OCC Inquest - Skene-Peters 2018
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given name(s): Kwasi
Held at: 25 Morton Shulman Avenue, Toronto
From: Sept. 17, 2018
To: Sept. 28, 2018
By: Dr. John Carlisle
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Kwasi Skene-Peters
Date and time of death: July 25, 2015 at 3:59 a.m.
Place of death: St. Michael's Hospital, Toronto
Cause of death: Gunshot wound to the chest
By what means: Homicide
(Original signed by: Foreperson)
The verdict was received on Sept. 28, 2018
Coroner's name: Dr. John Carlisle
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
We the jury, recommend to the Toronto Police Service
- Consider whether there would be value in establishing a system whereby officers on scene directing a “high risk” activity could call, if time and circumstances permit, to consult an individual with the relevant experience and training. The purpose is not to “second guess” those on scene, but to support them by ensuring that all appropriate factors have been considered in formulating a plan to carry out the task as safely and effectively as possible.
- The Toronto Police Service (TPS) should take steps to consult with the Special Investigations Unit (SIU) to establish a protocol for cases where the law mandates that the SIU conduct the investigation, to appropriately delegate and expedite notification to next kin, by either TPS or other third party.
- Consider implementing a communication plan prior to a “high risk” take-down to ensure that communication is unimpeded and that all parties involved are properly informed at all times (for example, all officers directed to use the same radio channel).
We the jury, recommend to the Toronto Police College and the Ontario Police College
- Consider using the circumstances of this case as a dynamic training scenario, including an initial plan and unexpected intervening factors, such as bystanders or vehicles that mean the plan cannot be carried out as anticipated. Participants should be debriefed after the exercise to assess the choices they made and discuss the availability of other options.
- Review and reinforce training practices in relation to subject, public, and police safety when dealing with an armed individual who is firing from a contained vehicle. Consideration should be given to utilizing both distance and cover to improve safety, when available and appropriate. The review should include best practices and procedures from other large North American police agencies that have dealt with such situations, and if appropriate consider implementing those practices within training programs.