CaseSummaryRecommendation(s)
2019-01  This 2016 case involved the homicide of a six-year-old female child by her 45-year-old mother who subsequently died by suicide. The perpetrator and her husband were separated.  Just prior to the homicide-suicide, the perpetrator had received notification from the family court that she would no longer have custody of the victim and that her husband had been granted sole custody. There were seven risk factors for intimate partner homicide identified.
  1. A funding envelope and guidelines should be developed for the family court to appoint an Amicus Curiae (lawyer as friend of the court) for cases with a self-represented litigant in a child custody trial that might impact significant parenting outcomes such as a change in custody or termination of access.   
  2. An expert panel should be convened on the process to change custody from one parent to another after a trial of the matter. The panel should include experts from the field of family law, child protection, judicial officers, police and mental health. Issues to be discussed should include, but not be limited to:
    • notification of parents
    • transition plans
    • having children in a safe place before transfer
    • required counselling
    • safety planning/risk management.
  3. The Office of the Children Lawyer (OCL) should complete an internal review of their initial assessment of the individuals involved in this case to see if there were missed opportunities to provide a more comprehensive and acceptable report for the family court.
  4. The regional supervising coroner for the area where this homicide-suicide occurred should conduct a review of the circumstances surrounding these deaths with the local agencies involved.   
  5. The Canadian Radio-television and Telecommunications Commission (CRTC) should consider studying the possibility of the reduction, management or elimination of web-sites that are published to inform people how to kill themselves or others.
2019-02This case involved the homicide of a 28-year-old male by his 33-year-old girlfriend. The couple had been in an abusive relationship for approximately three years before the incident that resulted in the victim’s death.   The victim and perpetrator were homeless and had severe alcohol and drug problems. Both had a lengthy criminal record including assault, uttering threats, theft, public intoxication and failing to comply with probation orders and recognizance. There were nine risk factors for intimate partner   homicide identified.
  1. Police services are encouraged to work more closely with culturally-appropriate healthcare and social services systems in order to address alcohol and substance abuse issues in a more holistic manner. Such an approach may include inviting community elders to assist with the process.
  2. Healthcare providers are encouraged to refer patients to culturally-appropriate mental health services (such as healing programs).
2019-03This case involved the death of a 56-year-old woman followed by the suicide of her 59-year-old husband.  The couple had been charged with fraud in the United States and prosecution procedures were forthcoming.  While the couple may have had a suicide pact, it is believed that the perpetrator assisted in the death of his wife, then killed himself.  There were no risk factors for intimate partner homicide identified.   No recommendations.
2019-04This case involved the death of a 65-year-old male victim by a 33-year-old male perpetrator. The victim was the father of the intended victim, who was the former female common-law partner of the perpetrator.  The perpetrator was attempting to attack the intended victim when the victim intervened and was killed.  The intended victim was injured and the perpetrator subsequently took his own life. There were 13 risk factors for intimate partner homicide identified.
  1. It is recommended that lawyers in family law practice receive mandated continuing education on understanding and recognizing the dynamics of domestic violence and the risk factors for lethality associated with separation, divorce, and custody and access.
  2. It is recommended that family law lawyers consider the risks and benefits of different strategies for communicating and serving family court documents, and in cases of domestic violence they consider serving papers in person.
2019-05This case involved the homicide of a 40-year-old woman by her 39-year-old husband. The couple were in the process of separating at the time of the homicide. The perpetrator suffered a stroke two years prior and was dependent on the victim for his financial, emotional and physical needs. The perpetrator was depressed and had other mental health concerns.  There were seven risk factors for intimate partner homicide identified.
  1. Hospital systems and health care models are reminded of the impact of major life changes to a patient’s mental health in addition to the physical health changes, and consider a mandatory mental health/psychological evaluation as part of the rehabilitation process prior to discharge from hospital based services.
2019-06This case involved the death of a 26-year-old woman who was killed by her 37-year-old partner. Both the victim and perpetrator misused alcohol, had a history of domestic violence with other partners and were unemployed. There were 14 risk factors for intimate partner homicide identified.   
