Office of the

Chief Coroner
Verdict of Coroners Jury
Bureau du Verdict du jury du coroner
coroner en chef
The Coroners Act Province of Ontario
Loi sur les coroners Province de lOntario

We the undersigned / Nous soussigns,

Toronto
of / de
Toronto
of / de
Toronto
of / de
Toronto
of / de
Toronto
of / de

the jury serving on the inquest into the death(s) of / membres dment asserments du jury lenqute sur le dcs de :

Surname / Nom de famile Given Names / Prnoms

MacIsaac Michael

aged 47 held at Toronto , Ontario

lge de tenue

from the 17th of July to the 2nd of August 20 17

du au

By Dr. / Dr David Evans Coroner for Ontario

Par coroner pour lOntario

having been duly sworn/affirmed, have inquired into and determined the following:
avons fait enqute dans laffaire et avons conclu ce qui suit :
Name of Deceased / Nom du dfunt
Michael MacIsaac
Date and Time of Death / Date et heure du dcs
December 3rd, 2013 at 3:57 AM
Place of Death / Lieu du dcs
St. Michael's Hospital, 30 Bond Street, Toronto
Cause of Death / Cause du dcs
Gunshot wound to the abdomen

By what means / Circonstances du dcs

Homicide

Original signed by: Foreman / Original sign par : Prsident du jury

Original signed by jurors / Original sign par les jurs

The verdict was received on the 2nd day of August 20 17

Ce verdict a t reu le (Day / Jour) (Month / Mois)

Coroners Name (Please print) / Nom du coroner (en lettres moules) Date Signed (yyyy/mm/dd) / Date de la signature (aaaa/mm/dd)
2017/08/02

Coroners Signature / Signature du coroner

We, the jury, wish to make the following recommendations: (see page 2)
Nous, membres du jury, formulons les recommandations suivantes : (voir page 2)

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 Office of the
Chief Coroner
Verdict of Coroners Jury
Bureau du Verdict du jury du coroner
coroner en chef
The Coroners Act Province of Ontario
Loi sur les coroners Province de lOntario

Inquest into the death of:

Enqute sur le dcs de :
Michael MacIsaac

JURY RECOMMENDATIONS
RECOMMANDATIONS DU JURY

To the Durham Regional Police Services Board, The Chief of Police of the Durham Regional Police Service, the
Ontario Police College and the Ministry of Community Safety and Correctional Services:

1. Specific training should be provided, in a dedicated block of time, around effective (calming) communication
and de-escalation, both verbal and non-verbal; that such training be provided both at the Ontario Police College (OPC)
and the Durham Regional Police Service (DRPS) during initial training and annual block training; that such training
focus on individuals with mental health issues (but not on the symptoms) and with the significant participation of people
with lived experience; that such training utilize a combination of approaches, including a substantial amount of time
dedicated to role playing by non-police personnel, preferably trained actors.

2. Include training on identification of issues that may impede communication between officers and subjects.

3. Train officers in strategies to disarm subjects possessing weapons of opportunity.

4. Emphasize the need to create time and space during police interactions with individuals in crisis.

5. Consider educating officers to recognize the potential for, and impact of, auditory exclusion and tunnel vision
that could occur during crisis interactions involving officers and subjects during which, some or all of the parties may be
experiencing these phenomena and how this affects their interaction.

6. Examine the allocation of funding to current training, and the contents of that training and techniques, to assess
if the funding is being used effectively to prevent deaths in similar circumstances; eliminate courses that are not
effective.

7. Provide mandatory in-depth mental health training to include all officers.

8. That any new training be based on approaches that have been rigorously tested and shown to be effective in
changing behaviour (and that all training be tested and measured to demonstrate if it is in fact having an impact on
changing behaviour going forward).

9. In situations where an individual in crisis has a weapon and has not responded to the standard initial police
commands (i.e. Stop. Police, Police. Dont move, and / or Drop the weapon), train officers to stop shouting those
commands and attempt different defusing communications strategies. Also train officers in such situations to coordinate
amongst themselves so that one officer takes the lead in communicating (and not all officers are shouting commands).

10. Consider creating a program to encourage, fund and support the participation of people with direct experience
with mental health and/or addictions issues and people with disabilities in training at the OPC, the DRPS and the
divisional level, and to participate in any standing or advisory committees.

To the Durham Regional Police Services Board and The Chief of Police of the Durham Regional Police Service:

11. Debrief all critical incidents to learn from the outcomes.

12. Assign mental health training and outreach portfolio to a Senior Officer (Inspector and above).

13. Dispatch / Communications and officers should be made aware of any mental health officers on shift through
notification at the platoon meeting at the start of the shift until such time as all officers have received training.

