Staying Visible
Staying Connected
For Life

Report of the Expert Panel
on Police Officer Deaths by Suicide

September 2019

 Foreword: Respecting Our Nine Lost Officers and Their Survivors

We begin by extending our respect and our appreciation to the families, friends and colleagues of the nine
police members whose untimely deaths by suicide during one single year became the catalyst for our Review
Panel. We know it cannot have been easy for these survivors to share their grief alongside their generous and
thoughtful observations on a system that was at times supportive, and too often flawed and frustrating.
We want these survivors to know that we recognize their loved ones for the fullness of their lives. Each of these
nine individuals served the public. Each of them committed themselves to high standards of professionalism.
Each of them chose and trained for a career filled with danger, stress, trauma and fatigue in order to keep
our communities safer for all. And, each of them also lived, laughed and enjoyed the loving company of their
families, friends, neighbours and colleagues.
We decided early as a panel that we would not identify the nine by name, nor would we showcase any details of
their life and passing. Policing is much too small a community to do so without violating privacy. But moreover,
we chose to direct this report toward the future. We chose to honour the nine by learning all that we can from
their experience, and our results are presented as collective findings gathered from the individual as well as
shared journeys of these fallen officers. And, we hope that by joining with them in this manner, we might help
to craft a legacy of better outcomes for all their brothers and sisters, present and future, who work within the
policing system in Ontario, and beyond.
The charge given to us by the Chief Coroner was clear in this regard: “Nine officers died by suicide. What would
they and their survivors say should have been done differently?”
Throughout our deliberations and through this report, we offer our best attempts to answer that question on
their behalf.

Respectfully,
The Members of the Ontario Chief Coroner’s Expert Panel on Police Officer Deaths by Suicide
September 2019

Report of the Expert Panel on Police Officer Deaths by Suicide
i

 Executive Summary

During 2018, nine deaths by suicide occurred among serving and retired police officers in the province of Ontario.
This number was thought to be unprecedented*. Soon after the year ended, the Office of the Chief Coroner
initiated an expert panel review process. The eight-member panel began its work in June 2019. The experts on
the panel understood that world research on suicide prevention has demonstrated that any specific death by
suicide is difficult to predict or prevent, given that the known risk indicators for suicide also exist in large numbers
of people who never attempt or die by suicide. Despite this, however, there are a number of evidence-based risk
indicators for suicide, which when taken together, provide a list of factors known to be present in the majority of
cases of completed suicide. Therefore, these points of risk can be used as potential targets for intervention when
dealing with a vulnerable individual, and for the panel’s purpose, these points of risk could serve as a method
for organizing and understanding the information obtained on the nine deceased police officers. These risk
indicators and potential targets for intervention to prevent suicide are described in Part One of our report.
These risk patterns were clearly evident in all nine of our
subject officers’ lives. In Part Two, we identify several
characteristics unique to policing that may place all police
members at greater risk, including the presence of mental
health challenges, whether mild, moderate or severe.
Given the presence of a diagnosable mental disorder (often
Depression) in over 90% of those who die by suicide, the
panel interpreted its mandate to extend beyond preventing
deaths by suicide, to include a focus on improving mental
health outcomes for all police members.
In Part Three of our report, we introduce and discuss
seven pathways to better outcomes. The first of these,
and perhaps the most vital, is the normalization of mental
health issues. We call for deliberate steps to introduce a
more open culture that will support earlier and continuing
visibility of mental health conditions, better and sustained
access to care, treatment and recovery, and an end to the
isolating social disconnections that can often carry these
conditions to their extremes. In a cross cutting manner,
the six remaining themes build upon other aspects of this
culture to strengthen organizational and clinical supports,
to protect the strong sense of identity that police members
value deeply, to more actively inform and engage police
members’ families and outside supports, and to better
unify and align the tremendous efforts at improvement
that are already underway across the policing and mental
health systems. Alongside this discussion, we also feature
in a running sidebar a number of specific observations on
the strengths and weaknesses in the current police and
mental health ecosystem. In Part Four, these themes are
consolidated into a broader legacy.

* A Note About the Number
There is currently no requirement in
Ontario for Coroners or others to record
or track deaths by suicide among first
responders, including police. Therefore,
it is not known if this number of suicides
in a single year was higher than the
number in previous years.
Statistically, it is much higher than
reported rates in the general public.
Anecdotally, it may reflect increases in
mental health issues across the policing
sector.
For the panel, for police services and
police association officials, for health
professionals, and most notably for the
surviving families, it is an alarming and
unacceptable number.

Report of the Expert Panel on Police Officer Deaths by Suicide
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 Assembled under 14 main recommendations in Part Five of this report, our panel outlines a total of 36
actions and specifications, most of which include proposed roles and responsibilities, and all of which reflect a
continuing theme of collaboration. First among these is a call for the formation of an Ontario Police Members
Mental Health Collaborative (OPMMHC) to serve as a standing body that will initiate, guide, monitor and report
on an urgent and comprehensive plan of action in Ontario.
The panel members are named in the Appendix, and we are all grateful to Dr. Dirk Huyer for his leadership in
assembling this expert panel and for inviting us to serve in this important work. We also extend our thanks to
the staff in the Office of the Chief Coroner for their valued guidance throughout our process.

Report of the Expert Panel on Police Officer Deaths by Suicide
iii

 TABLE OF CONTENTS
i 

Foreword: Respecting Our Nine Lost Officers and Their Families

ii 

Executive Summary

1 

Part One: Understanding the Common Tragedy in Any Death by Suicide

4 

Part Two: Learning From Deaths by Suicide and Mental Health Issues in the Context of Policing

6  
6  
8  
8  
9  
10  

Stigma and Self-stigma for Mental Health Issues
The Lifeline of Police Identity
The High Costs of Accommodation
The Give and Take of Post-Traumatic Stress Disorder (PTSD) Presumptive Policy in Ontario
The Confounding Interplay among Workplace Stressors and Life Events for Police
An Enduring Commitment to Duty Despite the Personal Costs

11 

Part Three: Seven Pathways to Better Outcomes

11 
12 
13 
14 
15 
15 
17 

 
 
 
 
 
 
 

18 

Part Four: A Much Broader Legacy

19 

Part Five: Our Recommendations for Action

22 

Appendix: Members of the Chief Coroner’s Expert Panel

1. Normalizing Mental Health Challenges
2. Navigating Through Transitions
3. Continuing Access to Quality Care and Solutions
4. Resourcing, Accommodation and Burnout
5. Preserving Identity: The Criticality of Criminal or Police Act Charges and Social Media
6. Managing Suicide Events
7. Joint Ownership and Collaborative Action