  1. Social Assistance (Ontario Works and Ontario Disability Support Program) case workers should receive specialized training in the dynamics of domestic violence. Case workers should ask evidence-based probing/screening questions if a client verbalizes wanting to kill or harm someone, particularly an intimate partner, and refer the client to other professional services (including the police) as necessary.
2019-07This case involved the homicide of a 32-year-old woman by her 42-year-old male partner. The couple were involved in a sadistic sexual relationship where the perpetrator dominated most aspects of the victim’s life.  There were 17 risk factors for intimate partner homicide identified.
  1. Public health and other sex educators should develop public awareness campaigns and informational resources on safe practices and warning signs for risk of non-consensual sexual and physical activity between partners involved in BDSM.
2019-08This case involved the homicide of a 39-year-old woman by her 43-year-old husband. The couple were in the process of separating when the perpetrator killed the victim while their children were present in the house.  There were 12 risk factors for intimate partner homicide identified.
  1. Domestic violence public education materials created by the Office of Women’s Issues should include information on the potential harm of exposure to domestic violence on children. Public service announcements (PSAs) should highlight the negative impact of domestic violence on children and encourage broader public awareness, particularly with friends, family, neighbours and co-workers.
  2. Education on the dynamics of domestic violence, including coercive controlling abuse and post-separation violence, risk assessment, safety planning and risk management strategies should be part of mandatory education and continuing education for law students and family law lawyers.
  3. The federal government should consider possible amendments to the Criminal Code of Canada to include homicide of a domestic or intimate partner as automatic first degree murder when there is a prior conviction of domestic/intimate partner violence or a pattern of abuse with that partner in the past five years, with the exception of behaviour that constitutes self-defense.
2019-09This case involved the homicide of a 39-year-old woman by her 42-year-old husband.  The victim went missing in July 2014 and her remains were located a year later.   The perpetrator had started a new relationship prior to the victim’s disappearance. There was one risk factor for intimate partner homicide identified.No recommendations.
2019-10AThis case involved the death of a 66-year-old female by a former intimate partner that had a lengthy history of intimate partner violence.  Victim 1   was one of three women killed by the same perpetrator within the span of several hours. There were 13 risk factors for intimate partner homicide identified in the relationship between Victim 1 and the perpetrator.

(recommendations applicable to cases 10A, 10B and 10C):

  1. Justice partners, health professionals and counsellors should better utilize case conferencing systems that share information and action plans to address safety issues and “high risk” cases.
  2. When information is received regarding assignment of a mobile tracking system (MTS) alarm to a victim or potential victim, there should be a special interest police CPIC entry linking the offender to the victim.
  3. Protocols and provincial standards should be established for the administration, funding and procedures for use of mobile tracking system alarms across all victim services in the province.
2019-10BThis case involved the death of a 36-year-old female by a former intimate partner that had a lengthy history of intimate partner violence. Victim 2  was the second of three women killed by the same perpetrator within the span of several hours. There were 16 risk factors for intimate partner homicide identified in the relationship between Victim 2 and the perpetrator.
  1. The Ministry of the Attorney General should provide funding for alarms for victims. The victim quick response program (VQRP), provided through victim service organizations across the  province, should receive additional funding to cover mobile tracking system alarms.
  2. Police and victim services organizations should establish a standard provincial policy regarding the use of mobile tracking system alarms.
  3. Crown counsel are encouraged to share information with other justice stakeholders and victims, as to why charges against a perpetrator are stayed or withdrawn.
2019-10Cn/a

Above recommendations, in addition to the following:

  1. Justice partners, health professionals and counsellors should better utilize case conferencing systems that share information and action plans to address safety issues and “high risk” cases.
  2. When information is received regarding assignment of a mobile tracking system (MTS) alarm to a victim or potential victim, there should be a special interest police CPIC entry linking the offender to the victim.
