-known,
established presence in his community and supported by a large cadre of
friends and loved ones who mobilized in a highly visible way when he
disappeared. Their powerful voices, together with the previously reported
disappearances of five gay / bisexual men from the Village, could not be
ignored by the police.
The perception that the police had failed to treat the prior missing person
cases seriously is understandable for at least two reasons. First, there were
clearly flaws in the earlier investigations – serious flaws that invite
scrutiny over whether overt or systemic discrimination explains them. Second,
it cannot be disputed that the Service failed to provide the public with
meaningful information about the earlier investigations. Even the
existence of Project Houston was essentially unknown to the public. This
lack of transparency contributed to the perception that, prior to the report of
Mr. Kinsman’s having gone missing, the Service had done little or nothing
to investigate these disappearances. Indeed, a number of officers told the
Review that, without jeopardizing the investigative work, the Service could
have done, and should have done, a much better job of communicating with
the affected communities.

***

In British Columbia, Justice Wally Oppal examined the investigations

conducted into the disappearances of vulnerable women from
Vancouver’s Downtown Eastside. Robert Pickton was implicated in many of
their deaths. Over the course of several years, the police ignored or failed
to properly investigate numerous leads concerning the women’s
disappearances, leads that incriminated Pickton. Justice Oppal concluded that
systemic bias against the women who went missing contributed to critical
police failures in the investigation of their disappearances. He found that the
police investigators cared about the missing women and were not overtly
biased. However, he
found that systemic bias, based on broader patterns of systemic discrimination,
was clear in the unreasonable departure of the police from the commitment to
provide equal services to all community members.
Here, the public is entitled to know what role, if any, overt or systemic
bias or discrimination played in the McArthur-related investigations. This
issue must be examined through a human rights lens. I do precisely that in
Chapter 12 of this Report.

Audiotape Transcript (Partial) of Chief of Police Mark

Saunders’s Interview with the Globe and Mail

Q: Is there something the community doesn’t understand about Project

Houston? There is a widespread sense that something went wrong, what don’t
we get?

Chief Saunders: There are a couple of things, first and foremost, when we deal
with Projects Houston and Prism and of course the eventual arrest, this was
something that hasn’t happened in our city before. We’ve sat back and
watched CNN and watched the news reports on serial killers in other countries,
but we haven’t seen it here. I can tell you from a police agency, if I were to say
what was the frustrating piece, I think that everybody takes a role in this one.
When we first came into play with Project Houston, when I look at the
amount of resources that were put in, I thought that we clearly were listening,
but the issue was, that we didn’t have any evidence that allowed us to move
any further. There is a responsibility piece for us as an organization, where if
you’ve got evidence and if that evidence is moving you, you go with it, and
you continue to go with it, and then there are parts when it evaporates and
there’s no more evidence whatsoever, and you’ve put up your pamphlets and
you’ve canvassed and you’ve patrolled and you’ve interviewed and you’ve
examined interviews, and you’ve created different tasks and responsibilities
and roles for people to do, and there is nothing left, then we have to wait until
more evidence comes in. And we didn’t have evidence, and I, the one thing
that I, I would say from a level of confusion is, and I now have the privilege of
hindsight like everybody else, because I’ve been reading the amazing
things that have come up now since we’ve made the arrest, and I’ve heard a
lot of
sources say certain things and had those sources said those things when we had
Project Houston up, I think that there’s a very strong potential that the
outcomes could have been different.
A lot of people self-vet, and I learned this in Homicide, where you may
have a piece of the puzzle, but you will vet it on your own, and when I say that
it’s – here’s the encounter that I had with this person, but I don’t necessarily
think that that person would do all of these things, so I’m not going to report
that to the police, because my fear is that if I say this, the police are going to
go and arrest this person for something that could be incredibly egregious and
I don’t want to be a part of that process, and not realizing that there’s a much
bigger picture. And we get this predominantly when it comes to that self-
vetting piece, we get this with sexual assault investigations, with, when you
have the bad date type of setting, and people will not understand that if things
aren’t reported it emboldens the suspect. And when we start arresting,
especially for sexual offences, and we put up the picture, and we say we’re
putting this picture up because we believe that there will be more that will be
reporting, there will be more that will be reporting, and 9 times out of 10, more
people report. And so, had that first person been brave enough, and I
understand why people don’t, it’s their right to make those choices.
But there’s always a bigger picture, and if it gets reported at the very
front end, that cascading effect of not emboldening that particular suspect gets
reduced, but a lot of people, for whatever reason will self vet. I think that the
justice system has a piece to do with it and there are other factors as well too,
and I’m hoping that there are opportunities to look at the law, and are
there other ways in which we can look at the justice system for any gaps of
any kind that can deal with some of the pressures that are existing today in
today’s world, because I really do think that there are some things and some
concerns with me when it comes to the judicial system, a big one for me is
with street gangs.

Q: You’re talking about reluctance from sources? How much did the
demographics of the missing men affect this issue in Project Houston?

Chief Saunders: It didn’t affect. I would not put my hand up and want to be
Chief of an organization if I thought that, understanding that we are the
most multi-cultural city in the world, I’m of the belief that all of my officers
will do the right thing for the right reasons. And if anyone makes decisions
because of race or demographics or any of those things, I’ve got a problem
with that.
Q: I don’t mean to say that your officers are racist, but you have people who
went missing, and they were vulnerable people, with financial issues who were
not out of the closet, I wonder if comprehensively it can – funnels them into
believing that they disappeared on their own volition.

Chief Saunders: No. When we do investigations of – the one thing that

you don’t do is you don’t funnel. You open all your lanes. You open all your
lanes and then you lead to your conclusion that’s based on the evidence. But if
you do investigations right, you’re never closing doors. And we’ve learned that
from days of old, where that’s exactly what we’d do, we’d funnel in, so the
fact that we’re open, that means we’re receptive to everything that comes in,
from any lane, and we will investigate it to its fulsomeness, until it closes and
then we will slowly cascade it, and so no, I, having worked Homicide, and I
heard that narrative quite a bit, you know, because someone is of a certain
way, you don’t put time or effort into it, but when someone is another way you
put lots more time and effort, and that is just not true. Categorically untrue.
We investigate based on the evidence that we have and based on the
willingness for people to talk to us, to give us that evidence, and there are
complications with investigations, I readily admit, there are hesitations with
people wanting to get involved in the judicial system. And if you say that, for
me to gather evidence, for me to bring it into a courtroom right now, I have to
bring you into a room and I have to put the DVD in, and I have to have you
swear or affirm that you’re telling the truth, and it’s going to be recorded, and
it’s going to be going to defence counsel, then I’ll conduct my investigation,
and once the interview is over, I take that out, because that sworn testimony,
if I don’t have that, it’s not going into the courtroom. So, you can’t sit with me
and say I’m going to give you everything, but I’m not going to go to court.
That doesn’t become evidence.

Q: Wasn’t this in the end though a pretty serious failure by Toronto police? I
mean, we had a serial killer abroad in the city for several years now. And
everybody in the gay community, not everybody, but many people in the gay
community suspected that might be the case, and you didn’t see it. Isn’t that a
failure?

Chief Saunders: No. And listen, we knew something was up, which is why we
went in to begin with. We did not have the evidence, and working it back
again, in hindsight it is very clear that he was able to navigate in the
community, he had friends, family, loved ones, he would be in bars, he was
Santa Claus, all of these things, and all the while, nobody knew. If anyone
would know before
us, it’s people that knew him very, very well. And so that did not come
out. And I’m not, this is not, I’m not going to point fingers, because we’re past
that. The loss of life is catastrophic here, and to move forward, what can
we do better? Our role is to follow the evidence. And if you don’t have any
evidence then you dig harder, to see, to make sure, you do the double check
with all of these investigations, you don’t just sit back on your hands and go,
nothing’s coming in, see you later. We go out and we aggressively try to
pursue and look for that. We knew that people were missing and we knew that
we didn’t have the right answers. But nobody was coming to us with anything.
Nobody.

Q: Can I just stop you there – you started this by saying that a lot of people
had a lot of different responsibility. But then you seem to suggest that the
community had to take responsibility for not coming forward to give you guys
more evidence. In December, you said you were going to launch a professional
standards review of how you handle missing cases. Yet here today you’re
saying, we did everything we could have, so, is there not a moment of
reflection right now, where you’re questioning did, we do enough, and are you
looking at your force, and thinking, did we do enough? Have you asked for
reviews? Or are you sitting here today, saying, no, we did everything,
absolutely everything we could have?

Chief Saunders: Well, we’re talking specifically about an investigation.

Q: I am talking about that investigation. You’re under a lot of criticism from

the community on that one. You seem to be saying, no, we did everything, so
is that where you stand? Are you going to ask for a review? Are you
asking your investigators to look into how they handled things?

Chief Saunders: They are looking into, yes, the missing persons portfolio, I
want to have a look at what we knew, when we knew it, and what did we do
with it, and I think that is critical. And you’re right in the sense that with the
public trust issue there are some huge concerns and I need to figure out exactly
what the cause of that is. I have, I can tell you that when it comes to any type
of, I don’t know the details to, the details to the McArthur investigation, but I
can tell you that it will be thoroughly examined, and if there are things that we
did wrong, I certainly will take ownership for that.

Q: And how are you moving to find that out? Have you asked for there to be
an investigation, what is happening actively to know if you guys did – ?
Chief Saunders: Right now there is an active investigation, because we have
certain investigations, we’ve got Alloura Wells, we’ve got Tess Richey, and
we are looking at those particular missing persons reports and investigations,
and we are figuring out exactly where were the gaps, the fact that a
mother found her daughter is something that I find horrific, and I think the
public found horrific as well too, and it’s certainly something that I could not
even, I don’t want to start to begin with what the emotions would be with that,
but we need to take that look to see where the gaps were with that.
And that’s when we’re dealing with over 4,000 missing people a
year. We have an incredibly high success rate, but what do we do to get better,
and that’s the overall objective of that particular thing. I do think that when
we’re dealing with a serial killer, you can’t package those two together. And so
with that particular issue, we have an opportunity to meet with the
community, which is what we are moving forward on, we definitely want to
sit down and listen to what the issues and what the concerns are, and if there
are things that we can do to increase relationships … things that we can do
operationally … better, then I am willing to hear that. So, I don’t mind
speaking on what we did, and, was I satisfied with what we did? At the time,
with the information that we had, the answer to that is yes. The answer to that
is yes.

Q: Why did you say so definitively in December that there was no serial
killer? You said there was no evidence –

Chief Saunders: That was cherry picking. I’ve been reading the reports, and I
don’t have that luxury of cherry picking. I said, based on the evidence that we
have right now, there is nothing that indicates that we have a serial killer. And
that is something that I am fine with, because I understand law. When I said
that, it was because that was the evidence that had been scrutinized for years
that came up with, was something going on that was bizarre – absolutely. I
don’t think anyone didn’t think that something was going on. We all knew that
something was going on. But we did not have the evidence. Nobody came in.

Q: It’s possible at the time that it was a serial killer, wasn’t it? You knew
something odd was going on, all these people disappeared, were disappearing,
why say definitely not a serial killer?

Chief Saunders: I didn’t say that. I said that based on the evidence, and that
was the fair statement. Because things shifted very, very dramatically based
on a particular day and then based on that evidence we received that day,
actions
were taken immediately and so if we had that before, it would have been a
game changer, but it just was not. And like I said, when this unfolds, I would
be open to any type of inquiry at the end of the day, I think that there are levels
of frustration because you know, we live in that world where we deal with law.
We deal with law.
And it’s a much harder pill to swallow if you truly don’t understand
what it’s like in the courtroom, trying to defend a case. I’ve had cases,
homicides, where the evidence was there and it comes back not guilty, so
understanding law and the frustrations of law are another layer that a lot of
people don’t know or understand, nor do they want to understand. I think that
at the end of the day, that the emotions are real, is there fear? Yes. Is there still
fear? Absolutely. And what can we do to go forward to build and develop the
relationships that are necessary so we can open those lines of communication,
and I also have to ask, is there something within our policing environment
that’s causing people not to want to come and talk to us, and not give us those
tidbits? I don’t know. So hopefully out of this, there’s an opportunity to learn a
little better.

Q: If you had said at that time, we don’t have any evidence that there’s a serial
killer, but we’re worried that there is, is that something you could say, would
that have compromised your evidence, or –

Chief Saunders: No, I’m not going to, no. I can’t speculate. I don’t think that I
have that luxury. You can, and in fact many people did. But we can’t do that.
That’s not my role, to speculate, to say, however, this could be the case.
Because if it comes out that’s not the case, it could, then if it’s two or three
different people doing different things, then all of a sudden, I’ve opened the
defence counsel to have a heyday in the courtroom. I don’t have that, that’s not
a role that I’m going to deal with. I have to stay on what I have, that is
tangible, that will stay solid.
I may not like it, but at the end of the day, on that moment, on
December 8, when I said what I said, I did not say that there was not a serial
killer, I was not being coy with the words, I put that statement out because
that was what
we had at the time. And it was the entire statement, not just partial statement.
It was the entire statement that obviously didn’t get communicated properly.
But I was pretty clear with what I said and why I said what I said at the time.
And I was asking the very same questions, because I wanted to make sure that
when I’m going say what I’m going say, I need to know. And so, the
investigators at the time, that’s what they had.
 Chapter 8 Tess Richey Goes Missing 297

Chapter 8

TESS RICHEY GOES MISSING

In Chapters 5, 6, and 7, I describe and evaluate the McArthur-related

investigations conducted by the Toronto Police Service (the Service), most
particularly those relating to the disappearances of Bruce McArthur’s
homicide victims. My mandate also requires that I examine the investigation
the Service conducted into the disappearance of Tess Richey. Although her
disappearance and death were not attributable to McArthur, they came at a
time when community members, particularly many in Toronto’s Gay Village
(the Village), were deeply concerned about the prospect of a serial killer in
their midst. The fact that Ms. Richey’s mother – rather than the police –
discovered her body, and that her body was very close to where she was
last seen alive, heightened community skepticism over whether the
Service was doing everything it could to solve these disappearances.
This chapter scrutinizes the Service’s investigation into Ms. Richey’s
disappearance. It identifies what the police did and did not do, and, ultimately,
what should have been done differently.
After Ms. Richey’s body was discovered, the Toronto police conducted
a homicide investigation that led to the arrest and prosecution of Kalen
Schlatter for murder. For two reasons, I have not evaluated that investigation.
First, my mandate is focused largely on how the Service has conducted
and continues to conduct missing person investigations or investigations
into unidentified bodily remains, and on whether cases are turned over to
the Homicide Unit in a timely way. It does not include the Service’s work
once a body has been found and identified and the case has been turned over to
the Homicide Unit. Second, according to the Review’s Terms of Reference, I
must not prejudice any ongoing criminal proceedings. When the Review
began, Schlatter was awaiting trial for first-degree murder. As a result, the
Review deferred interviews of several trial witnesses until the verdict had
been delivered.
On March 23, 2020, Schlatter was convicted of first-degree murder.
However, unlike McArthur, Schlatter denies his guilt. He appealed the verdict,
and the appeal has yet to be determined. I must therefore continue to ensure
that my Report does not prejudice the ongoing criminal proceedings. The law
also precludes me from expressing any conclusion or making any
recommendation regarding the criminal responsibility of anyone connected
with Ms. Richey’s death.
My Report has another limitation that relates to Ms. Richey’s case. Two
officers involved in the search for Ms. Richey are facing charges of
misconduct and neglect of duty under the Police Services Act.1 The hearing
into those discipline charges has not yet taken place. Although the
officers’ conduct is relevant to how the police investigated Ms. Richey’s
disappearance, I will not express an opinion on whether their conduct
amounted to professional misconduct. That is a determination to be made at
a discipline hearing based on sworn evidence and governed by the legal
protections and rights afforded to the parties at such a hearing.

