Report to the Minister of Justice and Solicitor General Fatality Inquiries Act

Public Fatality Inquiry

WHEREAS a Public Inquiry was held at the Edmonton Law Courts in the City of Edmonton , in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 2nd to 5th day of May , 2016 , (and by adjournment year on the day of , ), year before Jody J. Moher , a Provincial Court Judge, into the death of Shaun Robert Collins 27 (Name in Full) (Age) Edmonton, Alberta and the following findings were made: (Residence)

Date and Time of Death: March 11, 2011 at 8:46 p.m.

Place: Royal Alexandra Hospital, Edmonton, Alberta

Medical Cause of Death: (“cause of death” means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization – The Fatality Inquiries Act, Section 1(d)).

Ischemic Encephalopathy due to hanging – intentional self-harm by hanging

Manner of Death: (“manner of death” means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable – The Fatality Inquiries Act, Section 1(h)).

Suicide

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Circumstances under which death occurred:

Background

A brief background is necessary to orient the inquiry into the death of Shaun Robert Collins. Shaun Collins was 27 years old when he died (DOB November 27, 1983). He had been a member of the Canadian Armed Forces (CAF) for nearly a decade at the time of his death. He was a member of Company C with the First Princess Patricia’s Canadian Light Infantry (1PPCLI) based out of Canadian Forces Base (CFB) Edmonton. He was deployed to Afghanistan twice: his first deployment from January 31, 2006 to August 11, 2006 and his second deployment from October 14, 2009 to May 10, 2010.

Immediately following his second deployment, Shaun Collins self-identified as requiring mental health follow-up given his experiences in Afghanistan. On August 23, 2010, he contacted a crisis help line and the Edmonton Police Service (EPS) was ultimately dispatched to his residence. No further follow-up was found necessary; the conclusion being that Shaun Collins was “having a bad day”.

On September 20, 2010, at approximately 10:00 p.m. Laura Boyd, Shaun Collins’ fiancée, called 911 as Shaun was upset and threatening self-harm. The EPS attended at his residence. Mr. Collins used a knife to stab himself on the right thigh, intending to cut his femoral artery. The EPS apprehended Shaun Collins under Section 12 of the Mental Health Act, RSA 2000 c. M-13 (Mental Health Act) and conveyed him to the Royal Alexandra Hospital.

On November 26, 2010, Shaun Collins was upset and emotional. He tried to cut his throat with a key. Again the EPS was called. Mr. Collins was apprehended under Section 12 of the Mental Health Act and conveyed to the Misericordia Hospital. He was subsequently released.

On February 24, 2011, Shaun Collins called a crisis help line. The EPS was dispatched to a parking lot, and again, Shaun Collins was apprehended and conveyed to the Royal Alexandra Hospital under the Mental Health Act.

Commencing in September 2010 until his death, Shaun Collins was seen by a number of mental health professionals, both with the Canadian Armed Forces and civilian health care professionals. He was ultimately diagnosed with Post-Traumatic Stress Disorder (PTSD), Occupational Stress Injury (OSI), and Major Depressive Disorder (MDD). His treatment included medication and psychotherapy. In the weeks leading up to his death, Shaun Collins and the various mental health professionals providing him with treatment were optimistic about his recovery. A part of the plan moving forward was for Shaun to transition out of the military into civilian life, and he had been referred to the Joint Personnel Services Unit (JPSU) to facilitate this transition.

Physical Facilities

In terms of the physical facilities at the MP station at CFB Edmonton, there was a foyer just inside the main MP station doors, a large patrol area, an interview room, and a solicitor/client phone room. There were four cells with metal bars on the doors. The cell doors provided a number of ligature points. A federal government audit confirmed the “cellblock does not meet any current Canadian standards”. Each cell was essentially empty, with the exception of a cot affixed to one wall. The cell area was separated from the main patrol area by a door, with a small window in the upper portion of the door.

There were several equipment issues associated with the MP station that were relevant to the

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sequence of events on March 9, 2011. There were no working cameras in any cell or in the cell area. The in-car camera (ICC) in Cpl. Pettem’s military police car was not working on the date in question. There were frequent operational issues with the computers in the military police cars used by the MPs. There was no Automated External Defibrillator (AED) in the MP station. There was an AED located in the trunk of each of the military police cars. The first AED brought into the MP station following Shaun Collins’ suicide was not working. It is unclear if the second AED brought into the MP station was working.

All four of the suicide attempts/threats including the three Mental Health Act apprehensions were listed on the Security and Military Police Information System (SAMPIS) under a search of Shaun Collins’ name. There was no SAMPIS search done that evening either by Commissionaire Michael Lamb, the dispatcher, nor any of the three MPs. All three MPs readily acknowledged that had they known of Shaun Collins’ history of previous suicide attempts and mental health history, Shaun would have been handled entirely differently that evening.

