ARCHIVED - Chair's Final Report on Use of Conducted Energy Weapon on Mr. Frank Lasser

RCMP Act Subsection 45.42(2)

March 26, 2009

File No.: PC-2008-1192

Table of Contents

• Overview
• Commission's Review of the Complaint
• Analysis
• Comments
• Appendices
  1. Condensed Timeline of Events
  2. RCMP Members and Related Persons Involved in Incident and Investigation (positions and ranks noted are as at the time of the events)
  3. Chair's Complaint
  4. Commissioner's Final Report [PDF Format, 1.43Mb]
  5. Summary of Commission Findings
  6. Diagram and Photographs of Hospital Room
  7. Photograph of the Knife
  8. Graphical Model of the IM/IM
  9. Notebook Policy

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Overview

Mr. Frank Lasser was an 82-year-old patient at the Royal Inland Hospital in Kamloops British Columbia on May 3, 2008. In the early morning hours, he was awake and sitting on his bed when a nurse entered the room to check on him and the other patient with whom he shared the room. She noted that Mr. Lasser was not wearing his oxygen nasal prongs and requested that he put them on. Mr. Lasser, who appeared agitated, responded by saying that he thought the other patient in the room was dead. The nurse checked the patient and could see that he was still breathing and appeared to be sleeping. The nurse noticed that Mr. Lasser put a knife down on the bedside table and she approached the table to take it. However, before she could do so Mr. Lasser grabbed it and waved it about.

The nurse called for security to assist her and, when the security guard arrived, Mr. Lasser threatened to "gut" him. The guard made several unsuccessful attempts to disarm Mr. Lasser, who responded by lunging at him with the knife in hand. The knife was a folding type and had a three-inch blade which was extended throughout the incident. The security guard was forced to quickly retreat from the hospital room, at which time he asked a nurse to telephone 911.

A short time later three RCMP members arrived, were apprised of the circumstances and then discussed options on how to deal with the situation. They first spoke with Mr.  Lasser but had no success in having him drop the knife, which he used to make threatening movements when the members approached him. They considered using pepper spray but chose not to do so, as the hospital staff indicated that it could adversely affect other patients in the hospital if it circulated through the ventilation system. Finally, they attempted to disarm Mr. Lasser by pushing a five-foot high food trolley at him when he put the knife down on the bed. They hoped to pin him against the bed and either prevent him from retrieving the knife or knock the knife out of his grasp if he managed to reach it before them. By disarming Mr. Lasser, the members hoped that they could safely round the trolley and take control of him.

However, Mr. Lasser grabbed the knife before the members could reach him. As Constable Mark Tugnum rounded the trolley, Mr. Lasser turned in his direction with the knife raised above his head and ready to strike downward at the member. At this time, as a last resort and fearing for the safety of Constable Tugnum, Constable Jean Michaud deployed his conducted energy weapon^{Footnote 1} (CEW) at Mr. Lasser. The two probes struck him and the shock caused him to release the knife, at which point the members were able to subdue him.^{Footnote 2}

On May 9, 2008, following public concerns about police use of force, in particular the use of the CEW in such circumstances, as the Chair of the Commission, I initiated a complaint (Appendix C) pursuant to subsection 45.37(1) of the RCMP Act. I raised two issues: Firstly, whether the RCMP members involved in the events on May 3, 2008 during which Mr. Lasser was allegedly subdued with the use of a conducted energy weapon, complied with all appropriate policies, procedures, guidelines and statutory requirements, and secondly, whether the existing policies, procedures and guidelines applicable to such an incident are adequate.
Accordingly, pursuant to the RCMP Act (the Act), the complaint was investigated by the RCMP. Pursuant to the Act, on completion of the investigation the RCMP Commissioner (or his delegate) shall send his Final Report to the complainant summarizing the results of the investigation and any action taken to resolve the complaint. In this case, the Commissioner's Final Report dated November 14, 2008 (Appendix D) informed me of his findings: that the RCMP members involved in the incident complied with the appropriate policies, procedures, guidelines and statutory requirements when subduing Mr. Lasser with a conducted energy weapon, and that the existing policies, procedures and guidelines were adequate. The Final Report also identified deficiencies in the note-taking of some of the members and confirmed that the individual members received operational guidance regarding the updating of notebooks in a timely manner, and that detachment briefings were held to reinforce adherence to policy and guidelines.

Pursuant to subsection 45.42(1) of the RCMP Act, the Commission is required to review any complaint initiated pursuant to subsection 45.37(1) of the Act. This report constitutes my review of the RCMP investigation into the issues raised in my complaint, and the associated findings.^{Footnote 3} With respect to the issue of the RCMP members' actions and use of force, I find:

Commission's Review of the Complaint

It is important to note that the Commission for Public Complaints Against the RCMP (the Commission) is an agency of the federal government, distinct and independent from the RCMP. When reviewing a Chair-initiated complaint, the Commission does not act as an advocate either for the complainant or for RCMP members. As Chair of the Commission, my role is to reach conclusions after an objective examination of the evidence and, where judged appropriate, to make recommendations that focus on steps that the RCMP can take to improve or correct conduct by RCMP members. In addition, one of the primary objectives of the Commission is to ensure the impartiality and integrity of RCMP investigations involving its members.