The Missing Person Investigation

Tess Richey was born and raised in North Bay, Ontario. She moved to Toronto
to further her education. Once there, she attended George Brown College in
the Assaulted Women’s and Children’s Counsellor / Advocate Program, and
Seneca College for the Flight Services Program. She supported herself by
working as a server at the Brass Rail Tavern.

November 25, 2017 – Tess Richey Reported Missing

On the evening of Friday, November 24, 2017, Ms. Richey told one of her
sisters, Ms. AH, she was going with a friend to the Crews & Tangos bar
located at 508 Church Street in the Village. As Saturday progressed, Ms. AH
became increasingly concerned about her sister Tess. Uncharacteristically, Ms.
Richey had not spoken to her that day and was not responding to her texts. In
fact, she noticed that her most recent texts were not even being delivered.
She was particularly worried because Ms. Richey had been going through a
“hard time” in recent days since she discovered that her boyfriend had been
unfaithful to her. On her own initiative, Ms. AH contacted some of her sister’s
friends, her employer, and a number of hospitals.
At 9:15 p.m. on November 25, Ms. AH reported Ms. Richey missing to
Toronto’s 52 Division – the division closest to her own home. Because
Ms. Richey’s residence was located within the jurisdiction of 41 Division,
the Service’s procedures dictated that 41 Division, located at 2222
Eglinton Avenue East in Scarborough, had to be in charge of the
investigation. As a result, 52 Division passed on Ms. AH’s information to
41 Division, and officers there took over the case. However, officers at 51
Division, located at

1
RSO 1990, c P.15, as amended.
51 Parliament Street near the Village, were also heavily involved in efforts to
locate Ms. Richey because she was last seen in an area policed by them.
On receiving the Missing Person Report, two 51 Division officers were
dispatched to several hospitals to make inquiries about Ms. Richey. The
officers’ memobook notes indicate that a “300 metre check” was done around
the area of the Crews & Tangos bar and the nearby TD bank. One of the
officers reported the completion of this search to two senior officers.

November 26, 2017

Shortly after midnight on November 26, two police officers from 51 Division
met with Ms. AH to obtain further information. Ms. AH told them her sister
did not have any mental health issues, was not on any medications, and had no
financial problems. She also said she usually spoke with or texted her sister
every day, but in her attempts to make contact over the last several hours, she
had discovered that her sister’s phone was not in service.
Ms. AH provided the police with the following information about
Ms. Richey’s last known activity. After a drink at Ms. AH’s house on the
evening of November 24, Ms. Richey left to meet a friend, Ms. AI. Ms. AH
had since spoken with Ms. AI, who told her she was with Ms. Richey that
evening at Crews & Tangos. Ms. AI remembered she last saw Ms. Richey in
the vicinity of the TD bank at 65 Wellesley Street East, on the corner of
Church and Wellesley streets, just north of Crews & Tangos.
In addition, Ms. AH told the police about her sister’s breakup with her
boyfriend, Mr. AJ. The breakup had led to a Domestic Incident Report filed on
November 24. When the police read the report, they learned that Mr. AJ had
called the police, alleging that Ms. Richey had slapped him and taken his
cellphone. The officers who responded to the call had cautioned both parties
not to contact each other.
Ms. AH also provided the police with the name of her sister’s employer
and the name and contact information of a friend. She indicated that her
sister’s “Fitbit” app/page had been updated between 4:30 a.m. and 5:00
a.m. on November 25, but there had been no recent activity on her
Instagram or Facebook accounts.
After speaking with Ms. AH, the police took steps that same day to
locate Ms. Richey. One officer spoke with Mr. AJ, who said he had not
seen her since they broke up on November 24. The officer then went to
Ms. Richey’s place of employment and was told she had quit her job a few
days earlier. The police were unable to speak with Ms. AI. They called
some hospitals. Two officers went to Ms. Richey’s residence and found
nothing out
300 Independent Civilian Review into Missing Person Investigations

of the ordinary. The police continued to check Ms. Richey’s residence

periodically over the next three days as they searched for her.
The police obtained information from Uber that Ms. Richey’s name and
number were associated with a ride ordered around the time she disappeared,
but it had been cancelled or not taken. Uber could not provide any further
details about Ms. Richey’s account without a formal request.
At 4:00 a.m., one of the officers who had spoken with Ms. AH
completed a Search Urgency Chart and a Missing Person Report. The chart
indicated a rating of “low” and designated the occurrence a “level 1
search,” the lowest level of search under the Service’s procedures. The
Missing Person Report identified the area around 65 Wellesley Street East, the
address of the TD bank, as the area where Ms. Richey was last seen.
Ms. Richey’s family quickly became heavily involved in the effort to
find her. Ms. AH told the Review that, at some point on November 26, an
officer told her a detective would not be assigned to her sister’s case until
Monday, November 27. Ms. AH and her partner went to Ms. Richey’s
apartment and reviewed the messages in her laptop. Ms. AH also texted with
Ms. AI to retrace Ms. Richey’s steps the previous night. Ms. AI described a
house on Dundonald Street, one block north of Wellesley Street, where she
and Ms. Richey had been the previous night.
Ms. RR called 51 Division officers at 3:38 p.m. to ask them to
investigate the house on Dundonald Street (later determined to be 50
Dundonald Street) and described the house. She told them that this location
was where Ms. AI last saw Ms. Richey. A few minutes later, two 51 Division
police officers, Constable Michael Jones and Constable Alan McCullough, met
Ms. AH at the house. They all spoke with Ms. AK, a resident there. She
advised them she had seen Ms. Richey on November 25 around 3:00 a.m.
They had met that night by happenstance and chatted before exchanging phone
numbers. Ms. Richey left, walking west on Dundonald Street with a woman
(Ms. AI) and an unknown man, who Ms. AK described. The police later
alleged that the unknown man referred to throughout this narrative was
Kalen Schlatter. Ms. AK felt the officers were not taking the matter
seriously. She volunteered a great deal of information, but the officers did not
appear particularly interested. Constable Jones and Constable McCullough did
not conduct a 300 metre search around 50 Dundonald Street. Because Ms.
AK had told them she last saw Ms. Richey walking west along Dundonald
Street, the officers drove west along Dundonald Street and south down Yonge
Street, checking the street as
 Chapter 8 Tess Richey Goes Missing 301

they drove. They submitted a Supplementary Report briefly summarizing what

Ms. AK had said. It was directed to the officer in charge of the case.2
The Service’s Missing Persons Procedure 04-05 that applied at the time
provided that, when investigating a missing person complaint respecting a
level 1 search, the “first police officer” shall

 interview the last person to see the missing person, where possible;
 search the home and the immediate area thoroughly;
 if permission to search the home or adjoining property is not granted,
notify a supervisor and add the details to the original eReport; and
 canvass the neighbours.

The procedure did not define a “first police officer.” In August 2019, this
procedure was changed to require first police officers to complete a 300 metre
radius search of the place last seen, if known, or, if it is determined that a 300
metre radius is not required, to record specific details in the original eReport
(the Occurrence Report) and advise a supervisory officer. The August 2019
procedure still does not define a “first police officer.” I discuss the applicable
procedure in the Summary and Findings at the end of this chapter.
At 4:54 p.m., Ms. AI gave another officer a timeline of her night with Ms.
Richey. She said they left Crews & Tangos around 1:35 or 1:40 a.m. and
walked to 50 Dundonald Street around 2:30 a.m., where they remained outside
the residence. Ms. AI’s memory was admittedly vague because she had
consumed a lot of alcohol. However, she did remember last seeing Ms. Richey
around 4:00 a.m. Ms. Richey was sitting on the sidewalk in front of 50
Dundonald Street with the unknown man and Ms. AK. Ms. AI could not recall
how they met the man.

November 27, 2017

In the early morning hours of Monday, November 27, Ms. AH telephoned the
police at 41 Division to provide more information. She alerted them to the
possible existence of video footage of Ms. Richey at Crews & Tangos. She
stated that Ms. Richey banked at the TD Bank and that there is a branch on the
2
The original Occurrence Report was an electronic document, as was the Supplementary Report. There was
a requirement that the Supplementary Report be placed with the original Occurrence Report. When the
Supplementary Report was prepared, no lead investigator had been assigned. Detective Matthew Wighton,
from 41 Division Criminal Investiga tion Bureau (CIB), who was appointed as the lead investigator just
before 7 a.m. on November 27, believes he would have read the Supplementary Report at some point, but he
has no recollection of doing so. In this context, the reference to the “officer in charge of the case” appears to
be used to mean “the lead investigator” as opposed to the officer in charge of the day-to-day running of the
division.
corner of Church and Wellesley streets just south of 50 Dundonald, where she
was last seen (see map). Ms. AH also told police that Ms. AI had given her
additional information, including that she remembered they were with a man
that night. Ms. AI had said Ms. Richey may have left with the man, but
because of her own level of intoxication, she could not remember what he
looked like.

Locations Ms. Richey visited in the early hours of November 25, 2017

Note: Distances are not always accurately reflected (see text below).
Source: City of Toronto map, amended by the Independent Review.

After speaking with Ms. AH, one of the detectives at 41 Division

reviewed Ms. Richey’s Missing Person Report. At about 2:00 a.m. on
November 27, Toronto Police Operations published a tweet in relation to Ms.
Richey’s disappearance. This tweet marked the first public announcement the
police made about Ms. Richey’s case since the report of her disappearance on
the evening of November 25.
A few hours later, just before 7 a.m., Detective Matthew Wighton from
41 Division’s Criminal Investigations Bureau was assigned as the lead
investigator in Ms. Richey’s case. Detective Wighton was extremely busy that
day. He was working on several serious cases, including a robbery, sexual
assault, and human trafficking. Near the beginning of his shift, Detective
Wighton received a call from Ms. AH about her missing sister. Ms. AH’s call
was significant because Detective Wighton candidly told the Review that if he
hadn’t received her call that morning, he may not even have reviewed the
Missing Person Occurrence Report until sometime later or realized that the
case had been assigned to him.
At 8:35 a.m. the same day, Toronto police issued a media release, which
had been arranged before Detective Wighton started his shift. The release
included both Ms. Richey’s photo and a description of her. It indicated she had
last been seen around 3:00 a.m. on November 25 in the vicinity of Church and
Wellesley streets and stated: “[P]olice are concerned for her safety.”
Between 9:51 a.m. and 1:19 p.m., Detective Wighton had another
officer look into Ms. Richey’s banking activity. Her account had been dormant
since November 25 at 4:02 a.m., when there was an Uber charge for a ride the
police learned later she never took.
That afternoon, a supervising officer instructed officers to check for
video footage at Crews & Tangos and near 50 Dundonald Street.
At 5:55 p.m., the police at 41 Division formally interviewed Ms. AK.
She told the police that the apartment building just across the street at 41
Dundonald might have video footage of Ms. Richey. Ms. AK also showed
them phone messages between her and Ms. Richey. The last message was sent
at 3:44 a.m. on November 25. Ms. AK indicated that Ms. Richey had been
upset about her ex-boyfriend and had expressed suicidal thoughts. Ms. AK
repeated the earlier information she had given to police about having last seen
Ms. Richey walking west on Dundonald Street with Ms. AI and a man.3
She described the man as “nice” and recalled he did not say much. Although
this information was the second time the police (albeit from a different
division) learned that Ms. Richey had last been seen at 50 Dundonald Street,
no one made sure that a proper search was conducted for her around that
location.
All the while, Ms. Richey’s family remained active in the search. Her
mother, Christine Hermeston, as well as Ms. AL (another of Ms. Richey’s
sisters) and Ms. AL’s fiancé, had travelled from North Bay to Toronto to look
for her. The family distributed flyers in the Village and appealed to the media
for assistance. An article the CBC posted on November 27 at 11:20 p.m.
included interviews with Ms. Richey’s family and Ms. AI. The family also
3
Although both Ms. AK and Ms. AI told police they last saw Ms. Richey with the other person, this
information does not appear to have affected the police investigation in any way.
posted information about Ms. Richey’s disappearance on social media and
visited her place of employment.

November 28, 2017

On November 28, officers including Detective Constable Robert Chevalier, a
local neighbourhood community officer, 4 canvassed the Village. The 5195
community centre provided him with flyers the family had prepared about Ms.
Richey’s disappearance. Detective Constable Chevalier noted in his
memobook: “[T]here had been several other people missing, including Alloura
Wells[,] so I particularly wanted to find this person, as fear was beginning to
grow in the community.”
That day, the police canvassed a variety of locations for video footage.
For example, at 12:01 a.m., two officers went to 50 Dundonald Street and
found no video. However, the officers did obtain footage from Crews &
Tangos for the night Ms. Richey disappeared. The footage showed her
being denied entry back into the club at approximately 2:03 a.m. The video
picked up Ms. Richey again at approximately 2:15 a.m. as she and Ms. AI
walked north on the west side of Church Street.
Another officer on November 28 obtained video footage from Ms.
Richey’s residence, and he viewed it the following day. Ms. Richey did
not appear on it, indicating she did not return to her residence after the
early morning hours of November 25.
At 12:58 a.m. on November 28, Detective Wighton called
Emergency Medical Services to see if Ms. Richey or a “Jane Doe” had been
transferred by ambulance around the time of her disappearance, but there
were no such records. That same day, the police again searched her apartment
and talked to her employers. The police determined that the clothes she was
wearing when she disappeared were not in her apartment. They contacted the
Marine Unit and women’s shelters and searched the shoreline. None of these
efforts yielded any information about her.
Around 7:30 a.m., Ms. AM, a bar owner, called the police and told them
she had served Ms. Richey at her bar on November 24. Ms. Richey had
seemed distraught over her ex-boyfriend.
4
In May 2013, the Service implemented a Neighbourhood Community Officer Progra m within selected
neighbourhoods. The Village is part of this program. Neighbourhood community officers (NCOs) are
supposed to work in partnership with local residents and community-based organizations to a ddress
community safety a nd quality-of-life issues. Their mandate includes building rela tionships and solving
problems within their neighbourhoods.
5
The 519, formerly known as The 519 Church Street Community Centre, is an agency of the City of
Toronto and a charitable, non-profit organization operating a community centre in the Villa ge. The Richey
family told me about the invaluable moral and emotional support they received from The 519 during the
police investiga tion and subsequent murder tria l.
 At 7:33 a.m., Detective Glen Cecile 6 created a “to do” list for obtaining
further video footage, including at 41 Dundonald Street and other addresses
west of number 50. The police records state that at 3:00 p.m. and again at
3:59 p.m. that same day, another officer instructed officers to check for video
at 41 Dundonald Street and the surrounding area.
At 2:30 p.m., two officers searched Ms. Richey’s ex-boyfriend’s
residence. Nothing of any relevance was found. Later that day at 11:00 p.m.,
the police interviewed the former boyfriend. He described a disagreement he
had with Ms. Richey. Apparently, she had not indicated any intention to leave
town.
At 4:04 p.m., an officer went to Ms. Richey’s apartment and took
photos. The officer concluded there was nothing in the apartment indicating
that Ms. Richey had deliberately left the area.
At 4:38 p.m., an officer received and reviewed Ms. Richey’s phone
records. The last recorded phone call took place on November 25 at midnight.
The officer also determined that Ms. Richey’s phone was not responding to
pings, meaning it was turned off, out of range, or its battery dead.