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14. Where possible dispatch a mental health officer as a first responder to calls involving persons in crisis, and
where possible this officer should act as the lead on such calls.

15. All designated mental health officers should be required to re-qualify by successfully completing a course
annually in order to maintain the designation.

16. Ensure communication systems (including computers in cruiser, CAD system, radios, etc.) are regularly
monitored and kept updated in fully functioning condition.

17. Consider equipping police vehicles with in-car cameras and officers with body cameras.

18. Implement the expanded use and deployment of less lethal force options in police vehicles (sedans and SUVs)
such as sock/bean bag rounds, and defensive equipment, such as helmets and shields, for all front line officers.

19. Make all possible efforts to notify first responders of the names of persons in crisis through communications /
dispatch / in car Mobile Data Terminal.

20. Consider adding the technical capacity to police vehicles to speak with other officers approaching the scene of
a call to allow an opportunity for advance planning (without losing incoming information from communications).

21. Where conducted energy weapons/Tasers are being provided to officers, distribute all operating manuals and
warnings; also require officers to re-qualify annually.

22. Have awards and recognition for good policing specifically with respect to de-escalation.

23. Establish a standing committee on mental health to advise Durham Regional Police Services Board on policy,
training, and practice. Membership to include stakeholders such as representatives of hospitals, community mental
health workers and people with lived experience who belong to peer based organizations that can effectively represent a
collective voice. Assign a senior officer as support to the committee and to act as liaison between the Durham Regional
Police Services Board and the committee.

24. Counselling and support shall be made available for civilian eye-witnesses of lethal interactions with police.
Ensure that such counselling is made available to police.

25. Provide a visible means of identification to officers with mental health training, until such time as all officers
have received training.

To the Ontario Ministry of Community Safety and Correctional Services and the Ontario Chiefs of Police:

26. In the upcoming review of the Use of Force model, the review should consider each of the use of force
options available to frontline officers with emphasis on de-escalation.

27. The Ontario Police College (OPC) shall extend its training by one week to focus solely on de-escalation
training (and the Ministry of Community Safety and Correctional Services (MCSCS) shall provide any necessary
approvals/funding to allow the OPC to do so).

28. Consider changing the name of the Use of Force model to Conflict Resolution model, Conflict
Management model, Incident Management model, Crisis Resolution model, etc.

29. Add de-escalation, verbal and non-verbal, specifically to the Use of Force model.

30. In any model, include and emphasize respect for the sanctity of life.

31. As a replacement or alternative to the current Use of Force model, consider alternative models, including the
Critical Decision Making model as adapted from the United Kingdom National Decision Model.

32. Collect, and make publicly available in a timely manner, both provincial and national statistics through Use of
Force Reports to measure the effectiveness of current training procedures.

33. Collect, and make publicly available in a timely manner, both provincial and national statistics through Use of
Force Reports to measure incidents of use of force, including if attempts to de-escalate were made and if the individual
was a person in crisis (revise the report if necessary to capture all this information).

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34. Fund provincial research into effective police training and interactions between the police and individuals in
crisis.

35. Review 911 protocols to ensure that the address given by the caller is passed on accurately to the first
responders.

To the Ontario Ministry of Health:

36. Consider funding research into understanding Post-Ictal Psychosis.

37. Consult with the Ministry of Community Safety and Correctional Service, the Chiefs of Police and appropriate
mental health advocates to ensure that an effective 24/7 crisis service for individuals in crisis is available before police
get involved.

38. The attending physician of a patient with epilepsy should counsel the importance of sharing with family details
of the patients condition as part of the strategy to be used in the event of a crisis.

Personal information contained on this form is collected under the authority of the Coroners Act, R.S.O. 1990, C. C.37, as amended. Questions about this collection should be
directed to the Chief Coroner, 25 Morton Shulman Avenue, Toronto ON M3M 0B1, Tel.: 416 314-4000 or Toll Free: 1 877 991-9959.
Les renseignements personnels contenus dans cette formule sont recueillis en vertu de la Loi sur les coroners, L.R.O. 1990, chap. C.37, telle que modifie. Si vous avez des
questions sur la collecte de ces renseignements, veuillez les adresser au coroner en chef, 25, avenue Morton Shulman, Toronto ON M3M 0B1, tl. : 416 314-4000 ou,
sans frais : 1 877 991-9959.

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