RCMP response to the mass casualty homicides that occurred in September 2022

Review team

After being tasked to lead this review, the first step was to establish a team of Subject Matter Advisors to assist. Major Case Management principles were utilized throughout the review process; however, the first step was to create a Review Team Command Triangle (CT). An early CT decision was made to draw on investigative resources from outside of F Division and additionally, to reach out to municipal partners for assistance. Team members were selected nationally, based on their expertise relating to the identified objectives. The entire Review Team included the following:

Line Officer (LO)

Chief Superintendent Kevin Kunetzki, K Division Criminal Operations

Team Commander (TC)

Staff Sergeant Ryan Breitkreuz, K Division Office of Investigative Standards and Practices

Primary Investigator (PI)

Sergeant Jeff Mulroy, K Division Office of Investigative Standards and Practices

File Coordinator (FC)

Sergeant Candace Robinson, K Division Office of Investigative Standards and Practices

Investigative advisors:

• Sergeant Kevin Misiwich, K Division Office of Investigative Standards and Practices
• Superintendent Gord Corbett, K Division
• Superintendent Scott McMurchy, D Division
• Inspector Shawn Pike, Winnipeg Police Service
• Inspector Chris Boucher, National Headquarters
• Staff Sergeant Chris Johnson, D Division
• Staff Sergeant Dean Grunow, K Division
• Staff Sergeant Bryce Long, K Division
• Staff Sergeant Cory Francis, Winnipeg Police Service
• Staff Sergeant Clint Grabowski, Calgary Police Service
• Staff Sergeant Bill Krull, Edmonton Police Service
• Sergeant Carolyn Arsenault, D Division
• Sergeant Chris Massart, D Division
• Sergeant Pat Frey, K Division
• Sergeant Katherine Severson, Calgary Police Service
• Sergeant Amberia Sovdi, E Division
• Sergeant Jackson Bernard, National Headquarters
• Sergeant Aaron Ewert, K Division
• Constable Vernon Hagen, K Division
• Rob Cyrenne, D Division
• Fraser Logan, K Division
• Steve Cox, K Division
• Heather Russell, F Division
• MCM Support: Michelle Hounsell, F Division

Independent observer

An Independent Observer was incorporated into the review to act as a liaison to the JSCN community and provide cultural guidance to the Review Team. Jason Stonechild, the Independent Observer, is the Executive Director of Justice of the Federation of Sovereign Indigenous Nations (FSIN) and retired Deputy Police Chief of the Prince Albert Police Service. He was integral in establishing connections to the JSCN community members and ensuring any communication was culturally appropriate and sensitive to their needs, at that time. Mr. Stonechild was invited to participate in all briefings and was provided access to all information available to the Review Team.

Comments from the independent observer

Following the tragic event that occurred on September 4 2022 within the First Nation communities of James Smith, Chakastaypasin and Peter Chapman, and the community of Weldon, Saskatchewan; Assistant Commissioner Rhonda Blackmore directed a thorough and comprehensive review of the RCMP's response to this event. The intention of this review was to ensure transparency and accountability in support of the RCMP's effort to maintain public trust.

I must start by addressing the people of the Three-Nations of James Smith; I have observed incredible strength from your people, First Nations are resilient because we have become accustomed to trauma. Our Nations are in crisis and our people need justice system actors that we trust and who are compassionate to the historic and continued traumas endured by First Nations.

This role of an independent civilian observer in relation to this review is a unique practice; such reviews, particularly reviews that are connected to significant events like the James Smith tragedy; could unveil many success stories along with potential mistakes. These reviews are done by teams that are external to the group being reviewed and typically consist of police professionals only. The addition of a civilian oversight that represents all First Nations within the Province of Saskatchewan was a true representation of the Saskatchewan RCMP's commitment to reconciliation through inclusion and transparency. I commend Assistant Commissioner Blackmore for her leadership and authentic interest to work with First Nations to address many justice issues that affect our people.

As such, I have the following opinions based on this review:

1. The team developed for this review is professional, highly competent, impartial, and were aligned to achieve the best outcome.
2. The review included external stakeholder consultation that was appropriate and represented the interests of the communities.
3. Community concerns regarding the RCMP's response were explored and included within the team's findings.
4. I am confident that the RCMP, under the leadership of Assistant Commissioner Blackmore, has a sincere interest in First Nation wellness issues.
5. I believe the findings contained within this report are accurate and meaningful.

I would like to acknowledge the professionalism and competence of the team, in particular Chief Superintendent Kevin Kunetzki, Inspector Ryan Breitkreuz, Sergeant Jeff Mulroy, and Sergeant Candace Robinson. Their expertise and dedication drove this review in a compassionate and meaningful manner, I thank each of you for the respectful treatment and inclusion I experienced throughout this journey.

I take great pride as a servant to our people and to our First Nations leadership. The Federation of Sovereign Indigenous Nations is a strong organization that protects the Inherent and Treaty Rights of First Nations, we do so through collaborative relationships, advocacy and supporting our Nations people. I acknowledge Chief Bobby Cameron and Vice Chief Edward Lerat (Justice Portfolio Executive), in addition to our Executive Chiefs at the FSIN as they have fully supported our efforts regarding this review and efforts in support of James Smith, Chakastaypasin, and Peter Chapman. Without the Chiefs support my role as a civilian oversight would not have been an option.

I am honoured with the privilege of being part of this review, I truly hope that its findings will assist community safety wellness for First Nations and non-Indigenous communities moving forward and will assist the RCMP as they strive to maintain the trust of the people they serve.

Ekosi, that is all;
Kinanâskomitin, Thank you,

Purpose of review

Perhaps the clearest way to define what this review encompasses, is to discuss not only what it is, but also what it is not. The purpose of this review is not to conduct a forensic audit of the investigation but rather to describe the review findings related to the RCMP response to the JSCN/Weldon event, outline what was effective, what improvements can be made, and to provide realistic and meaningful recommendations with supporting rationales.

This is an internal review with specific objectives, and it differs from more publicized review processes (below) that have already been declared, or may be in the future.

Review objectives and methodology

The Review Team travelled to Saskatchewan during the week of October 17 to 21, 2022, in order to conduct interviews with those key participants in the RCMP response. During the course of the week, over 60 members of the RCMP, including those in senior leadership roles, members in specialized units, members that were first on scene, media relations, and telecoms operators, were spoken to and provided valuable feedback as to their role in the event. Although participation was not mandatory, all that were asked to provide input cooperated fully.

During these interactions, the goal was to establish a clear understanding of what occurred, acknowledge instances where improvements can be made, and collaboratively develop achievable recommendations.

Prior to commencement of this review, the original intent was to document findings within each objective, separately. As the review progressed; however, it became readily apparent that very little of what took place occurred in isolation, making the task of detailing each objective independent of the others, impracticable. The Review Team was led by the information that they were receiving and soon after commencement discovered, due to the dynamic and evolving nature of the overall event, multiple instances of overlap and cross-referencing of information amongst the various sections. As such, reporting the findings as laid out below became the manner in which to best document the assigned objectives.

The report methodology included a review of the information obtained from review interviews, including any subsequent follow up. Further, information and reporting on the overall event was documented on the Police Reporting and Occurrence System (PROS) by the involved RCMP members. The Review Team was granted access to the PROS file as part of this review which allowed for reference of relevant documents or information in order to provide further context, when required. It is important to note the review was not exhaustive, nor all-inclusive; however, it was conducted in such a manner that strategically focussed findings and useful recommendations were derived.

The following areas were recognized as the more significant components of the Divisional and National response and will be expanded upon throughout this document:

• Initial Response
• Command Structure
• Major Crime Branch response
• Air Services
• Strategic Communications
• Operational Communications
• Mass Casualty/Victim Response
• Pre-Event Intelligence

Past events

Reviews of this nature are not uncommon. The unfortunate reality is that they evolve from tragic events that have far reaching implications. Although an evaluation regarding the RCMP response to these events is inevitable, they also reveal perhaps the more important question as to whether the RCMP has learned from the past and have evolved as a result of recommendations from past events.

Previous mass casualty reviews on a National level, such as the MacNeil Report that documented the June 4, 2014 killings of three RCMP members in Moncton, New Brunswick, were considered and recommendations that relate to this event, will be highlighted in red throughout.

A Public Inquiry led by the Mass Casualty Commission (the Commission) into the more recent mass casualty event that occurred in Portapique, Nova Scotia in 2020, resulting in twenty-two people being murdered, concluded in late 2022. The Commission's finalized recommendations were released on March 31, 2023. Due to the timing of the issuance of this report coupled with the sheer volume of the Commission's final report, the relevant recommendations from that document are not correlated in detail, throughout this review. That being said, the accessibility of 'Foundational Documents' that were available for review allowed for a certain amount of insight into the Commission's findings.

Community perspective

At the recommendation of the Independent Observer, the engagement of the residents of both the JSCN and Weldon was sought, along with any feedback and dialogue related to their observations of the RCMP response to the events that affected their respective communities so deeply. This community involvement in the process became critical in understanding the nexus between the RCMP and the communities, and how to best foster a spirit of community policing going forward.

To do this, interviews with the JSCN community members were arranged in direct consultation with the Independent Observer and in collaboration with representatives from the JSCN Band Counsel and local Elder(s). These meetings were conducted in Edmonton on November 23 to 25, 2022. Steps were taken to minimize the potential of re-traumatizing anyone from the community. Similarly, on January 10, 2023, members of the Review Team travelled to Weldon to conduct interviews with a cross section of community members.

These interviews served as opportunities for residents from both communities to voice any concerns or observations directly related to the RCMP response to their respective communities. There was an overall appreciation for the response made by the RCMP; however, there were areas of growth that were identified.

With respect to the JSCN specifically, early on in the review process it was learned that the community itself is made up of three bands: Peter Chapman (Chief Robert Head), Chakastaypasin (Chief Calvin Sanderson), and James Smith (Chief Wally Burns). For the purposes of this report, James Smith Cree Nation (JSCN) will be used to reference the location of the events that took place on September 4; however, it is recognized that the victims from that day were comprised of members from all three Bands.

Event summary

During the early morning hours of September 4, 2022, Melfort RCMP began receiving reports of multiple stabbing incidents in the Northern Saskatchewan community of JSCN, and later, in Weldon. Soon after the initial call, there was a realization the situation was evolving into a major event where the RCMP was confronted with the managing a mass casualty incident. A province-wide search for a suspect would last three days and culminate in an eventual arrest of the suspect, approximately 140 kilometers southwest of JSCN. In the aftermath, eleven victims would be murdered and an additional seventeen injured, resulting in one of the worst mass murders in Canadian history.

Instantaneous to the end of the mass casualty event, the process of reviewing the RCMP response to the JSCN/Weldon event was actioned by the Commanding Officer, Assistant Commissioner, Rhonda Blackmore. This report is the result of initiating that process.

RCMP overall response

The RCMP response to this mass casualty event required measures be taken in the midst of a complex situation. Upon recognition of the magnitude of what was unfolding, an initial public alert was issued, to notify the public of the situation and recommend to seek shelter. Thirteen additional public alerts would be issued over the course of the event.

Throughout the days that followed, over 500 RCMP members across all business lines responded. Municipal and provincial partners were called upon to further supplement efforts to engage various response functions such as support for the victims' families, to assist with apprehension efforts, to process over 40 crime scenes that generated over 700 exhibits, and to complete a criminal investigation.

Culturally appropriate members of RCMP Indigenous Policing were summoned both from within F Division and externally and assigned to key areas, allowing for constant communication between key stakeholders and the RCMP and to further provide crucial insight into culturally appropriate conduct for responding members.

Given the circumstances, multiple levels of RCMP Command were activated; different levels of Government were engaged; the Federation of Sovereign Indigenous Nations (FSIN) were involved; and National interests were prevalent.

Broad findings

On a broad level, the Review Team did not identify any common underlying circumstance that significantly impeded the RCMP's ability to manage the response to the JSCN/Weldon event. At the same time, certain areas for growth were identified with the underlying purpose of enhancing responses to future, similar situations.

Throughout the document, any suggested recommendations to any of these or other identified areas will be highlighted and italicized as they are raised. An all-encompassing list of recommendations can be found at the end of the document.

In addition to any organizational gaps that were noted within the review, there were areas of effectiveness that were discussed and will be highlighted as effective practices for future responses.

Conclusion

The RCMP are becoming increasingly challenged to manage complex critical events. In Saskatchewan alone, over the past several years, the RCMP have responded to a number of tragic events. The La Loche school shootings in 2016 resulted in four people being killed and seven others injured. The Humboldt Broncos bus crash of 2018 ended with sixteen people perishing and thirteen others injured. Although the circumstances of these events were unique, the fact of the matter is that they each elicited a coordinated and extensive police response. Given the frequency with which these critical events are occurring, it becomes a necessary step to use every available opportunity to identify effective practices and lessons learned in order to enhance our ability to respond.

In the wake of the JSCN/Weldon event, a review of how the event unfolded and the processes that were utilized by the RCMP can provide the opportunity to highlight strengths, expose shortcomings, and identify challenges. When conducted in a methodical and thoughtful manner, reviews of this nature can result in meaningful changes to police responses to mass casualty events and other major events alike. The hope is that the findings of this review will provoke both regional and national level discussions regarding policies and tactics during these events.

Next steps

This report is provided to the Commanding Officer of F Division for review and will be disseminated as required. While the many recommendations provided are specific to F Division policies and procedures, a goal of this review was also to ensure that the findings and lessons learned are considered by the RCMP nationally. Some recommendations contained in this report can be implemented more easily, while others will take more time and collaboration.

September 1

Myles Sanderson (the suspect) arrived on the JSCN on September 1 with [REDACTED]. During this time, they were staying with Damien Sanderson (Damien) and [REDACTED].

September 2

During the afternoon of September 2 the suspect got into a physical altercation [REDACTED], assaulted her, and attempted to drive over her, outside of Damien [REDACTED] residence. This caused [REDACTED] and return home, to Saskatoon. This incident was not reported to police until after the homicides took place. The suspect remained on JSCN in the company of his brother Damien and, later that evening, the two took [REDACTED] vehicle and drove around JSCN selling cocaine.

September 3

At some point (around midnight on September 2) the suspect and Damien went to [REDACTED] residence. [REDACTED] Damien got into a fight. The suspect and Damien left, eventually making their way to [REDACTED] North Road in [REDACTED] vehicle, sometime during the early morning hours of September 3.

At 4:03 am on September 3, [REDACTED] reported her vehicle to police as being stolen by [REDACTED], Damien. While travelling to the JSCN, the responding Melfort RCMP members queried Damien on their mobile workstation and located a picture of him to familiarize themselves with his appearance should they have encountered him. Members were also aware Damien had outstanding warrants for his arrest.

Melfort RCMP members located [REDACTED] vehicle at [REDACTED] at 5:35 am. When they arrived, they could hear loud music coming from a RV next door and they checked the RV for Damien before attending [REDACTED] Two males were located in the RV who appeared very intoxicated. The males provided their names to the police but were not requested to provide identification as neither of them matched the description of Damien.

RCMP members then attended [REDACTED] the identified resident. [REDACTED] advised members that Damien was not there. She did not know his whereabouts, or how [REDACTED] vehicle arrived at her residence. The members entered the residence to search for Damien and found a number of people, including three adult males who did not match the description of Damien. The keys to [REDACTED] vehicle were found on the kitchen table and were returned to [REDACTED], who attended the residence after being notified by police that her vehicle was recovered.

The Melfort RCMP members left [REDACTED] and continued to search for Damien on the JSCN, attending locations provided to them by [REDACTED] as places Damien could be located. The members spoke to [REDACTED] several times that morning (believed to be 8-10 times) and [REDACTED] made no mention of anyone else with Damien when he took her vehicle, and at no point was the suspect, Myles Sanderson, discussed.

Throughout the day, Damien and the suspect travelled to Kinisinto to get food and then back to the JSCN where they went back and forth between various residences. At around 5:00 pm, the suspect and Damien went to [REDACTED] residence at [REDACTED] and while there, the suspect commented that he was 'there for one body' referring to [REDACTED]. [REDACTED] eventually showed up to the residence and was assaulted by the suspect. There is no record of this incident being reported to police until after the homicides.

Following this assault, Damien went to the Kinistino Bar with [REDACTED]. While at the bar, Damien made a comment to a [REDACTED], stating that that he and the suspect had 'a mission to do'. Damien was eventually dropped off at a [REDACTED] place. It is unknown where the suspect was at this time.

At approximately 11:00 pm, [REDACTED] returned home to find the suspect sitting on the stairs outside of his house, at [REDACTED] Edward Burns Avenue. The suspect departed and said that he was going to go look for Damien. The two eventually re-connected and arrived at [REDACTED] and while there, physically assaulted [REDACTED] before leaving and going to [REDACTED] residence where they remained until the early morning hours of September 4.

September 4

At approximately 2:00 am, the suspect and Damien went to [REDACTED] residence, took her Grey Dodge Caravan and sold cocaine for a time until returning back to [REDACTED]. At approximately 4:45 am the suspect and Damien were at [REDACTED] and were said to be 'guzzling booze' to 'pump themselves up', prior to departing again, in the Grey Dodge Caravan.

At approximately 5:30 am, the suspect and Damien entered [REDACTED].

After searching the house [REDACTED], Damien told [REDACTED] that it would be the last time that she would see him. Damien then took [REDACTED] cell phone and departed the residence with the suspect. From there it is believed that the suspect and Damien traveled to [REDACTED] North Road, still in the Grey Dodge Caravan.

[REDACTED] North Road

At approximately 5:40 am the suspect and Damien entered the residence located at [REDACTED] North Road and initiated an altercation with the homeowner, [REDACTED]. The suspect tried to stab and kill [REDACTED], at which point Damien was said to have intervened. [REDACTED] sustained non-fatal stab wounds prior to the two departing. This altercation resulted in the initial call to the RCMP relating to the events that were about to unfold. Additionally, it was the information from this complaint that was used in the first Public Alert that identified both the suspect and Damien, as being responsible for the spree of violence.

After departing in the Grey Dodge Caravan, the suspect stabbed Damien multiple times while inside the vehicle. Damien was able to exit the van and wandered off the road where he would later succumb to his injuries. Damien's body would not be discovered, however, until 11:25 am the following day (September 5).

[REDACTED], New York Road

After killing Damien (Homicide 1), more stabbings were reported shortly after 6:00 am, at [REDACTED] New York Road, a location approximately 12 kilometers southwest of the original call to police ([REDACTED]). The suspect crashed the Grey Dodge Caravan into [REDACTED] and after gaining entry, stabbed [REDACTED] multiple times before leaving on foot to [REDACTED] residence at [REDACTED]. [REDACTED] would be found deceased (Homicides 2, 3, and 4) and [REDACTED] injured. This was the first location that the Melfort RCMP would attend at approximately 6:23 am. The suspect took [REDACTED] White Ford F350 truck from [REDACTED] and departed.

[REDACTED] Edward Burns Avenue

From New York Road, the suspect travelled north toward the 'town site' of the JSCN (approximately 6 kilometers away) and eventually to [REDACTED] Edward Burns Avenue where he attacked and injured [REDACTED] at approximately 6:14 am, before abandoning the White Ford F-350 and proceeding northbound on foot to another nearby home at [REDACTED] Edward Burns Avenue, where he stabbed and killed [REDACTED] (Homicide 5) and injured [REDACTED].

[REDACTED] North Road

The suspect remained in this area, on foot and stole a White GMC Terrain from [REDACTED] Angus McLean Drive and, by 6:19 am, had driven to [REDACTED] North Road (the area where the original assault occurred at 5:40 am). It was here that the suspect attacked [REDACTED], with a knife. The suspect stabbed [REDACTED] several times while [REDACTED] sustained non-fatal wounds. Both the suspect and [REDACTED] drove away from the residence; the suspect in the White GMC Terrain and [REDACTED] in a school bus. [REDACTED] eventually succumbed to his injuries and would later be found deceased (Homicide 6) in the school bus approximately 2.5 kilometers southwest of his residence.

It was around this point in time (6:20 am) that the first two RCMP members arrived at the JSCN and began the process of determining the extent of the victims and scenes based on the calls that had already been received and the severity of injuries to the victims. RCMP initially attended to [REDACTED] New York Road as they thought this was the first homicide scene. As mentioned, Damien is believed to have been the first murder victim; however, his death was not known to RCMP and his body had yet to be discovered. One RCMP member remained at [REDACTED] New York Road and the other, proceeded northbound (approximately 10 kilometers) to the original call for service to [REDACTED] North Road, arriving there at 6:32 am.

[REDACTED] Abel McLeod

After making an assessment at [REDACTED] North Road, the member departed south to the town site and [REDACTED] Abel McLeod (approximately 5.5 kilometers) as there was a report of two more deceased at that location. Upon arrival [REDACTED] (Homicides 7 and 8) were found murdered with [REDACTED] sustaining injury. While driving to [REDACTED] Abel McLeod, RCMP passed the school bus in the ditch that [REDACTED] had used; however, were unaware that he was deceased at this point in time. [REDACTED] would not be discovered until 8:28 am on this date.

Return to [REDACTED] Edward Burns Avenue

After abandoning the Red Dodge Caravan, the suspect returned to [REDACTED] Edward Burns Avenue where he had previously killed his fifth victim ([REDACTED]) and proceeded to kill [REDACTED] (Homicides 9 and 10) before travelling on foot and breaking into a nearby home at [REDACTED] Abel McLeod Street, and stealing [REDACTED] Black Nissan Rogue.