November 29, 2017

On Monday, November 27, Ms. AK had suggested to the police that they
should look for video footage of Ms. Richey at 41 Dundonald Street. Although
on the morning of November 28, Detective Cecile had included that location
on a “to do” list for checking to see if video footage was available for the early
morning hours of November 25, and the task had been assignedlater that same
day, it was not until November 29 at 1:09 a.m. that police officers actually
went to 41 Dundonald Street to canvass for video footage. The reason for this
delay is not clear to me. When two officers finally did go to 41
Dundonald, they observed video cameras both there and at 576 Church
Street, on the southwest corner of Church and Dundonald streets, which could
have captured Ms. Richey’s movements. However, not surprisingly given the
time of night, no one was available at either location to allow them to view
the videos. At 1:15 p.m., officers returned to 41 Dundonald to check again for
the video. They were not able to access the video at that time, but a staff
member told them it would be provided later that day.
At 6:00 a.m. on November 29, the police checked Ms. Richey’s phone
records for leads, along with her social media accounts and a website she
frequented. Later that day, Detective Cecile and another officer worked on a
timeline of Ms. Richey’s movements on November 25. The police also
created
6
Detective Cecile, now retired, was Detective Wighton’s partner.
a map of what was known about her whereabouts. The timeline and map
showed the following steps:

 at 11:59 on November 24, a bank withdrawal was completed using Ms.

Richey’s bank card at the ATM located beside Crews & Tangos;
 Ms. Richey left Crews & Tangos between 1:35 a.m. and 1:40 a.m.;
 she walked north on Church Street toward Wellesley Street;
 she exchanged cellphone numbers with Ms. AK at 3:44 a.m. in front of
50 Dundonald Street; and
 she was last seen around 4.00 a.m. walking west on Dundonald with an
unknown man.

The police followed up on several reported sightings involving Ms.

Richey which were ultimately unverified. In one instance, a member of the
public reported to Detective Wighton that around the time Ms. Richey went
missing, he saw someone who looked like her at the McDonald’s restaurant at
470 Yonge Street. Detective Wighton reached out to 51 Division to see if its
officers could search the area immediately. He was told 51 Division
officers would not do it, though he was not given a clear answer why they
would not. As a result, he had to send two 41 Division officers downtown to
check this tip out. The officers met the person who provided the tip and
reviewed McDonald’s video footage. They concluded that Ms. Richey was
not the person seen at McDonald’s.
On November 29 at 1:47 p.m., two officers went to 576 Church Street to
check for video. Because the video was too difficult to view on site, the
staff agreed to transfer the footage to a USB key to give to the police later.
At 2:36 p.m., Detective Constable Chevalier was still looking for Ms.
Richey in the Village. He and another officer met Ms. Hermeston and Ms. AN,
who had travelled from North Bay to help look for Ms. Richey. The two
women asked the officers to check 50 Dundonald Street. The officers agreed
to do so. As well, they planned to continue looking for video footage. But
before they could do so, they learned that Ms. Hermeston and Ms. AN had
found Ms. Richey’s body.

Discovery of Tess Richey’s Body and the Aftermath

Tess Richey Is Found

On November 29, just before 3:00 p.m., Ms. Hermeston and Ms. AN were
looking for Ms. Richey in the area around 580–582 Church Street, an elegant
old semi-detached residential property located at the corner of Church and
Dundonald streets. This location is about 300 metres from Crews & Tangos,
and about 80 metres from 50 Dundonald Street. 7 The property was under
construction, and the building was boarded up. There was a large pile of gravel
in front of an outdoor staircase.
Ms. Richey’s mother found her daughter’s body at the bottom of the
stairwell – a mother’s worst nightmare. The fact that Ms. Richey’s body
was discovered by her mother during her own private search is, frankly, a
disturbing commentary on the quality or scope of the earlier search by the
police. Ms. Richey was found in the clothes she was wearing when she
was last seen. She had a purplish bruise on her face, but there were no obvious
signs of head injuries or trauma. She was lying face up and on her left side,
with her chin resting on her chest in an awkward position.
Ms. AN called 911. More than a dozen police officers as well as a
coroner, Dr. Anaїs Bélanger, soon arrived. Detective Wighton told the Review
that he did not get there from his office near Eglinton Avenue and Birchmount
Road until after the coroner and these first officers, who were probably from
51 Division, had released the scene8 and left the site. The early responders
included a forensic identification officer. By this point, the discovery of Ms.
Richey’s body meant that the investigation had become a sudden death
investigation within 51 Division’s jurisdiction, and was no longer a missing
person case with 41 Division.

Initial Reaction by the Coroner and the Police

Some police officers initially believed that Ms. Richey’s death was accidental,
based on the position of her body in the stairwell, her immediate surroundings,
and her consumption of a considerable amount of alcohol the night she
died. They theorized that she may have fallen down the stairs on her way
home. The early media reports reflected this belief that she died by accident.
Dr. Bélanger’s comments at the scene were interpreted in different
ways. Several officers stated that she told them Ms. Richey’s death did not
appear to be suspicious and could be explained by a combination of
intoxication and positional asphyxia9 or even hypothermia. Dr. Bélanger told
the Review that, at the scene, she did consider the possibility that Ms. Richey
had died from hypothermia after falling asleep or from positional
asphyxia, based on the
7
These distances are based on Google maps.
8
The police may “hold” a scene – that is, continue to cordon it off pending further forensic work – or
release it if they consider it need not be preserved as it was found.
9
Positional asphyxia is a form of asphyxia that occurs when someone’s airway is blocked because of an
awkward body position, preventing the person from breathing.
position of her head on her chest which, potentially, blocked her airway. She
indicated she did discuss these possibilities with the police. However, Dr.
Bélanger also told the Review that she treated Ms. Richey’s death as
suspicious until proven otherwise. Ms. Richey was a young woman who had
been found dead in a stairwell on a busy street after leaving a bar, and her
leggings were low on her hips. Dr. Bélanger therefore ordered an autopsy.
She said she told several officers that, until further notice, she wanted the
scene treated as suspicious and would follow up with a warrant for an
autopsy. She then left the scene to go to other calls.10 It was only sometime
later that she learned the police had released the scene.
The Service’s Preliminary Homicide Investigation Procedure 05-01
includes the following steps:

 Specialized Criminal Investigations – Homicide (SCI – Homicide) shall

… support field officers with the investigation of suspicious deaths.
 Officers are reminded to remain vigilant for the possibility of foul play in
every circumstance where there is a sudden, unexpected death …
 Upon discovering … a suspicious death or a suspected homicide, which
may include an unexplained or unknown cause of death … [or] any other
suspicious circumstances, [a first police officer] shall treat the death as
suspicious.
 When advised of a suspicious death or suspected homicide [the first
supervisory officer] shall … ensure a member of the On-Call Homicide
Team is notified.
 Upon being notified of a suspicious death or suspected homicide [the
divisional detective] shall … consult with a member of the On-Call
Homicide Team prior to leaving the scene. Note: The On-Call Homicide
officer will determine whether a Homicide investigator shall attend the
scene.”
 Upon being notified of a suspicious death or possible homicide [the
Officer in Charge] shall … ensure SCI – Homicide and FIS [Forensic
Identification Services] are notified. [Emphasis in the original.]

The officers at the scene did not contact the Homicide Unit as set out in
this procedure. I address this issue later in my findings.
Dr. Bélanger prepared a coroner’s warrant for post-mortem
examination. This warrant authorized a pathologist to conduct the post-
mortem

10
Dr. Bélanger told the Review that on November 29, 2017, she was the only coroner on duty in the entire
city. Changes have since been made so that there are now two coroners on call each day.
examination (commonly referred to as an autopsy) of Ms. Richey’s body.
It states, in part:

[D]eath appears to be accidental in nature, though foul-play cannot be ruled

out at this point. Positional asphyxia and/or hypothermia are likely
possibilities. A fall down the gravel pile to the bottom of the obscured
stairwell at night while intoxicated is a probable scenario.

On December 6, 2017, according to the memobook notes of

Detective Sergeant Graham Gibson, Dr. Bélanger told him and Detective Ted
Lioumanis, the detectives in the Homicide Unit who had been assigned on
December 1 to take over Ms. Richey’s case, that she felt pressured by the
officers at the scene to label the death as not suspicious. She advised the
Review, however, that she didn’t know if “pressured” was the right word to
capture what she expressed and felt. She felt the police at the scene took a
“narrow-minded view” of the circumstances of Ms. Richey’s death. They
appeared to have their minds made up that it was an accidental death and
quickly dismissed her concerns without really listening to her.

Further Steps Taken by the Police

November 29, 2017

Shortly after Ms. Hermeston discovered her youngest daughter’s body, the
police called an ambulance for her, and she was taken to the hospital for
assistance. A member of the Service’s Victim Services Program arrived soon
after to assist the family.
When Ms. Richey’s body was found, the police began an extensive
search for video footage in the surrounding area. Within a few hours, video
footage from 576 Church Street and 41 Dundonald Street was obtained
and reviewed. The police had gone to these same locations earlier in the
day to review the video footage, but had been unable to do so. The video from
576 Church Street showed Ms. Richey at 4:03 a.m. on November 25 walking
south on the west side of Church Street with Ms. AI and an unknown man.
The group then turned west on Dundonald Street. At 4:08 a.m., the group
walked east on the north side of Dundonald Street. They stopped in front of 50
Dundonald Street, Ms. AK’s home, where Ms. Richey spoke with Ms. AK.
Between 4:50 and 4:59 a.m., all three left.
At 5:09 p.m., officers from 51 Division as well as Detective
Wighton met with the Richey family at the hospital. According to the family,
the police told them Ms. Richey had probably fallen down the stairs and
bumped her
head. Detective Wighton does not recall anyone saying these words to the
family, but he agreed the police should not comment on the cause of death to
a family until that cause has been medically confirmed. Ms. Richey’s family
were in shock. They expressed anger that the police had never issued a media
release while Ms. Richey remained missing. An officer informed them that
one had been issued.
At 7:34 p.m., an Uber representative told the police that Ms. Richey
either cancelled the ride she was scheduled to take on November 25 from 50
Dundonald Street or was a “no show.” The representative agreed to
provide the driver with the detective’s contact information. Several months
later, police learned the Uber driver waited for Ms. Richey at 50 Dundonald
Street, but she did not show up – so the driver cancelled the ride.

November 30, 2017

The investigation continued. At 12:36 a.m., the police interviewed Ms. AL,
Ms. Richey’s sister from North Bay. They also spoke with another resident at
50 Dundonald, Mr. AO, who had seen Ms. Richey with an unknown man the
morning of November 25. Mr. AO gave police a description of the man.
At 12:49 a.m., two officers interviewed Ms. AI again. She described her
night with Ms. Richey. They were drinking and dancing at Crews & Tangos,
then walked north toward the intersection of Church and Wellesley streets with
an unknown man who they “picked up along the way.” She also recalled
meeting Ms. AK outside 50 Dundonald. There were portions of the night Ms.
AI could not recall because of her level of intoxication.
The police continued to collect video footage from a variety of locations
on and around Church Street. At 6:22 p.m., two officers obtained and reviewed
the video footage from 582 Church Street, the old mansion on the corner of
Church and Dundonald streets. This video showed Ms. Richey at 7:17 a.m.
holding hands and walking with an unknown man in the driveway of 580
Church Street toward the stairwell where her body was ultimately found. At
8:03 a.m., the man on the video could be seen leaving the area alone.
Supervisory officers were advised of this video’s contents, which later turned
out to be key evidence in the investigation.

December 1, 2017
The police continued to seek additional video footage from Crews &
Tangos and footage from various locations on Church and Wellesley streets.
They also conducted further interviews with Ms. AL, her fiancé, and Ms.
AH. Police attempted to contact Mr. AO again, to ask more questions.
Preliminary Autopsy Findings

On December 1, the preliminary autopsy report for Ms. Richey was completed
and given to the police. The pathologist who performed the autopsy believed
that Ms. Richey’s death was a homicide. She called Detective Sergeant Gibson
to discuss the case and told him that the preliminary finding in her report was
that Ms. Richey’s death was caused by neck compression. (Her final
report, dated March 28, 2018, confirmed that Ms. Richey’s death was caused
by neck compression, not positional asphyxia or intoxication.) This finding
was not consistent with the earlier theory that Ms. Richey might have slumped
forward with her chin resting on her chest, accidentally cutting off her own
airway. Simply put, her death was a homicide, not an accident. A few
hours later, Detective Sergeant Gibson and Detective Lioumanis were
assigned to the case. Sometime after the autopsy, the police told Dr.
Bélanger and the pathologist about the video that showed Ms. Richey and
the unknown man holding hands and entering the construction site. Dr.
Bélanger told the Review it would have been best practice for this
information to be shared before the autopsy, but at that point in the day,
the Homicide Unit officers had not yet been called into the investigation. At
a later date, the Chief Pathologist’s Office held a meeting to discuss the fact
that Ms. Richey’s death had not been flagged as a homicide before the
autopsy and to discuss communication issues among the police and the
Offices of the Chief Coroner and the Ontario Forensic
Pathology Service.
Following the release of the preliminary autopsy results, Dr. Bélanger
also spoke with Ms. AH and told her that Ms. Richey’s death was a homicide.
This conversation, Ms. AH explained to the Review, marked the first time she
was given this information.

The Homicide Unit Takes Over

December 1, 2017
On the afternoon of December 1, 2017, the Homicide Unit’s investigative
team held its first formal briefing regarding this case. They discussed
canvassing for video footage, returning to the scene where Ms. Richey’s body
had been found, and obtaining judicial authorizations to obtain more
information.
At 5:05 p.m., Detective Sergeant Gibson reviewed a timeline of Ms.
Richey’s final movements. That same evening, Ms. AH handed over to the
police Ms. Richey’s laptop. The police began investigating her social media
platforms and examined her computer.
 Sometime before 9:50 p.m., the police published a media release stating
that they were investigating her death as a homicide. Some media stories also
reported that Ms. Richey was involved in sex work. At 10:30 p.m., Ms.
AH called Detective Lioumanis about the information reported by the media:
she was upset because the police had not told her about the release before it
was made public and also because of the allegations about her sister being
involved in sex work. Detective Lioumanis told her the police had received
information suggesting this allegation was true, but they had not given the
information to the media.
That same evening, two detectives spoke with a hot-dog vendor who
recognized Ms. AI from a photo. He recalled that she and Ms. Richey bought
hot dogs from him on November 25 and that they were with a man. He
provided a description of the man.

The Richey Family’s Criticisms of the Missing Person

Investigation

On December 2, 2017, the media quoted Ms. AH as being critical of the way
the police had handled Ms. Richey’s case. She said her sister’s body had been
found close to where she was last seen, suggesting the police had not
conducted a proper search. She also disputed the suggestion that Ms. Richey
worked as an escort.
Ms. Richey’s family spoke positively to the Review about Detective
Sergeant Gibson and Detective Lioumanis, who took over the case when it
became a homicide investigation. The family described the officers as
professional, attentive, and thoughtful. However, they expressed frustration
that the earlier missing person investigation never seemed to go anywhere. Ms.
AH felt she needed to get things done herself. She reported being told by more
than one officer that her sister was an adult and that sometimes people her age
do not want to respond to texts. Although she felt the police were receptive to
the information she provided, their interactions with her came across as
superficial and dismissive. She also felt powerless during the missing person
investigation because the police did not share information with the family
about her sister’s case. The Richey family felt alone in their search for their
loved one: Ms. Hermeston personally told me that she felt she had to find her
daughter herself.
Moreover, the Richey family were frustrated that the police took two
days after Ms. Richey was reported missing on Saturday, November 25, to
issue a public statement about her disappearance. The lead investigator in
charge was not assigned to the investigation until Monday, November 27. Ms.
AH also indicated that, in the early days of her sister’s disappearance, when
she tried to contact police at one division, she was told, on more than one
occasion, to contact another division.
During the months that followed, members of Ms. Richey’s family,
through the media, continued their criticism of the police investigation.
Sometimes the police responded through the media. For example, on
December 4, 2017, an officer told CBC news:

From the time that Tess Richey was reported missing, we took that investigation,
as we take all missing-people investigations, seriously … We had a command
post, we mounted a search, we canvassed people that may have been in the area
to see if they had seen her.