Report of the Expert Panel on Police Officer Deaths by Suicide

 Part One: Understanding the Common Tragedy in Any Death by Suicide

Our panel consisted of eight members selected by the Chief Coroner of Ontario for the expertise
and perspective that each member could bring to the review. Several members are mental health
professionals with expertise in suicide and suicide prevention, with experience working with police
and other first responders. Others are current or past members of police organizations representing
executive ranks, civilian specialties, and front line police officers with lived experience. One member
is a mental health professional with extensive experience working with a police service outside of
Canada, which has a reputation for excellence in promoting member mental health and well-being.
One member is an educator and researcher with a special interest in policing culture. An early priority
for the panel was to share their expertise and find a common frame of reference for understanding
suicide. Following a discussion of the literature and the task at hand, two well-researched models
for understanding suicide appeared to best fit the requirements for the review, the Canadian Forces
Modified Mann Model for Suicide Prevention, and the Policing and Mental Health Ecosystem,
and both are discussed further below. The panel also received input from outside delegations.
We accessed a wide range of literature on the subject, digested other models from medical and
sociological research, and we consulted the notes and themes culled from often painful interviews
with survivors.
We learned that there is no prototype. Each and every suicide, whether attempted or completed, is
in many ways as unique as the person involved. Although there is no single pattern that all suicides
follow, the panel reviewed commonly studied and accepted factors associated with death by suicide.
These include the presence of a mental health problem, often depression, combined with: a stressful
life event or significant loss, which may be personal (loss of an important relationship through
separation or divorce); experiencing stressful or overwhelming events related to work, such as
violence or loss of status; or stress due to other factors (especially those causing embarrassment or
shame). These conditions and events may then lead vulnerable persons to start thinking of suicide
as a “way out”, or a way to solve their problems. There are then a number of factors, which have
been shown to increase a person’s chances of acting on these thoughts and dying by suicide. These
factors include: impulsivity, where either the person acts quickly and without much consideration,
when a method of suicide is close at hand; or, the person uses drugs or alcohol which can decrease
impulse control and lead to impulsive action; hopelessness or pessimism, where the person no longer
believes there can be positive solutions or outcomes for them; emotional dysregulation, where the
person is having difficulty controlling or moderating their feelings and behavior, and may be angry,
aggressive, or prone to risk-taking; access to lethal means, where the person has a lethal method of
death close at hand, which gives them no chance to deliberate on their actions, and kills quickly; and,
contagion or imitation, where a vulnerable person learns of the death by suicide of someone whom
they admire, or with whom they identify, and suicide begins to look like a “reasonable alternative”
to the stresses and problems the vulnerable person is facing (the phenomenon of “copycat suicides”
when the suicide of a public figure or celebrity is widely publicized is an example of this).

Report of the Expert Panel on Police Officer Deaths by Suicide
1

 While hope and opportunities for intervention will always remain, once a clear intention to end one’s
life has been formed, options narrow considerably for preventing that death. There are many more
opportunities before that point to prevent that decision from being made.
We recognized a distinctive pattern that would prove vital to our deliberations, a pattern that was also
clearly evident in our nine subject deaths. We observed that by the time each of our subjects formed
that determined intention to end his or her life, each had traveled a series of pathways, and each
pathway had reached its end. The intersection of three specific pathways stood out for us. One is the
path of acute mental health issues, often with associated substance use disorders. Another is the path of
lost or diminished access to timely and quality care, effective treatment services and a range of essential
supports. And the final one is the path of actual or perceived emotional disconnection from family,
friends, and organization, often pushed to its endpoint by one or more precipitating events, sometimes
at work, and more often in personal and family life.
We recognize that this observation may not break new ground in medical science, but our own
discussions of this evident pattern proved instrumental in shaping the direction of our review. We
recognized that we would be greatly limited if we were to direct our efforts solely to ‘preventing
suicides’, per se. On the other hand, the imagery offered by these three critical pathways and their
ultimate tragic convergence opens a much wider field of opportunity for changing the conditions. We
know that if these conditions are unchanged, they will continue to lead some to that ultimate point of
despair, and they will most certainly lead too many others to experience deterioration in the quality
of their life and career. It is on these upstream aims and opportunities for improvement that we have
chosen to focus this report.
We reviewed available literature and best practices in suicide prevention with a view to anchoring our
own work in credible models. We noted that the US Air Force implemented a comprehensive suicide
prevention program to reduce the risk of suicide, implementing 11 initiatives aimed at strengthening
social support, promoting development of social skills, and changing culture to encourage effective helpseeking1. We also found utility in the Mann Model for Suicide Prevention in the Community2. Moreover,
we found a closer fit with the adaptations to that model made by the Canadian Forces (CF).
In many ways, the CF-modified Mann model3 (Figure 1) reflects a wider range of opportunities for
intervention that are consistent with our pathways observations, and which also closely align with the
paramilitary nature of policing and its organizational culture.

USAF (2001). The Air Force Suicide Prevention Program: A description of program initiatives and outcomes (AFPAM 44-160).
Suicide Prevention Resource Center.
2
Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A et al. Suicide prevention strategies: a systematic review. JAMA
2005 October 26;294(16):2064-74.
3
Report of the Canadian Forces Expert Panel on Suicide Prevention (PDF).
1

Report of the Expert Panel on Police Officer Deaths by Suicide
2

 Figure 1: Canadian Forces Modified Mann Model for Suicide Prevention

We include in our recommendations (see Part Five below) a call for further research and development that
might lead to a police-specific version of the CF-modified Mann model for broad application across the sector,
incorporating any additional factors and interconnections addressed within this report.

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 Part Two: Learning from Deaths by Suicide and Mental Health Issues
in the Context of Policing
Our mandate was to examine deaths by suicide specifically among police officers. No doubt, much of the general
knowledge and social science about suicide applies as much to this sub-set as it does to the general population.
Police members are people first, and like everyone else, their lives are subject to the same successes, challenges
and complexities as their non-policing peers. But, even the expression of our mandate implies that there might
be something different from the norm in the pathways traveled by our nine, and by other police officers and
civilian members that have arrived at the same tragic point outside the scope of our study. Our panel shared that
same suspicion from the outset, and we set out to dive deeply into the question.
First, we noted that there is important work being done across Canada to better understand, through research,
the mental health and well-being challenges faced by those in the policing profession, as well as in the broader
community of first responders. Specific priority has been placed by the federal government on understanding
and serving the mental health needs of public safety personnel in Canada through a number of efforts, including
the passing of the Federal Framework on PTSD Act in 2018. The Canadian Forces has invested considerable
research and development to better serve the mental health needs of active service members and veterans.
Our panel recognizes the work of the Canadian Institute for Public Safety Research and Treatment (CIPSRT), the
Canadian Institute for Military and Veteran Health Research (CIMVHR), their funding partners, and countless
others working in this field for the commitment they have shown to improving outcomes for first responders,
including police. The deliberations, conclusions and recommendations of our own panel are timely and relevant
in the overall pattern of efforts in Canada in this regard.
We also note that there have been significant advances in mental health awareness and resilience training
across Ontario police services in recent years, along with a growing number of staff and consulting psychologists
embedded within the ranks to increase access to professional support and organizational guidance. In 2017,
the Canadian Association of Chiefs of Police (CACP) established a Psychologist Sub-Committee under its Human
Resources and Learning standing committee in an effort to achieve greater alignment and to create a network of
best practices, among other aims.
The Ontario Provincial Police (OPP) has been engaged in a multi-pronged examination of mental health and
suicides among its members, and the efficacy of current mental health supports available through its partnerships
with its principal collective bargaining units, the Ontario Provincial Police Association (OPPA) and the OPP
Commissioned Officers Association (COA). They have also engaged within these studies the active support of
charitable and not-for-profit agencies that provide peer support, early intervention, and health care referrals,
most of them working on a volunteer basis. The OPP reviews are broader in scope than our review, spanning a
longer time frame of lived experience and including extensive consultations with active and retired members.
We were fortunate to have the opportunity to interact with their study team members, their executives, and the
OPPA during our own deliberations, and to review some of their findings and several proposed and promising
solutions that are well underway.
We also received delegations from the Toronto Police Association (TPA), the Police Association of Ontario (PAO),
and the Ontario Association of Chiefs of Police (OACP), each of whom showcased progressive and encouraging
steps being taken along with expanded services in place or under development. We gained an international
perspective on emerging practices related to police well-being from a recent global scan executed and
summarized for us by a team from Deloitte.

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 All of these discussions yielded a progressively clearer picture of a policing and mental health ecosystem (see
Figure 2), as others have noted in their own research. In our view, mental health and wellness issues in general,
responses to moderate to acute illness, and deaths by suicide must be situated and understood in this context if we
are to change the conditions and reduce risk for all police officers and civilian staff.

Figure 2: A Policing and Mental Health Ecosystem

We note there is an extensive health and social infrastructure intended to serve the broader public across Ontario
in every phase of prevention, as illustrated in Figure 2. And, we also learned of ongoing initiatives to strengthen
those supports, reduce suicide risk, and improve mental health outcomes for everyone, including police members.
We encourage interested readers to consider all of these ongoing efforts to improve outcomes. Within the scope
of our own report, suffice to say that the evident levels of commitment to these issues within policing give strong
evidence that there are indeed apparent and urgent differences from broader society in the pathways experienced
by police officers and their civilian colleagues in the policing sector.
Through our own analysis and discussions, we developed several observations on factors that are either unique, or
at least uniquely acute within policing culture. We outline below those we found most salient to our study, and we
highlight them for their real and potential impacts upon the mental wellness of police service members in Ontario.