During this time RCMP had arrived at [REDACTED] Abel McLeod Street and observed the White GMC Terrain. The responding member was of the belief that this was the suspect vehicle at the time and was not aware that he was currently in the Black Nissan Rogue, a few houses to the north. Due to the close proximity of the two homes it was possible that the suspect would have seen the RCMP patrol car and could have been the first instance the suspect was made aware of the RCMP presence on the JSCN and may have ultimately brought about his departure from the community.

Kinistino to [REDACTED], Weldon

By 7:00 am there were reports the suspect had arrived in Kinistino, some 27 kilometers southwest of JSCN, looking for gas. Following this, the suspect travelled 12 kilometers west to Weldon, where at 7:10 am he broke into [REDACTED], and killed his last victim, [REDACTED] (Homicide 11).

At 7:12 am, the first of a number of Public Alerts was broadcast by the RCMP advising the public of the stabbings on the JSCN and for residents to seek shelter.

Following his last murder, the suspect was observed at various locations in Weldon rummaging through vehicles and requesting assistance from various community members as he advised that he had been stabbed. The suspect was observed to be covered in blood by witnesses. At 7:24 am the Black Nissan Rogue was observed on video travelling south, presumably out of Weldon.

At 7:57 am the Second Public Alert was issued that named the suspect and provided both his physical description and the vehicle he was believed to be driving in.

Highway 41 sightings

Between 4:00 pm and 8:08 pm there were reports of sightings of a lone suspect (Myles Sanderson), near Highway 41 between Melfort and Wakaw. By this time Damien had been killed; however, his body would not be discovered until the following day. One of the complainants knew the suspect personally through a family connection. Wakaw RCMP responded but did not locate either the suspect or the Black Nissan Rogue.

September 7

One Arrow First Nation

At approximately 2:40 pm, [REDACTED] reported the suspect at his residence located at House [REDACTED] One Arrow First Nation. The suspect was outside his residence asking for ride to the city. [REDACTED] said that his truck was not working and watched the suspect leave westbound at a high rate of speed, in the White Chevy Avalanche.

At 3:17 pm an unmarked police vehicle located the White Chevy Avalanche travelling west bound toward Rosthern on Highway 312. Eventually the suspect realized that he had been detected, began to flee from police, and a pursuit ensued. The suspect was eventually travelling southbound in the northbound lane of Highway 11 (toward Saskatoon) until the RCMP forced the White Chevy Avalanche off the road south of Rosthern at 3:32 pm.

The suspect was arrested and went into medical distress immediately following. EMS transported the suspect to hospital in Saskatoon at 3:51 pm; however, he was declared deceased at 4:38 pm despite efforts made to revive him.

The 911 Call(s)

The Saskatchewan Public Safety Agency (SPSA) provides province-wide access to 911 emergencies through the Sask911 system. Emergency calls for police, fire, rescue or emergency medical services are taken by trained 911 operators. These trained call takers determine the nature of an emergency and transfer the call to an emergency dispatch operator.

In Saskatchewan, 911 calls are taken by Public Safety Answering Points (PSAP) in Regina, Saskatoon, and Prince Albert. Outside the municipal boundaries of Saskatoon and Regina, 911 calls are answered in Prince Albert.

The 911 calls related to the JSCN/Weldon Mass Casualty Event were first answered by the PSAP in Prince Albert, where they were initially assessed as police, fire, or ambulance, and then transferred to the Division Operational Communication Centre (OCC) when found to be police-related. This will be further discussed later in the Operational Communications section of the review.

Tactics and response to initial call

In general, police respond to types of situations that are either under control, where there is no longer a threat to public or police safety; or evolving, where information may be limited and there is imminent danger to the public and/or police. The type of situation will dictate whether the actions taken by initially responding members are more investigative or tactical.

Constable Tanner Maynard (Constable Maynard) of the Melfort Detachment was contacted by the OCC at approximately 5:44 am. Constable Maynard was already at the Detachment as he had been called out previously, on an unrelated call. The initial complainant reported that the suspect and his brother had broken into the complainant's house and stabbed him, causing non-fatal injuries. Both the suspect and his brother had since departed in an unknown direction.

Following dispatch, and as per policy, Constable Maynard immediately called his back up, Constable Dave Miller (Constable Miller), to assist. When Constable Miller arrived at the detachment, Constable Maynard was waiting in his police vehicle. Constable Miller joined Constable Maynard and both departed in the same vehicle to the JSCN, approximately 9 minutes after being dispatched. At this time, there was only one complaint that had been received and the members were responding to what they thought, was a single stabbing with the suspects having already departed from the scene.

While travelling to the JSCN, the OCC and the Member Operational Support Services (MOSS) Unit (explained later) were updating the members. The situation was clearly evolving rapidly, as both the number of victims and scenes were learned to be increasing. Once on scene, Constables Maynard and Miller relied on information from the initial and subsequent complaints (provided by the OCC and MOSS) coupled with their own observations to make tactical decisions, which will be reviewed as part of this objective.

Ops Manual Ch. 16.9.3.1 outlines that when responding to an incident, members must conduct a risk assessment in accordance with Ops Manual Ch. 17.1 (Incident Management Intervention Model) that will be discussed below.

Upon arrival at the initial scene at the JSCN, some 28 minutes after departing Melfort, the initial responding members began attending scenes, starting first with the report from [REDACTED] on New York Road. When the first deceased victims were discovered at this location, Constables Maynard and Miller discussed their strategy moving forward. They had very little time to develop a plan as information continued to be received as the situation was evolving. A decision to separate at that time was made, leaving Constable Miller to provide first aid and to maintain scene continuity (Ops Manual Ch.1.2.2.4), at what they believed were the first homicides. Constable Maynard then attended the more northern location of the initial call for service while continuing to triage additional victims and scenes as he was made aware of them. At this point, they did not know where the suspect(s) were and the number of victims and scenes were continuing to rise, as outlined above, in the 'Chronology of Events'.

One or Two-Person Patrol Cars

This review identifies that Constable Maynard and Constable Miller are to be commended for their actions as they relate to their overall response to this event. Their work was outstanding, in a situation that was incredibly difficult. They were quick to respond, decisive, and they faced unimaginable challenges.

With this being clear, in this circumstance, the members' decision to separate put them at a tactical disadvantage, at least for a period of time. The suspect(s) were still at large (believed to be two at that time), and when Constable Maynard arrived at [REDACTED] North Road, the two members were then about 12 kilometers apart. Portable reception on JSCN was also poor, which will be discussed at later points in this review, and Constable Miller had no means to back up Constable Maynard, had he (Constable Maynard) encountered the suspect(s). Alternately, had the suspect(s) returned to [REDACTED] New York Road, Constable Miller would have been alone. Although this circumstance did not materialize, it is worth analyzing the circumstances and potential risks that come from this situation.

A further question becomes, however, were they at a tactical disadvantage only due to their separation at that time, or was it in part also due to the decision to travel in a single patrol vehicle at the outset? This question is complex, and organizationally there is not yet national policy or guidance on the issue of one or two-person patrols. Depending on what had happened, some might say they were better to have travelled in the same patrol car, if they hadn't separated. They would have had at least two of them, together, if they had then encountered the suspect(s). Alternatively, some might argue that travelling in separate vehicles would have allowed them the ability to cover more ground, to search for the suspect(s), and attend other calls, while still ensuring they remain close.

While the advantages and disadvantages of one or two-person patrol cars are still being debated today, it could be said here that two-person patrols are more common, in large municipalities, where generally more resources are available, within a close proximity. And while some will argue for, and some against, two-person patrol cars in large municipal environments, it becomes less clear on what is the best tactical option for rural environments, or where there are only two members initially available.

The most obvious solution would be to always deploy the maximum number of members with the maximum number of patrol vehicles possible; however, the reality is this scenario is seldom available in rural policing environments, today. This being the present reality, the organization would benefit by analyzing this issue in greater detail. Part of this analysis should call attention to the risks of separation, regardless of the decision to have one or two-person patrol cars.

The Incident Management Intervention Model (IMIM)

The IMIM is what RCMP officers use to assess and manage risk in all encounters with the public. This model is used mainly as a guideline to assist an officer in articulating their decision-making process involved in selecting a particular intervention option. The responding members were never compelled to physically engage the suspect upon arrival at the JSCN during the initial call, therefore there is no question as to whether the appropriate intervention tool was used at that point in time. Having said that, consistently found in all components of the IMIM is the notion of mere officer presence being a key factor in intervention. As pointed out above in 'Chronology of Events', the point at which the suspect may have first observed the RCMP members on the JSCN could have contributed to his departure from the community.

When making a determination of level of intervention that is necessary under the circumstances, the various stages of the IMIM illustrate the necessity to constantly evaluate risk throughout a situation.

The Melfort RCMP Detachment Commander, Staff Sergeant Darren Simons (Staff Sergeant Simons), was contacted by the MOSS Unit shortly after the initial dispatch and was advised of the situation. The MOSS Unit will be detailed in the 'Command Structure' section of this document; however, to offer context at this juncture, the MOSS Unit is staffed with Senior RCMP Non-Commissioned Officer's (NCO's) that are embedded 24/7, within the Operations Communication Centre (OCC) location in Regina. MOSS members are available for consult at times when a supervisor or detachment commander is not working. Staff Sergeant Simons directed the MOSS member to begin the process of calling out additional members and resources.

Upon his arrival on the JSCN, Staff Sergeant Simons met with Constable Maynard and was provided an overview of the events to that point. Staff Sergeant Simons was confident in Constable Maynard's grasp of the situation and left him to continue to coordinate and secure scenes. As calls continued to come in advising of fatalities, Staff Sergeant Simons proceeded to attend scenes as required.

Whether they were aware of it or not, much of the initial response to the JSCN/Weldon event followed the 'principles' that are part of Incident Command System (ICS) that will be explained in further detail in the following section, Command Structure.

Although Constable Maynard was effectively managing the situation, it is worth noting that there are a number of on-line courses that all regular members have access to that offer entry level training for management of critical incidents. This training evolved from recommendations made in the MacNeil Report.

Among the available courses are the following:

Initial Critical Incident Response (ICIR) - Level 100 course provides regular members with the knowledge to effectively take command and control of a critical incident in a logical and methodical fashion, until such time that a Critical Incident Commander (CIC) assumes command.

Initial Critical Incident Response (ICIR) Detachment Tabletop Exercises is a course that was in order to better prepare supervisors to manage and supervise throughout a critical incident until a Critical Incident Commander (CIC) assumes command. A number of scenarios designed as a table-top exercise are offered for teams to plan out and rehearse when responding to a critical event in a detachment area.

If not already prioritized, entry level ICIR training for both junior members and supervisors should continue to be encouraged in order to be best prepared for any future critical incidents.

As the situation evolved, victims were being triaged and treated by Emergency Medical Services (EMS) or Community First Responders, while STARS was on scene to transport some of the injured to hospital. The situation was chaotic and some described it as a war zone. As additional RCMP resources were arriving at the JSCN, they were being approached by members of the community (some of which were covered in blood) directing them to additional scenes. Victims' families were attending the scenes, searching for answers and wanting information. Additionally, there were concerns of further violence through retaliation, once the information as to who was allegedly responsible was being disseminated amongst the community.

This 'first wave' of responding RCMP members were forced by circumstance into managing the situation themselves, with MOSS support (explained further below), until more supervisory resources arrived. The tasks of triaging of scenes, the victims, and allocating the resources as they became available were being completed based on the principles of command and control which is common terminology used to describe the majority of policing operations in Canada.

Command refers to the chain of command police agencies organically enter into in order to manage any type of incident from the onset. The principles for command and control are scalable and allow for a similar evolving response from police, should an event expand into a critical incident. Oftentimes these roles and tasking are based on rank, seniority, or experience.

As will be outlined in the section that follows, from the onset of the initial calls for service to the JSCN, to the recognition of it being a larger, more critical event, other command structures were introduced.

Radio communication

During highly stressful events such as the circumstances described above, radio communication protocols can tend to erode. Those that responded and were communicating via their portables (when able) or radios in their police vehicles were in large part, utilizing appropriate radio communication. Although it is not known at exactly what point a dedicated encrypted radio channel was identified, plain language was being utilized for the most part. There were some reports of some 10-Codes still being broadcast; however, these instances did not appear to create any gaps in communication. There were no occasions where a gap in communication resulted from poor radio protocol or communication displayed by members.

There can be a tendency for members to avoid using plain language if they are unsure whether their communication is encrypted, to avoid details being broadcast to the general public. Given the fact that the RCMP 10-Codes are readily available in the public domain, the risk especially during this event to using plain language, whether communication was encrypted or not, was minimal. Radio communication will be discussed further in the review of Operational Communications later in this document.

Some members interviewed during the course of the review pointed to the Immediate Action Rapid Deployment (IARD) scenario based training they had completed as being beneficial during the stressful incidents they were involved in, where clear communication was vital.

Outside of the language used during this critical incident, it must be identified that portable radio reception was very poor on the JSCN. There were reports of members having to leave residences every time they wished to transmit over their portable radios. This scenario was described by members as a common issue while on the JSCN. Virtually all members interviewed throughout this review expressed their concern with the poor radio communication on the JSCN.

[REDACTED] It should be noted that although [REDACTED] can provide a remedy to poor radio (portable) reception, in reality it only works in a very specific type of scenario and for the most part, is not practical.

Although not as efficient as radio usage, all members that responded to the JSCN were equipped with cell phones that were said to have worked well as a back up to the poor radio coverage. The potable radio coverage issues while on the JSCN will be addressed more in depth later, in the review of Operational Communications.

Equipment and intervention options

A review of the equipment that members had access to, any equipment they were in need of, and after action reporting were topics that were included in the review objectives, and will briefly be outlined. Certainly not all of the over 500 police officers that were called upon for the JSCN/Weldon event were interviewed as part of this review; however, those front line members that had potential to be in the most compromised positions, based on their role, were. The initial responding members and members of the Emergency Response Team (ERT) will be discussed below.

JSCN community interviews

Following the interviews of the community members from the JSCN, the following information is relevant to this objective:

Response time

One of the areas of concern that was raised by the JSCN community members was the time that it took RCMP members to arrive on the JSCN on the morning of September 4. Naturally, in a situation like the one that evolved that morning, any amount of time spent waiting for police and other emergency services to arrive will be questioned. Not limited to the JSCN community, the public as a whole places a significant amount of value on police response time largely because it creates feelings of security and is believed to be a key factor in crime prevention.

Response time itself, is not necessarily difficult to measure as one can simply determine the time that a call for service was received and the time that it took for police officers to arrive on scene (as will be seen below). Having said that, there are variables that can have an affect on the time that it takes the police to arrive at a scene. As discussed earlier, the Melfort RCMP Detachment has a policing model where a RCMP member is required to be 'on-call' for periods of time where they may be called out from home to respond to a complaint. Further, once a call is received (in this case through a 911 call centre), there may be a period of time between receiving that call and dispatching the police that can affect a response.

Delays from 'on-call'

In the case of the initial response to the JSCN, the following times are known:

Time of the initial 911 call regarding the JSCN

5:40 am

Time the 911 call was dispatched to Melfort Detachment

5:43 am

Time that members departed Melfort, en route to the JSCN

5:52 am

Time the members arrived at first scene ([REDACTED] New York Road)

6:20 am

Total time from dispatch to arrival

37 minutes

It is worth noting at this point that information from the GPS report of the police vehicle that dispatched members were driving indicated they took the route that went straight north from Melfort on Highway 6 (see above map) and speeds varied between 155 km/hr and 178 km/hr, on that main highway. On secondary highways, speeds varied between 115 km/hr and 140 km/hr.

To briefly re-visit the chronology of events that were outlined above, the investigation revealed the following with respect to the length of time that the assaults/homicides occurred on the morning of September 4:

• The stabbing of [REDACTED] is believed to have been the first assault committed by the suspect. This attack is thought to have occurred between 5:30 am and 5:40 am
• The first homicide victim was Damien Sanderson, which was thought to have occurred after he and the suspect departed [REDACTED] residence around 5:40 am
• The last homicide victim was [REDACTED] that was believed to have occurred at approximately 7:10 am
• Based on these times, the suspect's spree of violent attacks lasted for approximately 1 hour and 40 minutes

As set out above, there are regular periods of on-call at the Melfort Detachment where a member is not required to be physically present at the detachment. On the morning of September 4, however, Constable Maynard was already at the detachment for an unrelated occurrence when the initial 911 call to the JSCN was dispatched. The only 'delay' in the response time from the Melfort RCMP was the time that it took Constable Maynard's backup (Constable Miller) to arrive at the detachment once he was called from his home to assist. There is no question that Constable Maynard followed policy by ensuring he had back-up to respond to this complaint. RCMP Policy dictates that back up was required due to the nature of the call. Proceeding to this call without waiting for back up was not an option, nor was it considered. Once Constable Miller arrived at the detachment, both members departed immediately for the JSCN.

The time that it took Constable Miller to arrive at the detachment was reasonable. The decision by Constable Maynard to wait for his backup to arrive at the detachment and board into his waiting police vehicle so they could depart together did not create any unreasonable delay in their response.

Delays from 911 dispatch

As discussed earlier, 911 calls in Saskatchewan are received by PSAP's in Regina, Saskatoon, and Prince Albert. In the case of the JSCN/Weldon event, the initial and subsequent 911 calls were forwarded from Prince Albert to the RCMP OCC, in Regina. From that point, the Melfort RCMP Detachment was dispatched.

During the review, there was no indication of competing 911 calls at the time of the initial call related to the JSCN on the morning of September 4. It was not until after the initial call, that an influx of additional 911 calls were received. The entire dispatch process for the initial 911 call took very little time and could not have been streamlined more than it already was.

The 911 calls related to the JSCN/Weldon event will be further discussed in the Operational Communications section of the review.

Given the above context under which the RCMP were initially dispatched to the JSCN, combined with the distance required to travel, their response time was appropriate.

RCMP visibility

Overall, the communities of both the JSCN and Weldon were appreciative of the efforts of all resources that responded to the events on September 4. During these discussions, however, community members naturally led into conversations about overall RCMP visibility, specifically on the JSCN.

Similar to police response time, police visibility in the communities they serve can entice those same feelings of security and is largely believed to contribute to overall crime prevention. When the public sees the police conducting patrols (either in a vehicle or on foot) of a neighborhood or town, there is naturally an increased awareness amongst citizens that their community matters. This notion is widely accepted and is not limited to the JSCN community alone.

A number of the JSCN community members held the belief that if there had been a member posted directly on the JSCN at the time of the offence, that there would have been fewer victims. This again, is a natural response following such a horrific event; however, that type of service delivery model was not an option and goes beyond the scope of this review, which is to evaluate the RCMP response. Nonetheless, the amount of community members that raised concerns over the lack of visibility (and familiarity) of the RCMP at the JSCN warrants it being addressed in this section.

After conducting interviews with JSCN community members, it became apparent that there are mixed opinion as to the overall relationship between the Melfort RCMP and the JSCN.

During the response to the events on September 4 and the days that followed, there were countless numbers of RCMP members in and around the community of JSCN. In acknowledging their appreciation for this response, some questioned why, aside from the Detachment Commander, the Melfort Detachment members did not respond. Since every available member from the Melfort Detachment responded to the JSCN, this perception may speak to the lack of familiarity of the Melfort Detachment members amongst community members.

The Melfort Detachment does have a dedicated Community Tripartite Agreement (CTA) in place with the JSCN. Under CTA arrangements, a First Nation or Inuit community has dedicated officers from an existing police service, usually the RCMP. As some community members pointed out, historically some of these dedicated members have 'clicked' and some have not. The member that holds that dedicated Indigenous position within the Melfort RCMP is an Indigenous member that was said to commit a large part of his time and duties to his responsibilities on the JSCN. He was spoken very highly of and was praised for his efforts in the community. As such, the JSCN community has embraced him. This member was not working during the events surrounding September 4, but it highlights the need to have more networking amongst all detachment members, not only those that hold that one specific job description.

The overall sentiment from the JSCN community was that the RCMP should make efforts to be more visible within the community and to encourage more (and better) communication with the JSCN, not only during planned community events when they are asked to participate, but in general. While increased public confidence may be a result of these efforts, community engagement is perhaps the most crucial component that can have any lasting effect on crime reduction in the community.

Areas of effectiveness

Incident command system overview

The Incident Command System (ICS) is a model for command, control, and coordination of emergency response at an emergency site. It provides a way of coordinating the efforts of agencies and resources as they work together toward safely responding, controlling and mitigating an emergency incident. Although originally designed in response to wildfires in the 1970's, ICS has evolved into an all-hazards system that is appropriate for all types of all types of incidents, including those involving multiple casualties that required a multiple agency response.

The ICS organization is built around the five major management functions of Command, Operations, Planning, Logistics, and Finance/Admin:

The Command function is directed by the Incident Commander, who is the person in charge at the incident and who must be fully qualified to manage the response. The role of IC is initially taken by the first responder to arrive at the scene. He or she is responsible for managing all tactical resources and overseeing Operations. In approximately 95% of all incidents, the organizational structure for Operations consists of command and single resources. Very seldom is there a requirement to 'scale up' and activate the Planning, Logistics, and/or Finance/Admin sections as they are management elements and have less to do with the tactical response.

When utilized, the Planning section maintains status of resources and prepares other incident-related documentation. The Logistics staff provides services and support to meet the incident or event's needs such as acquiring necessary resources and other services. Finance/Administration staff monitors costs and keeps track of incident-related expenses such.

GSB overview

The GSB framework provides a structure for delivering a strategic, operational, and tactical response to a spontaneous incident or a planned operation. It also allows processes to be established that facilitate the flow of information, and ensures that decisions are communicated effectively and documented as part of an audit trail.

Most incidents and operations are resolved by using a simple GSB command structure, with the responsibilities and accountabilities of each commander clearly set out in command protocols. The command structure is role, not rank, specific and allows for flexibility.