My findings, as detailed below, are based on a careful examination of the following materials: the RCMP's operational file; the RCMP's investigation into the Chair-initiated complaint, including all applicable statements^{Footnote 4} and medical reports; the transcripts of calls to 911, the RCMP Commissioner's Final Report; as well as applicable law and RCMP policy.

It should be noted that the RCMP provided unfettered access to all materials contained in the original investigative file and to all materials identified as part of the Chair-initiated complaint investigation.

The following account of events is based upon my assessment of the evidence collected during the public complaint investigation. The work of the investigator, Sergeant Glen Penner, the non-commissioned officer in charge of the "E" Division Commercial Crime Section in Kelowna, was of the highest quality and of great assistance in my deliberations. The investigative team included two other senior investigators from the "E" Division Commercial Crime Section in Vancouver, Staff Sergeant Tim Windle and Corporal (now Sergeant) Angela Rodricks.

At the outset, Sergeant Penner sought to identify all involved members to ensure that he did not have a working or personal relationship with any of them which might give rise to a perceived or real bias.^{Footnote 5} All relevant witnesses were contacted and interviewed. The statements taken were thorough and Sergeant Penner's record-keeping was comprehensive, including observations relating to the demeanour and responsiveness of both the civilian and police witnesses. The statements are consistent in most respects save for Mr. Lasser's recollection of events, which was admittedly poor and was likely impacted by other factors, most notably his medication.

Assessment of Mr. Lasser's Recollection

In assessing the evidence of all of the witnesses, I note a general consistency in the recollection of events except for that of Mr.  Lasser. He stated that he did not recall all of the events. Those events that he did recall were largely contradicted by the other witnesses and by the audio recording of his call to 911,^{Footnote 6} which captured his comments and the background comments of others at the scene. I do not believe that these contradictions were intentional or designed to be deceptive. Quite the contrary, I believe that Mr. Lasser provided his best recollection of events and that his memory was negatively impacted by other factors.

Hospital records revealed that on May 5, 2008, Mr.  Lasser was medically assessed because of ongoing concerns about his confusion and aggression after a subsequent altercation with a nurse in which he damaged her glasses. The resulting medical report indicated that Mr. Lasser did not recall much of the preceding four days. Additionally, he admitted experiencing some hallucinations during that time. As a result of this medical assessment, Mr.  Lasser's medication was changed.

During his interview Mr. Lasser readily admitted that his recall of the events culminating in the deployment of the CEW was "vague." Mr. Lasser mentioned that upon admission to the hospital he was prescribed a new drug, which he described as making him go "haywire." His son, Mr. Keith Lasser, who had spent a significant portion of time with his father during the hospital stay, described his father in these words, "[...] he didn't know where he was, in the hospital he was completely confused and had no idea." Mr. Keith Lasser further indicated that his father improved after he was prescribed different medication.

Mr. Lasser and the nursing staff referred to another issue that may have played a role in both Mr. Lasser's actions and his memory. At the time of the incident in question Mr. Lasser was not receiving oxygen as ordered. Mr. Lasser was reported to require oxygen at home and to have had a heightened need for oxygen in the hospital because his respiration was negatively affected by pneumonia. Many of the nurses expressed a belief that this may have manifested itself through the confusion and acting out exhibited by Mr. Lasser. This belief is supported by the rapidity with which he regained his faculties once oxygen was re-established.

I am satisfied that these medical considerations were likely the cause of Mr. Lasser's uncharacteristic behaviour and his inability to recall events accurately. For these reasons and the largely contradictory nature of his recollections when compared with those of the other witnesses and the transcripts of his 911 call, I find that I cannot rely upon Mr. Lasser's version of events to assist me in my deliberations. Accordingly, where his recollection differs from that of the other participants and witnesses, I have relied upon their version.

Mr. Lasser's Hospitalization and Treatment

The following examples of aggressiveness manifested by Mr. Lasser both before and after the altercation with the police are given only to illustrate the difficulties that he experienced during his hospitalization and to give some context as to what the hospital staff and the members were faced with during their dealings with him. While the members were unaware of these incidents, the statements of hospital staff revealed that Mr. Lasser's demeanour varied from courteous and cooperative to belligerent and physically aggressive.