Report of the Expert Panel on Police Officer Deaths by Suicide
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 Stigma and Self-stigma for Mental Health Issues
We often hear of stigma as a major factor in how society responds to persons experiencing mental health issues,
and we salute efforts such as the Bell Let’s Talk initiative, anti-stigma outreach programs from the Canadian Mental
Health Association (CMHA), the Centre for Addiction and Mental Health (CAMH), and a host of community based
organizations and public and private sector agencies. No one is served well by a social prejudice that differentiates
mental suffering from physical, and we believe outcomes would be considerably better for everyone if this false
separation could be eliminated.
And so, the starting point for the average police member may be no different than for others. At least, that is, until
they enter the academy, hit the streets, or begin to work at the communications centre. In most police jurisdictions
across Ontario, estimates run as high as 40% of police calls for service being tied to incidents involving persons with
mental health issues. Whether or not the police are the appropriate response in many of these cases is a topic of
considerable debate and outside the scope of our study. But, the fact remains that within the first few years of
service, a police officer, communicator, or other specialist will have come to recognize those with mental health
issues among the highest frequency of calls, and often for patrol officers they may even rank among their primary
encounters with the public. Sadly, if the police are being called, they may also be encountering such individuals
at the very worst times and often under the most critical stages of their condition. And in extreme cases, these
encounters may involve violence and a direct threat to the safety of the public and that of the responding officers.
It is also worth noting that it is police officers that must respond to almost every suicide that occurs in the general
public.
Police members have reported to us directly and in other studies we consulted that notwithstanding their high
degrees of compassion, training and their on-scene professionalism that is the norm in these thousands of calls
for service, most police members will soon come to regard any person with mental health issues as someone they
would never want to be. They also told us that they often become disillusioned about the effectiveness of mental
health care when they bring acutely mentally unwell people to hospital only to see them leave shortly afterwards
with little to no change in their condition or circumstances.

The Lifeline of Police Identity
Sworn police officers in Ontario and across Canada are invested with extraordinary responsibilities. They have
the power under due circumstances to deny a person’s freedom through arrest and detention, to enter private
homes and communication devices with judicial authorization, to investigate and interrogate, to confiscate vehicles
and other property, and when required, to apply escalating levels of force up to and including ending someone’s
life. They carry a range of use-of-force options on their duty belt and in their patrol car, and while they have an
unenviable obligation to use them when warranted, they also carry the most exacting levels of accountability to
formal authorities, to public oversight bodies, and to the informal world of mainstream and social media. When
crisis or violence erupts, members of the public tend to move away from it, while police officers are duty-bound to
move toward it. They must face it head on, often with great risk to themselves and their on-scene colleagues on
whom they often must rely so that they remain safe and, so that no one else is injured.
Police officers represent 0.18% of the Canadian public (a number that is similar in Ontario). Put another way,
99.82% of Canadians do not carry these same authorities and responsibilities. Most police members will tell you
that their career is not a job but a calling, and this distinction from almost all other Canadians is not lost on them.
It is a source of great pride, and it carries its own burdens and every day stressors that most of us cannot imagine.

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 In any occupation, if a co-worker began to report or display mild symptoms of a mental illness, such as depression,
anxiety disorder, or even moderate substance use, his or her colleagues might be alarmed, might recognize and
pick up some workload imbalance, and might even be troubled periodically by behaviour they see as odd. It is
doubtful that most co-workers would feel threatened by this individual’s personal condition except in rare and
extreme circumstances.
In policing, if a member reports or displays mild mental health issues, for at least some colleagues and even for the
member himself or herself, such ‘odd behaviour’ can rise to life and death significance. It could be interpreted as,
or merely feared to become a direct threat to the member and any colleagues who may be called to rely upon him
or her at any time during a shift. While such dire situations may be infrequent in reality, they are by their nature
unpredictable, and there is little margin for error when they occur. Apparently, from members’ own disclosures,
this is not lost on the average police officer, ever.
When combined with the self-stigma described above, this fear of being the one to let down the team may be
even greater for the officer with the mental health issue, no matter how mild or moderate, than it is for his or her
colleagues. Officers are trained to be team players and in truth, they will typically support one another. But, this
may not be what goes through the mind of the afflicted. Instead, due to the early training and conditioning and
the ongoing workplace culture of policing, many officers report becoming quite binary in their view of such things:
either you are fit for duty, or you are not. As such, any loss or limit on your ability to perform the full scope of your
duties can amount, in the mind of the individual, to a loss of your identity as a police officer.
Interestingly, this is not usually the same, or at least is not experienced to the same degree, if the deficiency arises
from a physical injury or illness. Injuries are not uncommon in police work or even in off-duty activities. Illnesses
can affect everyone in relatively uniform measure. Police can be very supportive, and when illnesses or injuries are
severe, they often exhibit outstanding levels of support for their ill or injured colleagues.
But, likely due to the stigma and self-stigma they share, when the deficiency is due to psychological injury or arises
from the same forms of mental health issues that affect 20% of all Canadians, the harsh and unfortunate term that
is often invoked in policing is “broken toys”. In other words, you are no longer fit for duty. And, as we all recall
from childhood, once broken, most toys cannot be fixed.
Faced with this harsh and often binary reality, a great number of police members will deny and shield the presence
of mental health issues for as long as they can. The literature suggests that they may turn, in greater than average
numbers, to alcohol and other substance use, and other often harmful self-medicating activities, in efforts to
mitigate symptoms and to contain their underlying issues from exposure and treatment. Despite considerable
investments by police services in their human resource departments, employee and family assistance programs
(EFAP), and many other supportive options, many will avoid such doorways out of fear of exposure.
Too often, by the time their condition either forces them to seek help of their own accord, or is recognized by
others or by consequences that leave them no choice but to seek help, they will have already traveled well down
all three of the pathways described above. They may be at a point of greater criticality in their mental health
issues. They may have a narrower range of secondary prevention and care options available to them. And, with
surprising frequency, they may be experiencing disconnection due to damaged relationships with their employer,
their colleagues, their friends, and their family as a result of their unmanaged illness and/or their unhealthy
reliance on intoxicants.

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 The High Costs of Accommodation
In the best cases, members who recognize or are recognized early for mild to moderate mental health conditions
will be quickly and effectively connected to the professional services and guidance they require. Enter the high
personal costs and heightened risks that stem from accommodation. This is a term, and a status, that can be
almost as loaded and stigmatized as mental illness itself in the policing culture.
If you are being accommodated by the organization, there are very differing responses that might apply. If you
are still able to come to work and execute tasks that remain central to the mission, you are still serving your
calling. Even if there are restrictions placed on your attendance, your deployment or your range of duties, and
others know this to be due to a temporary or even permanent physical injury or illness, you may still be regarded
as a dedicated and courageous member for continuing to serve when and where you can.
But, something appears to change if the reasons for modified duty or extended absence from work are left open
to speculation and rumour, as can often be the case when a member chooses to remain private about mental
health issues they are experiencing, or about the nature of their treatment and path to recovery. Stigma and
misinformation about mental health care and recovery can lead to harsh and even hostile presumptions among
peers, supervisors and managers that a member’s behaviour is simply malingering, especially where there have
been past performance issues or workplace conflict. This despite evidence that real malingering is actually quite
rare. And, to quote one demeaning descriptor used by some, a member has been reduced to “counting paper
clips” if a reassignment falls far outside their usual scope of duties, notwithstanding that it is still significant and
dignified work.
Again, it is easy to see how quickly and how much further a member being accommodated for mental health
reasons under these prevailing conditions might travel down those three pathways. Some may deny their
own conditions completely, or deny themselves access to the care and treatments available due to self-stigma
and cultural perceptions. Even if receiving care, the motivation will be very strong to suppress symptoms, to
exaggerate wellness, and if accommodated or absent, to push hard toward full reinstatement, thus risking an
increase in the criticality of the underlying mental health issues. The tendency to eschew available supports
and services will be a common tactic to remain unrestricted in one’s duties. If performance issues or conflicts
with supervisors begin to surface, it may be without the benefit of true explanation. And, these additional
stressors and ongoing deceptions at work and at home will often continue to deepen other actual and emotional
disconnections from family and friends, especially when substance use also increases as a chosen means of
coping.