The Gold commander is in overall control of their organisation's resources at the incident. This person will not necessarily be on site, but at a distant control room where they will formulate and oversee the strategy for dealing with the incident.

The Silver commander is the operational commander who manages operational implementation following the strategic direction given by Gold, and makes it into sets of actions that are completed by Bronze. Whether the Silver commander is present at the scene can vary by incident and agency.

A Bronze commander is responsible for the command of a group of resources and carrying out functional or geographical responsibilities related to the tactical plan.

If an incident is widespread geographically, different bronze commanders may assume responsibility for different locations.

The established structures of ICS and GSB have been debated for some time, and continue to be. The two command systems are utilized due mainly to the built in flexibility allowing response organizations (police, emergency services, etc.) to utilize only those aspects that are practically suited to a given incident. Both models promote adaptability without jeopardizing clear lines of communication or accountability. Regardless of the model an organization observes, the inherent processes and methodologies should be the focal point, not the model itself.

Command interface

Immediately following the initial call for service and the attendance of the first responding members, the Critical Incident Program was activated and a CIC was mobilized and would eventually assume command, on-site by mid-morning on September 4, for the majority of the event. Also during this time, senior management were working out of the Division Emergency Operations Centre (DEOC) that was in the early stages of activation to assist with event logistics, fulsome briefings, and upper management reporting. The DEOC was being staffed to the extent that arrangements were being made to enter into a shift schedule to manage the likelihood of having more than one operational period. The Major Crimes Unit (MCU) were activated and after determining the scope what was unfolding, developed a number of 'sub-teams' out of necessity who, in turn, reported to the Team Commander of MCU.

The activation of these various levels of command in such a short period of time illustrated the earlier point of how police are generally proficient in operating within a more localized organizational structure; however, when a situation evolves past that level is where lines of command can become less clear.

Emerging reporting lines

In the hours and days leading to the arrest of the suspect, reporting lines were developing whereby, those tactical units on site (MCU, CIC, FIS, etc.) reported up to the DEOC where the eventual Incident Commander and DEOC Commander were positioned.

Although the various functions were sufficiently utilized for the duration of the event, there were elements of the command model that would have benefitted from a more structured approach. This emergent reporting structure, although not outlined at the time of the event, may have contributed to some of the ambiguity as to who was in 'overall command' at various points in time.

Command of the JSCN/Weldon Event

Despite the fact that very little of what took place throughout the course of the JSCN/Weldon event occurred in a linear fashion, with clearly defined start and end times for the various levels of command, a sequential review of the various command roles that evolved became the most logical review format to consider. As will be seen, the activation of a certain command functions did not happen in isolation as there were multiple duties being prepared for at any given time that led to various groups and tasking's specific to certain command elements being assigned.

When the incident grew to a divisional level response, the primary command functions for the JSCN/Weldon event largely revolved around the Critical Incident Commander and those managers that were working out of the DEOC; thus, those two functions will encompass the majority of this section. Additionally, the response by the F Division Member Operational Support Services Unit (in conjunction with the initial responding members) and the Criminal Operations Duty Officer, and the Major Crimes Unit (MCU) will be focal points of review. The actions taken by the initial responding members were discussed at length in the previous section and will only be expanded upon when necessary, from this point onward.

The original intent was to evaluate each command portion as a separate objective; however, as the review of this section progressed, documenting each role in isolation did little to promote clarity for the reader. It is well-documented that various levels of command had substantial interaction and sometimes became inter-twined; thus, documentation of specific command roles do not simply begin and end within the sub-headings below but rather, will be noted throughout the entire section, when relevant.

Member Operational Support Services (MOSS) Unit

Initial command

MOSS Unit / initial responding members

As outlined in the previous section, Constable Maynard was dispatched by the OCC to a call of a stabbing on the JSCN at approximately 5:44 am on September 4. During this time, there was a MOSS member on duty in the OCC who was aware of the initial call.

Although urgent in nature, there was nothing to suggest that this complaint differed from others of a similar nature that had been received in the past and there was no information at this time to suggest that a more serious incident was unfolding. When another call came in minutes later, the MOSS member contacted the responding members and there was discussion surrounding whether the two calls were related. Constables Maynard and Miller had yet to arrive at the JSCN to determine exactly what was happening and were unsure at this time if the calls were associated. At approximately 6:11 am, additional calls came in to the OCC and it became clear at this point that there were multiple victims. Constables Maynard and Miller were driving to JSCN at the time of these updates and from this point onward, maintained consistent communication with MOSS member and worked in concert to command the unfolding event, at that time. The MOSS member made immediate calls to Staff Sergeant Simons and to the on-call Duty Officer (explained below) to make them aware of what was transpiring. By 6:47 am the on-call Critical Incident Commander (CIC) had been notified. Despite these notifications, command of the incident remained the responsibility of the initial responding members (with oversight from the MOSS Unit) as they had the most situational awareness at that time.

By 7:00 am, there was a shift change and incoming MOSS member(s) continued the process of calling other members or units out to assist at the JSCN. MOSS members have 'back line' contact numbers for partner agencies and were able to reach partner agencies such as the Regina Police Service (RPS) quickly. The value of this direct contact information was demonstrated at the time that information was received identifying a suspect. A Correctional Service employee responsible for the suspect was able to be contacted in short order. Police Dog Services (PDS), Major Crimes Unit (MCU), Forensic Identification Services (FIS), and all other requested units were contacted by the MOSS Unit and were being deployed. The MOSS member who took the initial call continued his duties and stayed on shift until later in the morning to assist with tasks in the DEOC (explained later), which was also in the process of being activated at this point.

The size and scope of the unfolding event at the JSCN/Weldon resulted in effective event recognition by the MOSS Unit members in conjunction with members at the scene. This recognition allowed them to scale up very quickly and obtain as many resources to bear as possible.

Effective practice

Have a list of back line numbers for various agencies and units to facilitate direct contact, especially during the early morning hours when most are not working or at their regular contact numbers.

Staff Sergeant Simons became the defacto Incident Commander upon his arrival on JSCN at 7:38 am, with support from the MOSS Unit. At this point in time, higher level command functions were being arranged; however, the members on-site were in command as they had all of the situational awareness and were directing whatever resources they had available to them. First responding members recognized this and understood that Staff Sergeant Simons was in charge upon his arrival at the scene.

Staff Sergeant Simons had received training in Incident Command Systems (ICS) and Initial Critical Incident Response (ICIR) which is training that stemmed from recommendations of the MacNeil Report (mentioned previously). Admittedly, however, Staff Sergeant Simons stated that no amount of training could properly prepare someone for what he and his members responded to on the morning of September 4.

Staff Sergeant Simons ultimately allowed Constable Maynard to continue with triaging victims, scenes, and directing additional resources that were arriving. This was a mindful decision as Staff Sergeant Simons had only been the detachment commander in Melfort for 6 weeks prior to this incident and in his estimation, Constable Maynard was more than capable of continuing the coordination of scenes.

Due to the complexity of the incident and the timeliness required to manage the situation, it would have been counter-productive for Staff Sergeant Simons to take on those duties based solely off his rank. Staff Sergeant Simons assisted with scenes and victims as was necessary, all the while liaising with MOSS members, the DEOC (once activated), and the OCC in an attempt to have more resources deployed to the JSCN to assist.

Duty officer and Criminal Operations Officer involvement

As previously mentioned, the MOSS member promptly notified Inspector Murray Chamberlin (Inspector Chamberlin) who was the on-call Duty Officer (Duty Officer) on September 4. For clarification, a Duty Officer is an assigned Commissioned Officer that receives higher level notifications or updates of unfolding events that are of Divisional interest. A Duty Officer is on-call during times when the District Officers and District Management Teams are not working, to have oversight and ensure that senior management is aware of any critical unfolding events.

Effective practice

F Division maintains an on-call Duty Officer program, where Commissioned Officers are rotated through a schedule to cover any significant issues or incidents. F Division maintains a Duty Officer matrix used by the MOSS Unit that outlines threshold for when notification is necessary.

At the time, Inspector Chamberlin (Duty Officer) also held the role of the North District Officer. Inspector Chamberlin was essentially assuming two levels of notification simultaneously; the Duty Officer and the (acting) North District Officer.

In his role as the Duty Officer, Inspector Chamberlin immediately notified the CrOps Officer, Chief Superintendent Teddy Munro (Chief Superintendent Munro) of the unfolding event. During their initial conversations, specifically at 8:32 am, the decision to activate the DEOC was made. It was decided that Inspector Chamberlin would manage the DEOC out of Regina HQ (discussed next) and Chief Superintendent Munro would travel back from holidays first to Prince Albert, to ensure that the North District Management Team (DMT) was running effectively, then to Regina to assume his duties as CrOps Officer out of HQ. Other key senior personnel from the Division were also directed to the DEOC where most remained for the duration of the event.

When Inspector Chamberlin had a conversation with Chief Superintendent Munro and the decision to activate the DEOC was made, Inspector Chamberlin's role of Duty Officer essentially ended and he transferred to the role of managing the DEOC. Although no specific designation was discussed, Inspector Chamberlin effectively became the DEOC Commander. No matter the role he was in, Inspector Chamberlin and Chief Superintendent Munro remained closely aligned for the duration of the JSCN/Weldon event.

As will be pointed out later in the Strategic Communications Section, Inspector Chamberlin approved the initial release of the Public Alert in his role as the Duty Officer; however, operational guidance was not issued from that role. In essence, the role of the Duty Officer was relatively short in duration.

At the time the Duty Officer notified the CrOps Officer of what was unfolding, by 8:32 am, the CrOps Officer had assumed overall command of the event and shouldered the ultimate responsibility and accountability for the RCMP response; however, any tactical direction in relation to the evolving event and on-site resource allocation remained with those initial responding members and any specialized units at the scene, with support from MOSS. Although not formalized, the following chart appeared to be the structure that was evolving.

At this stage, there had yet to be an identified Incident Command Post. Although the DEOC was being activated for assisting with resources, the Critical Incident Commander (described below) had yet to arrive on-site to establish any type of base from which to oversee the entire operation.

The event, as it unfolded, was very dynamic and urgent in terms of the requirement to scale up the response from the first members attending out of Melfort Detachment. The MOSS Unit's initial deployment of resources combined with the Duty Officer and CrOps Officer's recognition of the expanding incident and the need for higher level strategic and longer-term decision making which constituted the activation of the DEOC, met this initial requirement.

Division Emergency Operations Centre (DEOC)

Evolving event

Once the DEOC was activated the coordination and consultation of the various agencies, units, and multiple commanders was carried out from that location for the duration of the event. By 1:00 pm on September 4, senior management held their first fulsome briefing in the DEOC.

Meanwhile, a Critical Incident Commander had arrived on scene and had taken command of the tactical (apprehension) component of the event. The Major Crimes Unit was in the process of coordinating scene management, the criminal investigation, suspect apprehension, and victim management. The arrival of all these units and resources in short order, and in relatively the same period of time naturally resulted in reporting lines being somewhat obscured at times.

Critical Incident Command

CIC role and response to the JSCN/Weldon event

As explained earlier, Staff Sergeant Bergerman, the initial CIC, had been notified by the MOSS Unit at approximately 6:47 am of what was unfolding at the JSCN. After being notified, Staff Sergeant Bergerman travelled from Prince Albert to JSCN. Staff Sergeant Bergerman had been in communication with the MOSS member(s) prior to his departure and was receiving information and updates while travelling to the JSCN. This communication allowed him to be aware of what he was confronted with when he arrived. Further, he was briefed by Staff Sergeant Simons and others first responding members upon arrival with the most recent information. Upon his arrival at approximately 9:00 am, Staff Sergeant Bergerman took over command of the incident and would assume command for the first 11.5 hours until he turned command over to Inspector Pugh.

Inspector Pugh was not on-call during the initial call out on September 4 but was notified of the situation via the related ERT call out that had been made. Inspector Pugh had his portable radio and laptop at his residence and was monitoring the situation prior to taking over from Staff Sergeant Bergerman.

Effective practice

Although not required, the involved CIC's had their portables and laptops at their residences, allowing the incumbent CIC to have the highest level of situational awareness at the time of transferring command.

Additionally, the two were in regular phone communication where information was shared as the situation was evolving. Inspector Pugh was part of fulsome daily briefings held through the DEOC in Regina which supplemented the information he had when he was preparing to take over command. This allowed for a seamless transition between the incoming and outgoing CIC. The CIC role was continuous for the duration of the event, with trained CIC's occupying the role throughout.

CIC arrival in the area of the JSCN replaced the regular command and control direction being given by the first wave of initial responding members (described in the previously) and resulted in a more formalized command structure. The CIC mission was 'to safely apprehend the suspects and recognize safety for the public, police officers, and the suspect'. During this time, the DEOC was in the process of being activated and staffed (discussed next) and MCU had also been deployed as it was clear the extent and nature of what was transpiring was going to require the highest level of investigation in many different areas. (MCU involvement will be explained in greater detail later in this report).

Establishing the Incident Command Post

By definition, an Incident Command Post (ICP) signifies the physical location of the on-scene incident command. One of the first responsibilities of the Incident Commander is to establish command by setting up an ICP to promote clear lines of authority and communication for the incident. Ideally, a single command post would be identified and positioned as close as possible to the area where the event is occurring. Other sections might have command posts that are responsible for certain aspects of an operation; however, there should be only one ICP from which the entire operation is managed.

An ICP can take on different forms such as the mobile CP's that are part of the Critical Incident Program or simply the vehicle that the CIC is driving. The ICP that is utilized by the CIC is widely known as an ERT Command Post (ERT CP) and will be referred through the remainder of this report as the command post that the CIC was working from, on-site, during the JSCN/Weldon event.

Major Crimes Unit (MCU)

Although not a traditional command structure, MCU utilizes the principles of Major Case Management (MCM) when conducting investigations. MCM uses a hierarchy of command and roles based on 'industry standard' established principles of conducting criminal investigations. Circumstances surrounding the JSCN/Weldon event caused the MCU structure to expand in concert with the evolving situation. As the structure expanded, so too did the reporting lines. This organizational expansion, along with a further explanation of MCM will be addressed later, in the Major Crimes Unit portion of this report. The reason it is introduced here is based on how it actually interfaced with the other command structures utilized in the JSCN/Weldon response.

Command uncertainty

As discussed previously, command lines were occasionally unclear and created uncertainty surrounding who was responsible for issuing some of the tactical direction. Perhaps the defining moment for this was on September 7, when the suspect vehicle was observed and the eventual pursuit that ensued.

For context, after the suspect vehicle was confirmed and a pursuit ensued, the suspect eventually reached speeds of approximately 140 km/hr travelling southbound, in the northbound lane South of Rosthern on Highway 11 toward Saskatoon. Highway 11 had been blocked off at Saskatoon to the south; however, there was traffic that was still traveling in between, that was at risk.

During this time, Inspector Chamberlin and Chief Superintendent Munro were situated in the DEOC and were receiving information from the MOSS member that was monitoring the pursuit in real time. The CIC at this time was not in the area of the pursuit and was perceived by those located in the DEOC to not have the situational awareness that was available in the DEOC at that time.

Chief Superintendent Munro and Inspector Chamberlin had a brief discussion where a determination was made to issue the direction to take the suspect vehicle off the road. Any amount of time lost relaying updates to the CIC in order for him to make this tactical decision would have taken too long, given the circumstances. Chief Superintendent Munro told the MOSS member to transmit direction over the radio for members to use whatever force necessary to stop the suspect vehicle. The MOSS member situated in the DEOC followed the directive, however, was confused by the order as the belief was that the CIC or the MOSS member himself should have been issuing that tactical directive.

To mitigate the confusion surrounding the perceived deviation of the command structure in a broader sense, communicating earlier on during the course of the event that the DEOC was in fact the Incident Command Post that had overarching authority, with the ERT CP commanding the apprehension aspect of the operation, may have alleviated any uncertainty from those involved. In the moment, however, those in position to provide direction from the DEOC, would have benefitted by have broadcasting their authority and made it clear that they would be making the necessary tactical decision at that time, without interference.

It must be noted that both the CrOps Officer and the DEOC Commander have vast incident command experience and were fully qualified to provide direction during the pursuit. The CIC further acknowledged that they would have issued the same direction, but ultimately felt it should have come from CIC and not those commanders situated in the DEOC. Where that situational awareness does not exist, it is vital that the CIC be directly linked to the ICP. Whether this comes in the form of being physically present in the ICP, or virtually, through technology.

It is conceivable that, as a force, the RCMP will be required to respond to other events of this magnitude. Developing specific plans for this type of scenario ahead of time will benefit response and offer clarity of direction for these seemingly inevitable situations.

An alternative may be to explore the idea of having multiple CIC's engaged, based on the size and scope of the event, with clearly delineated roles so as not to overlap areas of responsibility. In the JSCN/Weldon situation consideration may have been to have a CIC in charge of apprehension efforts on-site, and a second CIC situated in the ICP at DEOC, if this is the preferred location, for the remainder of the division.

Ultimately there was an agreement as to the decision that was made and any uncertainty surrounding the command structure at any point in time had no adverse effect on any outcomes in the overall event. The JSCN/Weldon event may have symbolized the fact that there is no singular blueprint or universal approach to reacting to events such as these and it was this the ability of the various levels of command to work together effectively in the moment that allowed them to overcome any momentary confusion related to command.

Command summary

Responding to and commanding an event of this magnitude does not come without challenges. Regardless the level of command that was recognized at any given time, the reality was that the RCMP was reacting to a situation that was evolving and had not yet stabilized. Suspect(s) were at large, and until they were apprehended, there could be no confirmation that their spree of violence was over. The element of time was a factor that loomed large over the entire police response, until such time the suspect was taken into custody on September 7.

Despite the challenges, appropriate levels of command were activated early and used effectively throughout the incident. Any command challenges noted throughout this review were mitigated by the positive working relationships amongst the senior RCMP management in F Division. Overall, the command structures being utilized and followed provided an extraordinary response to the victims of the tragedy and the pursuit of the suspects.

The intent of this section is not to argue the strengths and weaknesses between ICS and GSB, but rather to emphasize the necessity of committing to a structure and the recognition that the processes and methodologies of these systems allow for the opportunity to make better decisions. In the absence of any policy at the National or Division level, the issue will remain as to what the standardized command structure will resemble, when localized events evolve beyond existing command structures.

Brief commentary on ICS/GSB

As previously mentioned, there was not a comprehensive organizational chart created for this incident, at the time. As such, the review team was not able to reconstruct the command structure as it might have been exactly. In lieu of having such a chart, the review team created various conceptual organizational charts, as best could be determined, from all participant interviews. As the Division and National Criminal Operations consider what might be the best command model for major events, it might be helpful to have a vision of what the organizational chart might have looked like, at the higher levels, had either the ICS or GSB models been utilized more exclusively.

Outlined below are 'conceptual' organizational charts of how the higher levels of command could have been set out, for a major event such as this.

The above conceptual organizational charts, albeit extremely brief, are not provided to endorse one model over another. The pros and cons of each model, as well of others, would require a much deeper analysis than could be effectively provided within this report. The more important reason for including the conceptual charts is to further identify how having a clear command structure, within our RCMP environment, might help us to ensure the greatest clarity of command for future major events.

DEOC functionality

Although not specifically related to commanding the overall event, the physical structure of the DEOC was mentioned on a number of occasions to be outdated and inadequate in both size of the space and workstations alike.

There is a technological gap that exists in the DEOC. The DEOC has access to the Computer Integrated Information and Dispatch System (CIIDS), described further in the Operational Communications Section. Briefly, the CIIDS system allows for the most widespread, real time picture of what resources are in play and where those resources are located. The DEOC has a dedicated television that accepts the CIIDS system that did not work on the first day. Although Informatics employees are not 'on-call', an employee was available on short notice and was able to fix the issue. This raised the point of considering an on-call rotation for Informatics. The larger problem still exists, however, where there was an inability to track resources at the initial stages of incidents such as this.

The DEOC appeared at times to be too easily accessed during the JSCN/Weldon event due to the overwhelming amount of people that were in the DEOC at any given time. The issue was exacerbated on September 4 when Inspector Devin Pugh (Inspector Pugh) was working out of the DEOC in a CIC capacity (described in the following section). The commotion in the DEOC caused him to move first to the building cafeteria and eventually to the JSCN where he setup in the command post. CIC felt better able to deal with the event from this position and felt that the DEOC was not the appropriate place for him at that time. Although the decision to move to the CP was probably the best choice for the CIC, it highlighted the issue with the DEOC space and the number of people, especially those that were not required, that were present during decisive moments.

Further, on September 7, during the pursuit and eventual arrest, senior management was filling the DEOC room, providing direction during the pursuit. The atmosphere was described at time as 'chaotic' and was limiting everyone's abilities to function at capacity. Along with any potential revamping of the DEOC as a result of this event, consideration should be given to efforts in restricting access to the DEOC to only those in senior management that are required to be present.

In late 2022, the F Division RCMP instituted a Division Innovation Committee and determined the need to modernize the DEOC as one of its priorities. The latest major incidents in Saskatchewan highlighted the need for enhanced and improved technological gaps within the DEOC. Work has begun to identify an increased capacity to stream live video feeds to the DEOC along with increased connectivity to the Android Team Awareness Kit (ATAK), Wi-Fi line speed, cellular boosters and PPSTN network coverage.

A project led by F Division Asset Management and Informatics will be working on renovating the current DEOC space with the objective of improving the ergonomics, operational space and increasing the capacity to work inter-operably with other Provincial and Municipal agencies.

