Inquest into the Death of Kenneth Allen

The Administration Committee recommends that:

(1) Council advise the Ministry of the Solicitor General that it supports Recommendation No. (12) embodied in the Verdict of Coroner's Jury Recommendation respecting the inquest into the death of Kenneth Allen, wherein it recommends that on or about the anniversary of the completion of the Allen inquest, the Office of the Chief Coroner make public, through a press conference, the progress of the implementation of the recommendations made by this jury; and

(2) the Toronto Police Service be requested to report as soon as possible, and in any event, by March, 2000, to the Administration Committee on its implementation of all recommendations of Coroner's juries relating to procedures in the treatment by Police of the mentally ill.

The Administration Committee reports, for the information of Council, having concurred with the recommendation embodied in the report (December 20, 1999) from the City Solicitor.

The Administration Committee submits the following report (December 20, 1999) from the City Solicitor:

Purpose:

The purpose of this report is to report the results of an Inquest into the death of Kenneth Allen held from September - December, 1999.

Financial Implications and Impact Statement:

There are no municipal costs associated with the matter.

Recommendations:

It is recommended that:

(1) this report be received as information; and

(2) this report be forwarded to the Community Services Committee.

Background:

By the adoption, at its meeting on March 2, 3 and 4, 1999, of Clause No. 19 of Report No. 2 of The Corporate Services Committee, Council authorized the City Solicitor to represent the City of Toronto and four paramedics at the Inquest into the death of Kenneth Allen.

Mr. Allen died in police custody on November 30, 1991. Prior to the commencement of the inquest, lawyers for several of the parties with standing chose to reserve their right to question the paramedic care of Mr. Allen, especially since the cause of death of Mr. Allen was a matter of medical controversy, i.e., whether he died from cocaine toxicity or asphyxia due to compression of the neck by a nightstick or both Mr. Allen had 2 and possibly 3 fractures in the throat area, including a fracture of the hyoid bone.

Comments:

The Inquest took about 45 days from September to December 17, 1999. The jury found that the primary cause of death was asphyxia due to the external application of mechanical force while Mr. Allen was in a state of cocaine toxicity.

The paramedics were unable to initiate CPR as soon as they would have liked because the police had trouble locating a key to remove the handcuffs from Mr. Allen. The jury made a recommendation directed to the police to require them to carry handcuff keys at all times.

It was apparent from the evidence that the paramedics responded quickly and treated Mr. Allen appropriately. There were no recommendations directed to the City of Toronto or to the paramedics.

Conclusions:

It is recommended that:

(1) this report be received as information; and

(2) this report be forwarded to the Community Services Committee.

Contact:

Jane Egan

Solicitor, Legal Services

Phone: 392-8703

Fax: 392-3841

e-mail address: jegan@toronto.ca

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Jury Recommendations

(1) One of the central themes of the Allen inquest has been the use of a nightstick. The Jury has discussed and debated at length whether routine orders, rules and regulations should be amended to permit the use of the nightstick in the neck and head area in certain circumstances, such as only to prevent serious injury or death to the police officer or to other persons. The jury has concluded that:

(a) There should continue to be no training in the technique involving placing a baton in the area of the neck of an individual and then compressing one side of the neck.

(b) All Police Services should include in their annual Use of Force training education concerning the risks relating to the use of a nightstick in the area of the head and neck.

(c) In 1991 the Director of the Ontario Police College issued a directive to the Chiefs of Police of Ontario advising that the decision has been made to discontinue the technique of placing the baton around the neck of an individual and then compressing one side of the neck. Accordingly, Toronto Police Rule 4.7.3 should be amended to include a statement that this particular technique is no longer to be used in any circumstances, due to the potential danger of causing serious harm or death.

(2) Command officers should be responsible for verifying that officers reporting to them have read and understood routine orders. The meaning of routine orders should be discussed thoroughly at "parade". Special attention must be paid to those routine orders that deal with issued relating to the safety of the public, for example - Routine Order Excited Delirium - June-99.