The evidence established, however, that there was no command post during
the missing person investigation.
The police also spoke to the media to explain the steps they took as part
of the investigation. They provided the description of the unknown man
seen with Ms. Richey and appealed to the public for more information.

The Public Response

By early December 2017, if not sooner, members of the public were voicing
their concerns over Ms. Richey’s death as well as their pre-existing concerns
about the unsolved disappearances of other people from the Village and the
possibility of a serial killer. On December 3, when police canvassed for more
video footage, a number of residents expressed their safety concerns to the
Service’s neighbourhood officers and the media.
News reports at the time quoted those who did not feel safe in the
area and were bothered because “so many people are disappearing.” Many
articles tied Ms. Richey’s disappearance to other missing persons from the
area, including Mr. Esen and Mr. Kinsman. The disappearance of Ms. Wells
was also mentioned at times (see Chapter 9). These articles stated that
some community members had begun to take their own steps to address
safety issues. For example, community members organized walk-safe
programs and created an online map of unsolved disappearances in the area
dating back to 2010. The media also captured the view that the police were not
taking the fears expressed by the communities in the Village seriously.
The Events Leading to Schlatter’s Arrest

As I explain at the beginning of this chapter, my focus is not on the Homicide

Unit’s investigation leading to Schlatter’s arrest but on the Service’s handling
of Ms. Richey’s disappearance. Accordingly, I describe Schlatter’s arrest only
briefly in the paragraphs that immediately follow.

December 2–10, 2017

During this period, the police continued to seek video footage and conducted
further interviews. They reviewed Ms. Richey’s iPhone and laptop. They
published media releases with an updated description of the man last seen with
Ms. Richey and then with stills of the man from some of the video footage
obtained. They requested assistance from the public in obtaining further
relevant video material. Detective Sergeant Gibson and Detective Lioumanis
met with the Richey family to provide them with an overview of the
investigation and to reconnect them with members of the Service’s Victim
Services Program. They submitted various samples taken from Ms. Richey’s
body to the Centre of Forensic Sciences for examination. They issued an
internal bulletin to Toronto officers to see if anyone could identify the
unknown man. They attempted to use facial recognition and enhancement
software to assist in the identification.
On December 8, Chief Mark Saunders attended a meeting with
members of the LGBTQ2S+ communities. This meeting was an open
forum for members to voice their concerns and fears about what was
happening in the Village. Ms. AH attended this meeting. After the
meeting, Chief Saunders spoke at a press conference. As I discuss in Chapter
7, he said “the evidence today tells us there is not a serial killer based on the
evidence involved.” He also announced there would be an internal review into
how the Service handles Missing Person reports and investigations. Chief
Saunders stated:

I do have some concerns … When they (families) are setting up their own
search parties to look for missing people[,] then I have to question whether
or not as a service we are offering the right value to the community. The key
to our success is relationship development and whenever that is fragmented
is when we start to have issues.

On December 10, Schlatter notified the police that he was the man they
were looking for. He was not arrested but was placed under surveillance.
A warrant was obtained to seize items from his home, and the
investigation continued. In the meantime, the media reported on the
safety concerns
expressed by members of the communities and their growing distrust in the
Service.
On February 4, 2018, the police arrested Schlatter and charged him with
the second-degree murder of Ms. Richey. In the media coverage of Schlatter’s
arrest, some members of Ms. Richey’s family indicated they were happy with
the progress of the homicide investigation. Ms. AN told the police she
appreciated the professionalism and assistance of the officers involved in the
initial search, but Ms. Richey’s family members did not share this view.
After Schlatter was arrested, the police conducted further
interviews. Some of the employees of Crews & Tangos told them they
remembered seeing Ms. Richey and/or Ms. AI on the night of November 25.
Schlatter’s charges were later upgraded from second-degree to first-
degree murder. On March 21, a media release advised the public of the new
charge.
On March 28, the final autopsy report reflected the following points:

 the cause of Ms. Richey’s death was neck compression (not positional
asphyxia or intoxication);
 the bruise over her left forehead could have been caused during a
struggle;
 Ms. Richey was intoxicated at the time of her death, but her level of
intoxication would not have been lethal; and
 Ms. Richey’s death was initially investigated as accidental.

Outline of Discipline and Other Proceedings

On December 4, 2017, the Service announced that its Professional Standards

Unit had launched an investigation into how officers initially handled the
report of Ms. Richey’s disappearance and the discovery of her body. This
investigation was prompted by a complaint about the conduct of certain
officers at 51 Division. Ultimately, the investigation resulted in charges of
misconduct and neglect of duty under the Police Services Act against
Constable Jones and Constable McCullough. The prosecution alleges that
although the officers were made aware of Ms. Richey’s last known location,
they failed to investigate the area and to notify a supervisory officer of all the
information they learned.
These discipline proceedings have been deferred until the criminal
proceedings involving Schlatter are over. As I indicate above, Schlatter’s
conviction is under appeal.
 Constable Jones and Constable McCullough dispute the allegations
against them. With their consent, we were provided with their detailed
statements to the Professional Standards Unit. I understand their position to be
that 41 Division was responsible for the missing person investigation. As 51
Division officers, they were simply attending a “check address call” at 50
Dundonald Street. Neither officer believed they were the “first police officers”
responding. As I explain above, the Service’s Missing Persons Procedure
imposed certain requirements on the first police officer who responds.
Both officers maintain that before they were tasked to check an address,
they were unaware that Ms. Richey had gone missing. Constable Jones
indicated that they interviewed Ms. AK at 50 Dundonald Street. She told them
that after Ms. Richey left this address, she walked west on Dundonald Street
toward Yonge Street. Because Ms. Richey was seen leaving that location,
neither officer felt that a 300 metre search was necessary. In any event, they
did not have sufficient information about the investigation to conduct a search.
Constable McCullough indicated that the officers completed a Supplementary
Report, which included the information they learned from Ms. AK, and
submitted it to the officer in charge. In Constable McCullough’s view, this
report constituted notification to their supervisor of what they had done.
On November 21, 2019, Ms. Richey’s family filed a civil lawsuit
against several defendants, including Schlatter, the Toronto Police Services
Board (the Board), Chief Saunders, Constable Jones, Constable McCullough,
the Crews & Tangos bar, and three businesses associated with the construction
site where Ms. Richey’s body was found. The documents the Richey family
filed include a number of allegations:

 that a lack of police presence in the Village made Ms. Richey vulnerable
to predators such as Schlatter;
 that the Toronto police ignored requests for service and reports of crime
in the area;
 that the police falsely reported to the family that Ms. Richey was working
as an escort; and
 that the police falsely told the family that Ms. Richey died by
misadventure.

The civil action also includes allegations that the Board, Chief Saunders,
Constable Jones, and Constable McCullough failed to respond promptly to the
report of Ms. Richey’s disappearance and that the two officers failed to search
the area around 50 Dundonald Street adequately. The Richey family members
further allege that the police failed to alert the public to a possible serial killer.
At the time of writing this Report, these allegations remain unproven.

Summary and Findings

Tess Richey was reported missing by her sister the evening of Saturday,
November 25, 2017. She was last seen in the Village. Her mother, Ms.
Hermeston, discovered her body on the afternoon of Wednesday, November
29. Ms. Richey’s body was at the bottom of a stairwell within 80 metres of 50
Dundonald Street, in the area where she was last seen. It had been there for
four and a half days.
The police failed to find her body. They should have. This failure is
both tragic and disturbing because it was Ms. Richey’s mother who discovered
the body during her own search of the area. No parent should have to bear
this terrible burden. For this reason and many others too, it is important to
identify what went wrong in the investigation into Ms. Richey’s
disappearance.

The Failure to Conduct a Second 300 Metre Radius Search

The police were well aware of the importance of conducting a 300 metre
radius search of the area where Ms. Richey was last seen. They carried out
such a search of the area around the Crews & Tangos bar and the nearby TD
bank. That area was initially identified as the last location where Ms.
Richey was seen. But the evidence changed when the police learned that, after
Ms. Richey left that area, she walked to 50 Dundonald Street. Officers
from both 51 Division and 41 Division were separately given this
information. This change should have resulted in a second 300 metre radius
search focused on the area around 50 Dundonald Street – but it didn’t. Had this
second 300 metre radius search been done, I am confident that Ms. Richey’s
body would have been discovered several days earlier. Ms. Hermeston would
have been spared the terrible ordeal of discovering her youngest daughter’s
body.
No one the Review spoke with disputed that the police should have
conducted such a search, including Detective Wighton, the lead investigator.
He assumed that the appropriate physical searches had been done before he
was assigned on Monday, November 27, 2017. There was no basis for this
assumption.
The Review also spoke with officers who belong to the Service’s
Emergency Management and Public Order Unit (EMPO Unit). If requested,
the unit’s search managers provide guidance to officers on how to conduct
missing person searches. When a missing person warrants a level 3 search,
representing the highest level of search, the EMPO Unit’s search managers
oversee and conduct the search.
The search managers told the Review that the origin of any missing
person search is that person’s last known position – generally, at least a
300 metre search should be conducted around that location. The police may
have to carry out multiple 300 metre searches as new information is provided.
The search managers shared the view that, in this case, the police should have
done a second 300 metre radius search. As well, search managers are
trained to prioritize certain locations, such as “hazards,” within the radius.
Hazards include a construction site in an urban setting, such as where Ms.
Richey’s body was found. In my view, had a search manager overseen the
search for Ms. Richey or provided advice, it is likely her body would have
been discovered several days sooner.
There is no requirement that search managers be deployed for searches
that are designated level 1 searches. Nor is there a requirement that officers
seek their advice in conducting such searches. In Chapters 13 and 15, I discuss
the existing procedures on level 1, 2, and 3 searches and make
recommendations for change. Regardless of whether search managers should
have been deployed or contacted in connection with Ms. Richey’s search,
however, it is basic to policing – and to plain common sense – that a second
300 metre radius search should be done when new information comes to light.
The issue is not whether such a search should have been done, but why it was
not done. In my view, the answer is largely rooted in systemic issues.
First, the Service’s Missing Persons Procedure dictated at the time, as it
continues to dictate today, that the division where Ms. Richey resided – 41
Division in Scarborough – should conduct the missing person investigation.
But most of the early investigative work to be done was in the downtown core.
It made sense that 51 Division officers should do much of or all that work. As
I explain in Chapter 13, in circumstances such as those connected to Ms.
Richey’s disappearance, the investigation should be assigned to the
division where the missing person was last seen, rather than where the person
lived. But the existing procedure meant that the Tess Richey investigation was
divided between two divisions, reinforcing the need for clear lines of
reporting and coordination. Neither line existed. In several instances, tasks
were duplicated and, in other instances, tasks were not performed in a timely
way or at all.
In my view, these shortcomings were attributable, in part, to the absence
of any true coordination of effort. In one instance, 51 Division refused,
without explanation, Detective Wighton’s request for 51 Division officers
to investigate an important downtown lead. This refusal speaks to the
need to
assign investigations where they can most efficiently be conducted and to
coordinate tasks that must be shared between or among divisions.
Second, no lead investigator was assigned to this investigation until
Monday, November 27, two days after Ms. Richey was reported missing. In
the interim, officers on duty worked on the case. But the absence of a lead
investigator made it less likely that the search would be conducted in a
comprehensive, coordinated way. Unfortunately, the concern about the impact
of the delay in assigning a lead investigator proved to be true. The Service’s
mandate is to serve and protect the public. I ask, rhetorically, what message
was being communicated to Ms. Richey’s family, who, in deeply stressful
circumstances, were told that no lead investigator would be assigned to Ms.
Richey’s disappearance until Monday, November 27?
Third, when Detective Wighton was assigned as the lead investigator,
he had already been assigned to deal with a bank robbery, sexual assault, and
human trafficking, all matters that had to be dealt with the same day. Detective
Wighton candidly acknowledged that given his workload, it was fortuitous he
learned on Monday morning he had been assigned to this missing person
investigation – and he learned about it only because Ms. AH knew he had been
assigned before he did and called him.
During this time frame, due to the challenges associated with shift work,
most missing person investigations were passed from officer to officer – with
the inevitable result of inadequate continuity during the transitions. It was also
typical that, with limited exceptions, missing person investigations were given
lower priority than other types of cases.
The point here isn’t that a missing person investigation, regardless
of circumstances, has higher priority than a bank robbery. Instead, the point is
that the police have an obligation, regardless of circumstances, to investigate
missing person cases in an effective and timely way. The systems in place in
2017 made it difficult to meet that obligation.
Fourth, at the time, the Service’s Missing Persons Procedure provided
limited direction on how to conduct a missing person investigation. It relied
too heavily on initiatives by individual officers, particularly officers with no
specialized training in these cases. As one of many examples, there was no
template or checklist to guide missing person investigations. The early
investigation into Ms. Richey’s disappearance appeared at times to be driven
largely by Ms. AH – by the information she provided or what she and others
urged the officers to do – rather than any investigative plan.
Fifth, at the time, the Missing Persons Procedure provided that the “first
police officer” shall “search the home and the immediate area thoroughly.”
Although in 2017 the desirability of a 300 metre radius search of the missing
person’s last known location was well known, the procedure did not make this
requirement explicit. It was only in 2019 that it was amended to require the
first officer to complete a 300 metre radius search of the place where the
person was last seen, if known. If the first officer determines that a 300
metre radius is not required, the procedure requires the officer to record
specific details in the original electronic Occurrence Report and to advise a
supervisory officer. However, the procedure has never provided a
definition for the term “first officer.” I find it difficult to understand why the
obligation should be confined to the “first police officer.”
As I indicate above, Constable Jones and Constable McCullough, two
51 Division officers, face outstanding discipline proceedings for failing to
conduct the 300 metre radius search around 50 Dundonald Street and for
failing to notify their supervisor of all pertinent facts. They say they were not
the first police officers under the Missing Persons Procedure – they were
merely conducting a “check address call.” They state they were directed that
41 Division had jurisdiction over Ms. Richey’s case, and they fulfilled their
responsibilities by filing a Supplementary Occurrence Report.
For the reasons I give above, I do not intend to make findings in
relation to whether these officers engaged in professional misconduct.
Regardless of those allegations, it is obvious to me that the systemic
circumstances I have
outlined above, including the lack of clarity in the Missing Persons Procedure,
contributed to the failure to conduct an appropriate radius search focused on
50 Dundonald Street as well as the failure of any supervisor to notice that such
a search had not been conducted.

Other Shortcomings in the Early Investigation

In my view, most of the same circumstances described above also contributed
to other shortcomings in the early investigation of Ms. Richey’s disappearance.

The Failure to Issue a Timely Media Release

No media release was published over the weekend of November 25–26. It
should have been. Detective Wighton acknowledged that an earlier media
release than the one issued at 8:35 a.m. on November 27 would have reflected
the best practice in this case, given the circumstances surrounding Ms.
Richey’s disappearance.

Untimely and Uncoordinated Assembly of Video Footage

The police did search for video footage of Ms. Richey, but their search began
only on November 28, more than three days after she was reported missing.
Not until November 29 did they look for video footage at the apartment
building at 41 Dundonald Street, as Ms. AK had recommended two days
earlier. It was only after Ms. Richey’s body was found that the police
discovered the video from the other half of the semi-detached building
next door, 582 Church Street, at the corner of Church and Dundonald streets.
This video showed Ms. Richey walking with an unknown man (later identified
as Schlatter) into the construction site where she was ultimately found.
In terms of timeliness, the best practice is for officers to obtain (and
view) relevant video footage as soon as possible. Many businesses and
residences have surveillance cameras, and video footage often yields critical
evidence. Equally important, the footage is frequently retained for only short
periods.
Another best practice for the police is to seek out video footage in a
comprehensive, coordinated way, particularly in an urban environment. Before
Ms. Richey’s body was discovered, their canvassing for video footage was not
properly coordinated or given the urgency it required. The use of a grid search
or mapping tool, such as that used by the EMPO Unit and other officers since
this investigation, is an excellent way to coordinate a search for video footage.
A grid search ensures that the police do not miss important locations and
makes it more likely that critical evidence is obtained quickly. Detective
Wighton agreed with this assessment and said the police now use a grid
search. A coordinated search for video footage also makes it more likely
that officers need not be dispatched to seek videos from private residences
and businesses in the middle of the night, when the prospects of obtaining
such videos are lower.