At the time of the incident under review, Mr. Lasser was hospitalized at the Royal Inland Hospital, where he was being treated for pneumonia and was receiving oxygen via nasal prongs. He occupied a semi-private room, which he shared with one other patient. His bed was closest to the door, which opened onto one side of his bed. On the other side of his bed was a curtain partition that blocked the view of all but the foot of the other patient's bed.^{Footnote 7}

One of the nurses described Mr. Lasser's behaviour in the days leading up to the incident as unpredictable and "Jekyll and Hyde-ish." The day prior to the incident, May 2, 2008, Mr. Lasser was reported to have had an altercation with one of the nurses while receiving a needle. He grabbed her arms and wrenched her thumb back and it was only through the intervention of another nurse that she was released. He was described as belligerent, uncooperative and deceivingly strong.^{Footnote 8} Later that day, he threw a thermos full of coffee against the wall for no known reason.

Subsequent to the incident under review, the hospital records show that Mr. Lasser had an altercation with a nurse and Mr. Joseph Larocque, the security guard who responded to the nurse's emergency call, during which Mr. Lasser damaged the nurse's glasses. The records indicate that on May 4, 2008 at 4:45 a.m., Mr. Lasser attempted to get out of bed. The nurse and Mr. Larocque tried to coax him back to bed but he grabbed a bed pan and swung it at the nurse. He then filled it with water and went into the hallway. Once another security guard arrived, the two guards were able to restrain Mr. Lasser in a blanket and return him to his bed.

On May 5, 2008, Mr. Lasser made a 911 call from the hospital alleging that he had been kidnapped by the church.

Interactions with Hospital Staff on the Night of May 2 and Morning of May 3, 2008

On the evening of May 2, 2008, nurse Lynn Bowers started working a night shift at the hospital. One of the patients under her care was Mr. Frank Lasser, who at the time was 82 years old and hospitalized for pneumonia. At approximately 5:30 a.m. on May 3, 2008, nurse Bowers entered Mr. Lasser's room. According to her statement, she found him sitting on the side of his bed and noted that his oxygen tubes were removed.

Nurse Bowers asked Mr. Lasser to put his oxygen back on. Rather than doing so, Mr. Lasser told her, "You'd better check the guy in the next bed [...] I think he's dead." Nurse Bowers peaked around the curtain separating the beds and noted that the other patient was breathing and appeared to be asleep. Upon turning back to face Mr. Lasser she noted that he was holding a knife, which he placed on his bedside table. She moved to the table and attempted to take the knife but Mr. Lasser saw what she was doing and reached it first.

The knife was a standard folding type with a wooden handle and three-inch blade. The knife was open with the blade exposed throughout the incident. I am satisfied from the photographs of the knife, attached as Appendix G, that it was a weapon which, if used, could have inflicted serious bodily harm or even death.
Nurse Bowers stated that, although Mr. Lasser did not say anything, she felt threatened by his body movements and the way he was waving the knife. Nurse Bowers recalled raising her hands in front of her and backing out of the room so that she could call for security. While she waited for security personnel, she returned to the room and tried to talk Mr. Lasser into giving up the knife. Eventually, she approached him and he again waved the knife at her, causing her to back away.

Mr. Larocque, a security guard employed by the Royal Inland Hospital, remembered receiving an urgent call from the switchboard at approximately 5:30 a.m. directing him to contact the nursing station at ward three west. He immediately returned the call and was informed that a patient had a knife, was refusing to surrender it and had threatened a nurse with it.

Mr. Larocque went to the nursing station and was told by the nurses that Mr. Lasser was confused, wanted to go home and had a knife. Mr. Larocque stated that he went to the doorway of Mr. Lasser's room, introduced himself, and asked Mr. Lasser what was wrong. According to Mr. Larocque, Mr.  Lasser got off the bed and grabbed the knife. He tried unsuccessfully to calm Mr. Lasser down by talking with him. Mr. Larocque remembered hearing Mr. Lasser say that he would "gut [him] like a fish" as he lunged at him.^{Footnote 9} Mr. Larocque backed away and called for assistance from another security guard but one was not immediately available.

He noticed that Mr. Lasser would occasionally put the knife down on the bedside table and determined that this might provide an opportunity to disarm him. He seized a mop and waited until Mr. Lasser put the knife down and bent over to pick up his shoes before trying to swat the knife off of the table. According to Mr. Larocque, Mr. Lasser reacted quickly and grabbed the knife off of the table and brandished it at Mr. Larocque. Mr. Lasser lunged at Mr. Larocque, who jumped back and exited the room. He asked nurse Bowers to contact the police.

Mr. Larocque's version of events was supported by nurse Cassandra Tremblay, who witnessed portions of the security guard's and police officers' interactions with Mr. Lasser and described him as being "quite agile." She noted that Mr. Lasser was agile enough to avoid the mop and that he responded by lunging at Mr. Larocque with the knife out in front of him and then took a few paces toward the door. She then stated that he returned to the bed where she heard him uttering obscenities at the guard. Although nurse Sheila (Teri) Gri was unable to see Mr. Lasser during the incident, she did hear him and recalled that he was "very aggressive and yelling."