The Give and Take of Post-Traumatic Stress Disorder (PTSD) Presumptive Policy in Ontario
An operational stress injury (OSI) is a non-medical term that is generally defined as “persistent, psychological
difficulties resulting from operational duties” . Within a broad category of operational stress injuries related to
policing, a number of mental health issues can be described as post-traumatic stress injuries (PTSI), including
depression, substance use disorder, and specifically, the clinically diagnosed condition Post-Traumatic Stress
Disorder (PTSD). With increasing acceptance and reduced stigma as a result, operational trauma is rapidly
becoming the exception that breaks the rule, when compared to police attitudes on mental health in general.
This is a positive development in and of itself.

4

Public Safety Canada (2019). Post-traumatic stress injuries and support for public safety officers.

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 The Ontario legislature passed presumptive legislation in 2016, expediting access to Workplace Safety and
Insurance Board (WSIB) benefits, and by extension access to care for members who have been diagnosed by a
psychiatrist or psychologist. It is no longer necessary to establish a causal link between a specific traumatic event
and the condition. There is little doubt that this step has brought many more police officers to the care they
require while also reducing the burden and added stressors of justifying their condition on the basis of a single
traumatizing experience.
However, the panel observed two difficulties that have arisen, perhaps as unintended consequences from this
progressive policy. The first is that WSIB and clinicians are still required to adjudicate the general pattern of
trauma in order to exert some measure of control over the uptake of these benefits and services. As such, while
a single precipitating event might not be required, some police officers experiencing symptoms of PTSD might still
find themselves trying to justify their basis, and if unsuccessful and benefits are denied, to pull away from the care
they require due to cost and now worsened self-stigma.
The second concern is that while the presumption opens a path to care for PTSD, it may inadvertently be
closing down other paths to care for more generalized mental health conditions, including the broader range of
occupational stress injuries. This can lead to misdiagnosis and over-diagnosis of PTSD on the one hand, since
that is where the benefits are most accessible, and it can leave those experiencing such conditions as depression,
anxiety disorders and substance use disorders without similar access and/or self-justification, on the other.
There is no doubt that trauma is a real and present danger in police work, and recent research is revealing more
about and reducing stigma around the genuine nature of OSI’s being experienced by military veterans and first
responders across the board. However, just as PTSD is gaining legitimacy as one condition, our panel recognized
the potential risk of narrowing the lens through which we view the entire spectrum of mental health challenges to
which police officers may be prone.

The Confounding Interplay among Workplace Stressors and Life Events for Police
It seems likely that any person who experiences a decline in their mental wellness might struggle to distinguish
the roles played by the stresses of everyday living versus those that have come from earning a living. Nonetheless,
our panel observes that there is an interplay among these sources that may be even more complex for police than
for others. As our nine subjects traveled down those three pathways to their tragic point of convergence, most
had become disconnected from their employer and organizational supports, and at the same time, most were
also disconnecting from their family, friends and social supports, if not in actual terms, then certainly to significant
degrees of emotional detachment. The inherent danger in this observation is that one might be easily inclined to
attribute their condition to on-the-job trauma and/or workplace dynamics, and miss the corresponding stressors
playing upon them from their interpersonal conflicts, economic challenges, and other stressors of everyday life.
Or, since in most of our cases and others we reviewed the most apparent precipitating events actually derived
from outside of work, it would be just as easy to ascribe their state of health to everyday life alone, and to discount
the roles played by their career-long experiences.
What makes this dilemma important in the context of policing is the interwoven nature of police identity
as described above. Many police members have described the difficulties they face in even recognizing the
distinction between work life and home life. The difference between on and off duty for a police officer is merely
a distinction of pay and equipment because in Ontario, once sworn, a police officer carries his or her authorities
and responsibilities 24 hours a day. Since they tend to see themselves serving and defined by a calling, and they

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 operate tightly within a team culture that is unique in society for its rights and its responsibilities, their identity
tends to travel with them. Many have described the way their children, spouses and significant others view them
as heroes. As such, disappointing one’s colleagues on the job may also be, in their own perception, to disappoint
those others outside of work and to fall short of that important identity for everyone.

An Enduring Commitment to Duty Despite the Personal Costs
Our final observation on the peculiarities of the policing context requires a disclaimer: neither a study of police
deployment options, nor a full appreciation of the economics of policing fell within our scope. We did recognize
that like all public services, police budgets must be managed and sometimes resources must be constrained.
Nonetheless, it appears to us as a panel that police resources in Ontario are strained to a breaking point in many
locations around the province. It follows that mental health impact can be expected to continue and perhaps even
grow in frequency and intensity if this situation is not somehow addressed.
These resource shortages may be real or perceived. They may be due to an inability or unwillingness to implement
new models and re-engineered practices as some might suggest. They may be due to an unwillingness of local,
provincial and federal governments to meet the real budget requirements as others would argue. They may be
due in part to a vicious circle where each new accommodation of a member with mental health issues further
aggravates already diminished staffing levels. But, while decision makers grapple with these arguments, police
members are burning out, many are becoming ill, and some are dying.
It is in their nature to keep coming to work. It is in their nature to deploy into harm’s way even when understaffed.
It is also in their nature to minimize and suppress their own symptoms until they can no longer do so.

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 Part Three: Seven Pathways to Better Outcomes
Earlier, we identified the three converging pathways that each of our nine subjects traveled to the ultimate point
of their tragic deaths by suicide. Throughout our deliberations, we also uncovered seven new pathways that we
believe will point the way to better outcomes for all police members in the future.
In Appendix A to this report, we list a number of specific recommendations, and where appropriate, we also
identify potential roles associated with each.
In this section of our report, we will first discuss these pathways as they emerged for us as clear themes for
action, as areas of opportunity, and as new ways of understanding and approaching the challenges outlined
above. These themes are cross cutting in nature, and many of our specific recommendations derived from several
of these pathways to change. They are discussed here in no particular order of priority. In the view of the panel
members, every one of them will play an important part in any comprehensive plan of action.

1.  Normalizing Mental Health Challenges
Removing stigma from mental health in general society is an important goal for everyone. In policing, it is a goal
that must be recognized and acted upon as an urgent priority. The goal must be to make mental health as normal
a subject as any other form of health, wellness and fitness for duty. To be effective, this normalization must begin
prior to recruitment, it must extend through basic training
at academies and remain evident in on-the-job orientation
training with well-prepared coach officers. It must continue
Panel Observations on Current
throughout policing careers, and it must extend to include the
Strengths & Weaknesses in the
families and significant others of police service members at
every stage.
Police Mental Health Ecosystem
Family members can play vital roles in the recognition,
management and support of mental health issues at every
stage of prevention and treatment, but only if they are
included in an open conversation from the outset and gain
continuing knowledge and awareness of what to look for and
how to respond.
Current attitudes about mental health issues among serving
police members at all levels represent a clear and present
danger. It matters not whether these attitudes have derived
from general society, or have been cultivated within police
ranks through their prolonged exposure to mental health
crises and the suicides of others to which they frequently
must respond. Policing as a system must transition to a point
that their own mental health risks, mild to moderate mental
health issues, and advanced mental health conditions are
recognized early and acted upon consistently with the support
of accessible care and suitable services. For this to occur,
mental health in policing must come out of the shadows.

Access to Appropriate Care and
Treatment
Privacy and Fear of Career Repercussion
Many care and benefit paths begin
with the human resources unit of the
member’s police service. Many members
fear reputational damage from disclosing
their mental health issues to fellow
employees and members of organizational
management.
For the panel, for police services and
police association officials, for health
professionals, and most notably for the
surviving families, it is an alarming and
unacceptable number.
cont. next page...