Containment

Since suspect identification occurred very early in the JSCN/Weldon Event, one of the primary objectives when CIC entered the picture was containment. Perimeter control and containment are a crucial part of the immediate response to a critical incident and is a prerequisite for establishing incident command. Naturally, efforts to contain the suspect(s) initially was the most crucial task for the CIC.

Initial containment was admittedly a struggle as it took longer than anticipated, mainly due to the limited resources that were available at the time and the distance that the JSCN was from where those resources would have been deployed from. Further, once resources began to arrive, there were difficulties in tracking them (discussed below). That being said, CIC believed that the manner in which the incident was resourced was appropriate under the circumstances. OCC/MOSS were dispatching all available resources at the time and in turn, the CIC was doing its best with the resources they had. The CIC was communicating with the Saskatoon Police Service (SPS), Prince Albert Police Service (PAPS), and Regina Police Service (RPS), utilizing both Provincial Traffic and RCMP Traffic Services for assistance with containment efforts. By 9:35 am, check stops were set up on Highway 3 at Prince Albert, Highway 6 south of Melfort, and the Highway from Melfort to Kinistino. MOSS contacted SPS and initiated check stops for Highway 11 North.

All that being said, the reality that the CIC faced in terms of how resources were deployed, was that the suspect(s) whereabouts were relatively unknown. As mentioned earlier in the Chronology of Events, the suspect's Black Nissan Rogue was confirmed on video surveillance at 7:27 am on September 4 in Weldon. Almost a half hour later the perimeter expanded when a possible sighting was reported approximately 28 kilometers southeast of Weldon (near Beatty, Saskatchewan). A believed reliable sighting in Regina at around 12:00 pm caused a shift in focus to that location until later in the day when the information was discredited. Further reliable sightings would not be received until later in the afternoon on September 4 when there were multiple reports of sightings in the Crystal Springs area, between 4:00 pm and 8:00 pm. Between September 4 and September 7, numerous tips were received from the public reporting sightings both in Saskatchewan, and across Canada. Needless to say, without reliable intelligence, the best that could be done was to make an inference as to where the suspect could have been.

Over the course of the following days, the CIC deployed all available means in an attempt to narrow down the area where the suspect could have been, but it was not until the events beginning at 2:06 pm on September 7 when the suspect stole a White Chevy Avalanche from an acreage near Wakaw that any type of containment was achieved. By 3:17 pm RCMP had located the suspect traveling westbound toward Highway 11.

CIC support

During the initial stages of CIC involvement, there was an extraordinary amount of information being received. In situations such as these, scribes allow for the real time documentation of the CIC critical decision making processes and the resultant tasking of resources in order to meet the objective(s). Strategic conversations had by the CIC in order to reach decisions can be captured by scribes and the documentation of these decisions can assist in answering many post-event questions based off the principle of 'what did we know and when did we know it'?

The CIC has a dedicated scribe; however, during this time that resource was diverted and another scribe was not requested. Instead, CIC utilized another regular RCMP member to accompany him, in a scribe capacity. Although not ideal as the replacement scribe was not trained, the CIC did what it could in order to properly document information and decisions. Nonetheless, a dedicated scribe for the entirety of the event would have been beneficial.

Common Operating Picture (COP)

Inspector Pugh admittedly had limited knowledge of where general duty resources were located at any given time when he took over CIC duties on September 4, which highlighted the need for an all encompassing Common Operating Picture (COP).

A Common Operating Picture is a display of relevant information that enables those in command and control of a situation to make informed decisions based on situational awareness. When performing at its best, a COP is available on a single display where information (such as location of resources) can be viewed by more than one command.

In the case of the JSCN events, a COP would have been useful, not only for CIC (who (located on site), but also for the DEOC (in Regina). As the event gained attention nationally, leadership in Ottawa began requesting updates and information. The demands from NHQ became unmanageable as everyone in the home division was already heavily tasked with no one to delegate to. NHQ did send assistance; however, by the time the resource arrived on September 6, a large portion of time that any further assistance could have been offered, had passed.

Operating Picture capabilities may have alleviated some on the pressure experienced with providing updates to National HQ; however, there are several benefits that can come from having a NHQ resource directly at the event. When NHQ is kept apprised of the situation, especially in real time, it puts them in a better position to assist rather than viewed as an added layer of reporting structure.

Alternatively, for those divisions who are engaged in proficient Emergency Management Systems (EMS), there may also be a remote option through these systems a receive regular situational reports and to have access to the event electronically. Although EMS not a focal point of this review, it is worth mentioning as an option at this stage.

For evolving incidents such as the one that occurred at the JSCN/Weldon, a real time COP is essential. Resource allotment was a large part of the initial response as command was dealing with securing multiple scenes as well as containment. Knowing what resources were available and where they were located, was crucial and has been addressed in previous reviews of this nature.

To mitigate the absence of a COP, steps were taken to create a 'makeshift' COP through members utilizing CIIDS (via mobile workstations), members that had access to the ATAK app on their cell phones, and the SAMM function on mobile workstations. The SAMM feature, as will be discussed in the review of Operational Communications, offered some remedy to tracking; however, it was dependant on an individual member's awareness that they could update their status, as per policy, on their own. Although the combination of these functions increased the ability of the various Commanders to allocate resources, they did not provide a fulsome picture of situational awareness at any given point.

ATAK will be mentioned at various points throughout this document as a potential remedy to tracking and communication gaps that occurred during the JSCN/Weldon event. As such, what follows is a brief overview of ATAK and its capabilities in order to provide context to areas where it is mentioned.

ATAK is a software application and mapping framework for mobile devices that promotes effective information flow and communications from the field to the various command locations (mobile command posts, DEOC). The app's capabilities also include text messaging, distance measuring tools, access to satellite imagery and terrain, chat and video communication, and tools to share information that will increase safety and collaboration. ATAK can provide a real-time view of operations by showing member locations on multiple devices, such as android phones or large-screen televisions. This information can be shared locally, regionally, and nationally.

The RCMP interest in ATAK as a contributing element to a COP stems not only from the tactical advantage that it offers, but more specifically from the MacNeil Report, which provided the following recommendations related to COP's.

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Operational availability

The CIC immediately identified the requirement for air support when notification of the unfolding events on the JSCN was received on the morning of September 4. The fact that the suspect(s) had yet to be located and were said to have been mobile, in a vehicle, brought about the evident need to locate and contain he suspect(s). Utilizing aircraft in an effort to contain and locate the suspect(s) was seen as a viable option.

F Division Air Services was contacted by the MOSS Unit on the morning of September 4 and were told that the Cessna aircraft was not operational at the time. As such, Saskatoon Police Service was contacted, resulting in their SPS plane being airborne by approximately 8:00 am. The Cessna is the aircraft that the Critical Incident Program most often requests [REDACTED]. The SPS plane has the same capabilities and is often requested instead the RCMP asset. [REDACTED] however, the mission equipment on this aircraft is obsolete and requires significant upgrading. The product produced [REDACTED] is severely lacking in quality and would have been ineffective for use in the JSCN/Weldon event. The similar type aircraft from O Division (GMPB) and C Division (C-GMPQ) had updated equipment and was in better position to assist should there have been the requirement for quality photos and/or video.

This inability to readily assist with operations led to an underlying belief that contacting and obtaining RCMP Air Services and their assets is difficult and cumbersome. If the assumption is that RCMP assets are difficult to obtain or that they will be unavailable, alternative air support is generally sought for urgent requests, as was the case with securing the SPS plane.

Air asset management

Inaccessibility is not necessarily the issue, however, when you gain an understanding of the ownership of F Division air assets. In F Division, the Federal Government does not own the planes, but rather the Provincial Government leases them. In the case of MPW for example, any upgrades to the aircraft, [REDACTED], need to go through the Government of Saskatchewan. The Cessna, which is a federally owned aircraft had been grounded for ergonomic and egress issues. Although there is a recognized need to upgrade mission equipment and remedy the issues preventing the use of certain assets in order to resume those duties in support of frontline policing units, the Provincial government seems reluctant to supply the funds. F Division Air Services have submitted multiple business cases to the province and now, following several high profile cases, are hopeful of making progress. All this puts F Division Air Services in a difficult position as far as being able to efficiently assist with operations.

After the SPS plane was secured, K Division's helicopter (FMPP) was requested and arrived in the Rosetown area by 2:06 pm on September 4. During this time, information was being reported that both suspects were in Regina and were exploring options of turning themselves in. A tip from the public was also being reported to the Regina Police Service advising of a sighting of the Black Nissan Rogue that had been part of previous Public Alerts. A plate number of the vehicle was not relayed to the operator; however, the plate number for the vehicle that was known to have been driven by the suspects was assumed by the operator and forwarded as part of the tip. The plate information provided additional credibility to the tip and was the catalyst first for re-routing FMPP to Regina and secondly for another Public Alert being issued at 12:07 pm, advising of a suspect sighting on Arcola Avenue in Regina.

Ultimately there were no confirmed sightings of the suspects or the vehicle in Regina from that point onward. The tip information that was received caused a momentary shift of focus for a limited number of resources to the Regina area but did not divert the on-going efforts that were being made in the JSCN and Weldon areas.

At this time, however, other air assets were being secured from across the country and led to the decision to stage all air assets in Regina. This decision ended up being a hindrance as travel to the JSCN area required an additional 40-minute flight north, when required. To mitigate this, a decision was made to stage FMPP at JSCN, as it was the slowest of the aircrafts.

Scheduling issues

Most gaps between F Division Air Services and the CIC revolved around the scheduling and coordination of aircraft. At one point it was noted there were six different requests coming in from various people. CIC, DEOC, OCC were all in positions where they were directly contacting the Tactical Flight Officer (TFO), pilots, base managers, or the OIC of Air Services. Because there was an on-going crisis, protocol was skipped.

Most notably perhaps, was during the afternoon on September 7, after the suspect was identified at a residence in Wakaw, it was discovered that all three air assets were down for fuel in Prince Albert (discussed later). CIC was of the understanding that FMPP (helicopter) was available for air surveillance; however, they were unaware that MCU had utilized the helicopter earlier, causing it to require re-fuelling. This caused a delay at a critical time and perhaps highlighted one of the key issues during this incident; there were too many entities (Regina Air Base Manager, F Division Air Services Line Officer, CIC, MCU, Tactical Flight Officer) competing for position with Air Services when the single point of contact such as an Air Boss or a Flight Coordinator (explained below) that could have directed all inquiries, was either not assigned or under utilized.

This led to a lack of clarity in the various roles and ultimately led to confusion on the part of the aircrew as to whom they should be taking direction from. For example, GMPW was being utilized [REDACTED], but also as a transport aircraft. There was a particular instance where the pilot was directed by the Regina Base Manager and the Line Officer to take on full fuel should he be deployed for longer periods [REDACTED], but then was asked to transport a full load of passengers out of Melfort. The aircraft has a maximum take off weight, and with full fuel, the pilot was unable to take all of the passengers because he had previously been instructed to take full fuel.

These particular decisions were not made by an Air Boss but rather by individual pilots based on direct communication with those commanders that they were speaking with first hand. During a time of crisis, a pilot will follow direction and because people were calling pilots on their own, they followed direction and at times, were essentially flying with little purpose. This may have been the cause of all assets being down for fuel at the same time in Prince Albert, just prior to the final pursuit on September 7. This again caused a short delay and all aircraft were eventually deployed, which was not an ideal situation either. Identifying a situation where you have four aircraft in the same area would have been better managed by an Air Boss, or prevented all together due to safety reasons.

Further, from the perspective of National Air Services Branch (ASB), ascertaining what was required for resources when trying to deploy them to F Division, it was difficult to get information. A first point of contact would have been the Flight Coordinator; however, that role was not utilized. This resulted in having to rely on the already deployed aircrew to provide the information required to adequately support F Division Air Services. Communicating directly with a Flight Coordinator or if the assignment of an Air Boss was designated to this event, this scenario could have been avoided.

Air Boss and Flight Coordinator distinction

A Flight Coordinator and Air Boss have two separate roles. The Air Boss is can typically be any subject matter expert (SME) from Air Services who is experienced in both aviation and dealing with Major Events or Critical Incidents. An Air Boss is typically embedded in the Incident Command Post.

Each RCMP Division has a Flight Coordinator assigned that, for lack of a better term, makes everything happen with regards to assigning air assets. Flight Coordinators view and prioritize the various requests, assess aircraft capability, assess operating environment, apply dispatch techniques, task aircraft, assign crew, and manage schedules. One of the most important assets in any division is the aircraft and the only way to have them operate efficiently, is through the Flight Coordinator. The Flight Coordinator is located at the base of operations and is responsible for directing operations at the base level, in accordance with operational flight requests and directions from the Air Boss. At the very least the F Division Flight Coordinator could have been that conduit from Air Services to the various requesting units but was seemingly omitted from any conversations about air assets.

The primary shortcoming in the Air Services response to the JSCN/Weldon event was a combination of local command's not requesting the assistance of the Flight Coordinator and not assigning the role of an Air Boss as part of the response.

This omission was addressed as the following recommendation from the 2014 MacNeil Report.

The requirement to have an experienced person that is familiar with 'all things' Air Services and put them directly in DEOC or the CP was a crucial step that was overlooked. What resulted was the potential strength of Air Services not being deployed properly.

There is an apparent discrepancy to whom the responsibility falls to for assigning an Air Boss. Although the Air Services Line Officer was called in to F Division HQ on the morning of September 4 as part of the initial call out, he was not designated as the Air Boss at that time. Amongst the planning that occurred in those early stages, the role of an Air Boss was not discussed, nor was it suggested, nor was it organically assumed by the Air Services Line Officer. Despite the Air Services Line Officer being present for DEOC briefings, a designated Air Boss was not directly situated in the DEOC or alongside CIC and were not in a position to contribute to tactical decisions being made in real time. Having this ability would have alleviated many of these gaps in communication. In reality, F Division Air Services do not work with the CIC very often and there is an apparent disconnect between the two entities as CIC have had limited success in obtaining RCMP assets and in turn, Air Services appreciates their frustration.

Regardless of whose responsibility it was to assign an Air Boss, the fact of the matter was that everyone involved desired the assistance of Air Services, but no consideration was given to appointing a single point of contact in order to make the process more efficient. This resulted in a loose structure of requesting Air Services assistance through whatever means was necessary, at any point in time.

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The following was a recommendation from the 2014 MacNeil Report:

Despite this, F Division Air Services, the Critical Incident Program (CIP) and, by extension, the Emergency Response Team (ERT) had seemingly not practiced and trained together in an effort to better understand their interoperability of skills and tactics. This resulted in both programs not fully understanding each others capabilities during the JSCN/Weldon event, and forced everyone to learn on the spot.

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Whether the result of communication issues, technological gaps, or the lack of interoperability with Air Services, the ability of CIC to respond appropriately to the situation was diminished.

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Since the JSCN/Weldon event

Since the events on the JSCN/Weldon, a gap in availability of aerial surveillance capabilities across the country was identified by the Air Services Branch and, as such, steps are being taken to establish working groups with CrOps representation be brought together to identify and confirm high-level requirements and possible solutions. As a result of the recent high-profile incidents (such as the JSCN/Weldon event), there has been a greater demand for Air Service support. To better provide support to critical incidents, Air Services are in the process of reviewing their current service model in order to provide 24/7/365 support.

MCU response and assignments

Staff Sergeant Rob Zentner was on-call for MCU on September 4 and was notified of the evolving situation at the JSCN at around 7:00 am. The information he received at that time was that there was at least one deceased and two suspects. Call-outs to team members commenced immediately through their normal process.

Upon arrival at their Saskatoon office and prior to departure to Melfort, a number of related PROS complaints were reviewed and it became apparent that the number of victims was rising quickly. As such, arrangements for additional resources outside of the immediate MCU team that was responding, were made. By the time the responding MCU team had departed from Saskatoon to Melfort, the number of deceased had increased to seven. The entire on-call MCU team of eleven members were utilized in addition to the following:

• Ten members that were on Operational Availability (OA)
• Canvassed members that were not on OA
• Additional Saskatoon MCU Teams
• 2/3 from the Regina MCU Team
• Historical Homicide Unit members
• F Division GIS resources
• K Division MCU resources
• K Division MCU took on-call for the F Division MCU.

One Saskatoon MCU member who was unable to deploy on September 4 was tasked with gathering information over the phone directly from the responding Melfort RCMP members while others were preparing for departure. This allowed for a timely briefing to occur amongst the Saskatoon MCU resources at 8:45 am, prior to their departure. The following information was provided at that time:

• An initial complaint was received by the Melfort RCMP reporting the incident
• Approximately twenty other complaints had been received since
• There were reports of two people breaking into residences on the JSCN
• ERT/Police Dog Services (PDS) had been deployed to the area in an effort to locate and arrest the suspects
• Suspects were identified, descriptions were provided for them as well as the vehicle they were reportedly in possession of (Black Nissan Rogue)
• The JSCN Band Office was being used to stage victims and STARS had already begun transporting victims out of the community
• Seven people were confirmed to be deceased and the exact number of injured was unknown at this point
• Police were also responding to a complaint in Weldon, where a younger male showed up with a cut up face and asked to go to the hospital. It was unknown if this complaint was related at this point in time

Following the initial briefing, a further update was received from Staff Sergeant Simons advising that the number of deceased had risen to eight, with fifteen injured, and at least sixteen separate crime scenes. The deployment to this mass casualty event was unprecedented and as such, the scope of the MCU response changed from a 'traditional' call out. For example, Superintendent Josh Graham (Superintendent Graham) who was in charge of the Major Crimes Unit, deployed to the Melfort/Prince Albert area to work directly with his team. Under normal circumstances the Officer in Charge (OIC) of MCU would be made aware of a team being called out, but would not attend the specific call for support. The OIC, who was off work at the time, returned promptly and provided further investigative support to the MCU team and shouldered many of the bureaucratic tasks that eventually would allow the team to function more efficiently.

As set out previously in the Command Structure section, because of the size and magnitude of the unfolding event, the DEOC became the Incident Command Post and was the location that many decisions, some of which affected MCU, were being made. For this reason, there may have been value for the Superintendent to travel to Regina and be present in the DEOC instead of fulfilling his role, closer to the scene. Having said this, Superintendent Graham liaised with the DEOC regularly, was part of the DEOC briefings that were being held, and there was MCU representation situated in the DEOC over the course of the three days. Despite this, there were occasions when key information was not communicated through the proper channels to MCU resources. This was more due to lack of identified workflow and these considerations will be discussed further in the Major Crimes Branch Response portion, later in this document.

MCU operates within a Major Case Management framework which is a methodology for managing major investigations that provides accountability, clear goals and objectives, planning, allocation of resources and control over the speed, flow, and direction of the investigation through the following nine principles:

• Command Triangle
• Communication
• Leadership and Team Building
• Management Considerations
• Investigative Strategies
• Ethical Considerations
• Accountability Mechanisms
• Legal Considerations
• Partnerships

One of the first steps when functioning within this framework is the requirement to identify a Command Triangle (CT) consisting of a Team Commander (TC), a Primary Investigator (PI), and a File Coordinator (FC). In a 'normal' investigation, all MCU resources are aware of the reporting lines and information flows from the various investigators through the CT in order for a methodical decision making process can take place.

In the case of the response to the JSCN/Weldon event, CT roles were based off skill and experience and this was evident in the forethought that was given to investigative roles that were assigned. The TC was one of the most experienced homicide investigators in the province. The PI position wasn't assigned to the member next in line to take on this role and instead it was transitioned to a more senior and experienced member who also had a vast amount of homicide experience. A member that excelled in organizational skills was tasked to be the FC.

Members were shifted from roles of 'Field Investigators' to various positions. Some were assigned as being 'Interview Coordinators' as it was anticipated that there would be a number of key interviews (witness and suspect) that would be required with teams of members completing those tasks. There were multiple scenes to secure and process so a Crime Scene Management Team Leader was identified. As the situation was fluid and it was not known what, if any, timely warrants would be required, a Judicial Authorizations Team Leader was identified. Given that the suspects were not in custody, a 'Target Apprehension Manager' position was created to coordinate the efforts underway to locate and arrest the suspects. Although some of the 'sub teams' had their own internal reporting structure, all eventually reported to the TC, creating somewhat of a hybrid command. This modification did nothing to lessen the effectiveness of the reporting structure but rather it worked to streamline the communication processes with MCU.

Based on the number of victims (both injured and deceased) there was a quick realization that a significant amount of work would be required for the Family Liaison Role. Communication was made early on with Sergeant Ashley St. Germaine (Sergeant St. Germaine) of the Prince Albert General Investigative Section (GIS) and she was tasked to take the lead in organizing the Victim/Family Liaison role. This tasking occurred while MCU members were still in the initial stages of processing the various scenes and making effort to apprehend the suspects. The actions taken by the Victim Support Teams are explained in greater detail later, in the Mass Casualty/Victim Response portion of this review.

In hindsight, the TC indicted he would have liked to have identified these lead roles earlier; however, the point at which they were assigned had the desired effect and ultimately lessened the workload for the Command Triangle (CT) and made the flow of information more efficient.

Both the TC and PI's phones were admittedly 'ringing non-stop' from the onset of them being called out and for much of the following days. The ability to properly document decisions and direction is crucial in these moments. It was noted that a dedicated scribe for the PI and TC would have been beneficial in order to take the onus off those in these crucial decision making roles to recall and document granular details of conversations or meetings that will likely be subject to some type of future disclosure.

Resourcing

As the situation on the JSCN and Weldon was evolving, essentially any investigative resource under the major crime branch was accessed. Inspector Chamberlin of DEOC reached out to the MCU team early advising them of whatever resources they required, they would get.