Nurse Natalie Romaniuk was also present when Mr.  Larocque tried to disarm Mr. Lasser and remembered Mr. Lasser lunging at Mr.  Larocque and swinging the knife at him. She stated that in her opinion Mr. Lasser was trying to harm Mr. Larocque.

Nurse Bowers called 911 and at about the same time nurse Romaniuk and Mr. Lasser called 911. The transcripts of these three calls were all made available and the transcript of Mr. Lasser's 911 call was particularly helpful to me in the conduct of this review.

RCMP Attendance

Upon receiving the 911 calls, the Operations Communication Centre assigned Constable Daryl McDonald and Constable Sadie Doer, who was a cadet at that time, to respond to a priority one call at the Royal Inland Hospital. Constable Tugnum and Constable Jean Michaud^{Footnote 10} were driving police cruisers close to the hospital and advised that they would also respond. Accompanying Constable Michaud was Constable James Prieur, a cadet at that time. In total, five RCMP members eventually responded to the call. The first members arrived at the emergency room entrance and were directed to ward three west. Upon arrival they noted a number of nurses and a security guard in the vicinity of the nursing station outside the door to Mr.  Lasser's room and received a brief situational update. The members looked into the room and saw Mr.  Lasser holding a knife in one hand and a cellular telephone in the other while sitting against his hospital bed. He was engaged in a telephone conversation, which the members later learned was with the 911 operator.

Constable Michaud indicated that he took charge of the situation, as he had the longest term of experience. He positioned himself just inside the door with Constables Tugnum and Prieur "bottle-necked" behind him. Constable Michaud recalled asking Mr. Lasser to put down the knife but he refused. Constable Prieur and Constable Tugnum also directed Mr. Lasser to put the knife down. All of the members recounted hearing the voice on the telephone asking Mr. Lasser to put the knife down. Mr. Lasser ignored these requests and Constable Michaud drew his CEW and held it pointing down beside his leg.

Both Constable Tugnum and Mr.  Larocque stated that they saw Constable Michaud point the CEW at Mr. Lasser with the laser dot on him. RCMP training on the use of the CEW emphasizes that merely pointing the CEW at a suspect with the target laser on may de-escalate the situation.^{Footnote 11} Although required by policy,^{Footnote 12} Constable Michaud gave no warning. However, from the statements Mr. Lasser made during the incident, it is clear that he recognized the device.

The display of the CEW did not have the desired effect. Mr. Lasser's response was to demand that Constable Michaud drop his CEW. The audio recording of his call to 911 confirmed that Mr. Lasser was insistent that Constable Michaud drop his CEW. Constable Michaud switched the CEW to his left hand, which was obscured from Mr. Lasser's view by the doorframe. He explained that he hoped that if it was out of sight Mr. Lasser might forget about it. However, from the commentary on the 911 tape it is apparent that Mr. Lasser was not fooled and continued to demand that Constable Michaud put the CEW down.

Mr. Larocque advised the members that he had unsuccessfully attempted to disarm Mr. Lasser with a mop. Constable Michaud suggested that pepper spray may be a suitable option but the hospital staff raised concerns about the spray getting into the ventilation system and harming patients with respiratory problems. At this point someone mentioned that Mr. Lasser had claimed that the patient beside him was dead. The statements of the hospital staff members demonstrated that this was an ongoing concern for them throughout this incident. Constable Michaud's concern about this information was heightened because the curtain obstructed their view of the other patient who by all accounts had not made a sound since the members had arrived.

Constable Michaud entered the room with the intention of talking to Mr. Lasser. Mr. Lasser responded by standing and picking up the knife, which he had previously laid down. The members all recalled Mr. Lasser threatening to throw the knife at them and indicating that he could do it well. These comments were captured on the recording of the 911 call. The members also reported that his gestures were consistent with preparing to throw the knife. Constable Michaud indicated that he considered backing out of the room and shutting the door to wait for Mr. Lasser to calm down but his concern for the other patient and his belief that Mr. Lasser was "clearly irrational" precluded that course of action.

Having concluded that some action needed to be taken, the members discussed other intervention options. They first considered using a garbage can lid as a shield to allow them to get close to Mr. Lasser and disarm him. However, they were unable to locate an aluminium lid and the plastic lid that they located was believed to be too flimsy. They settled upon using a food cart, which stood about five feet high and contained narrow slots to hold the trays. These slots were assessed as being too narrow to let an arm pass through. The members decided that on Constable Michaud's call, when Mr. Lasser next put the knife down, Constable Tugnum would push the cart at him and attempt to prevent him from reaching for the knife or to force him to drop it if Mr. Lasser retrieved it prior to being hit. It was at about this time that Constable McDonald and Constable Doer arrived. Both members looked into the room but did not enter or engage Mr. Lasser until after he was subdued.