The Role of the Missing Person’s Loved Ones

As I outline in Chapter 15, community members and the loved ones of those
who go missing must play an important role in locating missing persons in a
timely way. If the police are involved in the search, they must work in true
partnership with others. In the Tess Richey investigation, family members,
particularly Ms. AH, were active in investigating leads and in urging the police
to pursue those leads. Their involvement was commendable. But the family
also felt, with some justification, that they were compelled to be as engaged as
they clearly were because of the limitations in the police response. Families
and other loved ones of missing persons should not bear the burden of
ensuring that an investigation is conducted properly.
The Approach to Risk Assessment
I explain in Chapters 5 to 7 how the police often failed to appreciate the level
of urgency that should have accompanied the reported disappearances of
McArthur’s victims. This tardiness relates directly to how the police assess
risk, whether related to possible foul play or other safety concerns. Here I
identify several systemic issues associated with risk assessment that had
particular application to the Tess Richey investigation:

 The Search Urgency Chart did not reflect an evidence-based approach to

risk assessment. Nor was any separate risk assessment done in this
investigation.
 The distinction among level 1, 2, and 3 searches is outdated and prone to
inconsistent interpretation or application. One senior search manager the
Review interviewed felt that the Tess Richey investigation should
have been elevated to at least a level 2 search.
 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.
 As I explain in Chapters 13 and 15, the interplay between the search levels
and provincial adequacy standards respecting when a missing person
investigation should be treated as a major case is not adequate.

In my view, apart from issues around the assessment of risk, the

urgency associated with a search must also be connected to the concerns
expressed by community members. In this case, members of the communities
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
concerns about safety should figure prominently in how the police respond to
a disappearance. I am not convinced that the Service’s approach to Ms.
Richey’s disappearance reflected the added urgency associated with these
community fears.

The Treatment of the Scene

When Ms. Richey’s body was discovered, the cause of death was not obvious.
The coroner, Dr. Bélanger, considered the possibility that her death was
accidental, but, given the circumstances, correctly ordered an autopsy. It
remains unclear precisely what Dr. Bélanger and the initial attending officers
at the scene actually said. Officers may have overinterpreted Dr.
Bélanger’s speculation or too readily expressed their own views about the
likely cause of
death. It was important that everyone remain open-minded about the
possibilities, pending proper medical and police investigative work. A lack of
precision in communication may have contributed to any misconceptions
about the cause of death. Similarly, it was both premature and unhelpful if,
shortly after Ms. Richey’s body was found, any officer told her family that her
death appeared to be accidental. Detective Wighton did not hear any officers
express that opinion to family members but agreed it would have been
inappropriate for them to do so.
Three related problems were associated with the discovery of Ms.
Richey’s body. First, the scene should have been held pending an autopsy or
further direction. It was not. Dr. Bélanger was surprised and troubled it was
not held. With respect, the evidence disclosed that Dr. Bélanger did not clearly
direct that the scene be held pending further investigation. There should have
been unequivocal dialogue around that issue.
The second problem relates to the involvement of the Homicide Unit in
the case. This case involved the sudden death of a young woman with no
known cause of death. The Service’s own procedure mandated that the
Homicide Unit be contacted in these circumstances. Detective Sergeant Gibson
also told the Review that, in his view, the Homicide Unit should have been
informed of this death in a timely way. He learned about her death only
because the forensic pathologist who conducted the autopsy contacted
him. The Homicide Unit potentially had an important role to play in
investigating the scene, but that opportunity was lost. In Chapter 9, I discuss
another situation, involving the discovery of Alloura Wells’s remains, that
should have triggered an immediate report to the Homicide Unit. Although my
focus is on missing person investigations and the related matter of how the
police investigate unidentified bodily remains, it is trite to say that missing
person investigators must ensure that subsequent sudden death or homicide
investigations are not adversely affected by their own conduct.
The third problem identified here relates to the concern that the forensic
pathologist who performed the autopsy was not provided with all the relevant
information before conducting the post-mortem examination. This issue
figured prominently at the Inquiry into Pediatric Forensic Pathology in
Ontario11 and was the subject of recommendations by its commissioner,
Justice Stephen T. Goudge. In Chapters 13 and 15, I address the systemic
issues identified in connection with the investigation into Ms. Richey’s
disappearance and make recommendations for change.
11
A copy of this Inquiry’s report can be found on the website of the Ontario Ministry of the Attorney
General at http://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/report/index.html
 Chapter 9 The Alloura Wells Investigations and Related Cases 325

Chapter 9

THE ALLOURA WELLS INVESTIGATIONS AND

RELATED CASES

Six of Bruce McArthur’s murder victims were reported missing between 2010
and 2017. In November 2017, Tess Richey went missing. A few days later her
mother discovered her body. In July 2017, Alloura Wells disappeared. In
August of that year her bodily remains were discovered. Not surprisingly,
some community members questioned whether all these cases were related.
Unlike the cases involving the six McArthur victims who were reported
missing, and unlike the circumstances surrounding Ms. Richey’s death, Ms.
Wells’s remains were discovered before she was reported missing to the
Toronto Police Service (the Service). Initially, her remains were not identified.
It took just under four months before the authorities connected the found
remains to Ms. Wells.
This chapter examines both the initial investigation 53 Division officers
conducted into Ms. Wells’s unidentified remains and the separate investigation
51 Division officers conducted into Ms. Wells’s disappearance. My
examination forms part of a larger discussion about how the Service, the
Office of the Chief Coroner (see Chapter 13), and the Ontario Forensic
Pathology Service work together in dealing with unidentified bodily remains.
Ms. Wells’s case was not the only situation in which a person’s
bodily remains lay unidentified at the Toronto morgue while family
members searched for their loved one. I also heard about the disappearances
of Kenneth Peddle and Dovi Henry and their loved ones’ active searches for
them, only to later learn that their bodies lay in the morgue – unidentified.
These cases inform the larger discussion about how unidentified bodily
remains are dealt with. Mr. Peddle’s case is discussed below, and Mr. Henry’s
case appears as a case study that follows Chapter 14.

The Alloura Wells Investigations

Ms. Wells was a member of Toronto’s trans community. She was Indigenous,
a sex worker, and struggled with drug abuse. When she died, she was living
under a bridge in Toronto. She was marginalized and vulnerable in
several
ways that intersected. She was loved by family and friends. Her life was
valued.
My examination of her case provides me with a valuable opportunity
not only to examine how the authorities deal with unidentified bodily remains,
but also to consider the Service’s relationship with the trans and other
marginalized and vulnerable communities.
In Chapter 2, I provide a brief biography of Ms. Wells. Here, I highlight
some aspects of her life that are relevant to the narrative that follows.
Ms. Wells was born in August 1990. She came out as a trans woman
when she was 17 years old. Her father, Michael Wells, was supportive of her
gender identity, counselling her to “do what you need to do. Just be a good
person.”
Ms. Wells was described as a vibrant, bubbly person and a “great soul.”
She had a variety of interests and aspirations, some tied to her Indigenous
heritage. At the same time, her life was a struggle in many ways, a common
experience for many trans women. She was a sex worker who had accessed the
services of Maggie’s Toronto Sex Workers’ Action Program (Maggie’s),
an organization that addresses the needs of sex workers. Ms. Wells had
also volunteered at Maggie’s. She attended programs at The 519, 1 including
its weekly drop-in Meal Trans program – a hub for trans women and men,
particularly sex workers, to connect and to share information.
Ms. Wells was reportedly last seen in July 2017. At the time, she
was living under a bridge in the ravine near Parliament and Bloor streets. This
area was known for sex work, for drug use, and as a site where marginalized
trans women lived. Ms. Wells was having difficulty dealing with her mother’s
recent death. To cope with the loss, Ms. Wells had turned to drugs.
Ms. Wells had been in a relationship with Augustinus Balesdent, the
only boyfriend she ever introduced to her father. Sadly, there were indications
this was a violent relationship. (Following the discovery of Ms. Wells’s
remains, Mr. Balesdent became a person of interest in the police investigation
into Ms. Wells’s death.)

Discovery of The Unidentified Remains

On August 5, 2017, at about 5:34 p.m., Ms. AP and Mr. AQ, were walking in
the Rosedale Valley Road ravine when they found a partially decomposed
body. The deceased was in women’s clothing and wore a blonde wig. A purse
containing a broken cell phone, but no identification, was found near the body.
1
As reflected in Chapter 8, The 519, formerly known as The 519 Church Street Community Centre, is an
agency of the City of Toronto a nd a charitable, non-profit organization operating a community centre in the
Villa ge.
Vomit and drug paraphernalia were on the ground nearby. Ms. AP and Mr.
AQ reported the discovery to the police.
The coroner who went to the scene estimated that the body had
been exposed to the elements for approximately two to four weeks. As a
result, the deceased was not easily recognizable. The bodily remains were
located within the jurisdiction of the Service’s 53 Division. As a result,
Detective Richard Proctor from that division’s Criminal Investigation Bureau
went to the location where the remains were found.2
The police initially suspected the cause of death to be a drug overdose.
Officers noted there was “nothing overtly suspicious” at the scene and nothing
to indicate foul play. The Service’s procedure on preliminary homicide
investigations provides that an officer who discovers a person who has
died unexpectedly or whose cause of death is unknown shall treat the
death as “suspicious.” The procedure also directs the officer to notify the
on-call homicide team of any suspicious death. However, Detective Proctor
did not notify any member of the Homicide Unit that unidentified bodily
remains had been discovered. Detective Sergeant Jordan Latter, an officer
with the Service’s Professional Standards Unit, later reviewed how the
investigations relating to Ms. Wells had been handled. He concluded that,
following the Service’s procedure, Detective Proctor should have
contacted the on-call homicide team before leaving the area where the
remains were discovered.3
The police canvassed three of the homes with backyards that faced the
ravine, but their questions produced no relevant information. Between August
6 and 8,4 Detective Randy Wynia, another 53 Division detective, was assigned
as the lead investigator. Detective Wynia had not been to the place where the
body was discovered. He did not suspect foul play. Nonetheless, he
correctly treated the death as “suspicious” pending determination of the
cause and circumstances and because foul play had not been ruled out.
Detective Wynia told the Review that, in conducting this investigation, he
followed the major case management (MCM) model, performing all the
command triangle roles required under the model and submitting a ViCLAS
booklet. (In Chapter 4, I describe the MCM model and ViCLAS
requirements.) The Major Case Management Manual provides that threshold
major cases include “occurrences

2
The bodily remains were discovered during the evening shift. Detective Proctor was then on duty, so he
went to the scene. However, he was notassigned to investigate the case. A detective on the day shift was
subsequently assigned.
3
An expert also advised the Review that a forensic anthropologist should have been called to the scene as
well.
4
There is a discrepancy in the evidence as to when Detective Wynia was assigned. I address this issue in my
Summary and Findings respecting this investigation.
suspected to be homicide involving found human remains.” It is unclear
whether the Service’s procedure on preliminary homicide investigations that
directs officers to treat unexplained bodily remains as suspicious also means
that such remains should be categorized as threshold major cases for the
purposes of MCM. I address this issue in my recommendations because
the interplay between the Service’s procedures and provincial adequacy
standards is unclear and unsatisfactory. I observe, however, that Detective
Wynia did not have access to PowerCase, the mandatory case management
software for threshold major cases.

Initial Attempts to Make an Identification

From the outset, the police attempted to identify the human remains. They
received information about women who possibly could be a match, but
this information did not lead to an identification.
On August 7, an autopsy was completed. It was unable to identify the
cause of death or the deceased’s race. The autopsy did reveal the deceased was
biologically male and between 20 and 29 years old. Fingerprints were too
degraded to permit a positive identification. A dental workup was done. The
police were advised about the possibility of having a reconstruction of the
person’s face created to assist in the identification. Detective Wynia
understood that the reconstruction would be done.
On August 17, Dr. Renee Kosalka, a forensic anthropologist, provided
a further profile of the deceased, a profile that included possible race, 5 height,
hair length and colour, and the presence of healed injuries for which the
deceased might have sought medical treatment. Dr. Kosalka also provided a
detailed description of the clothing and other items found with the body,
including the blonde wig. About a month later, a DNA profile from the body
was generated and uploaded to the Canadian Police Information Centre
(CPIC).6
Given the information collected, the police were of the view that the
deceased was likely transgender. Detective Wynia learned that a man named
Augustinus Balesdent was known to “hang out” in the ravine and associate
with trans women. The police conducted checks on Mr. Balesdent but, at the
time, did not learn about his connection to Ms. Wells. Police later learned,

5
The “ancestry estimation” included possible Indigenous and/or Greater Asiatic, Caucasian, or admixture of
Indigenous / Grea ter Asia tic and Caucasian.
6
CPIC is a na tional repository for policing agencies to enter la w enforcement and public safety operational
information. It contains data on charged, wanted, a nd missing persons, stolen vehicles, a nd stolen property,
and other crime-related data.
however, that Mr. Balesdent had been under a court order to not contact
another trans woman.
Ms. AP, who, with Mr. AQ, had discovered the body, remained in
contact with Detective Wynia and learned, as a result, that the deceased was a
trans woman who still remained unidentified. On August 17, Ms. AP did a
Google search to identify organizations, including Trans Alliance Canada and
The 519, that were involved in assisting and supporting trans individuals. Ms.
AP emailed the general email address of The 519, indicating that on August 5
she had found a body in the ravine. She asked if anyone knew of any
transgender women who had been reported missing. At the time, the police did
not know Ms. AP had emailed The 519. The 519 had acted as a conduit
between the police, particularly those in 51 Division, and community
members. The police had previously provided information to The 519 about
missing person investigations.
On August 25, a community organizer at The 519 responded to Ms.
AP’s email. He told her he would reach out to his contacts in the Service
and requested the contact information for the detective handling the case. He
also offered counselling services, if she needed them. In response, Ms. AP
provided Detective Wynia’s name and contact information. Unfortunately,
this information was not “elevated” to The 519’s leadership team for
appropriate follow-up. (On December 12, 2017, The 519 issued a public
apology for mishandling the information it received from Ms. AP. It also
apologized to Ms. AP.)
The police continued their investigation into the unidentified human
remains. A victim profile of the remains7 was uploaded into CPIC and, as
previously indicated, Detective Wynia submitted a ViCLAS booklet to the
OPP ViCLAS Unit.8 He also ensured that 53 Division’s crime analyst was
fully aware of the investigation so the analyst could flag any Toronto missing
person occurrences to be checked against the unidentified remains.
Detective Wynia understood that submitting a ViCLAS booklet
meant the OPP ViCLAS Unit would automatically send information on
the unidentified human remains to the provincial Missing Person and
Unidentified Bodies Unit (MPUB) and to every police service in Canada so
that any missing person occurrence reported across the country could be
compared to the unidentified remains. In reality, the ViCLAS Unit does not
notify MPUB of any unidentified remains cases. For an unidentified
remains case to be