Federal investigators were used to assist with any [REDACTED], Special Tactical Operations (STO) teams from Alberta, any available resources from F Division, D Division (Manitoba), and PRT resources from the province assisted with scene security. [REDACTED]; [REDACTED] was engaged should they have been required; and Polygraph was engaged to deal with potential suspect interviews. All FIS resources supported further by Traffic Reconstruction members and Bloodstain Pattern Analysts (explained later) were engaged and assistance from the Division Criminal Analysis Section (DCAS) was requested almost immediately.

Although MCU teams do not have embedded analytical support, the DCAS manager contacted MCU while they were travelling to Melfort to determine what support they required. MCU requested analytical support from DCAS and were granted two analysts that attended the location along with MCU with others supporting remotely. One of the attending analysts worked with the main investigative team and the second analyst worked with the target apprehension team. Analytical support received specific tasking from MCU which was clear and efficient for the DCAS resources that were deployed. DCAS resources were included in briefings and relayed information back to their managers located in Regina, in a timely manner.

Aside from the natural lack of resources upon the initial call out, MCU members did not identify any additional resources that may have assisted with their duties, aside from a system for tracking the resources that were already deployed. The ATAK system was mentioned as a remedy to this and will be covered in more detail in section(s) to follow.

Logistics

MCU arrived at the Melfort Detachment at approximately 10:45 am on September 4 and utilized the detachment coffee room for their initial base. It was quickly ascertained that this was not an ideal location as the room was too small and there was insufficient bandwidth for ROSS/Internet/Shared Drive access to accommodate their needs. Meanwhile, they still had to allow for the detachment to maintain other normal business activities without interference. As such, on September 5, the MCU team moved locations to the District Support Services Building in Prince Albert where they would remain for the duration of the event. Once requests to bolster the technology capacity were made, the Informatics Unit (described later) outfitted MCU with laptops, a smart board for planning and mapping purposes, portable radios, and the appropriate bandwidth for the movement of data.

Further to this, one of the mobile CP's (mentioned earlier) was set up in and used as a staging area for the MCU, Crime Scene teams and interview teams on the JSCN. The trailer was set up at the Band Office, beside the Critical Incident Commander in the ERT CP (described earlier), and the third mobile CP that was being used as a base for Crime Scene Security, Community Security, and other RCMP Support Services.

From that point onward, MCU was based out of Prince Albert. The decision by MCU to move their 'home' locations did not affect their ability to respond and investigate. If anything, the move enabled them to have a larger space with better access to technology. This move had no affect on the field investigators other than a minimally longer drive back to Prince Albert, when required to do so.

The number of scenes and exhibits that MCU and FIS were processing was uncommon. As will be explained later in this section, priority was given to any outdoor homicide scenes due to the extent of the confirmed victims. The Melfort Detachment had already arranged for door to door searches to be conducted for additional victim's/crime scenes and reported back to MCU upon completion. This was done in conjunction with the ERT Team. Further open area searches for victims were conducted with drones.

MCU initially used the Melfort RCMP Detachment to store exhibits; however, its capacity became quickly overwhelmed by the amount of seized items. Exhibit storage was eventually transferred to the District Support Services Building in Prince Albert and finally to the MCU Exhibit Storage Room in Saskatoon. There were nearly 700 exhibits seized as part of this investigation.

Normal practice for police is to have as few members as possible seizing exhibits. This lessens the strain on proving proper continuity for key exhibits. The fewer hands that touch an exhibit the less articulation is required to prove the exhibit has not been tampered with. For this reason, in a typical homicide investigation, there will be one identified member tasked with seizing exhibits.

There were over 40 separate crimes scenes including buildings and vehicles in the JSCN and Weldon. The number of scenes did not directly relate to the number of victims. If victims moved from one point to another after being injured, the number of scenes increased and became more complex. There was evidence that the suspect was driving a number of different vehicles which also increased the number significantly. To add to the complexity, some of the scenes were a significant distance apart. As such, tasking only one member with seizing exhibits was not an option.

A decision was ultimately made by the MCU Exhibit Coordinator that, if there was no MCU crime scene manager at the scene, FIS was to seize all exhibits and turn them over to a the MCU crime scene manager. When Bloodstain Pattern Analysis (BPA) became involved, they seized their own exhibits as well. Given the number of seized items, exhibit management became very time consuming.

RCMP Forensic Lab Services

National Forensic Laboratory Services (NFLS) is part of a single public laboratory system with three sites located in Ottawa, Edmonton and Surrey.

With respect to the forensic lab submissions specific to the JSCN/Weldon event, the MCU Team discussed the most relevant exhibits and, based on circumstances, decided what was to be sent to Forensic Lab Services (FLS), for analysis. The Edmonton FLS was utilized in this case. Investigators generated a document, sequentially listing the proposed exhibits, along with the requested analysis by the MCU Team. This document was sent to the lab and was ultimately declined as it was not in the standard C-414 document format. This resulted in the crime scene management team's perception of FLS process delaying submission.

To understand the method of submitting lab exhibits, one must also consider the protocol that FLS must go through when they receive a request. From the FLS perspective, the C-414 is a standardized form that contains all of the necessary fields of information that FLS requires to begin processing. The use of this standardized form permits streamlining and ensures consistency and effective exhibit processing for case submissions. Further, it is a form that is used many different units throughout the lab as the case progresses, and is used by laboratory staff at many stages throughout the process. If, in a situation such as the JSCN event, FLS was to accept a 'non-standardized' form there is a real possibility that communication would have to occur after the fact, between the Forensic Assessment Centre (RMS) Strategist and the investigator for further clarification. Further, the information contained in the C-414, when received by FLS, has to be manually inputted into another system by the strategist, which is also time consuming.

There is an understanding from FLS that in this particular case, the requirement of the C-414 was cumbersome and time consuming, considering the events took place in a rural community, and that investigators had limited access to the internet and digital tools that would normally make such a submission easier. Further, given the time required to process the large number of crime scenes and exhibits, and the fact that a large file was shared with event details, this administrative requirement was an additional time and energy burden. For future events of this magnitude, the RMS could agree to support the transfer of information from another document into the C-414 form; however, the draft will need to be reviewed and approved by the investigator prior it being accepted by RMS. This communication would be crucial in order to avoid any information being misrepresented, or left out.

Current FLS practice is such that upon receipt of a lab request from an investigator, the RMS Manager will assemble the appropriate specialists to ensure there is a team approach. For future mass casualty events, FLS appreciates the need to bring this internal group together in a timelier fashion to ensure an efficient and effective approach for the submission of exhibits. This may require additional interaction with investigators in order to understand the context of the case and ensure the most probative exhibits and known samples are submitted first and as quickly as possible.

Many of the misconceptions around the process of forwarding exhibits on large, complex events may have been resolved by the investigative team and the RMS strategist engaging in early conversations regarding the capabilities that FLS had to potentially assist investigators with transferring information from their document to the C-414 format. Had this communication occurred, the investigative team may have continued on with their work and FLS would have been receiving the information in the format they required.

It is worth noting that as part of their modernization initiatives, the NFLS intends to develop an electronic tool that will be less cumbersome and more dynamic to use than the current C-414 template. This tool is not yet available for use.

Command clarity

Command structure was reviewed in an earlier section of this document; however, it is worth noting, from a MCU perspective, how the CIC, DEOC, and OCC/MOSS roles were viewed. MCU's reporting lines were clear. All information flowed from the MCU CT to the OIC of MCU (Superintendent Josh Graham), who then passed it along to the division managers situated in the DEOC, and ultimately the Commanding Officer of F Division.

Any issues that were noted between the various commanders resulted more from limited communication rather than any uncertainty of command.

Communication

Due to the number of teams that were tasked out (as noted above in the MCU Org Chart) and the fact that many teams were not in the same geographic location at any given time, the MCU Team was unable to hold regular 'fulsome' briefings. The CT did what it could to debrief with the various 'sub-teams' that were created and all MCU members were kept apprised of the pertinent information they required.

Any areas of concern with communication stemmed from not having a MCU resource embedded or otherwise linked directly to the OCC. To illustrate this point, following the broadcast of the Public Alerts that contained suspect information, there was a large influx of complaints being called in to the OCC regarding potential sightings. During this time, the MCU Tips Intake Coordinator was situated in the DEOC, not in OCC. It was later discovered that that a number of public tips relating to sightings from the Wakaw area on September 4 and 5 were never forwarded to the tips coordinator, and ultimately to the MCU investigators from the Apprehension Team. MCU investigators held the belief that the DEOC was monitoring/coordinating all of the resources outside of the MCU Investigation, including any of the complaints received by OCC. Since the Tips Intake Coordinator was not monitoring the calls in the first instance being received by OCC, some of the sighting complaints did not make their way to investigators until after the fact.

By this time the CIC was fully engaged in apprehension efforts and were working alongside the MCU member tasked as the Apprehension Team Leader. An agreed upon communication strategy for CIC and the Apprehension Team was discussed and it was agreed the two entities would have to work closely together as both of their objectives (apprehension) were clearly aligned. The Apprehension Team eventually relocated to another building, which impacted the timeliness of communications and forced them to rely on frequent phone calls. It should be noted that an unrelated ERT deployment happened during this time, which may have rushed the decision to relocate the Apprehension Team and may have overshadowed the need for both to remain in the same location.

Had the MCU Apprehension Team had knowledge of the incoming tip information as it was received, they could have strategically re-allocated resources. If the Tips Intake Coordinator in the DEOC had an understanding of the how the tips were being handled by the OCC or vice versa, the belief is that there would have been a more seamless transfer of the information. For context, the OCC and DEOC are not physically located in same work space but they are in close proximity within F Division HQ in Regina. Despite this, the two units have little interaction.

The topic of Triaging Tips will be further discussed in the 'Operational Communications' section of this report.

Based on the above information, on September 15 the decision was made to complete a full audit of all complaints received in Saskatchewan between September 4 and 7 by DCAS. This audit is on-going.

Forensic Identification Services (FIS) response

When a crime is committed or disaster occurs, FIS members are called in to secure, record, and document the scene as well as collect and package exhibits for analysis. Depending on the type of investigation, this may include crime scene photography and sketches, fingerprint, footwear and tire-track examinations, looking for trace evidence, bloodstain pattern analysis, and collecting samples for DNA. The evidence collected is used to identify suspects or victims, and is interpreted and presented in court.

There are more than 70 Forensic Identification Sections (FIS) units across the country, 5 of which are located in Saskatchewan (Regina, Saskatoon, North Battleford, Prince Albert, and Yorkton), that provide Forensic Identification services to RCMP detachments, Canadian police services, and assist National and International organizations in disaster victim identification.

F Division FIS units each have a member that is on-call daily, following every shift and in position to field questions from investigators that may be at a scene and respond, when necessary. Further, F Division has at least one member scheduled to work in the office everyday of the year.

Specifically relating to the JSCN, once contacted, the on-call FIS member from Prince Albert immediately realized the situation exceeded the capacity for a single FIS unit to deal with and contacted the Division FIS Manager, who was at his residence. The FIS manager had all of the contact information that he required on his phone to make immediate call outs to deploy the other 5 FIS Units in Saskatchewan.

FIS does not always make an immediate response to scenes and does not attend every call. FIS will determine the potential for evidence and the urgency of the scene based on information provided by the first responder to the scene. There are clear instructions (flowchart) as to making a decision whether or not a FIS resource is to attend a scene when contacted. Needless to say, the events that occurred on September 4 received an immediate FIS response when called.

Resourcing

Naturally, at the onset there were limited FIS resources as other units were in the process of travelling to the area. Prince Albert FIS arrived at the JSCN along with Saskatoon FIS members and were directed to immediately begin processing outdoor scenes where there was a deceased. This was a mindful decision to not only preserve any evidence from the elements but also to avoid the negative perceptions of family members or public viewing the deceased for an extended period of time. As additional FIS members arrived, team leaders were identified and were in charge of each individual scene and were the point of contact for the FIS Manager. Scenes were prioritized as those with deceased persons (outdoor) as the priority, followed by indoor homicide scenes, blood letting scenes, and break and enters. As scenes were completed, the FIS Manager would assign team leads their next assignment.

Ultimately, FIS would be responsible for processing the over twenty scenes (eight with deceased persons, ten with surviving victims, and four vehicles). Further to this, FIS was required to attend ten autopsies at various times.

From a resource perspective of what was available in the division, the dispatch of members was deemed adequate. Given the circumstances, more resources are always desired; however, all available FIS resources in the division were drawn in with others being called in, as required after the fact. Prince Albert Police Service (PAPS) provided 1 FIS member, and Bloodstain Pattern Analysis (BPA) specialists were called in from outside the division as well (explained later). Resources from Regina FIS were not contacted for assistance as the Division Manager was mindful that, although what was happening on the JSCN and in Weldon demanded a robust response, should another call have come in that FIS was required to attend, he would have access to another FIS Unit. Further, it was anticipated that the various deceased bodies would be transported to either Saskatoon or Regina for autopsies, which ended up being the case. Having an available unit allowed for those FIS resources that were processing scenes, to continue their work.

Crime scene security for the various locations was resourced by the DEOC with Saskatchewan Highway Patrol, Saskatchewan Environment Resource Management, K Division members, D Division members, and whatever available resources from F Division were still available. These additional resources were deemed essential for the crime scene management portion as they contributed to the FIS members never feeling pressured to complete a scene examination, allowing them to complete their duties as best they could.

Whenever a major incident such as this occurs, police naturally want to help. In reality, however, not every member can be called in for duty to assist. As mentioned, not all FIS resources were deployed as part of the JSCN and Weldon incident. Some of these resources felt that they may have been overlooked or were wondering if there was some type of negative reason that they were not utilized. The Division Manager was sure to stay in contact with those units or members that were not brought into the incident and included them in contingency planning and in final briefings.

FIS equipment

The circumstances surrounding many of the scenes on the JSCN were such that many family and/or community members were present and remained on scene during the FIS examination. There were many cultural factors at play that members on scene were aware of and did their best to accommodate. These cultural factors will be explained further in the Mass Casualty/Victim Response section of this review.

Given the fact that there were a number of family and/or community members at each scene, FIS members naturally interacted with them at times. FIS members occasionally had to provide instruction for community members to re-locate further back from crime scenes. For the most part, family and community members complied with no issues; however, there were reports of FIS members being completely exposed to the public, which is not an ideal situation for them to conduct their work. If any contentious issues arose, a member of a Family Liaison team was usually available to speak with family members regarding forensic integrity and the need to allow FIS members to do their work. In one instance where there was a body lodged between two vehicles. Scene security was asked to reposition their vehicle in order to block the family's view when the blanket tarp was removed. During the course of this review, interactions with JSCN community members revealed some concerns over the amount of time that certain scenes remained visible to on-lookers, which is natural. Ultimately, FIS members did their best to conceal any deceased or evidence that would have upset any non-police that may have been present; however, there may have been instances where exposure was causing unintended strain on those present.

Although tarps were available at all scenes, some type of private enclosure (fabric wall, tent) would have assisted with covering the deceased and also to act as a shelter for the FIS members to relocate to should they have required it while processing outdoor scenes.

The trailer (mobile CP) that was being utilized by other units as a 'home base' was not a feasible option for FIS to use. A larger, on site base would have served as a point of contact for FIS, including a place to display an org chart for members, org charts mapping out scenes, photos of any physical evidence, or other FIS intelligence/information sharing whether informal or via regular briefings.

Incidents of this magnitude naturally attract attention not only on a divisional level, but nationally as well. The Division FIS Manager made sure to brief his supervisor on a daily basis in order that accurate information can be relayed to those with a vested interest in Ottawa.

Body removal

During body removal, everyone in charge of scenes was aware of the possibility of family members wishing to perform cultural ceremonies prior to removal and, when requested to do so, it was facilitated. Family and/or community members were present at most, if not all scenes. There were times that upwards of 60 people were outside of a scene waiting for directions from FIS. FIS members that were processing the various scenes were cognizant of the impact of such an event on the community and were sensitive to the needs of the community in allowing these ceremonies to take place, despite delaying the examination process. The FIS members at some of these scenes experienced difficulties where vehicles were community members were present. There were times when FIS were fully exposed to victims' families, who were sensitive about FIS members touching or moving the bodies during the scene examination. These types of issues were mitigated when Family Liaison Team members assigned to the various victim families, were able to provide communication that balanced the investigative need for forensic integrity and the need for victim families to perform cultural ceremonies on their loved ones. Following the processing of scenes, any family member requesting time with the deceased were granted whatever time they required.

Body removal was done as quickly as it could have been given the circumstances. Two coroners eventually attended each scene and the queue was significant given the number of scenes. Naturally, it would have expedited removal had there been more coroners available. Efforts were made by the Coroner's Office to streamline their attendance at scenes and they eventually split their teams in an attempt to expedite the process.

Bloodstain Pattern Analysis (BPA)

Requesting BPA resources attend any given scene is a decision that is made only after a FIS member has attended the scene and, in conjunction with the investigator on scene, determines if BPA analysis would aid the investigation. BPA can provide input and opinion on scene examinations, exhibit examination, consultation on scenes and exhibits, training sessions on BPA, and case photo review and analysis.

BPA can contribute to crime scene examinations regarding the location and description of individual stains and patterns, mechanism(s) that created the stains, direction a blood droplet was traveling, area of origin (location of blow into blood source), type of object used in attack (edged, blunt, firearm, etc.), minimum number of blows, presence of a subject at a scene - linking suspects, victims and objects, location of the victim, perpetrator, and objects during events and their movements, and the sequence of events. BPA was reached out to for assistance due to the significant amount of blood letting at the various scenes.

BPA members are located in British Columbia (E Division), Alberta (K Division), and Nova Scotia (H Division). The Edmonton BPA resources responded from K Division. The Edmonton BPA section is located in the RCMP Forensic Laboratory in Edmonton and provides 24 hour services to K, F, D, G (NWT), part of V (Nunavut) Divisions along with other police agencies in Alberta, Saskatchewan, and Manitoba. BPA sections are now divisional supplements, whereas they used to be national. K Division led the BPA response to the JSCN. In total there were 2 BPA resources utilized from K Division and 1 from E Division.

Specifically, in relation to the JSCN, K Division BPA was contacted in the early afternoon of September 4 by a FIS member that was on scene at the JSCN. This is a normal process whereby an attending FIS member will contact BPA to determine whether BPA assistance would be beneficial. At that time, the BPA member requested photos of the scenes they were being consulted on in order to make a determination of whether to attend. After it was ascertained that attendance was necessary, by 10:00 pm that night, BPA was of the understanding that they would be attending to process 5 scenes and plans were made to depart the following morning from Edmonton. The Edmonton BPA resource had access to an understudy and was confident that processing the 5 scenes was not unrealistic and thus, did not call any additional resources at that time. BPA arrived the following day and were advised that there was now a requirement to process all of the scenes. It was at this time that another BPA resource would be required and one was secured from E Division.

The communication and teamwork amongst the various units when it came to processing the scenes was excellent according to BPA resources. The time that it took to properly process the various scenes was done as quickly as it could have, partially due to the attending FIS members' ability to identify blood staining for further analysis by BPA, prior to arrival. This recognition may have been in part, due to obtaining appropriate training in basic bloodstain pattern recognition. When FIS employees obtain this entry level training, it provides an increased level of awareness and ability to determine whether a BPA is warranted, the best method for recording bloodstain evidence for remote BPA support, and for assessing bloodletting scenes and consulting with a BPA member:

This training used to be mandatory; however, is no longer. Further, this course is a pre-requisite to becoming a certified BPA analyst which can be a 12-18 month long process through the BPA Program.

Resourcing of BPA positions was noted to have been an issue across the country. There are simply not enough BPA resources to draw from in the event something like the JSCN/Weldon event were to occur again. As pointed out above, many of the divisions do not have BPA resources and even if all the positions were filled, they would still be short for the amount of work that BPA is being asked to do.

One avenue to mitigating the shortage of BPA positions could be to look beyond Regular Members and to consider civilians assuming some of these roles if qualified to do so. The Integrated Forensic Identification Services (IFIS) supports Forensic Identification Services (FIS) employees and includes FIS specialists, as well as civilian forensic assistants, forensic scientists, policy makers, and administrative staff. Only FIS members certified by the Director, IFIS, as Bloodstain Pattern Analysts can interpret and report opinions on bloodstain evidence.

About media relations

F Division Media Relations are staffed with seven employees who fulfill a variety of roles. Among these are managing social media, writing/assisting with news releases, internal messages to staff, and writing/issuing the public alert messages for significant incidents. The Media Relations unit and their strategic communications team fall under F Division's Operations Strategy Branch (OSB).

About Operations Strategy Branch (OSB)

OSB supports RCMP operations by ensuring that the Division is a strategically focused, aligned, and intelligence-led. The role of OSB is to coordinate client service and strategic relationships, oversee business planning, coordinate business cases, provide business intelligence and research, facilitate integrated risk management, and manage continuous improvement throughout the division.

Initial call and issuing the public alerts

To briefly re-visit the 'Initial Response' section above, the initial 911 call in relation to the JSCN was dispatched to the Melfort RCMP members at 5:43 am. Members departed Melfort at 5:52 am, travelled to the JSCN, and arrived at the first scene at 6:20 am.

The Media Relations Officers (MRO) staff began receiving notifications regarding JSCN at approximately 6:30 am of September 4 and immediately determined that a SaskAlert (Public Alert) was required based on the circumstances at that time. In the following 20 minutes, urgent calls were made between MRO resources and arrangements for both the technology to issue the Public Alert's and the wording for the alert were in the process of being completed. It should be noted that all MRO resources (even those that were not on call) had their laptops at home and had the ability to remotely access the National Alert Aggregation and Dissemination (explained below) that is required to issue the Public Alert. While preparations for the Public Alert were underway, the MRO was being informed of the numerous emergency calls that were into the OCC.