We believe much can be gained by linking mental wellness
Report of the Expert Panel on Police Officer Deaths by Suicide
11

 to peak performance, a concept that most police officers
recognize and value. This will require taking conversations
and training events well beyond ‘mental readiness’.
Such events must also include a greater awareness and
understanding of the secondary and tertiary prevention
and care models that are available. They must demonstrate
that even broken toys can be repaired, and that the path
to recovery will be fully supported without diminished
identity and without marginalization from the core mission
of policing.
We envision that a broad and multi-faceted campaign will
be necessary to bring about this transition. In many ways,
it is already underway as reflected in our own review and
others occurring in parallel, and in the promising initiatives
undertaken by Ontario police services and their varied
associations. But in our view, it must be scaled up and
amplified. Openness, awareness and supportive behaviours
toward fellow members experiencing mental health issues
should become essential competencies tied to performance
and promotion systems at every level, and other forms of
recognition should also be explored.
It has been said that police officers are prepared to die for
one another. They must also be prepared to live for one
another, and at the same time, to live fully for their families
and friends without suffering in silence.

2.  Navigating Through Transitions
When it comes to mental health issues in policing, the
devil seems to lurk in the transitions. Our studies revealed
consistently that some of the greatest risks for interruptions
in care, for denial and suppression of symptoms, and
for aggravated levels of stress tend to occur most during
pivotal transitions in an individual’s deployment status in
the workplace. Critical transitions may include: periods of
repeat short term absence necessitated by mild to moderate
symptoms, whether diagnosed or not; initial disclosure
and while applying for benefits and psychological services;
reassignment to modified roles due to conditions affecting
fitness for duty; reassignment back into full service; and,
periods of extended leave due to escalated conditions and/
or to access more intensive levels of care and treatment.
Of all of these transitions, return to work (RTW) stands out
as the point of greatest risk. The complex decision-making
processes about returning to modified duties or to full

Access to Walk-in Support
Access to Walk-in Support
Some agencies have introduced
independent staff and outside
psychologists and some have established
out-of-office locations for walk-in support
without risking disclosure. Relatively few
police services currently offer this option.
Limited Access in Small Urban, Rural and
Remote Settings
Smaller police agencies may lack the
resources to provide support-with-privacy
options for their members. As well,
smaller communities may have limited
clinical resources, requiring significant
travel and potentially more absences from
work for those seeking assistance.
Benefit Limits
Some member associations (OPPA and
Ottawa Police Association) recently
negotiated no-limit arrangements with
their benefits providers. In most Ontario
police services, there are restrictive limits
on the length of care provided under
existing benefits and insurance schemes,
and co-pay costs vary significantly.
WSIB claims face ongoing pressure to
reduce or restrict uptake, duration and
cost, and often require extensive efforts by
member and families to justify the need
for care, treatment and compensation for
absence from work. An additional barrier
is the requirement to be seen by only
WSIB approved treatment providers. The
WSIB payment scheme is generally paid at
a much lower rate than market.

Report of the Expert Panel on Police Officer Deaths by Suicide
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cont. next page...

 reinstatement can generate significant stress for individuals,
their families, their co-workers, their care providers, and
their benefits administrators including the WSIB. Among our
nine subjects, RTW factored heavily and frequently into their
worsened health conditions, triggered open conflict with their
organization and peers, initiated or aggravated performance
and professional standards issues, and often led to financial
stress.
Further aggravating these stressors is the current
fragmentation that individuals and families must navigate.
Certain services and supports may be available from the
employer, while others may be provided only through their
Police Association. Individuals may be directed to some
services by independent peer support workers, by benefits and
EFAP providers, and by clinical care providers. Some of these
same agencies may provide ‘system navigator’ supports. But,
experience has shown that rarely do such navigation supports
cross the full spectrum of clinical guidance, procedural
assistance, and educational programs to help the individuals
and families affected.
A full scope of navigation supports should be readily available
to all members in all police services, built upon consistent
best practices, yet remaining flexible to the needs of each
individual, family, and police service involved.

3.  Continuing Access to Quality Care with  
Evidence-based Treatment and Solutions
Based on our lived experience sources including the voices of
survivors, the confidence level among police members and
their families in the current patchwork of care providers is at
best moderate to low. We heard of service professionals with
little to no familiarity with policing or first responder issues,
including the role played by recurrent trauma. We heard
of others who initially established a strong connection with
their patient, only to later refuse to continue providing care
under established benefit fee schedules. And, we heard of
well-qualified and policing-knowledgeable professionals who
established strong bonds and achieved successful outcomes
with their patients.

Availability of Trauma and Policeinformed Clinicians
When seeking treatment, members face
limited availability of practitioners who
are familiar with the unique demands
of police work and the role of trauma
in mental health issues. No universally
reliable reference source currently exists,
though some are under development.
Inconsistency in Peer Support Models
Volunteer-driven police and first
responder peer support providers
have emerged in the past few years,
and many are seeing demand grow for
their services. Currently, peer support
practices and service offerings are viewed
to be inconsistent in scope, quality, and
integration with other MH services.
Balancing Affordability vs. Quality of
Treatment
When faced with benefit limits, or due to
fear of disclosure to their employer and
colleagues, members and their families
often struggle to access and sustain
affordable care paths, often forced to
choose between high quality care and
treatment for a very short duration, or
questionable care over a longer period of
access. Many simply withdraw from this
challenge and elect no continuing care.

Given the often fragile state of any police member who is
coming to terms with symptoms or with a mental health
diagnosis amid the cultural dynamics described earlier in this
report, any barrier to access can be a reason for them to revert
to suppression, denial and withdrawal from care. For some
of our nine subjects, the last years and months of their lives

Report of the Expert Panel on Police Officer Deaths by Suicide
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cont. next page...

 were clearly punctuated with stop-start patterns in their
care path. For others we heard from, their descriptions of
their own care paths ranged from successful, to frustrating,
to futile.

Availability of Supportive Care for Family
Members

It is imperative in our view that access to quality care
become universal among police members in Ontario,
and the quality of care options must extend to include
policing and trauma informed clinicians and the application
of evidence-based treatments and solutions. It is our
understanding that some of the volunteer agencies and
police associations in Ontario have begun to establish
referral lists of suitably qualified professionals and support
networks. This work should be accelerated and made
widely available as soon as possible.

Currently, family members are very often
excluded from the care path of their loved
ones dealing with mental health issues. It
appears that this is may be due to a lack
of information about options available,
lack of knowledge about mental health
in policing, real or perceived privacy
concerns, or it may be a symptom of the
member’s disconnecting behaviour.
System Navigators & Patient Advocates

4.  Resourcing, Accommodation and Burnout
For most municipal police services in Ontario, Police Service
Boards are responsible to maintain adequate staffing levels
to meet demand for service in their jurisdiction. For the
OPP and First Nations police services, this responsibility
rests with the provincial and federal governments. Most
police budget-setting processes establish an ‘authorized
strength’ of members. The authorized strength model
is built on the premise that all the police positions are
filled and all members are at work. The model does not
adequately take into account that staffing vacancies occur
when recruitment numbers fall short, and also when
members are away from the workplace on medical leave.
This gap translates to an additional workload for members
who are working. Through intensified workload demands in
regular deployment, and often through increased overtime
levels, essentially it falls to the members to subsidize the
shortfall in the authorized strength.
The repercussions of this model are that those left working
are forced to function in an environment where they are
short-staffed which may lead many to burnout. Some
may also develop a feeling of contempt toward members
that are on medical leave. And, all of this leads to further
erosion in the identity issues occurring for those absent
members.
Under the current model, staffing gaps contribute to an
ongoing systemic deterrent to disclosure of mental health
issues, create a significant barrier to those who need to
access and maintain proper care paths, and uphold a false
expectation of fit-for-duty capacity that perpetuates stigma
and self-stigma surrounding mental health and occupational

When police members find themselves in
crisis they are often required to navigate
unfamiliar and complex processes which
can be a barrier to care, while also having
a detrimental effect on the member’s wellbeing, especially for those already reticent
to disclose. Some members and families
may also incur financial strain by paying
for expenses which may be eligible for
coverage. A full scope of system navigator
supports will span clinical, educational,
and financial challenges.