7
This is a biological profile of the body including attributes such as eye colour, hair colour, weight, and
identifia ble markings.
8
In Chapter 4, I discuss the OPP ViCLAS Unit and the submission process for ViCLAS booklets.
compared to all missing person cases in Canada, it would need to be added to
the National Centre for Missing Person and Unidentified Remains (the
national centre) database.9 Information about all unidentified remains cases in
Ontario are provided to the national centre’s database by the Ontario
Forensic Pathology Service, working in concert with the Office of the Chief
Coroner. Ontario Forensic Pathology Service staff fill out a CPIC form with
information about the unidentified remains. The form is then emailed to
the national centre’s CPIC operator at the OPP, with a copy sent to MPUB.
The operator then inputs all the information from the form onto CPIC,
which then automatically populates the information onto the national centre’s
database. (MPUB and the national centre’s database are discussed in
greater detail in Chapter 13.)
Detective Wynia emailed ViCLAS to provide this information. 10 In
early September, he was advised that the information had been uploaded on
the National Centre for Missing Persons and Unidentified Remains database
(the national database). Detective Wynia subsequently received notifications
of possible matches of the unidentified remains to missing persons both inside
and outside Ontario. He quickly determined that none of them matched the
bodily remains he was investigating. As I explain later in this chapter, at this
juncture Ms. Wells’s disappearance had not yet been reported to the police.
Ms. Wells’s family and friends mistakenly believed her to be in jail.
During the investigation, Detective Wynia decided not to publish a
media release about the discovery of the unidentified human remains. He
believed the Centre of Forensic Sciences11 would be creating a full facial
reconstruction photo that would provide more information to the public than
the vague or generic descriptors he had. Unfortunately, the reconstruction was
delayed when other injuries on the body were discovered. Ultimately, other
events, described below, intervened and the reconstruction was never
completed.12 In late August, Detective Wynia prepared an internal bulletin
about the discovery. This bulletin circulated across the Service. He also posted
the discovery on 53 Division’s “special attention” board.13
9
To date, only Ontario, British Columbia, and Alberta have signed a memorandum of agreement with the
RCMP and the federal government regarding the national centre. It follows that not all of Canada’s missing
person and unidentified remains cases are in the national database (see Chapter 13).
10
For a period of time, the MPUB Unit was located within the same section of the OPP that included
ViCLAS. It has since been moved and is now within another section. At the time of Detective Wynia’s
email, the person he contacted was working within both ViCLAS and the MPUB Unit.
11
He wa s mistaken. The Ontario Forensic Pathology Service creates facial reconstructions.
12
The Review was advised that facial reconstructions take a lengthy time to complete, are not always
reliable, and are often employed only as a last resort when other identification techniqueshave failed.
13
At the beginning of each shift, the sergeant reads the new notices posted on this board to the officers, to
ensure that every officer at 53 Division has been notified about their content.
 In late August, Detective Wynia reviewed all Missing Person reports in
Toronto from July 1, 2017, onward for possible matches to the unidentified
body. There were no matches. Ms. Wells had not yet been reported missing to
police.

The Disappearance
As I indicated, Ms. Wells was last reported being seen alive in July 2017. In
the past, there had been stretches of a month or two when she had no contact
with her family. However, she had always been active on social media. That
activity stopped – something very unusual. There was also a strange “RIP”
post on her Facebook page. Ms. Wells’s sister understood this post to
mean Ms. Wells had passed away. Worried, the family began looking for
her, reaching out to several of Ms. Wells’s friends and social media
contacts. Shortly before Ms. Wells’s disappearance, she had been
distressed and confided in a friend that her boyfriend had beaten her up. She
had also become involved in drugs. At least one friend expressed concern that
she might have overdosed or been put in jail for a minor offence. This
friend contacted a nearby women’s jail and was told a person with the last
name of Wells was incarcerated. The friend told Ms. Wells’s sister that Ms.
Wells was in jail. This information proved to be inaccurate but, at the time,
reduced the family’s concern.
When fall arrived, Ms. Wells’s family and friends were worried that
there was still no sign of her. They canvassed the jails to discover that Ms.
Wells had not been incarcerated after all. Michael Wells, Ms. Wells’s father,
contacted the Office of the Chief Coroner. Mr. Wells told me that someone
there indicated there were some remains at the morgue that could not be
identified because of the state of the body. Since Ms. Wells’s family had still
not heard from her, they decided to report her disappearance to the police.
Unfortunately, they were unaware that a body had been found in the ravine in
early August, important information that was not generally known to the
public.

53 Division’s Initial Involvement

On November 4, 2017, Michael Wells went to 53 Division, the station closest
to his home, to report his daughter’s disappearance. He spoke to the booking
sergeant, indicating it was unlike his daughter not to contact him and not to be
active on social media for such a lengthy time. He also advised the
sergeant that his daughter was trans. Mr. Wells told the Review that the
sergeant responded by saying Ms. Wells would come back, and not to
worry – Ms.
Wells was young. Mr. Wells did not recall seeing the sergeant make any notes
or check anything on the computer. He said the entire interaction took only a
few minutes. The booking sergeant would later tell the Professional Standards
Unit that he conducted CPIC and Versadex checks 14 on Ms. Wells, but they
yielded no helpful results.
It is undisputed, however, that no official Missing Person Report was
taken at that time. The sergeant indicated to the Professional Standards Unit
that he advised Mr. Wells he could wait for an officer on the road to become
free to take the Missing Person Report or he could go home and call the non-
emergency police number to have officers come to his home to complete the
report. Mr. Wells told the Review he was not provided with these options. He
was upset by the dismissive manner with which the police treated his
daughter’s disappearance. He felt the police were too busy to take his concerns
seriously and that he was “a day late and a dollar short” in seeking their help.
He felt that his daughter’s disappearance was not regarded as a priority, and
that “it all plays a part, being transgender, addicted, homeless.” He worried
that it seemed like, to the police, his daughter was a “nobody.”
As I note below, on or about November 30, 2017, the unidentified
human remains were determined to be those of Ms. Wells. On December
9, Chief of Police Mark Saunders met with Mr. Wells to personally apologize
for the Service’s failure to take a Missing Person Report when Mr. Wells was
at the police station on November 4. The Service’s LGBTQ2S+ liaison
officer also attended this meeting. Mr. Wells advised me he suggested to
Chief Saunders that if his daughter had been affluent, the police response that
day would have been different. On the day of his meeting with Mr. Wells,
Chief Saunders issued an apology and publicly acknowledged that the
interaction between Mr. Wells and the police could have been better and
presented an opportunity for the police to improve.

The Missing Person Investigations

Following Mr. Wells’s visit to 53 Division on November 4, Ms. Wells’s
family continued their own efforts to find her. A community member
suggested to Mr. Wells that he should contact 51 Division because there was
an investigator there he could speak to.
As a result, on November 6, Mr. Wells called 51 Division, and an
officer took the information about Ms. Wells over the phone. Mr. Wells told
the police he had not seen or heard from his daughter since July. He gave
them other names she sometimes went by and provided further information
about her,

14
I explain these checks in Chapter 4.
 Chapter 9 The Alloura Wells Investigations and Related Cases 333

including that she was transgender, was a drug user, had no fixed address, had
a criminal record, and was currently wanted on an arrest warrant. He also
provided the police with the name of the last person he knew to have seen Ms.
Wells. He advised the police that he had already contacted the Office of the
Chief Coroner, to be told that, to its knowledge, no one with either Ms.
Wells’s date of birth or any known alias had died. The officer who took
down this information completed the Search Urgency Chart and assigned
the highest level of urgency to the matter but, curiously, categorized the
search to be conducted as a level 1–2 search – not the highest level in the
search hierarchy. Two officers at 51 Division also contacted the Office of
the Chief Coroner. One officer’s memobook notes state: “Coroners office
contacted … Neg results for names and alias. No unidentified persons at
morgue with no prints on file from that time frame.”
A few days after the information about Ms. Wells was received by
51 Division, Detective Constable Guy Kama became involved in Ms.
Wells’s case.15 He was 51 Division’s sudden death and missing person
investigator, meaning he assisted other officers with such cases and was aware
of all the missing person cases in the division. 16 Detective Constable Kama
regarded the matter as urgent and immediately began reviewing Ms. Wells’s
social media accounts. He spoke to Ms. Wells’s sister and contacted three
addiction centres to see if Ms. Wells was receiving treatment. He also learned
more about Ms. Wells’s outstanding criminal charges.
ss
Ms. AP saw the media release that included the contact information for
Maggie’s, prompting her to tell Maggie’s about her discovery in the ravine.
She expressed hope that the body did not belong to Ms. Wells.
Nonetheless, she felt that “nobody seems to care about this lady we found and
I want to give her family some kind of closure.” This was the first time
Maggie’s and, more generally, community members were made aware of the
remains found in the ravine. Shortly after this contact, Maggie’s told Ms.
Wells’s family about the information Ms. AP had provided. The family
contacted Ms. AP directly.
In the meantime, Mr. Wells met with Detective Constable Kama, saying
his other daughter had heard rumours from Mr. Balesdent that Ms. Wells died
from an overdose in a park near Parliament and Bloor streets and that Mr.

15
Detective Constable Kama does not believe he was assigned as the lead investigator of this missing person
investigation, but he could not recall which officer was assigned. He said he was never the lead investigator
in these matters; he only assisted the assigned detectives. The police records did not assist the Review in
resolving that question. I address this point in my recommendations.
16
When he left this position in 2020, two officers replaced him, given the time-consuming nature of the role.
334 Independent Civilian Review into Missing Person
Investigations
Wells had heard about an unidentified body located in August in the Rosedale
Valley Road ravine. This was the first time Detective Constable Kama had
heard anything about an unidentified body recently found in that area. It was
also the first time he had heard Mr. Balesdent’s name, although, unbeknownst
to him, it was a name familiar to Detective Wynia at 53 Division.
Detective Constable Kama immediately followed up on the information
relating to the unidentified bodily remains. He located the Occurrence Report
on file and emailed Detective Wynia. Mr. Wells felt that Detective Constable
Kama was taking his daughter’s case seriously. Detective Constable Kama
indicated Michael Wells’s DNA would be sent to the Centre of Forensic
Sciences to compare it to the DNA extracted from the human remains. He also
advised the Office of the Chief Coroner that the remains could belong to Ms.
Wells. As a result, the office obtained copies of Ms. Wells’s medical records.
The investigators at both divisions continued to conduct their
investigations separately while they waited for the DNA testing to be
completed. They did communicate with each other. Detective Wynia
interviewed Ms. Wells’s sister and one of Ms. Wells’s friends. Detective
Constable Kama initiated a BOLO17 alert for Mr. Balesdent, indicating he was
a person of interest in the missing person and unidentified remains
investigations. The officers involved in each of the two investigations
interviewed some of the same witnesses.

Community Efforts to Find Ms. Wells

In early November, Ms. AR, a leader in the trans community, contacted the
Service’s LGBTQ2S+ liaison officer to discuss what the police were doing
about Ms. Wells’s disappearance and the communities’ efforts to try to
find her, including an organized search. Ms. AR wanted to discuss her
concerns about how the search might affect the police investigation, her
suspicion that Ms. Wells might have been murdered, and rumours circulating
about a trans individual’s body being found in August. She was upset that the
police did not notify Ms. Wells’s family or the trans community about this
discovery. Ms. AR and the liaison officer exchanged Facebook messages
and Ms. AR left voicemails, but the two were never able to set up a time to
discuss the matter. Ms. AR then contacted Deputy Chief Barbara McLean
about her frustrations at not being able to connect with the LGBTQ2S+ liaison
officer. Deputy Chief McLean agreed to put Ms. AR in touch with someone
from the liaison officer’s
17
A BOLO alert is a Canada-wide notification to all police services to “be on the lookout” for an individual.
That person might be a person of interest in a particular investigation. In this case, the BOLO alert indicated
that both Detective Wynia and Detective Constable Kama should be contacted if Mr. Balesdent was found
by any officer in Canada.
unit. As I describe below, later that month Ms. AR met with Deputy Chief
McLean and other senior members of the Service to discuss Ms. Wells’s case
and her concerns.
On November 11, Ms. Wells’s family and friends organized a search of
the ravine. Some of the searchers asked the police to come to Riverdale Park
because they found what they regarded as suspicious holes in the ground and
a nearby shovel. This discovery was about two and a half kilometres from the
ravine where the unidentified remains were found, and in an area where Ms.
Wells had been known to stay. The police determined there was no indication
of recent digging or signs of foul play at the site.
Some community members felt the police were still not taking Ms.
Wells’s disappearance seriously. One of Ms. Wells’s friends voiced the
concern that the police responded to Ms. Wells’s disappearance only after
community members contacted the media. On November 19, a rally in support
of Ms. Wells took place at police headquarters. Throughout November and
into early December, Ms. Wells’s friends and family were quoted in several
articles in the media about their concerns that the police were giving
insufficient attention to her disappearance. Some felt this lack of attention was
explained by the fact that Ms. Wells was a homeless trans sex worker with
addictions. Family and friends also criticized the police for not coming to the
searches organized for Ms. Wells. One of Ms. Wells’s friends told the Review
that the police

didn’t really want any help from the community in the sense of
information. They were being very closed-lipped about it. You know, they
weren’t giving us any information which is understandable. But, at the
same time, they weren’t really connecting with the community to find out
who this could have been.

Ms. AP and Ms. Wells’s sister also told the Review they were
disappointed with the police investigation into the unidentified remains. Ms.
AP indicated that, on several occasions, she had reached out to the police to
obtain an update on the case, to see if she could do anything to assist and to
find out whether the police had identified the remains. She felt the police
treated her in a dismissive manner. Both Ms. AP and Ms. Wells’s sister felt the
police could have done more, and should have done more, to try to identify
Ms. Wells sooner – for example, by communicating with trans organizations
as Ms. AP had done.
 The Service publicly apologized for its officers’ inability to attend the
searches, indicating the police had searched the area previously.18 A
police spokesperson also insisted the police were taking the missing
person case seriously and that the investigation into Ms. Wells’s
disappearance had been promptly initiated and was ongoing. On November
20, when Ms. AR met with senior members of the Service, she expressed a
concern about the quality of the police investigation and what she perceived
as a “breakdown of communication between police jurisdictions”
involving where the body was found and where Ms. Wells’s disappearance
was being investigated. She indicated that someone had told the Wells
family that the police do not care about the trans community. Ms. AR was
also troubled by the lack of engagement, as she saw it, between the Service’s
LGBTQ2S+ liaison officer and the affected communities.
Ms. AR also spoke to Detective Wynia about her concerns and
information circulating within the communities regarding Ms. Wells’s
death. Detective Wynia told the Review he felt the concerns were the
result of miscommunication by officers to the family about the different
levels of urgency assigned to missing person investigations and the
various search criteria that are applied. He acknowledged that much of the
criticism could also have been prompted by the lack of information the
police provided to the public.
As the investigation into the unidentified remains continued,
community members provided additional information to Detective Wynia
about Ms. Wells, her relationship with Mr. Balesdent, and rumours
circulating about statements Mr. Balesdent made about Ms. Wells’s death.

The Identification of Ms. Wells’s Bodily Remains

On or about November 30, 2017, the unidentified remains were confirmed to
be those of Ms. Wells. After notifying Ms. Wells’s family of the identification,
the Service issued an updated media release. The identification ended the
missing person investigation. Detective Wynia at 53 Division continued to
investigate the matter as a sudden death. As I indicated earlier, the autopsy did
not reveal a cause of death. The investigation is still open. In the
circumstances, I do not intend to describe it in any detail. I can say that,
although Detective Wynia has received second-hand information about the
circumstances surrounding Ms. Wells’s death, at this point that
information is unsubstantiated. Mr. Balesdent has not been located. Alloura
Wells’s family and friends understandably want answers as to how and why
she died.
18
There was also some discrepancy in the evidence, which I need not resolve, about whether any officer was
delegated to attend the search.
The Professional Standards Review
I earlier referred to a review the Service’s Professional Standards Unit
conducted into how the police had investigated the unidentified bodily remains
and Ms. Wells’s disappearance. The unit identified three areas where the
police could have done more to advance the investigations:

1. The divisional detective at the scene where Ms. Wells’s bodily remains
were found should have notifiedthe on-call homicide team in accordance
with the procedure on preliminary homicide investigations.
2. A media release should have been issued in relation to the discovery of
the bodily remains.
3. It would have been prudent for the officers in charge of both
investigations to seek the assistance of the Service’s LGBTQ2S+ liaison
officer.