By 7:00 am the Duty Officer, Inspector Chamberlin, had granted approval to issue the initial Public Alert.

At 7:12 am, the first Public Alert message was issued to the areas of JSCN, Melfort, and Humboldt areas at 7:12 am was as follows:

The message:

A Dangerous Persons Alert is being issued by the Melfort RCMP after several calls of stabbings on the James Smith Cree Nation. Saskatchewan RCMP are responding and trying to locate two male suspects. If in the area, seek immediate shelter/shelter in place. Use caution allowing others into your residence. Do not leave a secure location. DO NOT APPROACH suspicious persons. Do not pick up hitch hikers. Report suspicious persons, emergencies or info to 911. Do not disclose police locations.

For clarity, SaskAlert is the Government of Saskatchewan's emergency public alerting program that provides critical information on emergencies in real time, so the public can take action to protect themselves.

Media Relations obtained the information they required to meet the threshold for a public alert almost immediately, which allowed for a quick approval of the planned messaging to the public. The communication between the MRO and the strategist who had the ability to input data into the National Alert Aggregation and Dissemination (NAAD) System was swift and efficient. The initial public alert was broadcast as quickly as it could have been.

The NAAD System provides the technical infrastructure of Canada's national public alerting system. The NAAD system accepts emergency alerts from Authorized Government Agencies (SaskAlert) which are then made available to broadcasters and other media distributors who voluntarily distribute them to the Canadian public. The NAAD System is not user friendly as those who are familiar with the system pointed out during the course of this review. The system was created for weather alerts but had been modified to suit other types of alerts.

The speed at which it was broadcast can be attributed to having practiced issuing public alerts. Strat Comms conducted quarterly training with Incident Commanders, Detachment Commanders, CIC, and CROPS Officers in order to create a shared ownership and promote an understanding of emergency alerting in the province. It should be noted that both the MRO and the media strategist that inputted the data in the NAAD System had their computers at their homes which enabled them to further expedite the timeliness of the initial public alert.

Once resources were present in their workspaces at RCMP Headquarters in Regina, the MRO was able to task unit resources more efficiently. Tasking included, but was not limited to, social media, completing the public alerts, completing media releases, and generating speaking notes for the Commanding Officer. To offer some perspective, over the course of the four days (September 4 to 7), the Media Relations Unit received more than 550 requests from various media outlets. It was deemed to be chaotic, but manageable.

There appeared to be frequent communication between the investigative team (MCU) and the Strat Comms unit that were embedded directly in the DEOC, in Regina. This created a link to the investigation in terms of acquiring pertinent and timely information and, in the view of Strat Comms, diminished the need to have a media advisor embedded in the command post, alongside MCU. From the MCU perspective, it would have been useful to have that immediate communication with Strat Comms working in tandem, at the same location. Given the fact there was efficient flow of communication between MCU and Strat Comms, the physical location of the resources did not have an effect any of related outcomes.

Aside from the initial Public Alert, MCU was consulted thoroughly on all others prior to their broadcast. There was a significant amount of communication between MCU and Strat Comms throughout the investigation with respect to what information could be broadcast to the public and the effect that it may have on the investigation. The only instance where released information had a direct impact on MCU resources will be addressed later in the Mass Casualty/Victim Response section, when the Family Liaison teams were unable to notify the victims' families of the positive identification of the suspect's brother on September 5, prior to the release of the information to the media.

Subsequent public alerts

September 4 at 7:57 am

Update for the Dangerous Person Alert issued by the Melfort RCMP for multiple stabbings on James Smith Cree Nation. Suspects are Damien Sanderson and Myles Sanderson. Damien Sanderson is 5'7" and 155 pounds with black hair and brown eyes. Myles Sanderson is 6'1" and 200 pounds with black hair and brown eyes. The suspects may be in Black Nissan Rogue with SK license plate 119 MPI. If in the area, seek immediate shelter/shelter in place. Use caution allowing others into your residence. Do not leave a secure location. DO NOT APPROACH suspicious persons. Do not pick up hitch hikers. Report suspicious persons, emergencies or information to 911. Do not disclose police locations.

Note

Included in the Public Alert (above) issued 7:57 am was an incorrect photo of Myles Sanderson. Once the suspect(s) were identified, a media specialist conducted database checks in an effort to obtain a photograph to accompany the media release to assist the public with identifying/locating the suspects so they can take suitable measures to protect themselves. There were two subjects contained in the database with the same name (Myles Sanderson), with an age difference of 5 years, and both from JSCN. During an extremely dynamic situation with frequent updates the media specialist chose the incorrect photo, initially. Of note, the subject of the incorrect photo had the more recent, documented activity on JSCN. Once aware of the erroneous photo, Strat Comms immediately replaced it with a correct one and steps were taken to remove the photo from the Public Alert system as well as any on-line photos.

September 4 at 8:20 am

Update for the Dangerous Person Alert issued by the Melfort RCMP for multiple stabbings on James Smith Cree Nation. Suspects are Damien Sanderson and Myles Sanderson. Damien Sanderson is 5'7" and 155 pounds with black hair and brown eyes. Myles Sanderson is 6'1" and 200 pounds with black hair and brown eyes. The suspects may be in Black Nissan Rogue with SK license plate 119 MPI.

September 4 at 10:01 am

Update 4: there are multiple victims, multiple locations, including James Smith Cree Nation and Weldon. Early indications may be that victims are attacked randomly. Suspects: Damien Sanderson and Myles Sanderson. Damien is 5 foot 7 and 155 lbs with black hair, brown eyes. Myles is 6 foot 1 and 240 lbs with brown hair and eyes. See new photo. This is a rapidly-unfolding situation. We urge the public to take appropriate precautions. Do not leave a secure location. Use caution allowing others into your residence. DO NOT APPROACH suspicious persons. Do not pick up hitch hikers. Report emergencies or info to 911.

September 4 at 12:07 pm

Update 5: SK RCMP received a report the suspects may be traveling in the Arcola Ave area around 11:45 am in Regina, SK in a black, Nissan Rogue with SK license 119 MPI.

If in the Regina area, take precautions and consider sheltering in place. Do not leave a secure location. Use caution allowing others into your residence. DO NOT APPROACH suspicious persons. Do not pick up hitch hikers. Report suspicious persons, emergencies or info to 911. Do not disclose police locations.

September 4 at 12:19 pm (Alberta)

A RCMP alert is being extended to Manitoba and Alberta. A Dangerous Person Alert is in place after multiple stabbing incidents reported September 4 in multiple locations, including James Smith Cree Nation and Weldon, Saskatchewan. Two male suspects may be traveling in a Black Nissan Rogue, Saskatchewan license 119 MPI.

September 4 at 1:28 pm (Manitoba)

SK RCMP issued a Dangerous Person Alert after multiple stabbing incidents reported September 4 in multiple locations, including James Smith Cree Nation and Weldon, SK. Two male suspects may be traveling in a Black Nissan Rogue with SK license 119 MPI. Whereabouts are unknown and alert is being extended to AB and MB.

The public should take appropriate precautions. Do not approach suspicious persons and report any information to your local police and emergencies to 911

September 5 at 11:39 am

Update 6: The Dangerous Person Alert issued by Sask RCMP on September 4 for multiple fatal stabbing incidents with multiple locations continues. The two adult male suspects continue to be at large and have not been located/direction of travel is unknown. Suspects may be travelling in a black, Nissan Rogue with SK license 1 1 9 M P I.

Remain vigilant and take precautions. DO NOT APPROACH suspicious persons. Do not pick up hitch hikers. Report suspicious persons, emergencies or info to 911. Do not disclose police locations.

September 5 at 4:35 pm

Update 7: Update for the Dangerous Person Alert issued by the Melfort RCMP for multiple stabbings. Damien Sanderson has been located deceased. Saskatchewan RCMP continues to search for Myles Sanderson, who is 6 foot one inch and 240 pounds with black hair and brown eyes. He may be injured and seek medical attention. He may be in a Black Nissan Rogue with SK license plate 119 MPI. It's unknown if he's travelling with anyone.

The public should take appropriate precautions. Do not approach suspicious persons and report any information to your local police and emergencies to 911.

September 6 at 11:40 am

Update 8: Update for the Dangerous Person Alert issued by the Melfort RCMP for multiple fatal stabbings. Investigators have received reports of a possible sighting of suspect Myles Sanderson in James Smith Cree Nation. RCMP are responding. If in the area, seek immediate shelter/shelter in place. Use caution allowing others into your residence. Do not leave a secure location. DO NOT APPROACH suspicious persons. Do not pick up hitch hikers. Report suspicious persons, emergencies or info to 911. Do not disclose police locations.

September 6 at 2:56 pm

Update 9 for the Dangerous Person Alert issued by the Melfort RCMP for multiple fatal stabbings. Further investigation has determined that Myles Sanderson is not located in the community of James Smith Cree Nation and the RCMP continues to search for him. As his whereabouts remain unknown, we urge the public to take appropriate precautions.

Do not approach suspicious persons and report any information to your local police and emergencies to 911.

September 7 at 2:39 pm

Update for the Dangerous Person Alert issued by the Melfort RCMP for multiple fatal stabbings.

Myles Sanderson is charged with multiple counts of first degree murder. He has NOT been located. Myles is 6 foot one-inch-tall and 240 pounds with black hair and brown eyes. He may be injured and seek medical attention. The Black Nissan Rogue with Saskatchewan license 119 MPI has NOT been located. The emergency alert remains in effect and we ask the public to remain vigilant. If heightened risk to public safety is identified, further emergency alerts will be issued. Investigational updates will be posted to rcmp-grc.gc.ca/en/sk as they become available.

September 7 at 2:49 pm

Individual reported to be armed with a knife is traveling in a 2008 White Chevrolet Avalanche, Saskatchewan license 953 LPL that was reported stolen out of Wakaw around 2:10 pm today. Last seen traveling in Wakaw on Cemetery Road. Their direction of travel is unknown. Unknown persons involved. We believe this may be related to the Melfort dangerous person alert issued Sunday Sept 4. in the Wakaw area, seek immediate shelter/shelter in place. Use caution allowing others into your residence. Do not leave a secure location. DO NOT APPROACH suspicious persons. Do not pick up hitch hikers. Report suspicious persons, emergencies or info to 911. Do not disclose police locations.

September 7 at 3:50 pm

CANCELLED - Dangerous Persons Alert issued by Melfort RCMP: Myles Sanderson was located and taken into police custody near Rosthern, SK at approximately 3:30 pm today. There is no longer a risk to public safety relating to this investigation. As updates become available, they will be posted to the Saskatchewan RCMP website: www.rcmp-grc.gc.ca/en/sk

Perceived value of public alerts

From those subjects that were interviewed (both police and public), the overwhelming view was that the public alerts were effective as they relayed important safety information to the public, quickly. Having said this, there were also reports of some people ignoring the alerts or having not received them due to not having a cell phone. As such, every alert that was issued was also sent out as a news release and posted on Facebook to enable the public's ability to obtain the information from multiple sources. Post event, there was discussion surrounding the extension of some of the Public Alerts to Alberta and Manitoba; however, it was deemed as justified, since the suspects remained at large and there was information that they were on the TransCanada Highway and could have been travelling in any direction.

There is little dispute that the Public Alerts that were issued were of considerable value. The majority of those interviewed agreed with the number and content of the alerts. Nevertheless, the natural consequence of alerting those involved in such a tragic and evolving event is that there was potential for a negative impact to survivors and victim families with the ongoing alerting and the jarring sound that notifies the public to them. Despite this, the value in the Public Alerts was recognized in the JSCN community; however, some believed that First Nations Communities should have their own Alert System due to the unique geographic and local needs and issues.

Whatever the circumstance there will always be a balance between the need to inform the public for safety reasons and informing the public to simply to provide an update. If only to provide an update to the public, consideration could be made to utilize Victim Liaison Teams to relay information to the affected families first, prior to an alert being.

Social media

We live in a world where an increasing amount of people rely on social media as their primary news source. Many expect to find breaking news first, on social media. Additionally, social media content tends to shape narratives and impact perceptions of their users. Notwithstanding, this can have both positive and negative effects however. Regardless of its perceived worth, social media has become an important means for sharing urgent news and updates with the public.

Specifically, in relation to the JSCN/Weldon event, Strat Comms staff posted all updates to social media feeds. These feeds were initially believed to have been a secondary way of informing the public about the critical events that were unfolding. Social media did however, become more important as time wore on. Once the investigation was at the point of simply sharing information or updates, social media and news releases became the primary means of reporting. Press conferences were livestreamed on Facebook and shared a link to the livestream could be found on Twitter as well.

As a means of receiving information from the public via social media, despite comments being turned off on Facebook, the public still had the ability to send private messages if they wished. K Division resources were prepared to assist with monitoring the Facebook in-box; however, there were so few messages, they were able to monitored in house.

The JSCN has a Community Facebook page that was re-posting the various RCMP updates. This method of relaying information was noted to have been an effective way to reach the community with accurate information. Conversely, however, speculative or unofficial updates were also posted on Facebook by community members that were sometimes inaccurate and caused confusion. This point was brought up when interviewing some of the JSCN community members where there was a suggestion that there could have been a dedicated member of the community tasked with providing accurate information on their Facebook page.

Senior leadership

The Commanding Officer, Assistant Commissioner (CO) Rhonda Blackmore, was the primary RCMP spokesperson and became the face of the RCMP response to the JSCN/Weldon event. The CO was engaged at the onset of the event and attended regular briefings which led to her being well versed with real time information that could be relayed. CO Blackmore advocated for transparency early on and this tone was expressed in her media availabilities. Examples of this transparency could be seen when it was announced early on that the suspect's brother was no longer being considered culpable in the multiple murders and the continual updates that were provided as to the number of the casualties. Updates from the RCMP generally do not occur as quickly as they did during this event and they were noted by RCMP membership and by extension the public, as timely and needed.

The primary focus for media interviews was to provide local TV, radio, and newspaper availability first, followed by national media interests. The CO appeared nationally on CTV National News and CBC's 'The National' and always made herself available for interviews and to provide updates. A large portion of the CO's workday was dedicated to media in order to ensure the public could stay informed.

Communication

Strat Comms representatives were involved in all briefings and meetings from the beginning, throughout, and following the JSCN/Weldon event. This communication allowed media relations staff to deliver informed, clear, timely, and transparent messaging to the public.

Communication with the Government of Saskatchewan occurred very quickly. By 7:07 am on September 4, the Assistant Deputy Minister of Policing and Community Safety Services was notified of the situation and was kept apprised. Further calls were made to senior leadership, the MOSS Unit, and FSIN.

Outside police agencies were communicated with appropriately. As news was received, for example, on September 4 that the suspect vehicle was believed to be in Regina, RPS was notified immediately of the situation and further, that a Public Alert specific to Regina was being issued. Although this information was never confirmed (as was discussed earlier), the communication flowed easily between agencies in large due to the pre-existing relationship between the Director of Media Relations for the RCMP and that of RPS Communications Director. This network further promoted brainstorming sessions amongst media strategists that further led to a consistency of information flow from the scene to Regina, as information was received.

Outside divisions were reached out to where D Division (Manitoba), K Division (Alberta), and National Communications Services were contacted for assistance if required. D Division and National Communications Services each sent one communications resource to assist and K Division was prepared to provide help in terms of monitoring social media if required.

Summary

Whenever police are confronted with responding to a situation where an individual that has committed violent crimes has fled and there is a distinct possibility that they may cause further harm to the public, there will generally be an analysis into the type and amount of police communication with the public throughout. In these situations, police have the difficult task of balancing the requirement for the public to know pertinent information in order to keep them safe with the potential of jeopardizing apprehension efforts and the ensuing criminal investigation.

These situations are unique and it would be unjust to compare specific details amongst various events from the past. That being said, there are generalities such as clear policies, planning, and training that should be considered commonplace in all responses.

The early communication between the Duty Officer and the Media Relations Officer (MRO) and the recognition of the requirement to disseminate information to the public early on, provided the basis for the public being well-informed for the duration of the JSCN/Weldon event.

Once the authority to issue the initial public alert was provided, the MRO became immediately entrenched alongside those in command and was a permanent fixture in the Incident Command Post. From that moment onward, public communications were fully integrated into critical incident response and the training scenarios that had been completed prior to this incident became readily apparent and should be seen as evidence of growth from past mass casualty events.

About F Division OCC

Located at the F Division HQ in Regina, the OCC receives over a quarter million-calls for service per year from the public. OCC provides assistance and works in conjunction with the nearly 1200 police officers in close to 100 detachments and units throughout Saskatchewan. Each OCC shift provides support to the three F Division Districts with a staff of between 6 and 12 operators.

The four OCC teams are designed to be staffed with 12 operators and 2 supervisors per team. Due to current staffing shortages these numbers may be lower from shift to shift. Through attrition, the OCC lost 12 people in 2022 which has contributed to 15 current vacancies that existed at the time of this review. The primary reason identified for those that have left the OCC is pay. The RCMP OCC is paid considerably less than their municipal counterparts (in Regina Police Service for example) where an operator can be paid upwards of $30,000/year more. Further, there are eight bilingual positions with only one, currently being filled. Presently, the OCC has seven 'term contracts' that will eventually fill some of the vacant positions once they have completed their yearlong training.

OCC has taken steps to garner public interest in becoming an operator by taking part in recruiting fairs and social media blitzes; however, the process takes time and there is no immediate remedy to the resource shortage.

Resourcing related to this incident

The initial calls related to the JSCN started to come into the OCC around 5:40 am, which is the back end of the night shift portion of the schedule in OCC. In general, night shifts tend to be slower so there was a lighter compliment of resources on shift; however, by 6:00 am there were three 'call takers' and two 'dispatchers' working which was normal. By 7:00 am the dayshift resources were coming in and were able to assist with the increase in call volume.

During the 24 hours following the time of the initial call alerting police to the JSCN, the OCC took approximately 2600 calls, whereas a normal call volume during this same time period would have been approximately 500.

The OCC manager, supervisor, and senior managers were all called in between 6:00 am and 7:00 am on the morning on September 4 and were assisting with taking calls to offset the requirement for more dispatchers. This was not an ideal situation as the time being put in to dispatching was taking away from supervisory responsibilities; however, the immediate need to field calls was viewed as more important at that time. Shortly after, additional OCC resources were called in.

OCC operators were in the position where they had to deal with a number of issues in real time with complainants on the line. OCC operators were directing complainants to leave whatever scene they were calling from and go to the band office for their own safety. There was obvious concern from complainants about waiting for the police to arrive at the various scenes and the OCC operators did their best to relay the message that that there were multiple scenes and that members were responding to and they were not able to attend all, simultaneously. Further, the ability to locate addresses on the JSCN proved to be challenging due to house numbers and street names not being clear to both the call taker and/or the complainant.

Throughout the days that followed, dispatchers stayed beyond their scheduled shifts and sacrificed breaks to compensate for the resource shortages and to ensure that any information from previous shift(s) could be relayed appropriately to those taking over.

Specifically, on September 7, OCC requested and received relief OCC workers as this was an extremely busy day. As a way to mitigate the shortages, the two zones (North and South) were combined and additional operators were called in on overtime. There were a total of ten operators for the remainder of the shift. Further to divisional resources, exploring the possibility of utilizing RPS operators may be considered during major incidents to ease the pressure of staffing shortages.

OCC was also relied upon to call out additional units when requested that resulted in having to shift focus away from the high number of incoming calls that required attention. The Everbridge System was identified as an alternative for some call out procedures. Everbridge is a mass notification system that sends alerts to employees that have generated user profiles. New recruits entering Depot generate profiles and utilize this system should there be an emergency while in training. This results is the ability for members to receive the most up-to-date information possible if an emergency were to occur. Using the Everbridge system for various unit call outs for future major events could alleviate some of the pressures that were experienced by the OCC during the JSCN/Weldon event.

Triaging calls

As was discussed earlier in the review of the tactics and response to the initial call, the process by which 911 calls are dispatched in Saskatchewan begins with the call going to one of three Public Safety Answering Point's (PSAP) in either Regina, Saskatoon, or Prince Albert. From that point, calls were directed to either police, fire, or EMS. Regina and Saskatoon dispatch generally deal with 911 calls inside their respective city limits, whereas the rural 911 calls (and those in relation to the JSCN and Weldon) are dealt with in Prince Albert. The Regina and/or Saskatoon dispatch centres may have forwarded a small number of 911 calls to the OCC in the event that a 911 caller was on hold for too long with the Prince Albert dispatch, but the majority that came in to the OCC, were coming from Prince Albert.

As mentioned earlier, OCC operator duties are broken down from shift to shift as being either a 'call taker' or a 'dispatcher'. OCC operators are trained in both call taking and dispatching. The duties are self-explanatory where the call taker will obtain pertinent information from the caller to be forwarded to the dispatcher. The dispatcher then contacts a member within the relating jurisdiction, forwards the information, and the member ultimately responds.

One of the gaps in the training for OCC operators was noted when an evaluation of how (and what) information from the public was being requested by the call takers. Operators are currently taught to obtain as much information as possible prior to ending a call. In an emergent situation such as the one that was developing on the JSCN, training does not cover the need for an Operator to potentially end or place a call on hold once the important details have been obtained, in order to allow the Operator to take other potentially more urgent calls in the queue. From 5:40 am (when the first call regarding the JSCN was received) to 7:12 am (when the first public alert was broadcast) there were (36) 911 calls directly related to the stabbings that were occurring, that were received by the OCC. Thirteen of these calls identified suspects, and two identified a suspect vehicle.