Events of March 9, 2011

On March 9, 2011, Shaun Collins was to report for the first time to the JPSU at CFB Edmonton, and he did so early that morning. It was a positive but stressful step. Shaun told Laura Boyd that he was frustrated that morning because many of the most important people he was to meet that morning were not available. Sometime between 2:15 p.m. and 2:30 p.m., Shaun Collins reported to the Base Personnel Selections Officer (BPSO) to obtain information with respect to educational opportunities as part of his transition.

At approximately 3:30 p.m. that afternoon, Shaun Collins went to the Junior Ranks Mess, one of three licensed premises at CFB Edmonton. He was drinking beer with other soldiers. At approximately 5:15 p.m., Shaun Collins was asked to leave the Junior Ranks Mess. He was emotional and disruptive; he was described as ‘going to a dark place’. Notwithstanding efforts to discourage him, Shaun Collins got into his vehicle and left the Junior Ranks Mess, heading off of CFB Edmonton. Shortly thereafter, a civilian bartender from the Junior Ranks Mess contacted the MP station by telephone and subsequently in person to report Shaun Collins as a suspected impaired driver.

On the evening of March 9, 2011, there were three MPs on shift at CFB Edmonton: Sgt. James Dean Boyd (Sgt. Boyd), the MP in charge, Cpl. Matthew Parkin (Cpl. Parkin), and Cpl. Jason Pettem (Cpl. Pettem). There was also a dispatcher at the MP station, Commissionaire Michael Lamb (Commissionaire Lamb).

Shortly after 6:00 p.m., Cpl. Pettem left the MP station in search of Shaun Collins’ vehicle. Cpl. Parkin left shortly thereafter in a separate military police car. At approximately 6:18 p.m. Cpl. Pettem located Shaun Collins’ vehicle and initiated a traffic stop at 97 Street and 160 Avenue, Edmonton, Alberta. Cpl. Parkin arrived immediately thereafter and the two MPs began an impaired driving investigation. It was clear that throughout his interaction with the MPs, Shaun Collins was intoxicated and agitated. At the roadside, Shaun Collins was questioning the MPs’ jurisdiction given the traffic stop occurred in Edmonton. Mr. Collins was demanding to speak to a military lawyer. He was visibly distraught when told he was being detained. He repeatedly told the MPs that he was not a “detainee”, the word having particularly difficult associations with prisoners in Afghanistan. Sgt. Boyd testified that detainees in Afghanistan were placed in flex cuffs, subjected to sensory deprivation, and placed in uncomfortable room/conditions.

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At approximately 6:39 p.m., Shaun Collins was arrested for impaired operation of a motor vehicle pursuant to the provisions of the Criminal Code of Canada, RSC, 1985, c. C-46 (Criminal Code), was placed in handcuffs, and then was placed in the back of Cpl. Pettem’s military police car. Three EPS officers attended the scene briefly during the 30 minute traffic stop, although none of them played a material role. At approximately 6:55 p.m., Shaun Collins and the two MPs arrived at the MP station on CFB Edmonton. Mr. Collins was escorted through the front doors of the MP station and placed directly into the solicitor/client phone room to allow him to exercise his right to contact counsel. Over the course of the next 50 - 60 minutes, Shaun Collins contacted counsel several times.

At approximately 7:21 p.m., Cpl. Everett Dalton (Cpl. Dalton), a good friend of Shaun Collins’, contacted the MP station. Cpl. Dalton had been told by a bartender at Junior Ranks Mess that the MPs were looking for Shaun as a suspected impaired driver, precipitating Cpl. Dalton’s phone call to the MP station. Sgt. Boyd spoke with Cpl. Dalton on the phone and advised that Shaun was at the MP station. He advised that if Cpl. Dalton were to attend at the MP station, Shaun Collins could be released to Cpl. Dalton.

Sometime between 7:55 p.m. and 8:05 p.m., Cpl. Dalton arrived at the MP station, sitting initially in the foyer. Cpl. Dalton could hear Sgt. Boyd and Shaun Collins speaking to each other with raised voices while he waited in the foyer. It is at this point that the MPs realized that the breath demand was not read to Shaun Collins at the roadside, as required under the Criminal Code. Cpl. Pettem and Sgt. Boyd attended initially at the phone room to read the first breath demand to Shaun Collins. Mr. Collins was agitated, was shouting and talking over Cpl. Pettem as he endeavored to read the breath demand to Mr. Collins.

Between 8:03 p.m. and 8:05 p.m., Sgt. Boyd resolved it was necessary to place Shaun Collins into one of the cells at the MP station. Sgt. Boyd and Cpl. Pettem escorted Shaun to the first cell in the cell area. Cpl. Pettem endeavored to read two further breath demands to Mr. Collins, without success. Shaun Collins was advised he was to be charged with refusing to provide a breath sample. Sgt. Boyd and Cpl. Pettem left the cell area together. Sgt. Boyd closed the door between the cell area and patrol area. The lights in the cell area were shut off, such that it was essentially dark in the cell area.

