Office of the Chief Coroner Bureau du coroner en chef Verdict of Inquest Jury Verdict de l’enquête The Coroners Act – Province of Ontario Loi sur les coroners – Province de l’Ontario We the undersigned / Nous soussignés, of / de Toronto of / de Toronto of / de Toronto of / de Toronto of / de Toronto the jury serving on the inquest into the death(s) of / membres dûment assermentés du jury à l’enquête sur le décès de: Surname / Nom de famille Ekamba Given Names / Prénoms Marc Diza aged 22 held at Toronto , Ontario à l’âge de tenue à from the 16th of May to the 3rd of June 2 0 22 du au By Dr. / Dr David Eden Presiding Officer for Ontario Par président pour l’Ontario having been duly sworn/affirmed, have inquired into and determined the following: avons fait enquête dans l’affaire et avons conclu ce qui suit : Name of Deceased / Nom du défunt Marc Diza Ekamba Date and Time of Death / Date et heure du décès March 20th, 2015 at 10:53pm Place of Death / Lieu du décès 3070 Queen Frederica Drive, Mississauga, ON Cause of Death / Cause du décès Multiple Gunshot Wounds By what means / Circonstances du décès Homicide Original confirmed by: Foreperson / Original confirmé par: Président du jury Original confirmed by jurors / Original confirmé par les jurés The verdict was received on the 3rd day of June 20 22 Ce verdict a été reçu le (Day / Jour) (Month / Mois) Presiding Officer’s Name (Please print) / Nom du président (en lettres moulées) Dr. David Eden Date Signed (yyyy/mm/dd) / Date de la signature (aaaa/mm/dd) 2022/06/03 Presiding Officer’s Signature / Signature du président We, the jury, wish to make the following recommendations: (see page 2) Nous, membres du jury, formulons les recommandations suivantes : (voir page 2) Office of the Chief Coroner Bureau du coroner en chef Verdict of Inquest Jury Verdict de l’enquête The Coroners Act – Province of Ontario Loi sur les coroners – Province de l’Ontario Inquest into the death of: L’enquête sur le décès de: Marc Diza Ekamba JURY RECOMMENDATIONS RECOMMANDATIONS DU JURY To all Ontario Police Services: 1. Improve knowledge and awareness for police communicators, call takers, and dispatchers of the signs of mental health crisis, and ensure that communicators are trained to ask questions directed at determining whether a call involves a mental health crisis. 2. Ensure that police officers responding to a mental health crisis are aware that police have responded previously to incidents involving the same parties, and facilitate access for responding officers to significant information regarding previous calls. 3. Ensure that all police officers who interact directly with the public are provided with the four-day mental health training currently provided to incoming police officers in their first year of service. Regular refresher training on mental health issues should be provided to all police officers who interact with the public. 4. Ensure that police officers can accurately identify their own Mental Health Act options and explain options available to complainants when a mental health issue is the basis for criminal conduct. 5. Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College, and engage with OPC on its experience with the training and its potential implementation. 6. Ensure that persons with lived experience from peer-run organizations are directly involved in the development and delivery of both mental health crisis and de-escalation training. 7. Mandate that all Police Service officers receive annual implicit bias and cultural competency training to address stereotyping of Black people, and the existing research on anti-Black racism in policing. 8. Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. 9. Develop and implement a pilot project to explore the feasibility of dispatching crisis support workers to mental health service calls that do not require police involvement, similar to Peel Regional Police Mental Health Strategies. 10. Create emotionally supportive debrief sessions for police officers at the division or platoon level for those involved in critical incidents resulting in serious bodily harm or death, with regard for the Special Investigations Unit investigative process. 11. Ensure that witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports. 12. Police Services and Police Services Boards shall establish standing or advisory committees on race and impartial policing and on mental health in order to meet with representatives of peer-run organizations and members of affected communities on an ongoing basis to discuss concerns and facilitate solutions. 13. Consult with the Ontario Anti-Racism Directorate to analyze race-based data collected by Police Services to measure and evaluate police service performance on use of force, take corrective action to address systemic discrimination and provide clear and transparent information to the public on bias and discriminatory use of force. 14. Police Services and Police Services Boards shall establish permanent data collection and retention systems to record race, mental health issues, and other relevant factors on use of force incidents. The data should be standardized, disaggregated, tabulated and publicly reported. The data should include age, gender, perceived race, and officer perception of whether the individual has any mental health issues; 15. The results of the data collected on use of force incidents must be taught to all frontline Police officers. 