The Failure to Issue a Media Release

After Ms. Wells’s bodily remains were identified, her family was upset that
the police hadn’t issued a media release when her remains were found. They
felt a media release might have led to the earlier identification. They were
right. A media release setting out what was known about the deceased,
including the existing profile, as well as the body’s location and immediate
environs, especially if these facts were brought to the attention of
Toronto’s trans community, might well have prompted additional leads or
resulted in an earlier identification. Detective Wynia candidly
acknowledged to the Review that such a media release would have been
well advised. As reflected above, the Service’s Professional Standards Unit
later came to the same conclusion in its review of the investigation.

The Failure to Involve the Liaison Officer

Detective Wynia from 53 Division did not reach out to any members of the
public or the trans community to seek assistance in identifying the deceased.
He had no previous exposure to trans organizations or trans community
leaders, who were largely based in the downtown core, closer to 51 Division.
He did not know what resources were potentially available to assist him. Those
resources included the Service’s LGBTQ2S+ liaison officer. She or others
similarly situated within the Service could have facilitated the engagement of
community organizations and members in attempting to identify the remains.
In hindsight, Detective Wynia agreed that engaging the LGBTQ2S+ liaison
officer in these circumstances would have assisted in bridging the gap between
police investigators and community members. As reflected above, the
Professional Standards Unit found that it would have been prudent for
Detective Wynia to involve the LGBTQ2S+ liaison officer. Detective Wynia
did contact front-line officers in the Community Response Unit shortly
after the bodily remains were discovered to find out who frequented the
ravine. Through this initiative, he learned about Mr. Balesdent’s connection to
trans women in the ravine.
Detective Constable Kama told the Review that when he met with Mr.
Wells, he believed the unidentified remains were those of Ms. Wells. In
the circumstances, he did not think that, at that point, it was necessary to
engage the liaison officer. Instead, he waited to see if Mr. Wells’s DNA
confirmed his belief.

Summary and Findings (Alloura Wells)

In many ways, the issues respecting the Alloura Wells investigations are a
microcosm of the systemic issues existing at the Service. Here, I refer to a
number of such issues.

Engaging the Community

The first issue relates to how the police failed to engage with affected
communities. Ms. Wells was a member of Toronto’s trans community. She
was also Indigenous, was a sex worker, and struggled with drug abuse. At the
time of her death, she lived under a bridge. Simply put, Ms. Wells was
marginalized and vulnerable in several ways that intersected. She was loved
by family and friends and known to many community members.
Based on the location of the unidentified human remains, the nearby
drug paraphernalia, and the limited profile, Detective Wynia was aware that
the deceased was likely a trans woman who might well be a sex worker and
involved with drugs. The profile also revealed that her ancestry might, in
whole or in part, be Indigenous. This is precisely the type of profile that called
out for community engagement. Ms. AP, the woman who had discovered the
body and subsequently made attempts to involve The 519, understood this
situation completely. One thing is certain: although Ms. AP’s efforts were
admirable and indeed welcome, she should not have been the one who ended
up assuming the burden to ensure that the affected communities knew about
the discovery of the bodily remains.
Detective Wynia took some appropriate steps to try to identify those
remains, including submitting a booklet to ViCLAS, attempting to match the
remains to outstanding Missing Person Reports, issuing an internal bulletin for
all Service members, and contacting members of the Community Response
Unit to learn more about the people who frequented the ravine. However, as
he conceded, he was unaware of the community resources available to assist
him, as well as the Service’s own resources, including the LGBTQ2S+ liaison
officer.19 As I explain in Chapters 5, 6, and 7, with several notable exceptions,
officers in the McArthur-related investigations similarly failed to use available
resources to partner with affected communities to advance their work. This
type of community engagement cannot be regarded as peripheral or optional.
Rather, it is at the core of effective investigative work. This is especially so for
missing person and unidentified bodily remains cases involving marginalized
and vulnerable individuals. Community members may well be important
sources of information who would assist investigators. However, they cannot
provide such information if they don’t know an investigation is even
taking place. Moreover, as I explain in my recommendations, if associates or
friends of a missing person feel at risk in speaking to the police – because, by
way of example, they are sex workers, are involved in illicit drugs, or are
trans individuals, whose community has historically been overpoliced,
underserviced, and discriminated against – the police need to cultivate
relationships with and avail themselves of trusted individuals within these
communitiesto act as conduits to those who have relevant information.

Issuing a Media Release

The second issue is related to the first. If the police are to act in true
partnership with affected communities, they must provide those communities
with basic knowledge to enable them to assist. Early in the unidentified
remains investigation, the police had more than sufficient information to issue
a media release. However, no such release was issued. A media release
represents only one of many ways in which the police can get the word
out. Robust use of social media with targeted audiences is important. The
Professional Standards Unit correctly concluded that, as was the case in the
Tess Richey investigation (see Chapter 8), the failure to issue an early
media release represented a deficiency in the initial investigation.

Identifying and Assigning a Lead Investigator

Effective missing person and unidentified remains investigations require the
prompt assignment of a lead investigator. There was an unacceptable delay in
assigning Detective Wynia as the lead investigator here. Detective Wynia
could not explain the delay. As I set out in Chapter 8, there was also an
unacceptable delay in assigning a lead investigator in relation to Ms. Richey’s
19
Those resources now include neighbourhood community officers, an initiative I describe in Chapter 14.
disappearance. These delays created the unfortunate message that the police
regard these investigations as unimportant.
Moreover, on a related point, it remains unclear – even today – who the
assigned lead investigator was for Ms. Wells’s disappearance. Detective
Constable Kama indicated he was not the lead investigator, but the records fail
to disclose who, if anyone, was assigned this role. In Chapter 5, I identify a
similar issue in relation to the initial investigation into Skandaraj
Navaratnam’s disappearance. It was unclear, at times, who the lead
investigator into Mr. Navaratnam’s disappearance was.20 The absence of
clarity about the identity of the lead investigator undermines an effective
investigation. It also makes supervision and accountability more difficult, if
not impossible.

Notifying the Homicide Unit

The evening Ms. AP and Mr. AQ found and reported the unidentified remains,
the detective who went to the scene failed to notify the on-call homicide team,
as required by the Service’s procedure on preliminary homicide investigations.
In Chapter 8, I identify this same failure following the discovery of Ms.
Richey’s body. A sudden death investigation arising from the discovery of a
body or bodily remains might well require the expertise of the Homicide Unit.
The unit obviously cannot lend its expertise to the investigation or, where
appropriate, assume carriage of it, unless it is aware of the discovery. The
unit’s ability to evaluate the situation is also potentially impaired when its
officers are prevented from going to the scene of the discovery in a timely
way.

Communicating with the Office of the Chief Coroner

The next issue relates to the need for clear and accurate communications by
the Office of the Chief Coroner, and an accurate record of those
communications. Before Ms. Wells’s remains were identified, both Mr. Wells
and the police contacted the Office of the Chief Coroner to find out whether
Ms. Wells’s body was at the morgue in Toronto. There is no reliable record of
precisely what Mr. Wells was told when he contacted the office, nor is there a
record of who spoke to him and to the police when they initiated inquiries.
(Similar issues arose in the case of Kenneth Peddle, discussed later in this
chapter.) It appears the chief coroner’s representative’s responses were either
inaccurate or incomplete (or both) and led Mr. Wells and the police to believe
there were no bodily remains at the morgue that could belong to Ms. Wells.
The Review was advised by the Office of the Chief Coroner that, until
recently,
20
See also Chapter 4. The Ontario Ministry of the Solicitor General’s 2019 Inspection Report on the
Service’s major case management practices recommends that the Service’s procedures be revised to require
that officers in the command triangle of major cases be clearly identified.
no procedure was in place to ensure that inquiries were accurately answered.
This situation sometimes resulted in the office’s giving out inaccurate
information. However, the office is currently in the process of creating a
procedure to ensure all inquiries are directed to the appropriate staff member
so that accurate information can be conveyed. As I later recommend, such
exchanges with the Office of the Chief Coroner should be properly
memorialized in writing to enhance accountability and avoid
miscommunication or misunderstanding. In my view, these exchanges raise a
critically important systemic issue; namely, the quality of communication
between the police, affected loved ones, and the Office of the Chief Coroner.
I address this systemic issue later in this chapter and in my recommendations.
This systemic issue is informed not only by the Alloura Wells case but also by
other instances in which loved ones searched for a missing person only to learn
later that the person’s body was at the morgue all along.

Completing Timely Missing Person Reports

The booking sergeant at 53 Division did not complete a Missing Person Report
when Mr. Wells first reported his daughter missing. As I discuss in
Chapter 13, it constitutes best practice to ensure that such a report always be
completed in these circumstances. No one should be sent away to pursue other
options. Such an approach discourages reporting, undermines timely
investigations, and signals, however unintentionally, that the police regard the
occurrence as unimportant. Chief Saunders’s apology to Mr. Wells for this
aspect of the investigation was appropriate.

Treating Affected Persons with Respect

Members of Ms. Wells’s family and friends, as well as Ms. AP, expressed
concern about the attitude they felt some of the officers, or the Service more
generally, exhibited in these investigations. Ms. AR, as a leader in the trans
community, raised similar concerns with senior officers. The police were
described, at times, as dismissive, uncaring, and uninterested. Mr. Wells felt
the booking sergeant at 53 Division gave the initial report short shrift and was
insensitive in telling him that his daughter would come back and not to worry
– she was young. He and others believed the police initially gave inadequate
attention to Ms. Wells’s disappearance because she was a homeless trans
sex worker with addictions.
Mr. Wells felt – as do I – that Detective Constable Kama took the
missing person investigation seriously. The officer conducted a largely
effective investigation. Although I identify deficiencies in Detective Wynia’s
investigation into the unidentified bodily remains – deficiencies he candidly
acknowledged – I do not in any way attribute them to an uncaring attitude.
During a number of my community consultations, I heard accounts
about police officers with poor attitudes, or with overt or implicit biases.
Although it is not my role to evaluate the officers’ conduct in relation to each
of these accounts, their sheer volume underscores an important issue about
how police officers interact with, or are perceived to interact with, community
members. The Review’s community engagement survey revealed that
many community members share the views expressed to me during some
of these consultations (see Chapter 10).
In Chapter 12, I scrutinize the role that bias or discrimination has played
at the Service and the extent to which it is relevant to the specific
investigations I examine in this Report. Here, I wish to address another
aspect of police
attitudes, or perceived attitudes, during missing person or unidentified bodily
remains investigations. I add “or perceived attitudes” because a police service
is most effective when the public has confidence in its work. Perceptions that
the police do not care or are dismissive undermine that confidence. Negative
interactions or perceptions may be fuelled both by the attitudes of specific
officers and by the systemic approach the Service has taken to missing person
investigations generally.
As I reflect in Chapter 13, the Service has generally given low priority
to missing person investigations. The Service’s approach to missing person
cases has manifested itself in a number of ways, including by delayed
assignments (already discussed); a lack of ongoing communication with family
members, loved ones, and friends; no continuity when assigned officers go off-
shift; and limited deployment or availability of resources. It is not surprising
that many people affected by a disappearance feel unheard and, in these
circumstances, regard the Service and its officers as dismissive or inattentive.
As I reflect in later chapters, unlike in cases where institutional support
is provided to identified victims of crime, the Service has done a poor job
generally in providing support to those affected by the disappearance of a
loved one or friend. Those victimized by the disappearances of their loved
ones deserve the same attention. Moreover, when police fail to adequately
communicate their efforts to family members and other loved ones of missing
individuals, it is understandable that those affected believe the police are
uninterested and unmotivated. Communication is one antidote to perceptions
of a lack of interest.
Finally, officers all too often attempt to minimize the concerns
expressed about a missing person – with comments like “he’s probably
just partying with friends”; or “she’ll come back – she’s young.” These
types of
comments may be motivated by the desire to give someone hope, but they may
also reveal stereotypical notions about certain missing persons. They feed into
a perception that the police are not taking a Missing Person Report
seriously. After all, the reporting individual is often better situated than the
police to know whether the disappearance of a loved one or friend should be of
concern. I address these points in my recommendations.

Issues Around Existing Procedures

The Alloura Wells investigations also highlight several systemic issues
addressed in my recommendations. As I state earlier, 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. My
recommendations address this lack of clarity.
An officer filled out a Search Urgency Chart when Ms. Wells was
reported missing and categorized the appropriate search level as 1–2. My
Review has disclosed that this chart was sometimes completed in missing
person investigations – but sometimes not. When it was filled in, as it was in
relation to Ms. Wells’s disappearance, I see no correlation between how it was
completed and how an investigation was conducted. I am unconvinced that,
across the Service, the contents of Search Urgency Charts were completed in
a consistent way or that the somewhat rudimentary assessments contained in
them were truly evidence-based. Here, it was even difficult to reconcile the
high urgency reflected in the Search Urgency Chart with the separate
categorization of the required level of search.
Finally, I observe that two parallel investigations at two different
divisions took place in relation to the unidentified bodily remains and Ms.
Wells’s reported disappearance. At one point, the steps taken in the concurring
investigations were duplicated. As I previously observe, Detective Wynia and
Detective Constable Kama interviewed some of the same witnesses. This
duplication clearly does not represent best practice but involves the
unnecessary use of police resources and imposes an unnecessary burden
on witnesses, who must tell their stories twice. I address these issues in my
recommendations.
The Kenneth Peddle Case

Key issues raised by the Alloura Wells investigations are not confined to
her case. They represent systemic issues that must be addressed. In this
chapter, I also describe the tragic case of Kenneth Peddle. His family
reported him missing and actively searched for him, not knowing that his
bodily remains had been recovered shortly after his death. I describe the cases
of two other missing men, Arthur Louttit and Dovi Henry, in case studies that
precede and follow Chapter 14.
Mr. Henry was a young Black man who went missing in 2014.
However, the police never took a Missing Person Report. Mr. Henry’s body
was found in Toronto shortly after he was last seen but was not identified
by police because there was no missing person investigation. His body
remained unidentified for two years, until his mother found a reference to
his unidentified remains on the OPP’s Missing Person and Unidentified
Bodies Unit’s website.
Mr. Louttit was an Indigenous man who had brain surgery shortly
before he disappeared in September 2012. The police conducted a missing
person investigation. However, Mr. Louttit’s body was not located until
almost two months later, not far from where he was last known to be.

