An independent review into how the Toronto Police Service conducted several high-profile missing persons investigations is calling for a major overhaul in policies, procedures and resources amid findings “systemic discrimination” factored into a number of cases.
“This report finds that systemic discrimination contributed to the deficiencies in a number of the investigations I examined. This finding is not dependent on an intention to discriminate but on the effect of differential treatment on communities traditionally overpoliced and underserviced,” retired judge Gloria Epstein said in her report on Tuesday.
“We are past the time for conversation only. The public is entitled to insist on transformative change with measurable, sustainable outcomes, timelines for completion, and accountability.
The four-volume, 1,109-page report entitled Missing and Missed, and issued by Epstein, contained 151 recommendations aimed at revamping missing persons investigations, including changes to civilian oversight, major case and data management, staffing, involvement of the community, prevention strategies, communications, training, relationship building, and ways to address bias and discrimination.
Specific recommendations included the requirement for police to regularly provide information about missing-persons cases to those affected and not “erect unnecessary barriers” to giving such information “based on an overly broad interpretation of what must be withheld to preserve the integrity of an investigation.”
The report also called for police to commit to using the mandated case-management system as required, and revise its procedures so that, whenever possible, missing-persons cases are largely investigated by the force or division where the person was last seen.
It also recommended doubling the size of the missing-persons unit to eight investigators and creating jobs within the unit for workers who would exclusively provide support for those directly affected by the disappearance of individuals.
The new investigative model proposed in the document would involve triaging cases in a way that could sometimes see social service agencies, public health agencies, community organizations or others take the lead rather than police.
Epstein headed up the Independent Civilian Review into Missing Person Investigations and was tasked with assessing how Toronto police conduct investigations into missing persons, especially involving people from the LGBTQ2, vulnerable and marginalized communities.
For the most part, the review was ordered in 2018 after Bruce McArthur, who was eventually convicted of murdering eight men — most of whom had ties to Toronto’s Church-Wellesley Village, was arrested.
The deaths of Selim Esen, Andrew Kinsman, Majeed Kayhan, Dean Lisowick, Soroush Mahmudi, Skandaraj Navaratnam, Abdulbasir Faizi, and Kirushnakumar Kanagaratnam resulted in major concerns being raised in Toronto’s LGBTQ2 community about how their initial disappearances were investigated.
In the report, it noted concerns were raised that investigations connected to McArthur were “infected by bias” and that there were “serious flaws” in many probes. It said some in the community felt it wasn’t until Kinsman, who was not a person of colour, disappeared that there was serious interest. The report noted many officers rejected that view since there were many officers who “worked tirelessly to solve these cases.”
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“That is true, but the full narrative must take into consideration systemic bias, discrimination and differential treatment,” it said.
“The disappearances of McArthur’s murder victims were often given less attention or priority than the cases deserved. These victims were marginalized and vulnerable in a variety of ways.”
Kinsman’s friends and family who organized “in a highly public way” were credited with ensuring the investigation got “the attention it deserved,” but the report said “proper” missing person investigations “should not depend on whose voices are the loudest in sounding the alarm.”
“At times, their perceptions impeded their work,” it said, noting there were missed opportunities to consult with those in the community with expertise and lived experiences in order to learn.
Poor communication, including public statements made by the force’s then-chief Mark Saunders, and excessive secrecy surrounding the investigations were also deemed “disturbing” in the report.
Epstein recommended implementing a more “holistic approach” to missing-persons investigations that would see greater reliance on civilians and social services rather than just law enforcement.
She also acknowledged some improvements have already been made, including the creation of a centralized missing-persons unit, but said more work is needed to ensure such cases are properly prioritized.
“These investigations continue to be severely under-resourced, an issue that is deeply troubling given the disproportionate number of marginalized and vulnerable people who go missing, and who are exposed to risks while they are gone,” Epstein said.
“Moreover, barriers that prevent some vulnerable people from being reported missing to the police are equally concerning.”
She also found investigations were inconsistent, and in many instances, “basic investigative steps were overlooked or delayed,” while searches were at times “disorganized, incomplete or poorly documented.”
In the McArthur investigation, officers’ repeated failure to identify the missing-persons reports as major cases, combined with some investigators’ dislike of the provincially mandated case-management system for such cases, meant very little data was entered in it at first, the report found.
During Project Houston, an operation that looked into the disappearances of Navaratnam, Faizi and Kayhan, “tracking of vital assignments depended largely on human memory and handwritten notes,” the report found.