Sgt. Boyd then went to the foyer, spoke to Cpl. Dalton and brought Cpl. Dalton into the patrol area. The discussion focused around Cpl. Collins’ release to Cpl. Dalton. During this period of time both of the other MPs were attending to the paperwork necessary to release Cpl. Collins. The cell area was quiet.

Shaun Collins used the sleeve from his military tunic/shirt as a ligature around his neck. He placed the sleeve of his tunic through the midpoint of the metal bars on his cell door. Shaun Collins then sat down on the floor of the cell and hung himself.

The three MPs in the MP station did not physically enter the cell area during the period of time from 8:05 p.m. to 8:27 p.m. At approximately 8:27 p.m., Cpl. Dalton entered the cell area. He was followed by Sgt. Boyd. The two men discovered that Cpl. Collins had hung himself on the cell door. The cell door was opened. The sleeve was cut off the door. Shaun Collins was lowered to the floor in the cell area, and both men began CPR. Commissionaire Lamb called the CFB Fire Department, which arrived shortly. The CFB Fire Department contacted the Edmonton Emergency Services (EMS), which arrived between 8:39 p.m. and 8:41 p.m. Shaun Collins was transported by EMS to the Royal Alexandra Hospital at approximately 9:00 p.m.

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Dr. Kutsogiannis, the intensivist physician who saw Cpl. Collins upon his arrival at the Royal Alexandra Hospital provided the opinion that for approximately nineteen minutes between 8:28 p.m. and 8:47 p.m. Cpl. Collins was asystole, without a heartbeat. Defibrillation by the CFB Fire Department staff resulted in a spontaneous pulse. Dr. Kutsogiannis diagnosed hypoxic ischemic encephalopathy secondary to hanging.

Recommendations for the prevention of similar deaths:

The mandate of the Fatality Inquiry pursuant to Section 53 of the Fatality Inquiries Act, RSA 2000, c. F-9 (Fatality Inquiries Act), is to determine cause, manner and circumstances of the death. As well, pursuant to Section 53(2) of the Fatality Inquiries Act, the Inquiry may make “recommendations as to the prevention of similar deaths”.

It is irrefutable that there were a number of potential opportunities to obviate or lessen the likelihood of Shaun Collins committing suicide that evening. The Department of National Defence/Canadian Armed Forces (DND/CAF) is a federal undertaking. The Inquiry ordered by the Alberta Minister of Justice and Solicitor General into the death of Cpl. Shaun Collins is a provincially constituted inquiry. There are a number of Supreme Court of Canada cases commencing with Attorney General of Quebec and Keable v. Attorney General of Canada et al., [1979] 1 S.C.R. 218, commonly referred to as “Keable No.1”, which provide that a provincially constituted inquiry cannot make recommendations with respect to a federal undertaking; a provincial authority cannot intrude into the administration or management of any federal department or agency. The Department of National Defence/Canadian Armed Forces falls exclusively within the jurisdiction of the Government of Canada.

The DND/CAF participated in the Fatality Inquiry; however it did not fully attorn to the jurisdiction of the Inquiry. The DND/CAF participated in the Fatality Inquiry only with respect to a determination of the circumstances surrounding the death of Shaun Collins. The DND/CAF refused to fully accede to the jurisdiction of the Inquiry in the case of Cpl. Collins’ death notwithstanding other federal department(s), including Correctional Services of Canada, have fully participated in Alberta provincial fatality inquiries with respect to in custody deaths. No recommendations are appropriate or necessary with respect to any other person or entity. In light of the foregoing, no recommendations can be made by the Fatality Inquiry in respect of the DND/CFB.

Given the mandate of a provincial Fatality Inquiry pursuant to Section 53(2) of the Fatality Inquiries Act, recommendations are appropriate in respect of provincial and municipal detention facilities. Recommendations which could prevent similar deaths are as follows:

1. The Canadian Police Information Centre (CPIC) database and all other police databases should be accessed and searched upon detention of a person, and certainly before a detainee is placed into custody.

2. If a search of a police database(s) reveals significant mental health issues or a risk of self- harm or if the detainee is acutely agitated, immediate medical assistance should be sought.

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3. In terms of physical facilities, all holding cells should have ‘suicide proof’ architecture with no ligature points accessible to persons in custody. There should be no open bars on holding cells and existing non-compliant cells should be completely retrofitted to prevent suicides.

4. Persons in custody should be monitored continuously, especially if intoxicated or at risk of self-harm. Continuous video monitoring should be supplemented by actual physical monitoring at minimum and irregular intervals.

5. Automated External Defibrillators (AEDs) or similar devices should be regularly maintained to ensure the device is operational and the batteries and accessories should be changed in accordance with the manufacturer’s guidelines. Storage of these devices at other than room temperature will mandate more frequent monitoring and maintenance in accordance with the manufacturer’s guidelines.

All of which is respectfully submitted.

(Original signed by) DATED June 27, 2016 ,

at Edmonton , Alberta. Jody J. Moher A Judge of the Provincial Court of Alberta

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