Internal Attitudes, Behaviours,
Knowledge and Skills
Unwarranted Perceptions of Malingering
Despite recent investments in mental
health awareness and resilience training,
suspicions and even outright accusations
of malingering remain common in policing
culture. Evidence shows that incidents
of malingering are rare, and in most
cases, the requirement for care and
accommodation is very real.
cont. next page...

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14

 stress injuries. The reality of staffing gaps must be confronted.
Each individual police service will undoubtedly continue to
face fiscal pressures, and in the short term at least, most may
be unable to resolve their current staffing gaps on their own.
Attention should be given to acting collectively to establish a
province-wide system for exceeding authorized staffing that will
allow for sufficient resourcing to fill vacancies when members
are away from the workplace on medical leave.

5.  Preserving Identity: The Criticality of Criminal or
Police Act Charges and Social Media
The RTW transitions described above represent the most
frequent high-risk points for police members with mental health
issues, but situations where officers face charges and/or public
embarrassment through mainstream or social media could
be described as the most acute. In our review of deaths by
suicide, if not managed with care these ‘hand-off’ situations can
clearly rise to the level of a precipitating event with an impact
equivalent to the loss of a primary personal relationship.
Recognizing the significant role that police identity has for
members deeply invested in policing culture, police services
have a special responsibility to ensure that any sudden
and extreme damage to that identity is managed with care
and support. We reviewed situations and practices where
special hand-off arrangements are in place and applied to
ease the negative consequences. Among our nine, we also
reviewed some situations that, whether intended or not by the
service, were experienced by the subject member as outright
abandonment. We reviewed others that fell somewhere in
between.
Every police service must take on the responsibility to establish
and apply hand-off procedures that will ensure that no matter
the severity of a member’s infraction or breach of duty, or
whether the scope of any disciplinary action contemplated is
seen as a minor set-back or a career-ending criminal charge,
supports will be in place to maintain a connection to the
member and his or her family, and to ensure a continuity of
professional care as may be required.

6.  Managing Suicide Events

Limited Knowledge among Supervisors
& Managers about Treatment and
Recovery
Anecdotally, many police managers,
supervisors and peers continue to regard
mental health conditions as a permanent
disability. Awareness of the true nature
and success rates of treatment and
recovery would greatly improve returnto-work transitions for members who
have experienced a mental health issue,
thereby aiding in stigma reduction
Limited Creativity and Sensitivity in
Assigning Accommodated Duties
The binary ‘fit for duty, or not’ attitude
described elsewhere in this report
continues to influence decisions on
modified duty. Members report the
negative impact on their dignity from
reflex assumptions about the limits of
their ability to perform and to remain
tied to the core mission with which they
identify strongly.
Unclear Guidelines on Privacy and
Connection During Accommodation
Supervisors, managers and peers report
being uncertain of if or how they might
maintain a connection to their colleagues
who are absent from work due to mental
health issues. This is further aggravated
if professional standards issues are also
involved. Greater clarity, established
guidelines around consent, and the
development of compassionate, traumainformed skills would be of significant
benefit in this regard.

We cannot manage, improve or learn from things we do not
know about. As important steps towards improving outcomes

Report of the Expert Panel on Police Officer Deaths by Suicide
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cont. next page...

 for all police members in Ontario, all coroners should be
directed to record and report on any death by suicide of a
first responder, a database should be established to permit
ongoing data capture and analysis, and any death by suicide
of a police member should trigger a death review in the
Office of the Chief Coroner. In our view the unique nature
within, and the place of policing in society, requires that we
closely track and learn from every situation that results in
a death by suicide, with a view to continuous improvement
across the entire police and mental health ecosystem.

Balancing Workload Pressures vs.
Compassionate Support
When entire police organizations
are under strain due to limited
deployable resources, the pressure
to return members to full active duty
often overrides compassion for the
individual, and reduces active support
for their continuing accommodation
and care.

Much of the foregoing discussion has centred on
opportunities in the prevention and intervention stages
of mental health. Postvention is also recognized as a best
practice in suicide prevention, and there are two aspects
to it that warrant priority attention and action from our
review. One of these involves extending caring support to
the bereaved, including direct actions to prevent collateral
mental health conditions among family members, close
friends and associates, and the other addresses the need to minimize the risks of a contagion effect across the
policing community.
In the first, we note that among the survivors of our nine, some degree of bereavement support from their loved
one’s employer, association, and colleagues was evident in most cases, but it can best be described as uneven
in its execution, its scope and its duration. When properly planned and constructed, postvention practices are
designed to achieve a number of aims in the aftermath of a death by suicide, specifically to:
• 
• 
• 
• 

prevent suicide among people who are at high risk after exposure to suicide;
facilitate the healing of individuals from the grief and distress of suicide loss;
mitigate other negative effects of exposure to suicide; and,
in a policing context, some means to respectfully memorialize the deceased.

All police services should have a prepared organizational response plan for postvention services designed to assist
the bereaved in managing the immediate crisis of a death by suicide and coping with its long-term consequences.
With regard to the broader community, there exists in the literature some evidence of a risk for contagion effects.
In other words, particularly among others in the same population group who may already be experiencing mental
health challenges, one or more suicides in that same group may have a triggering effect. Clusters of deaths, as
seen in our nine cases in a single year, certainly heighten concerns in this regard. It is important to note that the
contagion need not necessarily amount to additional suicides for us to be concerned. The potential to exacerbate
the mental health issues of any police member or group of members is also worthy of our concern.
Postvention is a critical part of suicide prevention, and can also be part of a comprehensive strategy for mental
wellness in general. Ensuring that postvention activities take place after any police member suicide should not
be the responsibility of one group, one police service or one individual. This will require a whole-of-community
commitment.

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 7.  Joint Ownership and Collaborative Action
Our police and mental health ecosystem model shown earlier in Figure 3 illustrates both the scope of resources
and capacities that currently exist to lend support to positive outcomes in police member mental health, as well
as the complexity and potential for fragmentation that currently exists across this system (see Sidebar above).
We also noted earlier the range of promising initiatives and policy considerations that are underway to bring
improvement to the level and quality of services at every stage of prevention, intervention and postvention.
Our deliberations led us to some concern that if left unchanged, continued fragmentation may undermine much
of this promise.
Policing as a system must adopt a no-wrong-door mindset in order to ensure that every member and family
affected by mental health issues, at their earliest presentation, faces no barriers in seeking out, accessing, and
affording the care and treatment they require. To fully achieve this, policing must act as the unified system that
it is in the eyes of its members.
We recognize recent collaborative undertakings among the OPP, its associations and its not-for-profit partners as
one promising model, but little will change if that same approach is not replicated across the remaining police
services that serve Ontario communities. Similarly, we were encouraged by collaborative discussions described
by the OACP and PAO, and by TPA with its employer partner the Toronto Police Service. We also recognize that
member mental health has become a priority agenda item for the Ontario Association of Police Service Boards
(OAPSB), as it has nationally with the CACP, the Canadian Association for Police Governance (CAPG) and the
Canadian Police Association (CPA). But, in our view there is a growing risk of lost effectiveness and efficiency
from an emerging patchwork of bilateral and multilateral initiatives taking shape, without the full involvement of
all parts of the ecosystem moving in common directions.
In Ontario, we believe the Ministry of the Solicitor General, guided by this report to the Ontario Chief Coroner,
is best positioned to provide the essential leadership and mobilization to achieve a whole-of-system approach.
We address this opportunity as the first of our recommendations for action in our Appendix A.