The 911 transcript revealed that Mr. Lasser repeatedly demanded that the member put the CEW down and leave the room. At the same time, the members and the dispatcher were repeatedly telling Mr. Lasser to put the knife on the floor. Constable McDonald heard the members commanding Mr. Lasser to put down the knife and described their demeanour as calm, firm and controlled.

Mr. Lasser put the knife down beside himself and while still cradling the telephone picked up a styrofoam cup of water, which he threw at the members. Constable Tugnum, whose view was obstructed by the cart, saw water splash on the floor just as Constable Michaud called for him to go. Constable Tugnum pushed the cart at Mr. Lasser but before hitting him Mr. Lasser was able to grab the knife and maintained his grip on it even when hit by the cart. Constable Tugnum and Constable Michaud circled to Mr. Lasser's left in order to gain control of him while Constable Prieur, who was slightly behind him, circled to Mr. Lasser's right. When Constable Tugnum stepped around the cart, he rounded the foot of the bed in an attempt to restrain Mr. Lasser from the far side of the bed. He estimated that he was about three feet from Mr.  Lasser who had raised the knife above his head and turned toward Constable Tugnum as if poised to stab downward at him. Constable Tugnum began reaching for his gun but before he could do so, Constable Michaud, who had moved to the foot of the bed, deployed the CEW in probe mode.^{Footnote 13}

Mr. Lasser dropped the knife and Constable Tugnum secured Mr. Lasser's left arm as he fell back on the bed. Constable Prieur secured the knife, which he passed to Mr. Larocque, and then secured Mr. Lasser's right arm. Constable Michaud recalled that once he heard Constable Prieur tell him that Mr. Lasser had dropped the knife, he stopped the CEW pulse.^{Footnote 14} Constable Michaud, Constable Doer and Mr. Larocque all estimated that the CEW was deployed for about two seconds.^{Footnote 15} A review of the CEW download report indicates that the CEW discharge was for the full five seconds. The discrepancy is accounted for by referring to the occurrence report prepared by Constable Michaud on the day of the incident, as opposed to his statement, which was taken six weeks after the event in question. In his occurrence report Constable Michaud noted that one of the probes dislodged after approximately two seconds. The result of the dislodged probe is to break the circuit, meaning that the current no longer flows and the CEW loses its effect. I am satisfied on the evidence that the discharge was shortened to a couple of seconds because of the dislodged probe.

Post CEW Deployment

Constable McDonald entered the room and helped Constable Prieur settle Mr. Lasser on the bed. The 911 recording included a brief time period after the CEW was deployed in which an unidentified male voice was captured reassuring Mr. Lasser that he was going to be okay. The members' occurrence reports confirm that within a few minutes he calmed down and the members described him as "much calmer," "cooperative" and "very nice to speak with." Constable McDonald started a conversation with Mr. Lasser by asking him how he was doing and stated that he was trying to help Mr. Lasser relax. Constable Doer recalled the exchange and described Constable McDonald as comforting Mr. Lasser.

Nurse Joan Wilson stated that the members were compassionate and that in her opinion they did not wish to use the CEW and only did so as a last resort.

Nurse Tremblay described the members' conduct after the CEW deployment in the following terms: "[...] when he was lying back down on the bed and they had got the weapon out of his hand, they did talk to him in a, in a sympathetic, you know, caring manner [...] they were just trying to calm him down and they were, they seemed concerned about his welfare."

Constable McDonald located Mr.  Lasser's oxygen supply and requested that a nurse reattach it. Both the nurses and members noted that Mr.  Lasser rapidly calmed down and became more coherent but did not seem to fully recall what had happened.

The members also recounted that Mr. Lasser became very upset when one of the security guards entered the room with restraints. Mr. Lasser yelled and swore at the guard to get away from him and Constable McDonald told the guard that restraints would not be necessary. The guard left the room and Constable McDonald reassured Mr. Lasser who again calmed down.

The hospital staff ensured that the other patient was not harmed and it was discovered that he had slept through the entire exchange.

Analysis

Use of Force

The central issue for consideration in this review was the use of the CEW in subduing Mr. Lasser. The deployment of the CEW must be in accordance with the principles of the Incident Management/Intervention Model (IM/IM).^{Footnote 16} From their earliest days of training as cadets, members are exposed to the IM/IM. This model is designed to aid members formulate appropriate intervention responses by considering a host of factors which may be relevant in the varied interactions carried on between the police and the public on a daily basis. A graphic model of the IM/IM is attached as Appendix H.

The key element of the IM/IM is the CAPRA problem-solving model^{Footnote 17}. The CAPRA model requires members to consider all relevant situational factors^{Footnote 18} when determining what actions to take including whether to use force and, if so, the necessary amount of force to use under the circumstances. These factors are the basis upon which a member will make the assessments called for in the IM/IM. Members are required to assess the risk posed by a subject, followed by a determination of the appropriate level of response, which may include the use of force.