As a result, investigators failed to quickly identify leads and possible connections between the cases and others, it found.
“One can never know for sure whether or not McArthur would have been apprehended earlier had these deficiencies not existed, nonetheless (Epstein) has also found that there were a series of lost opportunities to apprehend and identify McArthur,” Mark Sandler, the lead counsel for the review, said.
The document also stated police failed at keeping the public updated on the investigations into the disappearances.
“This lack of communication reinforced the broadly held impression that ‘the police did nothing.’ It heightened existing mistrust and it ultimately diminished, rather than protected, the integrity of existing and future investigations. None of these issues – all existing at a systemic level – depends on any intent to discriminate,” it said.
Also highlighted was the “inaccurate, and unfortunately misleading” comments Saunders made regarding the investigation in December 2017, when he said the evidence did not indicate the presence of a serial killer. The report said his words had the effect of “further rupturing the already precarious relationship” with community.
An interview Saunders gave to a Toronto newspaper the following year, in which he defended the investigation and stated that no one from the community had come forward to help investigators, also stirred backlash, the document found.
The review also examined the deaths of Tess Richey and Alloura Wells.
Richey died in 2017 and her body was found by her mother in an outdoor stairwell in the Church-Wellesley Village less than 300 metres away from where she was last seen. It was determined she was in the stairwell for more than four days.
“The police failed to find her body. They should have. This failure is both tragic and disturbing, and no parent should have to bear this terrible burden,” the report said.
In 2020, a Toronto man was convicted of sexually assaulting and killing Richey. Her family launched a lawsuit against him, Toronto police and others over the psychological devastation they said they suffered as a result of her death.
The report highlighted how officers failed to conduct a second search for Richey after receiving new information on where she was last seen, something police didn’t dispute should have been done.
“The issue is not whether such a search should have been done, but why it was not done. In my view, the answer is largely rooted in systemic issues,” it said, also noting a lead investigator wasn’t assigned until two days after she went missing.
The document noted Richey lived in Scarborough but went missing downtown, which are two separate police divisions. It called for cases to be assigned to the division where the person was last seen.
There were also issues cited with the two-day delay in issuing a news release, something the report said went against best practices. It also said it wasn’t until three days that officers searched for video.
“I identify several systemic issues associated with risk assessment: for example, as concerns deepened over Ms. Richey’s disappearance, there did not appear to be any re-evaluation of whether the search level should be elevated,” the document said.
Wells, a woman who was Indigenous and part of Toronto’s transgender community, also went missing in 2017. Her remains were found and kept in a morgue for several months before they were ultimately identified. The report found the investigations into Wells’ disappearance are a “microcosm of the systemic issues existing at the service.”
It noted the investigators didn’t consult the community, something that was called for surrounding the initial discovery of Wells’ remains.
“This type of community engagement cannot be regarded as peripheral or optional. Rather, it is at the core of effective investigative work, especially in missing person and unidentified bodily remains cases involving marginalized and vulnerable individuals,” the document said.
“Community members may well be important sources of information who would assist investigators. However, they cannot provide such information if they don’t know an investigation is even taking place.”
Similar to Richey’s death, the report cited issues with a delay in assigning a lead investigator and noted a media release wasn’t issued. Also, it was noted the service’s on-call homicide unit team members weren’t notified right after Wells and Richey were found.
“If the police are to act in true partnership with affected communities, they must provide those communities with basic knowledge to enable them to assist. Early in the unidentified remains investigation, the police had more than sufficient information to issue a media release. However, no such release was issued,” it said.
“A media release represents only one of many ways in which the police can get the word out. Vigorous use of social media with targeted audiences is important.”
Interim Toronto police chief, board chair accept findings, pledge to act on recommendations
During a news conference Tuesday afternoon, Toronto Police Services Board chair Jim Hart and interim chief James Ramer addressed the findings contained in the report.
“It is difficult for us to see the many ways in which the Board and Service did not meet the standards that residents of Toronto can and do expect of us, but it is vital for us to see what went wrong and, importantly, the ways in which we can and must be better,” Hart said.
“We fell short of certain policing requirements and of our responsibilities to effectively engage the communities we serve. This occurred at a particularly challenging time when they feared for their safety and for the safety of their loved ones. With these significant shortcomings, we did not inspire the public trust and confidence that is essential to democratic policing. We cannot let that happen again.”