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 Part 4: A Much Broader Legacy
Taken collectively, these seven pathways encompass a range of opportunities for a whole-of-system solution to
a very real problem in policing that extends well beyond and well ahead of any specific occurrences of death by
suicide.
We hope that police and association executives, boards, and mental health service providers will embrace these
opportunities and work together on the specific actions we propose below. We believe a new policing culture
can emerge where the full cycle of prevention, recognition, appropriate disclosure, care and treatment, recovery
and reintegration can occur with greater openness, greater success, and without repercussion to anyone facing
mental health challenges whether due to operational or organizational stressors, or from any other cause inside or
outside of work.
And, we hope that every police member, sworn and civilian, will bring the same courage that they bring every day
in service of others, to embrace and thrive in this new and more open culture. We hope that current and future
members will remain visible so that others can assist them, and will remain fully connected to their families and
friends as well as to the calling they have chosen. We know it is a calling they value, for life.
Finally, we hope the foregoing discussion and the 14 specific recommendations that follow below will inspire the
comprehensive and collaborative action on police member mental health that is urgently required in Ontario.

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18

 Part Five: Our Recommendations for Action

1.  The Policing Services Division of the Ministry of the Solicitor General (PSD-MSG) will lead the development
of an Ontario Police Members Mental Health Collaborative (OPMMHC) as a standing body accountable to
the Deputy Solicitor General, to meet quarterly on a continuing basis and to operate under the following
initial terms of reference:
a)  OPMMHC will be comprised of qualified volunteer representatives from police service boards, police
service executive management, police associations, police supervisors (sworn and civilian), police
members with lived experience, police family members with lived experience, police psychologists and
other mental health providers with expertise in policing, researchers, peer support groups, and insurance
and benefits providers;
b) OPMMHC will be co-chaired by one representative of police executive management and one police
association executive;
c) OPMMHC will serve in a steering and coordinating role to identify and act to resolve gaps, overlaps and
service deficiencies in order to improve the effectiveness, efficiency and universal accessibility of mental
health supports to police service members across the province;
d) OPMMHC will establish and disseminate appropriate benchmarking tools and metrics, establish
implementation timelines, report semi-annually on progress of recommendations in this report and from
other sources, and execute other initiatives as OPMMHC members may determine;
e) OPMMHC will develop an agenda of priority research topics for policing in Ontario, including
encouraging the development of a police specific interpretation of the CF-modified Mann model
for suicide prevention depicted in Figure 1 of this report, incorporating any additional factors and
interconnections addressed within this report.
f) MSG will provide administrative support and base funding sufficient to sustain the meetings of the
OPMMHC;
g)  OPMMHC projects will be otherwise staffed and resourced through in-kind contributions from the
participating members;
h) and, other terms of reference as PSD-MSG and the participating OPMMHC stakeholders may determine.
2.  The OPMMHC, once established, will lead the development of a Communications Sub-committee
(OPMMHC-Comms) dedicated to the design and ongoing execution of a broad campaign aimed at
normalizing mental health challenges, reducing stigmatizing behaviours and assumptions, achieving
healthier identity and work life balance, and building awareness of supports, treatments and recovery
outcomes in all police services, police academies, and police-related program units in Ontario Community
Colleges and Universities;
a)  OPMMHC-Comms will be staffed on an in-kind, part-time basis by Ontario police services, and
supported by PSD-MSG with additional funding on a project-by-project basis, as required;

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 b) The normalization campaign will be available for province-wide roll out by December 31, 2020.
3.  The OPMMHC, once established, will lead the development of a Knowledge Translation Sub-committee
(OPMMHC-Education) dedicated to accessing, interpreting, adapting and disseminating best practice
education and training resources for mental health and suicide prevention to all identified end-users
(including police members, leadership, families, peer supporters, clinicians and the general public) from
available sources, including universities, governmental and non-governmental organizations such as the
Canadian Institute for Public Safety Research and Treatment, the Canadian Institute for Military and Veteran
Health Research, the Public Health Agency of Canada’s PTSD Secretariat, Veterans Affairs Canada, the
Department of National Defence, and other police professional organizations and stakeholder groups;
a)  The Knowledge Translation Sub-committee will be well developed and materials will be rolling out
province-wide by December 31, 2020. There will also be provisions for measuring application and retention
of new knowledge by the end-users, continuous improvement, and updating of materials as needed.
4.  OPMMHC will work with Ontario police services, peer support agencies, insurers and clinical providers to
establish clear guidelines for the qualifications and standards necessary to provide clinical care and peer
support services to police members.
5.  OPMMHC will produce by January 1, 2021 a single, consolidated and living referral source outlining the
availability of suitably qualified care providers and treatment options in all regions of the province.
6.  OPMMHC will work with all partners to advance a no-wrong-door policy across the province, with a view to
reducing administrative and funding barriers to members in need of immediate access and care.
7.  PSD-MSG will direct all police services in Ontario to develop and implement a comprehensive mental health
(MH) and wellness strategy by June 30, 2021;
a)  Comprehensive MH strategies will include local normalization initiatives; provisions for ensuring access
for their members to suitable evidence based and qualified prevention, self-care, intervention, and
postvention supports;
b) Comprehensive MH strategies will also include training and education initiatives, as informed by
OPPMHC-Education, designed to meet the needs of recruits, members, coach officers, supervisors,
managers, human resources specialists, peer support providers, mental health professionals, and families;
c)  Comprehensive MH strategy elements may be provided directly by a police service, through partnerships
with other police services, and/or in partnership with third party providers, as required;
d) Comprehensive MH strategies will provide for engagement of family members in learning and discussion
sessions and other activities related to police member mental well-being during the recruitment process, at
critical transition points (as defined in this report), and periodically throughout policing careers;
e) Comprehensive MH strategies will include the establishment of specific competencies and performance
expectations, related to maintaining and supporting mental wellness and/or responding to mental health
issues, for all members in general, and specifically for supervising members, and will be incorporated into
promotion, performance management, and recognition systems by December 31, 2021.

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 8.  OPMMHC will assist and guide police services in establishing web-based Members and Families Mental Health
Portals, service-specific for larger services and/or general access for all services, to make available information
and resources to support open and informed conversations about mental health and well-being. Portals will
be established and accessible to all services by June 30, 2021.
9.  OPMMHC will guide the development of best practice guidelines for managing all mental health related
accommodations and return-to-work (A-RTW) decision processes by December 31, 2021;
a)  A-RTW processes will include collaboration among management, human resource specialists, members,
families, associations, insurers and third party clinical advisors, with clear roles and responsibilities
established for each;
b) A-RTW processes will include specific guidelines for maintaining supportive connections with
accommodated members and those who are absent from work, and with their families when permitted.
10.  OPMMHC will guide the development of best practice guidelines for managing all high-risk ‘hand-off’ support
processes by December 31, 2021;
a)  Hand-off processes will apply to any situation involving or with the potential to involve Police Service Act
charges, criminal charges, removal of use-of-force options, or member identification and negative attention
from mainstream or social media;
b) Hand-off processes will include specific guidelines for maintaining supportive connections with
accommodated members who are absent from work, and with their families when permitted.
11.  PSD-MSG will encourage more police services in Ontario to hire mental health professionals to the extent
affordable on their own, or in partnership with neighbouring police services.
12.  The Ontario Association of Chiefs of Police (OACP) will be encouraged by this report to establish a provincial
parallel to the CACP’s Psychologist Sub-committee to facilitate greater cooperation, capacity, and the
development of Ontario-specific best practices.
13.  PSD-MSG will encourage more police services in Ontario to adopt, if they have not already, police mental
health partnerships along the lines of COAST, PACT and similar models across Canada, and Project ECHO in
the USA, in order to improve relationships and interactions between police and persons with mental health
issues in the community, and to further normalize member awareness and knowledge about mental health
prevention, treatment and recovery.
14.  The Office of the Chief Coroner (OCC), in partnership with others as required, will seek to establish policy in
Ontario that requires all coroners to report and share information on any death by suicide of a first responder,
including police, and to initiate a death review committee in all such cases;
a)  The OCC will lead the development of a suitable system for capturing data from all such deaths by suicide
and resulting death reviews;
b) The OCC will lead the design and development of analytic tools, through consultation with OPMMHC and
others, to learn from cumulative deaths by suicide with a view to identifying opportunities for continuous
improvement in the first responder mental health ecosystem.