In assessing Mr. Lasser's intentions, nurse Bowers and Mr. Larocque both felt that he was prepared to use the knife against them. Other members of the hospital staff who saw Mr. Larocque trying to deal with Mr. Lasser confirmed that, in their opinion, he was prepared to use his knife.

In formulating the course of action to be followed, the members must next consider the behaviour of the subject. The IM/IM lists subject behaviours as ranging from cooperative to non-cooperative to resistant to combative to posing the threat of death or grievous bodily harm. At various times during their interactions the members came to the conclusion that Mr. Lasser posed the threat of grievous bodily harm or death. Constable Prieur stated that he identified the threat of grievous bodily harm or death from the time that Mr. Lasser was threatening to throw the knife at the members. Constables Michaud and Tugnum came to the same conclusion when Mr. Lasser raised the knife above his head and was poised to stab Constable Tugnum.

In this instance the key elements of the risk assessment, as noted by the members, were the facts that Mr. Lasser was armed, he was irrational, he threatened the members and others with a weapon, and that there was another patient in the room who may have required medical attention. All of these factors together elevated the level of risk and the need for prompt intervention.

In general, once a member makes a determination as to the behaviour and risk posed by a subject, he or she must then choose an appropriate response. Early intervention options include officer presence, verbal intervention and physical control. As the threat increases, the member may turn to greater levels of physical force, intermediate weapons (OC spray^{Footnote 19} or CEW), impact weapons (baton) and finally the application of deadly force.

Verbal interventions and tactical repositioning occur regardless of the level of risk to assist the member in maintaining control of the situation, de-escalating any confrontation and ensuring maximal safety for all concerned. This is consistent with the underlying principles of the IM/IM, which stress the safety of the public and the member and define the best strategy as the least amount of intervention to manage a risk. Accordingly, the best intervention causes the least amount of harm.

After attempting verbal intervention without success the members repositioned behind the doorway and discussed their options.^{Footnote 20} They were advised of the concerns about the other patient and determined that some urgency was required in their response. This meant that continuing efforts to talk to Mr. Lasser and waiting him out were not appropriate. OC spray was ruled out by hospital staff because of the potential harm caused to other patients and at that stage the members did not wish to use the CEW because they were trying to use the least amount of force necessary. They next discussed using a shield to get near Mr. Lasser with the hope of either preventing him from picking up the knife or of knocking the knife out of his hand.

At this point in the incident, Mr. Lasser's behaviour could reasonably have been described as posing the threat of grievous bodily harm or death. It was only after the failed attempt to control Mr. Lasser with the food tray cart that the members elevated their use of force. When Mr. Lasser turned on Constable Tugnum the situation clearly posed a threat of grievous bodily harm or death. At that instant Constable Tugnum reached for his gun fearing being stabbed and Constable Michaud, who expressed the same concern for Constable Tugnum, fired his CEW. Both Constable Michaud and Constable Prieur were able to articulate the facts that caused them to believe that Mr. Lasser had the ability to carry out his threats, the clear intent to cause harm and the means, by way of the knife to effect that harm.

The CEW is currently classified as an intermediate device. At the time of this incident, weapons in this category could be used against subjects who exhibited resistant behaviour or more threatening behaviour, such as being combative. When members are faced with situations posing the risk of death or grievous bodily harm, they are trained that the CEW is only appropriate^{Footnote 21} if another member can provide lethal over-watch.^{Footnote 22} This means that at least one other member should have a gun ready to shoot in case the CEW misfires or is ineffective and the threat is not neutralized.

Under the circumstances, including that the members were faced with an armed antagonist who was known to have threatened hospital staff as well as themselves, that the suspect was not acting rationally and had failed to comply with police commands, and that there was some urgency in checking on the health and safety of the other patient, RCMP policy permitted the use of a significant amount of force from the early stages of the altercation. Simply put, the members could have chosen to have one or more members draw their firearms and provide lethal over-watch while Constable Michaud deployed the CEW from a distance. If the CEW deployment failed and Mr. Lasser attacked with the knife, the members would have been justified in shooting him both pursuant to policy and the Criminal Code of Canada. However, the members exercised their discretion in an attempt to ensure the least amount of harm to Mr. Lasser, thereby exposing themselves to personal risk. Indeed, they resorted to the deployment of the CEW as a matter of last recourse when Constable Michaud feared for the safety of his fellow officer. Accordingly, I find that the use of the CEW was reasonable and justified^{Footnote 23} under the circumstances.