Rationale: This would allow for questions, clarification and feedback between command officers and those police officers reporting to them. Police Officers work closely with the public and should have a good understanding of routine orders.

(3) The Police Services Board should implement a "sign-off" system whereby police officers must acknowledge (either electronically or otherwise) that they have read and understood each rule, regulation and routine order.

Rationale: This recommendation will ensure that all police officers are personally accountable for reading routine orders. If some officers are in non-compliance, senior management would be aware of this occurrence and corrective measures could be taken. This is important to ensure that new information regarding rules, regulations and routine orders are understood and implemented uniformly throughout the entire force.

(4) When the decision has been made to transport a violent prisoner to the police station, the police station should be notified of the fact in advance of the arrival.

Rationale: This would allow the booking sergeant or the officer in charge to be aware of the situation. Efforts can then be undertaken to remove any vehicle that may be in the sallyport, or to provide any assistance to the arresting officers that may be required upon their arrival.

(5) A dedicated camera should be installed outside of 52 Division (and other police stations as appropriate) to ensure that every transport of a prisoner into the Division is fully captured by the video recording system.

Rationale: This allows for the booking procedure to be video taped in its entirety.

(6) We recommend that at 52 Division the doors from the sallyport into the vestibule and from the vestibule to the booking hall be widened to facilitate the transport of officers with prisoners. Where applicable consideration of the above should be given to other police stations.

Rationale: In the inquest into the death of Kenneth Allen, it was noted that the officers had difficulty in the transport of Mr. Allen through the doorways.

(7) The words "handcuffs and keys thereto" should replace the word "handcuff" in the list of regulation attire for patrol.

Rationale: In any situation, especially in an emergency, handcuffs can be removed immediately.

(8) The jury was concerned with the effectiveness of the First Aid applied to Mr. Allen when he was on the floor in the bullpen at 52 Division. We recommend that those who are responsible for the training of officers in First Aid consider carefully whether changes need to be made in the quality and regularity of First Aid training.

(9) The Chief Forensic Pathologist for the Province of Ontario should review the autopsy reports of all deaths in police custody and SIU investigated deaths.

Rationale: These deaths may lead to a criminal investigation of the circumstances and will definitely result in a Coroner's Inquest. Accordingly, we believe it is imperative that these autopsy reports be subjected to review and analysis.

(10) It is recommended that the Office of the Chief Coroner conduct a review of the procedures utilized by other jurisdictions in North America concerning the conduct of autopsies of persons who have died in police custody.

Rationale: It was noted by the Jury that in one jurisdiction (i.e., Manitoba) post-mortem examinations are conducted by two independent pathologists and autopsy procedures are video and audio taped. Comparisons with other jurisdictions may lead to further improvements in Ontario's post-mortem examination procedures. With respect to video and audio taping it should be recognized that suitable electronic technology may be implemented in a non-intrusive manner.

(11) Post-mortem reports should include a section where the pathologist notes what information he/she received about the circumstances of the deceased's death. The pathologist should note on the post-mortem report who gave him or her the information and when.

Rationale: There are three important sources information that the pathologist uses when conducting a post-mortem review: the pathology report, the toxicology report and the circumstances surrounding the death. The pathology and toxicology reports are recorded. Based on the evidence in the Allen case we recommend that all three sources of information be recorded to ensure accuracy and completeness.

(12) The Jury understands that the Chief Coroner issues an annual report on all inquested findings. We recommend that on or about the anniversary of the completion of the Allen inquest, the Office of the Chief Coroner make public through a press conference the progress of the implementation of the recommendation made by this jury. All parties to this inquest including the jury should be invited to this press conference.

In conclusion, the death of Mr. Kenneth Allen illustrates the need for ongoing vigilance in the treatment by the police of the mentally ill and of those who are under the influence of drugs. We commend the Coroner's Office and the Toronto Police Force for issuing revised memoranda and routine orders regarding 'Excited Delirium and the Use of Restraint'. We encourage the Coroner and the Chief of the Toronto Police to keep this issue front and center with the force.