Hart went on to say the work needed to implement the report will be “ongoing and dynamic,” where there will be a need to regularly reassess it and the need to check in on progress.
“As Judge Epstein was clear to emphasize, the cost of not acting is not a cost our communities or our members can bear,” he said.
“This report is not simply a document filled with facts and recommendations. It represents the voices of the missed, the voices of the missing, and the aspirations of the people of this great city for what they expect in their police service. It is a call to action we will work together with our communities to answer, to rebuild that vital trust so essential to our collective community safety.”
When recounting the report, Ramer said he found many chapters “difficult to read” and found the “disconnection” between police and LGBTQ2 and marginalized communities “very, very difficult” to accept.
“Judge Epstein’s report lays bare that there were mistakes and missteps in the way that missing persons investigations were handled, and in particular those that related to people from Toronto’s LGBTQ2S+ communities and in Toronto’s Church and Wellesley area,” Ramer said.
Although, as Judge Epstein states, the deficiencies were neither overt nor intentional, there were too many times that we did not live up to what is expected, and in some cases required of us to keep you safe and the consequences were grave, affecting lives in the most profound ways.
“We know that many in Toronto’s LGBTQ2S+ communities felt, and still feel, that our communications deepened a sense of mistrust between us. That this was not the Service’s intention and we apologize for the anger, hurt and damage that caused. Others have said we were not hearing them, that their fears were not taken seriously and even that they were blamed for the victimization they experienced. None of this is acceptable. None of this should have happened.”
Ramer said the police service is looking at how to implement all of the recommendations and confirmed it will actively report on the progress.
He also said he was immediately moving to double the complement of investigators in the missing persons unit (there will now be eight instead of four), designating missing persons coordinators for every division and looking at how to integrate civilian supports into the work done by the unit.
Ramer said the superintendent that oversees the homicide squad and sex crimes unit has been tapped to co-lead a team that will act on Epstein’s report.
A statement issued by the Toronto Police Association, the union that represents officers and civilian members, said the organization needs to “carefully review it and subsequently provide its response.”
“What we know for certain is that Toronto police officers are united in the goals of public safety, good policing and fostering improved relations with the LGBTQ2S+ communities and vulnerable communities,” Jon Reid, president of the TPA, said, adding Ramer’s actions announced on Tuesday were important.
“We look forward to many collaborative discussions ahead with the Toronto Police Service as we address this report in detail with a shared focus on continued progress and advancement.”
Community reaction to the report
Shortly after the report was released, Christine Hermeston, Richey’s mother, issued a brief statement thanking Epstein.
“While nothing will bring Tess back, we’re hopeful that greater public scrutiny will lead to better policing that will ultimately save lives,” Hermeston wrote.
“A shift in police attitude and understanding would go a long way in better serving and protecting all members of our community.”
Haran Vijayanathan, a community advisory group member who provided advice to Epstein and the review team who also serves as the executive director of the Alliance for South Asian AIDS Prevention, told Global News there were a lot of “systemic issues that led to discriminatory behaviour.”
“Police need to take community seriously, and engage more, and rebuild that trust that’s lost and has been lost for several years now,” he said.
Vijayanathan also said when it comes to missing persons reports, generally, a better job is done with seniors and children, but “not necessarily” that middle-aged population and those in marginalized communities.
He said as part of his work with the community advisory group, he was able to participate in stakeholder roundtables and heard consistent comments from community members, especially surrounding the need for transparency and effort needed to build trust.
“People are afraid to go and we don’t really take people seriously, and so the past negative experiences don’t allow people to be more forthcoming and engage the police,” Vijayanathan said.
He said Epstein’s report can’t be ignored going forward and hopes Ramer and the board respond to all of the recommendations.
On Twitter, Pride Toronto issued a statement in response to the report.
“Our thoughts are with the families and loved ones of the victims as they grapple with the findings of the report.
“Pride Toronto is committed to working with the 2SLGBTQ+ community and partners to determine how we can better protect our racialized and most vulnerable community members, hold police accountable, and move forward with transformative change.”
Mayor John Tory, who also serves as a member of the Toronto Police Services Board, said in a statement he wants to see the relationship involving the city’s LGBTQ2 community, marginalized communities, and police improved.
“I will be working with the police service, the police board, and city council to ensure that these recommendations are implemented,” he wrote.
“We must do this to honour the memory of those we have lost and to make sure our police service is protecting and serving everyone in all of our communities.”
— With files from The Canadian Press
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