Note-taking

After first concluding his initial statement during the course of the Chair-initiated complaint investigation, Constable Tugnum was re-interviewed with respect to his note-taking on this incident. In response to the question of whether he took notes, Constable Tugnum stated,

Not at the time, no. I did learn from this, especially given the use of force, to take notes. It was addressed by the NCO [non-commissioned officer] of Operations, Staff [Sergeant] GOFFNER, and I realized the importance of it, especially on a situation like this. And so in turn I have been really focusing on more details in my notes and especially when there's any use of force used.

...

I've been doing that lately. Taking my notes detailed in my notebook but as soon as I get back to my car I do up an occurrence report on scene with details of the use of force right away.^{Footnote 24}

Constable Prieur also failed to take notes of the incident and considered his occurrence report, which was not made until May 8, 2008, to constitute his notes. He stated that, as a result of his failure to make notes, he was given a learning plan to ensure compliance and his notes were later checked by a supervisor who found them to be satisfactory.

RCMP policy speaks to the importance of investigators' notebooks and the need to maintain them in a complete and timely manner.^{Footnote 25} The policy describes a member's notebook as a "fundamental investigative tool" and underlines the necessity of maintaining "complete and accurate" notes. Against any reasonable measure the members in this instance did not meet the standards prescribed by policy.

In this case, Constable Michaud provided some brief notes relating to the incident, which were further enhanced by completion of an occurrence report made later that day and a CEW usage report. Constable Michaud's notebook entries were two pages in length and provided the basic details of the incident. Even though no charges were laid, force was used and the circumstances of this intervention called out for a degree of detail missing from Constable Michaud's notes.

The same inadequacy was apparent in the first CEW usage report prepared by Constable Michaud. Policy required that this document be reviewed by a supervisor, who concluded that the narrative was not sufficiently detailed. He required Constable Michaud to prepare a revised copy. I have reviewed both of these documents and am satisfied that the changes made to the second document enhance the detail but do not alter the substance of the event as told in the original document. Furthermore, the facts are consistent with the evidence adduced during the investigation. The second version meets the expectation of completeness and clarity and should serve as a lesson for Constable Michaud as to how to properly document future incidents.

I am satisfied that Constables Tugnum and Prieur received appropriate guidance that underlined the importance of thorough timely note-taking and that they have committed to ensuring compliance with the notebook policy in future. I am also satisfied that the revisions to Constable Michaud's CEW usage report demonstrate a reasonable level of detail and that the exercise should serve to highlight the importance of proper record-keeping.

The Commissioner's Final Report advised that the Kamloops City Detachment went further and held briefings to remind all members of the detachment to adhere to policy, procedure and guidelines relating to notebooks. I am satisfied that the steps taken individually and detachment-wide will adequately address the record-keeping shortcomings evident in this file.

The second aspect of my complaint was to assess the adequacy of the existing policies, procedures and guidelines. With respect to the deployment of the CEW, the facts as set forth above do not give rise to concerns about the application of policy in the instant case. It should be noted that since I initiated this complaint, the RCMP has modified its policy relating to CEW use. The Commission has undertaken a broader review of the adequacy of the policy in the form of a public interest investigation into in-custody deaths proximal to CEW use and this investigation will take a broader view of the adequacy of the existing policies, procedures and guidelines relating to CEW use.^{Footnote 26}

Comments

While the deployment of the CEW in this case may not have given rise to concerns about the application of policies related to its use, other issues relating to CEW management and reporting are worthy of comment.

CEW Control Log

RCMP policy requires the detachment commander to, "Maintain a control log for each CEW assigned to the unit by recording time, date and name of each member who has a CEW."^{Footnote 27} However, at the time this report was written, the detachment was unable to locate the control log for this incident. The failure to locate the control log did not hinder my review in any way, given that the facts normally elucidated by its production into evidence are not in dispute. The investigation provided ample corroborated evidence as to the CEW control and use during this incident. However, this is not the first time that a control log has gone missing from the Kamloops City Detachment.^{Footnote 28}

The policy as it relates to the control log is designed to establish best practices. In this regard, there was an apparent recurring failure to adhere to the policy and best practices, which leads me to suggest that the RCMP review the practices in place at the Kamloops City Detachment to ensure policy compliance in relation to the CEW control log.

CEW Download Report

The CEW download report, prepared by Staff Sergeant (now Inspector) S.A. Wade, was comprehensive and clearly written. It stood out as a report of significantly higher quality than that which is often received by the Commission when conducting its reviews. The report contained the particulars of the testing as well as an adjustment for the internal clock, which was found to be slow by 16 minutes 11 seconds.^{Footnote 29} On occasion these reports consisted of little more than the raw download material with dates, times and duration of use. In some cases the reports offered no evidentiary assistance. Such reports would benefit from having specified national standards designed to ensure that they contain consistent, relevant and reliable information.

Pursuant to subsection 45.42(2) of the RCMP Act, I respectfully submit my Final Report and, accordingly, the Commission's mandate in this matter is ended.

