OCC Inquest - Carby 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Carby
Given Name(s): Jermaine Anthony
Age: 33

Held at: 5 Ray Lawson Blvd, Brampton, Ontario
From: May 9
To: May 26, 2016
By: Dr. William Lucas, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jermaine Anthony Carby
Date and time of death: September 24, 2014 at 10:58 p.m.
Place of death: Brampton Civic Hospital, Brampton
Cause of death: Gunshot wounds of torso
By what means: Homicide

(Original signed by: Foreperson and Jurors)


The verdict was received on May 26, 2016
Coroner's name: Dr. William Lucas
(Original signed by coroner)


We, the jury, wish to make the following recommendations:


Inquest into the death of:

Jermaine Anthony Carby


Jury Recommendations

To the Ontario Police College and the Peel Regional Police Service:

  1. Consider using the circumstances of this case as a training scenario to examine whether new recruits or experienced officers demonstrate awareness of issues regarding:
    1. "unconsious bias" in the exercise of police discretion concerning traffic stops,
    2. the application of the new provincial regulations regarding collection of identifying information,
    3. the most effective methods of de-escalation, if the need develops, and
    4. decision-making to select the lowest level of force appropriate if use of force should be required.
  2. Provide specific training relating to situations involving persons with an edged weapon
    1. where the person has failed to respond and/or comply with police commands (i.e. Drop the knife), train officers to stop shouting those commands and to attempt different defusing communication strategies, and
    2. train officers in such situations to coordinate amongst themselves so that one officer takes the lead in communicating with the person so that not all officers are shouting simultaneously.
  3. Consider the most appropriate methods (including external consultation) to measure whether the training has been effectively delivered and absorbed by those receiving the training in recommendations one and two.
  4. Develop a method to objectively measure the effectiveness of officer training (both initial and continuing) for unconscious bias, mental health issues, de-escalation and use of force.  Officers should be tested, graded and must meet a benchmark in order to pass.
  5. Provide new recruits and experienced officers with enhanced training regarding in-cruiser databases such as the Canadian Police Information Centre (C.P.I.C.) and the information they contain. 
  6. Provide new recruits and experienced officers with additional training regarding effective communication of  relevant C.P.I.C. and current situation information with other officers at the scene so that all officers share a common understanding of the situation and approach.  
  7. Provide new recruits and experienced officers with training on techniques for containing crisis situations wherever possible to slow down the course of events and permit the involvement of specialized teams such as the Mobile Crisis Intervention Team if required.

To the Peel Regional Police Service:

  1. Consider the most appropriate methods to determine and measure the application of training as set out on recommendations one and two when officers are performing their duties and interacting with the public.
  2. Consider the most effective ways to enhance consultation or direct input by a cross-section of communities within Peel Region into the content and delivery of police training. By working with the diverse populations within their communitiy to build understanding and trust regarding the communities' respective views on policing, police will be better equipped to exercise sensitivity and discretion concerning interactions with the public.
  3. Study and evaluate the feasibility of in-vehicle and/or body-worn recording devices to document their interactions with the public.
  4. Work with the R.C.M.P Canadian Police Information Centre (C.P.I.C.) to study the possibility of enhancing information available to officers (i.e. information on warrants, prior occurrence details, mental health warnings, prior de-escalations, etc.).
  5. Consider revising the process for performance reviews to:
    1. establish an explicit criterion that experience with people in crisis will be considered,
    2. place a greater emphasis on de-escalation skills such as communication, empathy, proper use of force and use of specialty teams where required, and
    3. determine the appropriate use of information contained in Use of Force reports in assessing an officer's performance and suitability for particular job assignments.
  6. Study the feasibility of assigning two officers per cruiser during the night shift.

To the Ministry of Community Safety and Correctional Services:

  1. In conjunction with the Ontario Association of Chiefs of Police and the Ministry of Health and Long Term Care adapt the Training Standard and Crisis Intervention and De-escalation Model developed in British Columbia as the Training Standard and Crisis Intervention and De-escalation Model for police services in the Province of Ontario.