As 911 calls were received by OCC regarding the JSCN and/or Weldon, Melfort detachment members were being dispatched and a separate file was generated for each complaint. These calls, however, did not necessarily follow the actual chronology of events occurring on JSCN as there are typically delays between the specific event and the time the complainants made the call. These sequential issues combined with the possibility of duplicate calls for singular events made it difficult for the OCC operators to ascertain exactly what was going on at the time. In hindsight one can more easily formulate an idea of what the police were responding to; however, in the moment this was understandably much more difficult.

When the resources in the OCC realized the extent of what they were dispatching members to respond to, steps were taken 'in house' to triage calls as best as possible. The OCC operator who had taken the original 911 call was tasked with dealing specifically with calls related to the JSCN and Weldon.

The specific operator that was dealing with the JSCN also had experience as a supervisor and was one of the more knowledgeable operators in the OCC at the time.

Following the initial calls (911 or otherwise) on the morning of September 4 relating specifically to injured or deceased victims, the nature of calls changed. Once information was being received as to possible suspect(s) and their whereabouts, Public Alerts were being broadcast. As mentioned, the initial Public Alert was issued at 7:12 am and from that point onward there was another influx of calls coming into the OCC in relation to possible sightings of the suspect(s). Call volume increased from an average of approximately 500 calls to around 2600. With this increase also came a marked increase in the public calling in simply to vent frustrations or to offer their various opinions on what was occurring. Further, there was an unrelated Public Alert that was broadcast on September 5, regarding incidents in Shellbrook and Onion Lake that ended up confusing the public and the call volume again, increased for the OCC. Although these incidents could not have been foreseen and in no way diminishes the value of forwarding pertinent information to the public, it should be mentioned as the OCC resources were left having to deal with it.

During this 'transition' in the nature of calls from the public there were a number of logistical and command decisions being made that affected the way information was being handled. The DEOC was being activated; CIC was becoming involved; and MCU was engaged. As pointed out earlier, MCU created an Apprehension Team dedicated to finding and arresting the suspect(s).

During the unfolding event, the MCU understanding was that all information being received (tips or otherwise) by OCC was to travel through them, in order that their dedicated resources (Apprehension Team) be kept apprised of the most recent and reliable information, and deployed accordingly. For a period of time; however, the OCC was seemingly unaware of the creation of the Apprehension Team and was continuing with the standard practice of dispatching members and creating files.

This unfamiliarity caused some disruptions of the supposed flow of information to MCU and ultimately, the Apprehension Team. Specifically, there were 'suspect sightings' near the community of Wakaw during the afternoon and evening of September 4 (reference photo in 'Chronology of Events - Highway 41 Sightings') that were not forwarded to MCU from the OCC. Subsequently, these calls (sightings) proved to be significant as one of the callers knew the suspect personally. Having said this, the caller did not relay the existence of the personal relationship to the OCC operator at the time of the call and this fact was only discovered later, when the caller was interviewed by MCU.

OCC supervisors were aware of all 911 related calls regarding possible suspect sightings through an Excel spreadsheet that was generated to track them. Communication between those supervisors and MCU (and ultimately the Apprehension Team) could have served as the link to ensure the information was forwarded to the proper unit and would have diminished confusion surrounding the tip information.

Some of the above communication lapses may have been lessened if there were a closer link between the DEOC and the OCC. Although physically located in close proximity, there was an apparent information sharing gap between the two units. The DEOC, as was outlined in earlier in the review of the Command Structure, acted as the 'hub' of information, as it was being received at RCMP HQ in Regina. It could be argued that the DEOC at any given time would have had the most up to date and 'real time' information related to the events that were unfolding on the JSCN and in Weldon. As an extension of the OCC, the MOSS member(s) that were embedded in the OCC could have easily acted as that conduit should they have been invited to briefings that were being held daily.

Technological issues and lack of interoperability between the DEOC and OCC were covered earlier in 'DEOC Functionality'.

Although less common, there were reports of information being received at individual detachments, as opposed to coming through the OCC. For clarity, when the public calls an RCMP Detachment, they can call the 'admin' line or the 'complaint' line. If there is no one physically inside the detachment to take the call, the usual process is that a message can be left on the 'admin' line or, if the 'complaint' line was called, the caller will be re-directed to the OCC. All calls in to the OCC are recorded and OCC operators are trained to gather appropriate information. Should a call have been received by the administrative staff at any of the detachments, the call is not recorded and there is no guarantee that the information received would have been forwarded on appropriately. As a remedy to this issue, phone lines in the immediate area of a major event can automatically be forwarded to the OCC to ensure recording capabilities and consistency of forwarding the information. It should be noted; however, that utilizing this remedy of automatic call forwarding could result in a number of non-pertinent and/or administrative calls being forwarded to OCC thereby further increasing their call volume.

Given the sheer number of calls that OCC Operators were dealing with in relation to the JSCN and Weldon it was inevitable that some callers had to be put 'on hold' or would have received an automated message, at times. The current 'call queueing' software that the OCC uses does not differentiate between 911 calls and less urgent calls that are in the queue, thus preventing OCC Operators from prioritizing the 911 calls. This problem will be solved with the installation of a new system (Next Generation 911) that is to take place later this calendar year.

Radio coverage issues

In order for police to perform their duties effectively and safely, they must be able to communicate both with each other and with the OCC. OCC and members who regularly work in Melfort are all aware that historically there are 'no coverage' areas within the Melfort detachment area, mainly for portable radios. This communication gap has been a persistent problem and was evident during the events that transpired on September 4. During the course of this review it was found that a significant number of members were either unable to communicate appropriately through their portable radios, or had to utilize an alternative form of communication to update their status or to relay information. As a result, information would be pieced together between radio and cell phone calls in to the OCC, which is not an ideal situation. The inability of members to readily communicate with one another is a threat to both police and public safety. New radio sites are an option for better coverage; however, they are very expensive to procure and to provide coverage in all locations, would cost several millions of dollars.

Although the solution to this problem goes beyond the scope of this review, recognizing it and identifying steps that can be taken to help mitigate the problem in the short term, should be clear. To understand the process, there first needs to be an understanding of the various agencies/units involved, and their roles.

Informatics

Generally, when members experience some type of 'tech' issue, their first attempt at problem solving occurs 'in house' followed by Informatics. The Informatics unit is well known amongst the RCMP. Members for the most part, are aware that when they are confronted with some type to 'tech' issue, this is the unit to contact.

Informatics in F Division is made up of three units designed to assist with technical issues that RCMP employees may experience.

Information Technology consists of seven units across Saskatchewan responsible for the support maintenance of all voice and data technology within the division. Their role is to provide leadership, technical solutions, installation, support and on-going maintenance for all computer, voice and data, mobile data, and mission critical systems in Saskatchewan. Radio inoperability issues would fall to this unit.

Information Management is responsible for all corporate information that must be managed within the existing Information Management systems that reflect the day to day business of our operations. This information must also be accessible and retrievable at all times to respond to Access and Privacy requests.

Operational Support looks after IT procurement (acquisition), and application services. Consultants are available to work with units or detachments on projects such as obtaining new computers or software.

When dealing with the issues of radio inoperability, the solution is not as simple as having the Informatics unit simply travel to the area where coverage is weak and set up a radio tower. There are Saskatchewan Government agencies that oversee the entirety of emergency services management that will be explained below.

Provincial Public Safety Telecommunications Network (PPSTN)

The PPSTN is the agency that manages the radio network through a partnership between SaskPower, the Saskatchewan Public Safety Agency (SPSA), and the RCMP. TheSPSA is the government agency responsible for provincial emergency management, fire safety and wildfire \ management in Saskatchewan and manages Saskatchewan's 911 emergency dispatching services.

PPSTN provides the RCMP with interoperable radio communications that allows them to communicate with other agencies (EMS, Fire, etc) during times of emergency.

There are PPSTN emergency response professionals ready to respond day and night to problems that may affect one or several of the more than 250 radio towers located in the province. They are available 24/7 to respond to a crisis at a moment's notice.

PPSTN also have access to Mobile Communications Towers (MCT) which are equipment trailers with a 100-foot telescoping tower that can bolster radio coverage for specific incident responses.

Specific to the JSCN/Weldon event, when radio coverage was deemed to be an issue, the OCC was notified and, in turn an Informatics manager had the authority to approve the use of a MCT. An employee of SPSA was notified and drove the tower to the site where Informatics was responsible for setting up of all the technology. A portable radiotower was set up in Melfort by September 5 which alleviated some of the radio coverage issues.

[REDACTED]

Digital Vehicular Repeater System (DVRS)

As was described earlier in the review of the tactics and response to the initial call, another way to mitigate areas of inadequate portable reception, can be by using DVRS. DVRS is an 'in vehicle repeater' that when used properly can extend the range of portable radios when normal PPSTN portable radio coverage is unreliable.

Essentially, DVRS provides anyone with a line of sight to their police vehicle to gain better reception on their portable. [REDACTED].

There are clear instructions on the F Division Infoweb - Informatics on how to use DVRS along with an instructional video that can be emailed to members, if requested.

DVRS have only been deployed to [REDACTED] of police vehicles in the division due to prohibitive costs. Further, repeater system has not been well received/used by members as it is viewed as only useful in a limited number of situations and requires tactile manipulations of the radio that, in a high stress situation, are not realistic.

BeOn App

In response to Health and Safety complaints filed by members who were negatively impacted due to a lack of portable coverage during certain incidents, the F Division Senior Management Team (SMT) ran a pilot project from September of 2021 to January of 2022 to investigate alternative communication methods. As mentioned earlier, new radio sites are expensive and would take time to procure and DVRS, although available, has limitations and is not widely accepted or used my members.

As a result, SMT selected a detachment in each district to run a pilot project using the BeOn application. BeOn is an application installed on a cellular device that provides Push to Talk (PTT) radio communications similar to a portable radio by using commercial cellular networks to connect cell phones to the PPSTN. This Push-To-Talk-over-Cellular (PTToC) technology provides users the ability to communicate on the PPSTN when regular radio coverage is not available.

Among some of the positive aspects of BeOn were that members liked the additional coverage [REDACTED] and that detachment commanders were able to monitor calls from home or inside the office. Provided there is adequate cellular coverage BeON will work over WiFi network, if the phone is connected.

Advantages

• Provides radio coverage where PPSTN is unavailabe
• Member are already in possesion of cell phones
• App is free to download and license costs are approx. $260/device (portable cost approx. $400 ea)
• [REDACTED]
• BeOn has an Emergency RTT function built in

Disadvantages

• Curently does not have the ability to Request-To-Talk (RTT)
• [REDACTED]
• Requires an internet connection to the PPSTN core that requires further security measures (firewalls)
• Possible for BeOn to miss calls or be unable to place calls during high usage time on cellular networks
• Members will need to be trained
• Should be used as a backup system
• There is a chance that changes made to smart phone Operating Systems by SSC could impact BeOn functionality
• Mapping function is unreliable

The obvious considerations of cost, time, and resourcing to install this type of application have yet to be determined; however, the recognition by management of the areas of poor radio coverage illustrate the efforts taken to improve the situation.

Member Status Updates

There were some 100-130 cars logged in with OCC at any given time during the event on the JSCN and in Weldon. Due to resourcing shortages in the OCC; however, dispatchers were unable to conduct regular status checks on members. On scene commanders were doing their own focused status checks; however, it was unrealistic for the OCC to know the status of every member at any given time. There were options available to provide a more accurate account of member' status and an overall Common Operating Picture (COP)that will be explored below.

Radio communication - interoperability

The JSCN/Weldon event elicited a response not only from the RCMP in F Division, but other RCMP Divisions, municipal police forces, and agencies. In order for immediate radio communication to occur between agencies (interoperability), there are many factors at play. It is not as simple a pushing a button and having the ability to speak with a member from a different police force, or even another province.

Through the OCC, there are a number of interoperability options available (F Div Ops Manual 46.100.5.8).

Radio communication - 10-codes vs. plain language

Historically, RCMP members have been taught to use 10-codes mainly because they are short and to the point. The drawback to using 10-codes however, is that their numbering is not standardized and not every police force uses the same codes which is problematic when multiple agencies are responding to the same incident. As a result, 'plain language' in certain situations should has been accepted, rather than communication over the radio in code.

According to policy, when operationally practical, RCMP members and OCC operators are to use 10-codes for radio communications. However, for multi-agency and/or multi-discipline communications, plain language should be used in place of 10-codes. (RCMP Policy - Informatics Manual Ch. II.2.11)

Part of the problem with using plain language is the possibility of transmitting private information over the airwaves can fall into the wrong hands. As the public routinely monitor police calls on scanners, some plain language has the potential of disclosing sensitive information about police or victims. Proper radio communication in critical situations will always attempt to strike a balance between the type of information that can be broadcast in plain language, or not.

From an Operational Communications perspective, radio communication as a whole was deemed appropriate throughout the JSCN event. There were very few instances of unnecessary radio chatter nor were there instances of confusion when using 10-codes were being used. For the most part, plain language was the primary mode of communication.

Supervision

OCC supervisors were deemed to have done an adequate job of maintaining communication with their operators. Further, having a full time MOSS member embedded in the OCC and attached to each team was viewed as an essential component for a situation such that unfolded at the JSCN and Weldon. The MOSS Unit was discussed previously in 'Command Structure'.

Initial RCMP response

Sergeant Ashley St. Germaine (Sergeant St. Germaine) of the Prince Albert General Investigations Section (GIS) was notified by her supervisor on the morning of September 4 that MCU out of Saskatoon was requesting the assistance of her unit on the JSCN as a result of what was unfolding. By this time, MCU had taken control of the criminal investigation and were at the early stages of accessing and processing various scenes and concentrating efforts on locating and apprehending the suspect(s).

Prince Albert GIS is a small unit of 6 members; however, they were operating with 1 vacant position at the time of the events of JSCN and Weldon. Sergeant St. Germaine immediately secured 4 resources (herself and 3 others) to travel to Melfort to meet with MCU. At this point in time there was no specific role that was assigned to Sergeant St. Germaine and her team as the number of reported victims (both injured and deceased) was increasing along with the number of scenes and everyone was still trying to ascertain the scope of what they were dealing with.

Upon arrival in Melfort, Sergeant St. Germaine and her team met with MCU and obtained names and contact numbers for the Crime Scene Manager as well as a Victim Services Unit worker. Her team was tasked with travelling to JSCN in order to start making contact and to initiate communication with victim families.

It is common practice in homicide investigations, for MCU to dedicate a single member to take on the role of the 'Family Liaison'. Due to the number of victims, however, Sergeant St. Germaine and her entire GIS team were tasked to begin organizing and completing Next of Kin (NOK) notifications for the deceased victims.

Sergeant St. Germaine recognized the importance of her teams' role during this event. She immediately recognized that her team's role was to provide accurate and timely investigative updates to those families and people, and to provide a link to RCMP Services (like Victim Services) if required. Although there was no official term for what Sergeant St. Germaine was tasked with, her role evolved into that of 'Victim Family Liaison Manager'.

Upon arrival at the JSCN, Sergeant St. Germaine met with the MCU crime scene manager and a Chief at JSCN Band Office to begin the process of obtaining names of those that were deceased. The Chief provided her with an initial list of victims who were both deceased, and injured. This list was the starting point for what would become a complete list of deceased victims, surviving victims, and points of contact.

After obtaining names, Sergeant St. Germaine and her team set out to the various scenes in order to identify victim family members and begin the process of communicating with them. Upon arrival at the various scenes, many of the victims' family members were already present, therefore identifying the various family contacts was done quickly, along with the NOK notifications. The priority was to make initial contact with the various deceased's' families; however, during this communication many other names of those that were injured and were witnesses were being relayed.

Sergeant St. Germaine distributed names of the deceased's families and surviving victims amongst her staff and assigned them as primary points of contact for the RCMP. Consideration was given to those members that were dealing with the suspect family as well as the suspect's brother's family as she was aware that those interactions would require more dedicated time. As such, fewer additional contacts were assigned to those members.

Communication with the Mass Casualty Response Team

By the end of day on September 4, following the completion of all NOK's for the deceased victims, Sergeant St. Germaine began receiving assistance for the next phases of victim support. She reached out the 'Mass Casualty Response Unit' (explained further below) to obtain any information that she could, from them, as to further steps that she and her team could take. After conversation, many of the immediate concerns that were raised had seemingly already been addressed; however, their input was valuable. Throughout the following week while the Mass Casualty Response Team was on site and offering assistance, Sergeant St. Germaine considered any of the advice that was offered with the lens of the Indigenous needs first and foremost.

Barriers experienced

Communication

After being tasked by MCU and understanding the importance of being able to relay timely and accurate information to the various families, the TC, PI and Sergeant St. Germaine made the collaborative decision to work alongside each other in Prince Albert. This move offered easy and direct communication between them and her team. This was a seamless transition as Sergeant St. Germaine and her team had a pre-established working relationship with MCU.

As the single point of contact, Sergeant St. Germaine was able to frequently exchange information with Victim Services Resources and the JSCN Band Office and their Emergency Operations Centre (EOC). Further, Constable Christian Stroet (Constable Stroet) was assigned to liaise with the JSCN Band Office EOC as another liaison between Sergeant St. Germaine's GIS team, the MCU CT, and the JSCN Band. This contributed to a better understanding of the various support resources being offered to families by both parties (VSU and the JSCN Band). VSU's role will be explained in more detail, later in this section.

The identified role of the Family Liaison within the EOC proved to be an important link between the JSCN Band and the RCMP. The three Chiefs from the respective Nations, a representative from the Prince Albert Grand Council (PAGC), and RCMP Indigenous Policing (explained below) were also represented in the EOC. This environment was utilized to communicate issues back and forth and to identify community needs/perceptions in a timely fashion. It was noted that some JSCN community members were uncomfortable speaking directly with the police during the search for the suspect and some information was passed through the Chiefs, which had implications for timeliness and accuracy of information but overall, communication flowed both ways, efficiently.

Another important function of having a RCMP member embedded in the EOC was that of managing community expectations of police abilities and limitations. An example of this was explaining the processes involved in obtaining the services of the RCMP helicopter and how those services cannot be garnered in mere minutes of a tip coming in or during some of the apprehension phases. This communication was crucial in maintaining healthy and functioning relationships in that environment.

The type of communication with the various victim families was found to vary, depending on the type of information that was being relayed. When there were updates to the investigation or any real time information to be forwarded, families for the most part preferred this come from an RCMP member. Aside from those updates, however, families wanted to hear from the Band or the Chief(s). Additionally, after the initial contacts and investigative updates were forwarded, most families preferred text messaging as opposed to 'in person' visits or even phone calls. There were strong feelings from some liaison team members that it should be up to the individual families as to how often they are contacted and by what means. Expectations can vary from family to family as to what their expectation for support and receiving information is. For example, liaison team members experienced the family of a victim preferring to get their support and information from non police sources within their community at one point.

Whatever the level of support and communication that is preferred, the Family Liaison Team's sights were always on showing respect to the families and victims. Evidence of this is when liaisons notified family members and survivors of upcoming RCMP media releases, to ensure they were given advanced knowledge and not caught unaware.

The Family Liaison role became a benefit to the overall investigation as well. Due to the prolonged contact that members had with the victims' families, the Liaisons would regularly receive information that could either be actioned or passed on to the investigative team in a timely manner. An example of this was when a member of the liaison team learned information that some community members were considering launching a 'manhunt' for the suspect(s). Liaison Team members were able to dissuade this group and mitigate the risks that spontaneous initiatives such as these could have on public safety and investigative efforts by police.

The amount of work required to keep the families informed as much info as possible without compromising the investigation became more than expected or anticipated. Indigenous Policing Services (explained further below) became involved and were tasked with forwarding information to some of the impacted families as well which alleviated some of the workload.

Because of the focus that was placed on the JSCN throughout, the fact that there was a victim from the community of Weldon as well, could have been lost. This was not the case, however, due in large part to the role of the Family Liaison.

Areas of effectiveness

Despite there being no specific RCMP operating procedures or guide for the role that became the Family Liaison Team, Sergeant St. Germaine and her team established their role quickly and sought assistance from various resources when necessary. They were able to establish themselves as the main points of contact for representatives from families of deceased victims and with surviving victims directly.

Since the JSCN mass casualty event, Sergeant St. Germaine has attended the Canadian Association of Chiefs of Police workshop related to piloting a Canadian Victim Response Framework for Mass Casualty Events. A meeting has been arranged in early 2023 to have formal discussions with F Division CROPS (with support from the District Management Team and MCU) as to the creation of a more formal framework for addressing some concerns raised in the response to the JSCN/Weldon mass casualty event.

Indigenous Policing Services' role

Prior to a review of the role that Indigenous Policing assumed during the JSCN event, it is relevant to document the service that they strive to provide and the goals they set out to accomplish.

About Indigenous Policing Services (IPS)

IPS in F Division strives to ensure the delivery of professional and culturally relevant police services to all of Saskatchewan Indigenous people within RCMP jurisdiction. The IPS Unit consists of seven 7 members ranging from an Inspector to Corporal(s). Other Divisional IPS members were deployed specifically in response the JSCN incident, namely: 2 members of K Division IPS and 1 member from J Division.

IPS mission

The IPS mission is to support employees in providing professional, proactive, and culturally appropriate policing services to Indigenous people and communities in Saskatchewan. With guidance, education and collaboration, IPS assists in the advancement of Reconciliation and strives to improve overall relations between Indigenous people and the RCMP.

IPS mandate

F Division Indigenous Policing works with all levels of government, Indigenous leadership and key partners to improve relationships between the community and the RCMP, to ensure culturally appropriate policing.