16. Police Services and Police Services Boards shall consult with third-parties, including individuals from the Black community, Black advocacy community organizations, persons with lived experiences from peer-run organizations, and appropriate content experts, and: a. Develop an objective methodology to measure and evaluate police service performance on use of force; b. Take corrective action to address systemic discrimination; and c. Provide clear and transparent information to the public on biased and discriminatory use of force 17. Training for new officers should be amended so that the question of the suspect’s mental health be as prominent in their considerations as the criminal activity they have committed. 18. Training should be given to establish who should lead the call when dealing with a potentially violent incident or crisis. All Ontario police services should seek and allocate funding and resources adequate to implement the above recommendations. To the Peel Regional Police: 19. Re-evaluate the capacity of COAST and MCRRT teams to meet the growing need for these services in the Region of Peel. Peel Regional Police should seek and allocate funding and resources adequate to implement the above recommendations. To the Ministry of the Solicitor General: 20. The Ontario Use of Force model should be renamed to accurately capture the intent and purpose of the model, which is a guide to police engagement with the public rather than to suggest that force is inherent in police interactions. 21. The Ontario Use of Force model shall be redesigned to highlight and emphasize the importance of de￾escalation at all points during police interactions. 22. The Ontario Police College shall ensure that persons with lived experience are engaged in the development and delivery of de-escalation training. 23. The Ontario Police College shall ensure that affected communities and persons with lived experience be directly engaged in the development and delivery of anti-bias training. OPC should ensure that community organizations who represent persons with lived experience are engaged in this work. 24. Revise the Use of Force Report form to require officers to document de-escalation techniques used. To the Ministry of the Solicitor General and Peel Regional Police: 25. There must be special recognition of the unique challenges Black people who also have serious mental health issues face when they come into contact with police. This unique intersection of Blackness and lived experience of mental health issues must be specifically addressed in any training on Use of Force, de-escalation, and police interaction with such persons. The Ministry of the Solicitor General and Peel Regional Police should seek and allocate funding and resources adequate to implement the above recommendations. To the Government of Ontario: 26. Commission a study to examine the creation and implementation of a province-wide, civilian-led crisis intervention system to respond to persons in crisis, including mental health crisis. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. 27. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. Measures to improve public awareness should be developed in consultation with content experts and community organizations that represent persons with lived experience. 28. Improve public awareness of both policing and non-policing community-based crisis responses to mental health crisis. Efforts to improve public awareness of these options should be developed in consultation with content experts and community organizations that represent persons with lived experience. 29. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones. 30. Improve public awareness and knowledge of community-based supports for persons experiencing mental health issues should target young people, and utilize channels of communication that are accessible and suitable for youth. 31. Rename crisis hotline services and create awareness campaigns to educate the public about their existence to make the public aware that these services are available before a person reaches the point of crisis. The Government of Ontario should allocate funding and resources adequate to implement the above recommendations. To Peel Housing Corporation: 32. Improve mental health awareness of housing support personnel, and in particular, concerning the recognition of mental health crisis. 33. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. 34. Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants. 35. Review and improve training to housing support personnel on cultural competency, anti-Black racism, implicit bias, mental health and its intersectional nature. Peel Housing Corporation should seek and allocate funding and resources adequate to implement the above recommendations. Personal information contained on this form is collected under the authority of the Coroners Act, R.S.O. 1990, C. C.37, as amended. Questions about this collection should be directed to the Chief Coroner, 25 Morton Shulman Avenue, Toronto ON M3M 0B1, Tel.: 416 314-4000 or Toll Free: 1 877 991-9959. Les renseignements personnels contenus dans cette formule sont recueillis en vertu de la Loi sur les coroners, L.R.O. 1990, chap. C.37, telle que modifiée. Si vous avez des questions sur la collecte de ces renseignements, veuillez les adresser au coroner en chef, 25, avenue Morton Shulman, Toronto ON M3M 0B1, tél. : 416 314-4000 ou, sans frais : 1 877 991-9959.