OCC Inquest - MacIsaac 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: MacIsaac
Given name(s): Michael
Age: 47

Held at: Toronto, ON
From: July 17
To: Aug. 2, 2017
By: Dr. David Evans, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Michael MacIsaac
Date and time of death: Dec. 3, 2013 at 3:57 a.m.
Place of death: St. Michael's Hospital, 30 Bond Street, Toronto
Cause of death: Gunshot wound to the abdomen
By what means: Homicide

(Original signed by: Foreperson)


The verdict was received on the 2 of Aug., 2017
Coroner's name: Dr. David H. Evans
(Original signed by coroner)


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


Inquest into the death of:

Michael MacIsaac


Jury Recommendations

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. Don’t 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:

  1. Debrief all critical incidents to learn from the outcomes.
  2. Assign mental health training and outreach portfolio to a Senior Officer (Inspector and above).
  3. 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.
  4. 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.
  5. All designated mental health officers should be required to re-qualify by successfully completing a course annually in order to maintain the designation.
  6. Ensure communication systems (including computers in cruiser, CAD system, radios, etc.) are regularly monitored and kept updated in fully functioning condition.
  7. Consider equipping police vehicles with in-car cameras and officers with body cameras.
  8. Implement the expanded use and deployment of less lethal force options in police vehicles (sedans and SUV’s) such as sock/bean bag rounds, and defensive equipment, such as helmets and shields, for all front line officers.
  9. Make all possible efforts to notify first responders of the names of persons in crisis through communications / dispatch / in car Mobile Data Terminal.
  10. 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).
  11. Where conducted energy weapons/Tasers are being provided to officers, distribute all operating manuals and warnings; also require officers to re-qualify annually.
  12. Have awards and recognition for good policing specifically with respect to de-escalation.
  13. 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.
  14. 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.
  15. 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:

  1. 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.
  2. 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).
  3. Consider changing the name of the “Use of Force” model to “Conflict Resolution” model, “Conflict Management” model, “Incident Management” model, “Crisis Resolution” model, etc.
  4. Add “de-escalation”, verbal and non-verbal, specifically to the “Use of Force” model.
  5. In any model, include and emphasize “respect for the sanctity of life”.
  6. 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.
  7. 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.
  8. 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).
  9. Fund provincial research into effective police training and interactions between the police and individuals in crisis.
  10. 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:

  1. Consider funding research into understanding “Post-Ictal Psychosis”.
  2. 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.
  3. The attending physician of a patient with epilepsy should counsel the importance of sharing with family details of the patient’s condition as part of the strategy to be used in the event of a crisis.