Mr. Peddle’s Disappearance and Death

On May 31, 2017, Kenneth Peddle took his own life. He was 72 years old. He
had two daughters – Vanessa McCarthy and Rebecca Bingeman. They loved
him dearly. For much of his life, he had been an IT specialist and consultant.
His work had taken him around the world, sometimes on behalf of high-profile
clients. Sadly, when he died, he was unemployed, suffered from leukemia and
diabetes, and was experiencing mental health issues, including severe
depression. He had lived in various locations across the country, including in
the area of Wellesley and Bay streets in Toronto. When he died, he was
homeless or underhoused despite prior efforts to assist him by his daughters
and Mr. AS, an ex-partner.
On the evening of May 31, Mr. Peddle left Mr. AS’s condominium in
the Village, where he sometimes stayed. Tragically, a few hours later, he
jumped off a bridge that overlooked a ravine and creek within David A.
Balfour Park. He died at the scene. A bystander contacted the police.
The Unidentified Remains Investigation
Because David A. Balfour Park is located within 53 Division’s boundaries,
officers from that division went to the scene, as did the coroner. No personal
items were found on the deceased’s body. His identity was unknown to the
authorities. His body was transported to the morgue, where fingerprints were
taken and an autopsy was conducted. The autopsy determined that death was
caused by blunt impact trauma from the fall. The death was classified as a
suicide.
The next day, on June 1, the unidentified body investigation was
assigned to Detective Sajeev Nair, who worked in 53 Division’s Criminal
Investigations Bureau. This was the last day of Detective Nair’s shift. He then
went off-duty, as scheduled, from June 2 to 7. During his absence, the
investigation was not passed on to another officer.
When Detective Nair returned to work on the evening of June 8, he was
told that the deceased’s fingerprints were not on the Service’s database
and, therefore, they did not assist in identifying him. Detective Nair
checked 53 Division’s missing persons log to see if there were any missing
person occurrences in the division that matched the unidentified body.
There were none.
Detective Nair told the Review that, at this point, the investigation was
at a standstill. In any event, he had to focus on other investigations. He was on
a typically busy evening shift, which consumed him with his other tasks. He
did not enter the unidentified remains information onto the Canadian Police
Information Centre (CPIC) at that time. He understood, incorrectly as it turned
out, that pursuant to major case management protocols, he needed to wait until
the deceased had remained unidentified for 30 days before the information
could be placed on the system. He understood the information would then be
included on the RCMP national database.
Detective Nair contacted morgue staff to find out if there were any
identifying features on the body to assist in identification. When interviewed
during the Review, he could not recall whether he had reviewed Missing
Person reports, media releases, or internal Service bulletins from other
divisions to determine if the unidentified remains matched any of those
occurrences. He had done that kind of review in some cases. Detective Nair
acknowledged that many Missing Person reports come in daily; he described
the difficulty in attempting to review them all. He said that, sometimes,
the Service’s crime analysts look for “commonalities” among the Missing
Person reports and unidentified remains occurrences, but there is no evidence
such an investigation was requested or took place in this case. Detective Nair
favoured
the creation of a single portal containing all missing people in Toronto and
their photographs, rather than sifting through what the division’s crime analyst
might send or looking at every media release distributed, while, at the same
time, attempting to wrestle with the daily volume of work. When this
investigation took place, Detective Nair was unaware of MPUB.
Detective Nair also considered whether to issue a public media release
or internal bulletin about the unidentified body. He felt this initiative would be
appropriate once the body had not been identified within the first 30 days and
he had exhausted other means of identification.

The Missing Person Investigation

On May 31, Mr. AS noticed Mr. Peddle had not returned. Mr. AS contacted
Mr. Peddle’s daughters, Ms. McCarthy and Ms. Bingeman. The next day, Ms.
McCarthy called the police to report her father missing. Because Ms.
McCarthy was calling from an address located within 53 Division, officers
from that division met with her and completed a Missing Person Report-. She
provided the officers with her father’s photograph and explained that he was
possibly suicidal. The available records did not enable the Review to
determine what steps, if any, 53 Division officers took to look for Mr. Peddle,
including whether they contacted the Office of the Chief Coroner to determine
if any unidentified remains matched Mr. Peddle’s description. Because Mr.
Peddle’s last known residence (Mr. AS’s home) was located in 51
Division’s jurisdiction and he was last seen in that area, the missing person
investigation was transferred to 51 Division where, on June 2, it was assigned
to Detective Henry Dyck.21
That same day, Detective Dyck and Detective Constable Robert
Chevalier spoke with Mr. AS, the last person to see Mr. Peddle. Mr. AS told
the officers that Mr. Peddle was unemployed and homeless before his
disappearance. Mr. Peddle had often stayed with Mr. AS for a few weeks
while he applied for IT contracts before moving on to another place. Mr.
AS had given Mr. Peddle a May 31 deadline to leave his condominium. Mr.
Peddle left around 7:30 p.m. that day. Their discussion that day had been polite
and casual. Mr. Peddle left all his belongings behind. Mr. AS told police
that he and Mr. Peddle’s family were concerned about him because his “back
was to the wall”: he refused to take any public funds, had nowhere to go to
live, and was unable to find new work. He had only $11 in his bank account.
Detective Constable Chevalier completed a Lost Person Questionnaire
based on the information provided. It included a description of Mr.
Peddle’s

21
Detective Dyck has since become a sergeant.
clothing, his current physical and mental health issues, and Mr. AS’s
description of Mr. Peddle’s current crisis over a place to stay. The police
looked at Mr. Peddle’s phone and found no incoming phone calls or messages.
Mr. AS told them about some coffee shops Mr. Peddle liked to visit. The
police searched the condominium and the contact list on Mr. Peddle’s
phone but found nothing to assist them. They also checked the common
areas of the building and spoke to the building management. The officers
asked for the building’s video footage. It was provided a few days later. 22
The same day, Detective Constable Chevalier arranged for officers
to conduct a 300 metre search around the building. Detective Dyck returned to
51 Division and immediately prepared a media release. He also updated
the staff sergeant about the Missing Person Report. At 10:30 a.m., the
police published a tweet about Mr. Peddle’s disappearance. It included his
photo and a description of the clothing he was wearing and where he was last
seen. The media release contained similar information, as well as Detective
Dyck’s contact information. It stated that the police were concerned about
Mr. Peddle’s safety. The police also contacted hospitals to see if they could
find him. Detective Constable Chevalier called the Office of the Chief Coroner
and was told either that the morgue did not have any unidentified remains or
that it had none which matched Mr. Peddle’s description. This information
was inaccurate as it turned out. Unfortunately, Detective Constable Chevalier
did not record exactly what was said or the name of the person he spoke to. It
is also unclear whether the police searched the Service’s Versadex system to
see if it contained any reports of unidentified remains that matched Mr.
Peddle’s description.
Mr. Peddle’s family were also trying to find him. On June 3, Detective
Dyck received two calls from Ms. Bingeman, who was understandably
distraught. She told him her father had told her he was going to “go sit under
an oak tree and die.” He considered himself a “nominal Buddhist” and had at
one time considered leaving everything for a monastery. Detective Dyck
followed up by asking the division’s front desk staff to contact nearby
Buddhist organizations. He also asked front-line officers to conduct a more
detailed check of the waterfront area and cafés Mr. Peddle was known to
frequent. These efforts proved fruitless. Detective Dyck’s staff sergeant sent
an email to Mr. Peddle’s Hotmail account and asked the Technological
Crime Unit to determine if Mr. Peddle had been online. On June 5, the unit
advised Detective
22
When Detective Constable Chevalier watched the video footage a few days later, he observed Mr. Peddle
depart a nd what he was wearing.
Dyck that somebody had logged into Mr. Peddle’s account, but Detective
Dyck learned, that same day, that Mr. Peddle’s family had accessed the
account through his computer. Detective Dyck obtained more of Mr. Peddle’s
email addresses and passwords from Ms. Bingeman and forwarded them to
the Technological Crime Unit.
On June 6, Ms. Bingeman advised Detective Dyck about a possible
sighting. The police investigated various possible sightings, obviously to no
effect given what we now know.
On June 7, Ms. Bingeman emailed Detective Dyck to ask if the
police could “hack” into her father’s computer to review his browser history.
She also asked if the police wanted Mr. Peddle’s phone number. The police
did not take Mr. Peddle’s computer at this time. On June 16, Ms. McCarthy
emailed Detective Dyck and told him she was continuing to try to get into her
father’s laptop. She understood that Detective Constable Kama, another 51
Division investigator who assisted on missing person cases, was going to ask
Microsoft to monitor her father’s email account and apologized if her efforts
came to Microsoft’s attention as a result. Eventually, Ms. McCarthy
overrode her father’s computer password, but found nothing of assistance in
his browsing history or files other than confirmation that her father had not
sent or read any emails since May 31. She asked Detective Dyck if he
wanted Mr. Peddle’s laptop. The next day, Detective Dyck told her he did not
need the computer at that point but would add the information she provided
him to the file. He told her to “keep checking periodically and if anything
changes let me know immediately.” Detective Dyck advised the Review
that he did not accept the computer because of privacy concerns. He did not
know if Mr. Peddle was still alive, and it would have been difficult for him
to obtain a warrant in the circumstances. As well, Ms. McCarthy was
checking the computer regularly. Detective Constable Kama also told the
Review that it is generally impractical for police to have the Technological
Crimes Unit examine a password- protected computer. It is time consuming,
and the unit often cannot process these requests in a timely fashion. I observe,
as did Detective Dyck, that the new Missing Persons Act confers greater
authority on the police to obtain a warrant in these circumstances.
On June 8, Detective Dyck emailed various community organizations,
including The 519, providing information about Mr. Peddle and a copy of the
media release, encouraging them to distribute the information throughout the
community.2 3 That day and the next, Ms. McCarthy emailed and
telephoned

23
As I note in Chapter 7, Detective Dyck emailed these organizations in rela tion to Selim Esen as well. In
fact, the same email contained both names.
the police with additional information, including a photograph of a unique
baseball cap her father wore. Detective Constable Kama attached the photo to
the Occurrence Report. He also obtained information about dentists who might
have had Mr. Peddle’s dental records; however, he did not request these
records at that time.
Within the first week of Mr. Peddle’s disappearance, his family and
friends made and distributed missing person posters around the city. They
continued to do so for several weeks. They also contacted shelters, soup
kitchens, LGBTQ2S+ community centres, bathhouses, the Centre for
Addiction and Mental Heath, and other locations. They followed leads on
Facebook and reached out to Mr. Peddle’s brother in British Columbia. On
June 12, Ms. McCarthy was in contact with a reporter regarding a story about
her father’s disappearance. The story was published the next day.
On June 13, Detective Constable Kama called Ms. McCarthy to update
her about the steps the police were taking. Ms. McCarthy told him that
someone appeared to be retrieving voicemail on her father’s phone because, at
one point, she was able to leave a message when the voice mailbox had
been full before. Detective Constable Kama immediately called Mr. Peddle’s
phone number but the voicemail was full. He also contacted his phone
provider, which was unable to say who was checking the voicemail.
On June 21, Ms. Bingeman and Detective Dyck discussed the voicemail
issue and whether it meant that her father was remotely accessing his
messages. Detective Dyck told her he would follow up. The next day, Ms.
McCarthy emailed Detective Dyck to tell him she may have put one of her
father’s email accounts on lockdown by trying to figure out his password.
She also asked whether it was possible for her father to have returned to
British Columbia, where he was originally from, without identification. Ms.
McCarthy received an automatic email in response indicating that Detective
Dyck was out of the office until June 26.
There is no indication that, after June 21, any officer was working on
the investigation.

The Identification of Mr. Peddle’s Remains

On July 1, 2017, Detective Nair came across a CPIC message about dental
charts being required for a missing person occurrence outstanding for 30
days.24 This message related to Mr. Peddle. Detective Nair viewed the
24
This notification would have been created by the Records Management Unit when Mr. Peddle’s name was
put on CPIC as a missing person. The records management operator would have set a 30-day diary date
reminder for dental records. In 2017, at the 30-day mark, CPIC sent an automated message to the assigned
division for the missing person case, advising that dental records are required. The detective sergeant at the
underlying Occurrence Report and realized that, although the Missing Person
Report had initially been reported to 53 Division and “put through the 53
Division queue,” it became a 51 Division case. This was why the 30-day
notice was sent to 53 Division, rather than 51 Division. Detective Nair read
Mr. Peddle’s description and then checked his photograph, realizing it
matched his unidentified remains case. Had this message been sent to 51
Division, as it should have been once the missing person investigation had
been transferred there, it is unclear how long Mr. Peddle’s body would
have remained unidentified at the morgue.
Detective Nair contacted 51 Division. The lead investigator of Mr.
Peddle’s case was unavailable so, to Detective Nair’s credit, he contacted Ms.
McCarthy directly and accompanied her at the morgue where she identified
her father’s body. Detective Nair offered her assistance from the
Service’s
Victim Services Program. Ms. McCarthy greatly appreciated his sensitivity.
The following day, Detective Dyck also contacted Ms. McCarthy and Ms.
Bingeman to offer his condolences about their father.

Summary and Findings (K enneth Peddle)

There are some obvious similarities between the issues raised by the
Alloura Wells and the Kenneth Peddle investigations. One of Mr. Peddle’s
daughters described how her father’s disappearance and the month-long
uncertainty of what happened to him tortured his family and represented the
most traumatic event in their lives. Before Mr. Peddle’s remains were
identified, the police contacted the Office of the Chief Coroner to find out
whether Mr. Peddle’s body was at the morgue in Toronto. Similar to the
inquiries made about Alloura Wells, there is no reliable record of precisely
what the police were told when they contacted the office, nor is there a record
of who spoke to the police when they initiated those inquiries. Nonetheless, it
appears the responses given by the chief coroner’s representative were
inaccurate and led the police to believe there were no bodily remains at the
morgue that could belong to Mr. Peddle.
The unidentified remains investigation was deficient in several
ways, some of which reflect larger systemic issues. The investigation largely
ground to a halt when the lead investigator went off-shift. His workload
made it difficult for him to devote considerable time to this investigation. He
was under the misunderstanding that he could not immediately enter
information about the unidentified remains onto CPIC. He was unaware of
the assistance that

division would receive the notification. The detective sergeant also has the ability in Versadex to set up a
reminder and follow-up respecting the request. The Service’s Missing Persons Procedure required the
detective sergeant to request the missing person’s dentist to complete an RCMP Dental Characteristics Input
Data Form if the missing person is not located within 30 days.
MPUB could potentially provide. His review of outstanding Missing Person
reports was not comprehensive and may have been confined to other Missing
Person reports within the division. He acknowledged that the system needed
improvement to permit a comprehensive search to be easily performed. He
mistakenly believed he was constrained from issuing a media release
pertaining to the remains for 30 days. A timely media release may have
produced more leads.
Detective Dyck and Detective Constable Chevalier, with assistance
from Detective Constable Kama, conducted a credible missing person
investigation. Indeed, this investigation stands in contrast to others I describe
in this Report. Although Mr. Peddle’s family were understandably
frustrated at times with their inability to access the assigned officers – a
systemic issue addressed in my recommendations – both detectives were
largely responsive to the family, followed up on a range of leads, contacted
community agencies such as The 519 and Buddhist organizations, updated
family members, and were sensitive to their concerns and pain. Detective Dyck
agreed that for Mr. Peddle to have been unidentified for such a long time was a
systemic failure and “obviously an issue of disconnect.” Of course, the
misinformation from the Office of the Chief Coroner undermined the
investigation. Detective Dyck agreed it would have been prudent to make a
follow- up call to the morgue, although he couldn’t recall whether he had
done so in this case. He suggested that the Office of the Chief Coroner should
send an email to the police every day about the bodies that just arrived at the
morgue, with details including their approximate age, gender, and
distinguishing features. In Chapter 15, I address how to improve the
timeliness of identifications of bodily remains. Some important
improvements have already taken place.
From a systemic perspective, one cannot ignore that, in the end, Mr.
Peddle’s bodily remains were identified largely because of a mistake.
Detective Nair came across a CPIC message about dental charts being required
for a missing person occurrence outstanding for 30 days. This message related
to Mr. Peddle. Detective Nair viewed the underlying Occurrence Report and
realized that the message should have gone to 51 Division, not 53 Division
where he worked. Had this message been sent to 51 Division, as it should have
been once the missing person investigation had been transferred there, it is
unclear how long Mr. Peddle’s body would have remained unidentified at the
morgue. Once Detective Nair saw this message, he acted quickly and
sensitively to meet with Mr. Peddle’s family and arrange for the formal
identification of Mr. Peddle’s body.
 In Chapter 13, I outline in detail how unidentified remains cases
have been and are currently conducted in Toronto, leading to my
recommendations in Chapter 15.