IPS out of Prince Albert took on the role of liaison between the RCMP and the Band Council for the JSCN event. IPS became embedded in the EOC very early on. IPS members identified that their being present 'on the ground' in JSCN on the first day was essential in providing a base for support, especially at a time when fear was rampant with the suspect being at large. IPS's presence fostered regular, in person communication with the 3 Chiefs and Grand Council where updates could be given and information from the Band could be relayed back to the investigative teams.

Other agencies that had a place at the table in the EOC were the Federation of Sovereign Indigenous Nations (FSIN), Indigenous Services Canada (ISC), and representatives from Public Health and Mental Health. The managers of the assisting agencies were there to discuss the event and safety concerns. IPS's role in this setting was that of a liaison between the RCMP and those agencies and representative at the table during briefings, for the RCMP. Attendance at these briefings and visibility within the EOC was important in building and maintaining the relationship between the RCMP and the Band. It opened a line for honest communication and through this, IPS members were able to build trust and rapport while at the same time providing and disseminating timely information through the appropriate RCMP channels. IPS members worked directly with the MCU Command Triangle in order that they had investigative information that could be relayed back to the families.

IPS's role was noted to be a critical part of the relationship based connection between the JSCN and the RCMP. The recognition by F Division management for enlisting IPS resources from other divisions cannot be understated. The nature of their role became that of an informal liaison, which allowed them to build strong community relationships. This 'informal' relationship was noted in interviews with some community members where they commented on how 'authority of the RCMP' was not at the forefront of communications with the community during the incident, but rather a more empathic tone was conveyed. The IPS component became important as concerns from the JSCN community began to be forwarded to IPS members surrounding the anticipation of RCMP resources and support becoming non-existent, after the event had concluded. IPS was able to relay these concerns to the Family Liaison Teams and allowing the Liaison Teams to convey the messages that they would remain available and engaged even after other members had left the JSCN.

As mentioned previously, there is a Melfort RCMP member that works closely with the JSCN community and is highly spoken of. This positive pre-existing relationship helped greatly with IPS's ability to assume their role in the EOC.

This notion was evidenced in a number of interviews from the Community members that were conducted during the later portions of the review where it was pointed out that the presence of RCMP members at the EOC briefings was both valued and appreciated.

IPS members were said to have been regularly engaged in the community, being supplemented further by the designated member from Melfort. That being said, according to a number of community members, there is room for improvement in the relationship between the Melfort RCMP and the JSCN. This topic was covered earlier in review of the tactics and response to the initial call.

Throughout the JSCN/Weldon event, IPS played an invaluable role in establishing and maintaining communication and information sharing between investigators and the JSCN. RCMP commitment and support to IPS is important to ensuring future incident response and service delivery are as safe and effective as possible.

Cultural sensitivity

Given the rapidly evolving situation that members were responding to on the morning of September 4, being culturally aware of the overall impact of this tragedy could have been overlooked, creating boundaries and hindering community trust toward the police. Quite the opposite occurred. There were a number of instances highlighting the efforts made by the responding members that showed empathy and an understanding of the cultural needs of the community.

Victim Services Unit (VSU) role

Victim Services Units (VSU) offer assistance that varies from more immediate services, such as crisis support to more long-term assistance such as informing victims about court processes. In addition to these services, other commonly provided types of assistance include giving referrals, providing information on the criminal justice system, informing victims about victim impact statements, and accompanying victims to court.

Victim's services offer support, assistance, information, and referrals in a compassionate manner that respects the dignity and privacy of those dealing with the impact of victimization.

VSU's in Saskatchewan are funded by the Saskatchewan Ministry of Justice, and are governed by an RCMP Board. Each RCMP based VSU program is administered by a local non profit board of directors. These boards have representation from community stakeholders and the RCMP. RCMP detachments provide office space in the detachment including phone, computer, and office supplies. Programs are staffed by community volunteer support workers and managed by civilian employees. Individual VSU's are their own entity, however, and make decisions based on their own assessments. RCMP members can provide relevant information to the VSU, but the decision to provide assistance lies solely with the unit itself.

The Northeast Regional Victim Services (NERVS) Unit specifically, was the group that responded to the JSCN. NERVS is comprised of one full-time coordinator, one full-time assistant coordinator, two part-time assistant coordinators, a part-time administrative assistant, and 18 volunteers. The NERVS Region encompasses a very large geographic area including the JSCN and Weldon.

The NERVS Unit has paid staff that work on an on-call rotation; however, they do not receive any monetary incentive in return. Staff can bank on-call time at a rate of 1 hour of banked time for every 24 hours on-call. They receive hour for hour banked time for time worked during a call out. This funding arrangement has been the main difficulty with both staffing and staff retention.

NERVS Unit referrals from the RCMP are typically communicated in a phone call from an RCMP member requesting victim services. When the unit receives a referral, it is first offered to a volunteer. If no volunteer is available, one of the paid staff members works directly on the referral. The NERVS Unit was noted as having a good relationship with the Melfort RCMP as the detachment was viewed as being very 'pro-VSU' and the NERVS Unit itself, felt that support.

NERVS unit response

On September 4, the on-call coordinator was first made aware of what had occurred on the JSCN when she was contacted by the Melfort hospital advising of the arrival of a number of victims from the JSCN and the hospital. The Melfort Hospital does not have medical social workers and was requesting NERVS Unit attendance to fill that support gap. At this point in time the NERVS Unit had not yet been contacted by the RCMP.

The attending coordinator began organizing volunteers via a group chat requesting attendance at the hospital in order to begin meeting with any victims that were in need of services. At this point in time, VSU efforts were focused on the victims at the Melfort Hospital and making a determination of who required support at that location. Contact was made with medical social workers at other locations (Saskatoon and Prince Albert) when patients were transferred out of Melfort, in order to continue that support on the receiving end.

Communication with both the JSCN Band Leadership and Weldon community leaders began on the first day. During these contacts a list of supports and resources that were available via the NERVS Unit were discussed and ultimately accepted. Throughout the initial day, those members of the JSCN that lived in homes that were now considered crime scenes, would need alternate accommodations and some others simply did not want to remain in the community. The NERVS Unit worked with the JSCN, FSIN, Prince Albert Grand Council (PAGC), and Red Cross in efforts to secure hotel costs for victim families.

The NERVS Unit was contacted by Staff Sergeant Simons from the Melfort RCMP approximately 2 hours after being alerted by hospital staff. By this time, the NERVS Unit volunteers were already at the Melfort Hospital providing assistance and their role did not change following their conversation with Staff Sergeant Simons. Although the NERVS Unit coordinator did not have all the information regarding the status of the investigation at his point in time, the determination was made that NERVS Unit workers would not be travelling to the JSCN due mainly to safety concerns.

On September 5, the NERVS Unit met in person with Sergeant St. Germaine. At this time there was very little information available as far as those victims that would require support. The list of victims that was forwarded was incomplete and still being compiled. While it was clear to the NERVS Unit workers that those on the list were deceased, other details were still not known and/or provided to Victim Services. Further, some victim services referrals were missing pertinent information including accurate phone numbers. It was understood by the NERVS Unit that the situation was still evolving and the information may be forthcoming; however, not having the ability (as will be set out below) to assist the RCMP in compiling the pertinent information was perhaps the biggest barrier to providing assistance.

Eventually Sergeant St. Germaine generated a spreadsheet with victim and family contact information in order to track both contact with the various families and the assigned members. In conjunction with the Mass Casualty Response Team (as set out below) this document was evolved, was updated, and continues to be an invaluable resource for those tasked as part of the victim support team.

VSU in Saskatchewan do not have access to the PROS database which causes a massive information gap between the RCMP and various VSU's.The inability to conduct database queries for basic details such as contact information is paralyzing for a unit that places such a value on being able to make timely contact with victims. The NERVS Unit believed that their ability to make these queries would have benefitted both the RCMP because it would have significantly reduced their workload, as well as their local VSU as they would have had the most up to date and timely information available to do their job.

It appears that restricting access to PROS is not only a Division-wide policy in Saskatchewan, but rather extends nation-wide. Since the implementation of PROS as the preferred Records Management System (RMS) for the RCMP, access was withdrawn from Victim Service units. Compared to previous RMS used by the RCMP (Police Information Retrieval System - PIRS), PROS contains several detailed fields of information as well as access to numerous reports, some of which contain sensitive information. As such, access to PROS became restricted, only granting to employees of the RCMP. For obvious reasons this was viewed as an impediment by VSU employees.

Eventually the NERVS Unit received names identified by the Family Liaison Team for follow up. NERVS workers travelled to the JSCN to meet in person with victims; however, during this time there were not many people remaining on the JSCN, as the suspect was still at large and many had vacated their homes. As such, home visits were paused. NERVS Unit provided the RCMP Liaison Teams with a list of available resources that the members could forward to victims and injured during this time that the NERVS Unit was not allowed on the JSCN. Eventually, a more fulsome list of names was provided by the RCMP and NERVS Unit workers began making phone contact with victims, on the evening of September 5.

This contact continued and, by the end of day on September 6 the NERVS Unit had received a list of witnesses (anyone who directly witnessed the incident or was exposed to trauma) from the RCMP Liaison Team. This witness list was divided between staff and their time was spent calling these clients on September 7 and 8.

In addition to client contact, the NERVS Unit was working with the JSCN Crisis Team to arrange for counselling services from victim families and obtain information on funeral costs. By this point, the NERVS Unit was becoming over tasked. The small unit had been working long hours in emotionally draining situations. Witness files that were opened were distributed amongst the NERVS Unit, Prince Albert VSU, and North Saskatchewan VSU. If those that required support were re-located to other places such as Saskatoon, those VSU's were contacted in order to continue support.

The NERVS Unit recognized the importance of providing support for the Weldon community members and had concerns that the multiple agencies that were offering support to the JSCN were unaware of the same need in Weldon. NERVS Unit workers attended Weldon for a community debriefing in a support role for the friends and family of the deceased on September 8. They advocated for the Weldon victims home to be cleaned and ultimately, federal government provided the funding. A relief team attended Weldon again on October 11 to 14.

Once the suspect was arrested on September 7, VSU resumed home visits on JSCN, beginning on September 15. These visits were guided by clients' wishes. During the week of September 19, a relief team arrived and assisted with proactive door knocks in the community (JSCN and Weldon) to distribute a resource package with information about victim compensation. In the JSCN specifically, a local community member was assigned to accompany the relief team with door to door contacts in order to provide these resources. Shortly after starting, the community member expressed their belief that all supports and services should come from the JSCN and not an external body (like the Ministry of Justice). Further, there was some ambiguity in the information that was being presented to victims regarding compensation that some community members thought may confuse victims. As such, on September 23 the door knocks were stopped and VSU have not returned to the JSCN. The JSCN leadership was unaware of the concerns and eventually reached out to the NERVS Unit to talk about the misunderstanding. The relationship between the NERVS Unit and the JSCN Band Leadership remained intact following this and the NERVS Unit continues to work with victims on the JSCN when they are requested.

Throughout the incident, the NERVS Unit was in communication with the Ministry of Justice. Specifically, as the days went on and the number of referrals was increasing, as mentioned above, the NERVS Unit was becoming overtasked and burned out. In addition to providing support to those for which they had generated files, NERVS workers attended funerals, conducted home visits, and provided support to staff and students at school, among other duties. The NERVS coordinator contacted the Ministry of Justice to arrange for a relief team of VSU workers to support their teams' efforts. The Ministry of Justice advised the relief team would be created, however, left all the coordination and logistics to the NERVS Team, which just added to their workload. The Ministry of Justice might have been the better point of contact with the JSCN leadership to provide clarity regarding the role of the relief team to mitigate conflict. Further, that department might have led the development of the Relief Teams. Putting the coordination and organization on the core victim services team added considerably to their workload and stress.

At the time of the incident, some RCMP members interviewed described their understanding of the functional roles of RCMP Victim Services as limited. Some were not aware if there was an electronic database or website of Victim Services they could offer to families. In advance of this incident, some members had no knowledge of the support that could be provided by Victim Services and all but associated VSU with options for providing/connecting with counseling. Since this event, members have learned more about what VSU can offer.

Despite the organizational structure of the NERVS Unit as described above and the number of resources that are ideally assigned, the reality is that there were approximately 5 NERVS Unit members that were involved in the JSCN response. When dealing with deceased victim's families, injured victims, witnesses, and community members, the file count is well over 100. This became unmanageable and unit members are not well. The NERVS Team has yet to receive any type of incident debrief and have no compensation for any type of counselling services, should they require. This incident has stretched their unit capacities past their limit.

NHQ Mass Casualty Response unit

The Canadian Association of Chiefs of Police (CACP) is comprised of both active and honorary members from across Canada. Through its members' police chiefs and other senior police executives, the CACP represents in excess of 90% of the police community in Canada. The CACP is dedicated to the support and promotion of efficient law enforcement and to the protection and security of the people of Canada. The CACP conducts its work through activities and special projects of a number of committees and sub-committees. One such committee is the Counter-Terrorism and National Security Commission chaired by Deputy Commissioner Mark Flynn (Deputy Commissioner Flynn). A sub-committee linked to this task force is the National Working Group Supporting Victims of Terrorism and Mass Violence (Mass Casualty Response Unit) led by Susheel Gupta (Gupta), the RCMP National Security senior strategic advisor.

Given the commonalities between what occurred at the JSCN and the spirit of the work being done by the sub-committee (above), Deputy Commissioner Flynn reached out to Gupta requesting they provide support to the RCMP on the ground in Saskatchewan.

Gupta contacted F Division colleagues on September 4 and was eventually introduced to Sergeant St. Germaine where information was forwarded regarding Effective Practices of family liaisons and major case management.

Assistance from sub-committee members from Alberta, British Columbia, and Ontario was offered and all travelled to Saskatchewan to assist in whatever capacity they could. When the decision was made that the Mass Casualty Response Team would travel to Saskatchewan, it was in a consultative role and they were not leading the response. Once team members arrived in Saskatchewan, their mandate was initially not clear; however, became so shortly thereafter. This period of ambiguity is to be expected as this was essentially an 'ad hoc' team that was put together to essentially provide whatever support was necessary, based on their experience.

On the ground, some members were initially skeptical of Mass Casualty Response Unit's role but, in the end, found the team to be helpful. Members of the team partnered with the Family Liaison Team(s) and worked to meet any needs such as providing assistance for tracking victim contacts and assignments. As set out above, the Excel document that was created, captured some of the complexities that may not otherwise have been tracked, but made the organization of the victims much more efficient. Members of the Mass Casualty Response Team developed a planning document to be forwarded to the Family Liaison Team that will assist in planning for the victims longer term as well.

Gupta and his team are in the process of developing a proposal of 'Rapid Deployment' specific to family/victim/Family Liaison Officer (FLO) support models.

Criminal history - suspect

The suspect was the subject of over 160 listed occurrences from 1996-2022 stemming from occurrences involving the RCMP, Prince Albert Police Service, Saskatoon Police Service, Regina Police Service, Kamloops RCMP, Prince George RCMP and Delta Police. A significant number of these occurrences were related to violence.

The suspect also had an extensive Criminal Record that included convictions for Assault x10, Mischief Under $5000 x6, Fail to Comply with Disposition, Fail to Attend Court x4, Unlawfully at Large x2, Dangerous Operation of MV, Fail to Comply with Undertaking x10, Resist Arrest x3, Assault Police Officer x2, Breach Conditional Sentence Order, Assault with Weapon x3, Break Enter and Theft, Possession of a Schedule II Substance, Fail to Comply with Probation Order x7, Obstruct Police Officer, Fail or Refuse to Provide Sample, Driving while Ability Impaired, Fail to Comply with Recognizance x3, Aggravated Assault, Uttering Threats x2, and Robbery.

The most recent convictions included three separate sentencing dates of September 24, 2018, January 23, 2019, and May 13, 2019 where the combined sentences totalled 4 years, 4 months and 19 days. The convictions included three counts of Assault with a Weapon, Robbery, two counts of Mischief, Assault Police Officer, Utter Threat to Destroy Property, Utter Threat to Cause Death/Harm, and Assault.

It goes without saying that the suspect had a significant criminal history and was subject to numerous police investigations, charges, and convictions on multiple occasions.

Correctional service of Canada and Parole Board of Canada records

As pointed out earlier, the suspect was on statutory release from incarceration but unlawfully at large for breach of his conditions when he committed the multiple murders and assaults on the JSCN and Weldon on September 4. For clarity, an explanation is required as to what statutory release is and how an offender is granted release back into society.

Warrant Enforcement Support Team (WEST)

F Division has a Warrant Enforcement Support Team (WEST), that came into effect in April 2022. This unit conducts law enforcement and intelligence activities with the objective of locating fugitives who escape from custody, or became unlawfully at large by violating bail, parole or intermittent sentence terms, including those with warrants for arrest.

WEST will target high-profile offenders with outstanding warrants who represent a significant threat to public safety. The team focuses on warrant enforcement across the entire province and are based out of Saskatoon and Meadow Lake. The Saskatoon / Meadow Lake WEST team consisted of a 6-member team (Sergeant, Corporal, and four Constables) all of which were deployed to the JSCN/Weldon event.

WEST role in the JSCN/Weldon event

Upon being deployed and arriving on the JSCN, WEST members were initially tasked with assisting MCU with obtaining statements for many of the witnesses to the 11 homicides. Although this was not part of their apprehension mandate, there was an abundance of information that was still being collected reading the incident and, until such time that they were tasked with apprehension efforts, the WEST team assisted wherever necessary.

The following day (September 5) the WEST team was back on mandate for apprehension efforts and remained as such for the duration of the event. WEST was situated in the MCU command post in Prince Albert alongside the Apprehension Team (described earlier). The WEST portion of the apprehension team in the command post included - MCU Team Commander, WEST Team Commander, a Senior Saskatchewan Enforcement Response Team (SERT) Analyst, and Affiant, and a File Coordinator. The WEST TC liaised with MCU team lead for the Apprehension Team and coordinated both the WEST and North Battleford Crime Reduction Team (CRT) resources to ensure the WEST portion of apprehension efforts were coordinated. WEST and CRT teams were working in separate locations and being coordinated and tasked by the WEST TC with direction from the MCU Apprehension Team lead (who was working in concert with CIC), in relation to apprehension. Efforts to continue apprehension continued in this fashion for the remainder of the event.

Since the JSCN/Weldon event

Since the commencement of this review, an additional WEST team has been approved for creation in Prince Albert. As this entire unit is relatively new, refining the methodology on how to prioritize offender selection and enforcement is ongoing. WEST does not have an embedded analyst; however, receives analytical support from the 9 analysts that fall within the SERT organizational chart.

[REDACTED]

This prioritization is essential as it was found that as of October 7, 2022, the statistics for outstanding RCMP warrants was as follows:

The Intelligence Manager for F-Div - Saskatchewan Enforcement Response Team (SERT) receives an UAL list that is regularly distributed by CSC. The UAL list includes the agency that laid charges, release addresses and who is the Police of Jurisdiction. Steps are taken, where possible, by the Intelligence Manager to determine if a broadcast should go out to a certain RCMP jurisdiction. Due to the large volume of warrants/UALs, broadcasts are not sent out on every subject.

Related past casualty review recommendations

Upon review of the MacNeil Report a similar objective to this one was found in their report and titled 'Section 11: Perpetrator /Information/Intelligence/ Prevention Opportunities' and included the same two underlining questions (listed above) with the below recommendation:

Based on the material available to this review, there were no specific RCMP supported initiatives that the suspect was identified as having been involved in and/or accessing.

It was noted, however, that F Division had undertaken recent initiatives focussed on improved police service related to mental illness. An example of this was from June 8, 2021 where Saskatchewan RCMP positioned two psychiatric nurses to its OCC to assist RCMP members in real time during mental health interventions with the public.

Although the suspect had not been involved in any RCMP supported programs/initiatives, he was found to have been involved in several programs while under the supervision of CSC, included the following:

• attended the Metis Addiction Council of Saskatchewan Institute's six-week day program in 2013 and received further outpatient treatment in 2015 and inpatient treatment in 2016
• While incarcerated, participated in:
  • Programming and cultural activities, engagement with Elders, completed employment certificates and self-help courses
  • completed the Non Intake Indigenous Primer and the Indigenous Multi Target High Intensity Program
  • Completed the Wastew Pimatisiwin: Shining Life (Grief Program)

Following the suspect's release into the community, he commenced the Indigenous Integrated Correctional Program Model (ICPM) Community Maintenance Program in October 2021, but was unable to complete the program due to his release being suspended in November 2021. Reports on file noted that he completed six sessions of the program in the community and failed to call in for four other sessions, prior to being suspended.

Mental health, community safety and initiatives going forward

Since the commencement of this review, Federal funding has been announced that could result in initiatives that are in line with the spirit of this objective and present opportunities for RCMP involvement.

On November 28, 2022, the Government of Canada announced committing $62.5 million over six years to support the healing, mental health, and well-being of community members impacted by the tragic events of September 4, and to support Indigenous-led approaches to community safety.

The news release from the Prime Ministers Office included the following:

• $42.5 million to help support mental wellness and healing, including through the building of a new wellness centre in the community and repurposing the existing Sakwatamo Lodge. It will also enable JSCN to develop and design programs that best serve the needs of their members including increasing access to mental health, trauma, and substance use services
• $20 million over four years towards the Pathways to Safe Indigenous Communities Initiative supporting JSCN and other communities in developing and delivering community-based safety and wellness projects
• $300,000 to address the specific mental health needs of children at the JSCN School
• In October, the Government of Canada, the Government of Saskatchewan, and the Prince Albert Grand Council announced a partnership with the aim of improving public safety and policing in its 12 member First Nations and 28 communities. This team will advance work on Indigenous-led public safety initiatives, tailored to the needs of each community.