March 26, 2009

____________________________________
Paul E. Kennedy
Chair

Appendix A – Condensed Timeline of Events

May 3, 2008

Approximate Time	Event
5:30 a.m.	Nurse Bowers enters Mr. Lasser's room. He tells her that the other patient sharing the hospital is dead. Nurse Bowers calls security after looking in on the other patient and unsuccessfully attempting to seize Mr. Lasser's knife.
5:35 a.m.	Mr. Larocque, the security guard, arrives. Mr. Lasser threatens him with a knife. Attempts to obtain the knife are unsuccessful.
5:45 a.m.	Mr. Lasser and nursing staff place calls to 911.
5:55 a.m.	Constables Michaud, Tugnum and Prieur arrive at ward three west. Mr. Lasser does not comply with verbal commands to surrender his knife and threatens the members with it. Members are advised by hospital staff of concerns for the other patient in the room and discuss options as to how to subdue Mr. Lasser.
6:00 a.m.	Constables McDonald and Doer arrive just prior to Constable Tugnum rushing Mr. Lasser with a food tray cart. Constable Michaud subdues Mr. Lasser with a CEW.
6:15 a.m.	Last member clears the scene leaving Mr. Lasser and the other patient in the care of hospital staff.

Appendix B – RCMP Members and Related Persons Involved in Incident and Investigation (positions and ranks noted are as at the time of the events)

RCMP Members who attended the Royal Inland Hospital on May 3, 2008

Person	Detachment	Position	Service	Role
Cst. Jean Michaud	Kamloops City	General Duty	6 yrs	Responded to 911 call, shot Mr. Lasser with a CEW.
Cst. James Prieur	Kamloops City	General Duty	3 mths	Responded to 911 call, assisted in subduing Mr. Lasser.
Cst. Mark Tugnum	Kamloops City	General Duty	3 yrs	Responded to 911 call, assisted in subduing Mr. Lasser.
Cst. Daryl McDonald	Kamloops City	General Duty	2 yrs	Responded to 911 call, involved only after deployment of the CEW.
Cst. Sadie Doer	Kamloops City	General Duty	5 mths	Responded to 911 call, involved only after deployment of the CEW.

RCMP Members who investigated the Chair-initiated complaint

Person	Posting at that time	Service	Role
Sgt. Glen Penner	Non-commissioned officer in charge of "E" Division Commercial Crime Section, Kelowna	33 yrs	Chair-initiated complaint investigator
S/Sgt. Tim Windle	Advisory non-commissioned officer, "E" Division Commercial Crime Section, Vancouver	32 yrs	Assisted in interviewing witnesses
Cpl. (now Sgt.) Angela Rodricks	"E" Division Commercial Crimes Section, Vancouver	17 yrs	Assisted in interviewing witnesses

Appendix E – Summary of Commission Findings

Finding: 1. The members' actions and use of force were a reasonable response to the threat posed by Mr. Lasser.

Finding: 2. Constables Michaud, Tugnum and Prieur failed to keep adequate notes of the incident but I am satisfied that the remedial steps taken by the RCMP adequately address the deficiencies.

Finding: 3. The circumstances of this case do not call into question the adequacy of the policies, procedures and guidelines applicable to such incidents.

Appendix F – Diagram and Photographs of Hospital Room

(Not to scale)

Appendix G – Photograph of the Knife

Appendix H – Graphical Model of the IM/IM

Text Version

Appendix I – Notebook Policy

RCMP Operational Manual 25.2

...

2. General

2. 1. The member's notebook is a fundamental investigative tool. It is essential that notebooks be properly compiled, complete and accurate in order to support investigations, corroborate evidence and increase the credibility of a member's testimony in court. Properly recorded entries (notes) may also prove to be invaluable in substantiating information years after an investigation.

2. 2. You may use notebook entries to refresh your memory for court if the notes were made at or near the time of the occurrence.

2. 3. If you are performing operational duties, use and maintain an up-to-date notebook. Record the date for any operational assistance in your notebook.

2. 4. To reduce duplication in minor cases, notes may be made directly on the continuation report, form 1624.

3. Types of Entries

3. 1. Take notes as events occur or at the first available opportunity. If possible, make your entries in black or dark ink, neat, legible, concise, informative and well organized. While the specific contents of your notebook will depend on the type and complexity of the investigation, your notes should contain:

• 3. 1. 1. your observations and actions;
• 3. 1. 2. the collection, identification and handling of evidence;
• 3. 1. 3. the grounds to support detention, arrest or search;
• 3. 1. 4. any cautions or warnings given to persons and details of the circumstances;
• 3. 1. 5. statements by suspects or witnesses, verbatim if possible;
• 3. 1. 6. the demeanor and emotional and physical state of persons, particularly when they make statements; and
• 3. 1. 7. personal information of any person involved in the investigation, excluding confidential sources.