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 Appendix: Members of the Chief Coroner’s Expert Panel

Dr. Lori Gray
Dr. Gray is a clinical, forensic, and rehabilitation psychologist whose focus has been best practices and
progressive approaches in early intervention and comprehensive care through her work with multiple
emergency services and peer support programs. She is currently based out of private practice in Barrie, ON and
works with first responders and emergency services across Ontario. Her background includes diverse experience
as the psychologist for one of the largest paramedic services in Canada, Centre for Addiction and Mental Health,
Detroit Receiving Hospital, Ministry of the Attorney General, Correctional Service of Canada, and postsecondary
teaching.
Dr. Gray has received the Future Pioneers of Psychology Award from the American Psychological Association,
Early Career Achievement Award from the Canadian Psychological Association Traumatic Stress Section, Odyssey
Early Career Achievement Award and GLAD Award for Teaching and Mentorship from the University of Windsor,
among other awards from agencies including the International Society for Traumatic Stress Studies, Canadian
Psychological Association, and Social Sciences and Humanities Research Council of Canada.

Dr. Simon Hatcher
Dr. Hatcher is a psychiatrist and researcher at The Ottawa Hospital Research Institute. He trained in psychiatry
in the UK before working in New Zealand for twenty years and moved to Canada in 2012. He has been the
principal investigator on several large randomized controlled trials of treatments for suicidal people. Clinically,
he runs a First Responder Clinic at The Ottawa Hospital and has received research funding to investigate the
preferences of First Responders for mental health care and to test different ways of screening for mental
disorders in first responders.
Dr. Hatcher is a member of the Canadian Institute for Public Safety Research and Treatment (CIPSRT).

Lieutenant Colonel (Ret) Alexandra Heber
Dr. Heber is the first Chief Psychiatrist of Veterans Affairs Canada (VAC), and an Assistant Professor of Psychiatry
at the University of Ottawa. She was the VAC lead author on the CAF- VAC Joint Suicide Prevention Strategy. She
has over 30 years’ experience working in Mental Health. Dr. Heber served in the Canadian Armed Forces (CAF)
and was deployed to Afghanistan as Psychiatrist in Charge of the CAF Mental Health Services for Task Force
Afghanistan. Her military experience included a decade as Clinical Leader of Military Mental Health in Ottawa,
then the establishment of the Section of Clinical Programs for CAF Headquarters, where she oversaw 30 CAF
mental health clinics across Canada.
She has presented and published nationally and internationally on Post Traumatic Stress Disorder and suicide
prevention in military, veteran, and first-responder populations. Her research interests include: suicide
prevention, the military-civilian transition experience, and the role of peer support in military and paramilitary

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 organizations. She has authored 2 online courses on PTSD and trauma-informed care, one for Canadian physicians
and one for the Newfoundland and Labrador Health Authorities, and she has authored a number of reports for
the Justice Department, Government of Canada, on cases involving torture and PTSD.
Dr. Heber works on developing strong collaborative relationships among government, academics, research
institutes, clinicians, military and public safety organizations, families and those with lived experience. She has
received the Veterans Affairs Canada Leadership Award, the Canadian Armed Forces Chief of Defence Staff
Commendation, the Queen Elizabeth II Diamond Jubilee Medal and the General Service Medal, South-West Asia.

Dr. Stephanie Barone McKenny
Dr. McKenny is a police psychologist with the Los Angeles Police Department (LAPD) and provides consultation to
several elite units including SWAT, Air Support Division, Criminal Gang Homicide Division, and undercover agents.
She has worked with law enforcement personnel at the international, national, state, county, local, and university
levels. Dr. McKenny is also a nationally certified sports psychologist and clinical trauma professional who applies
peak performance skills in designing and implementing officer wellness programs, including the Mother of All
Suicide Prevention Campaigns (which led to 25 months of 0 suicides at LAPD), the Resilience Task Force, the
Substance Abuse Task Force, the Smart Detective, the annual Heart of LAPD Walk, and the pending Tactical Relief
Checks.
As the spouse of a Navy Captain and the sister of a Lt. Colonel, Dr. McKenny understands at a very personal level
the demands and sacrifices that police members make every day, and also the demands and daily sacrifice of their
spouses, children, and extended family.

Serving Police Member
This panel member is a currently active police sergeant who has served as a police officer in Ontario for over
30 years. His career includes over 25 years of front-line uniform policing assignments as well as six years of
administrative and corporate experience.
While often described by others as a “high performer” and “go-to guy”, this member also describes himself as
“someone who has suffered in silence for over 15 years while enduring the profession’s unrelenting exposure to
critical incidents and traumas”. He is committed to leveraging his lived experience to create a legacy of preventing
police suicides by improving police culture, eliminating stigma, and promoting mental wellness and resilience.
His fellow panel members are thankful for the courage and insight this member brought to our deliberations. His
name is withheld here solely out of respect for his and his family’s privacy.

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 Angela Slobodian
Ms. Slobodian is the Acting Director of Wellness at the Ottawa Police Service (OPS). As a registered nurse she
has worked in hospitals and in public health. In 1994 she moved from her native Nova Scotia to Belleville,
Ontario to begin work as an Occupational Health Nurse at a global telecommunications company, and this
began her interest and passion in occupational health. She completed her diploma in Occupational Health
Nursing and received her certification in 2002. She left the private sector company in 2009 as Director of
North American Health Operations, moving to the Ottawa Police Service as Manager of Health, Safety and
Lifestyles. As a nurse she has always had a commitment to health promotion and illness prevention.
The opportunity came to lead the development of a Wellness program at Ottawa Police, and Ms. Slobodian
was pleased to take the lead. She currently has responsibility for the Health and Safety team and for the Peer
Support and Resiliency program and OPS.

Clive Weighill, C.O.M.
Chief Weighill (retired) is a veteran of policing in Saskatchewan. He served as the Chief of Police for the
Saskatoon Police Service from 2006 to 2017 following his 31 years of service with the Regina Police Service,
leaving that service at the rank of Deputy Chief. In September 2018, Mr. Weighill became the Chief Coroner
for the Saskatchewan Coroners Service.
During his policing career Mr. Weighill worked in Patrol, Communications, Crime Prevention, Commercial
Crime, Property Crime, Drugs, Vice, Planning and Research and Senior Administration. He also served as the
President of the Canadian Association of Chiefs of Police (CACP) from 2014 to 2016. He is the recipient of
the Police Exemplary Service Medal and Bar, the Saskatchewan Protective Services Medal, the Saskatchewan
Centennial Medal, the Queen’s Diamond Jubilee Medal, the Lieutenant Governor’s Gold Medal for Excellence
in Public Administration in Saskatchewan, and he is a Commander of the Order of Merit of the Police Forces.

Norman E. Taylor - Panel Moderator and Lead Writer
Mr. Taylor has served Canada’s policing community for over 25 years in his combined roles as an independent
policy advisor, educator, researcher and author. Since 2014, he has organized and executed three national
conferences on policing and mental health issues in partnership with the Canadian Association of Chiefs
of Police (CACP) and the Mental Health Commission of Canada. In his capacity as co-founder and Program
Director of the CACP Executive Global Studies Program, he has led global research studies on policing
interfaces with the mental health system, and on some of the unique patterns and behaviours that shape
the internal culture of policing. Mr. Taylor also provides strategic advisory and educational services to many
police services, communities, and at all government levels across Canada and in the USA.
Mr. Taylor is a recipient of the Queen Elizabeth Diamond Jubilee Medal on nomination by the CACP, the
Premier of Saskatchewan’s Award for Excellence in Public Service: Innovation, and in 2018 he was proud to be
named an Honourary Commissioned Officer in the Ontario Provincial Police.

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