  3. Protocols and provincial standards should be established for the administration, funding and procedures for use of mobile tracking system alarms across all victim services in the province.
  4. The Ministry of the Attorney General should provide funding for alarms for victims. The victim quick response program (VQRP), provided through victim service organizations across the  province, should receive additional funding to cover mobile tracking system alarms.
  5. Police and victim services organizations should establish a standard provincial policy regarding the use of mobile tracking system alarms.
  6. Crown counsel are encouraged to share information with other justice stakeholders and victims, as to why charges against a perpetrator are stayed or withdrawn.
2019-11This case involved the death of a 20-year-old male by his 20-year-old girlfriend. The couple had a child together and both consumed alcohol.  There were five risk factors for intimate partner homicide identified.No recommendations.
2019-12This case involved the death of a 54-year-old Aboriginal woman by her 45-year-old male common-law partner. The perpetrator had a history of substance abuse and mental health issues.  There were five risk factors for intimate partner homicide identified.
  1. Hospital A should conduct a lessons-learned case review of the circumstances surrounding this case particularly as they relate to the initial assessment and discharge of the perpetrator from the emergency department.
  2. It is recommended that the College of Physicians and Surgeons ensure that educational interventions for family physicians, emergency department physicians and medical residents on mental illness highlight the way that such problems elevate the risk for lethality in situations of ongoing intimate partner violence.
  3. All emergency departments in hospitals should have access to mental health crisis support workers that can engage with patients involved with substance abuse. Engagement with patients should also consider the safety of support people and intimate partners and/or family members. This would likely require more liaisons with external agencies, and more allocation for mental health resources and services across the province.
  4. The Ministry of Health should increase community initiatives and public education to build awareness of substance abuse issues and resulting implications for intimate partners, families, friends and co-workers.
2019-13This case involved the death of a 21-year-old Indigenous woman by her 19-year-old boyfriend.  Both the victim and perpetrator had been involved with the child welfare system when younger. The couple had an on-again off-again relationship. There were 13 risk factors for intimate partner homicide identified.
  1. A meeting, co-chaired by the regional supervising coroner and senior officials in the Ministry of Indigenous Affairs and Indigenous Services Canada (Ontario Region), should be held with service providers involved in this case across all sectors including Indigenous and non-Indigenous police services, court-related professionals, Indigenous and non-Indigenous social services and  child protection services, mental health and education to address the need to provide culturally appropriate services for victims and perpetrators of domestic violence.
2019-14This case involved the deaths of a 42-year-old woman and a 35-year-old woman (victim 1 and victim 2), who were both in dating relationships (at the same time) with the 47-year-old perpetrator.  There was a total of ten risk factors for intimate partner homicide identified in the relationships the perpetrator had with victims 1 and 2.No recommendations.
2019-15This case involved the homicide of a 41-year-old woman by her 39-year-old husband. The victim had progressive Multiple Sclerosis and was dependent on her husband for all her care needs. The perpetrator struck the victim after becoming frustrated with her crying. There was one risk factor for intimate partner homicide identified.No recommendations.
2019-16The victim was a 39-year-old woman who was killed by a 38-year-old man who she had an open intimate relationship with. The perpetrator had a long history of mental health issues and domestic violence and was found not criminally responsible for the victim’s death. There were eight risk factors for intimate partner homicide identified.
  1. The Ministry of the Attorney General should consider developing legislation that would allow potential domestic violence victims and their family members to apply for access to information about intimate partners where there is a concern that they may have a history of violence and abuse in other relationships and present a serious risk. Albert and Saskatchewan have enacted similar legislation that is known as Clare’s Law named after a domestic homicide victim in the United Kingdom whose family advocated for this reform after their daughter was killed by a serial offender.
2019-17This case involved the homicide of a 70-year-old woman by her 71-year-old husband. The couple had been married for 48 years and had been separated (although living in the same residence) for five years. There were 13 risk factors for intimate partner homicide identified.
  1. It is recommended that the police service involved conduct a lessons-learned case review of the circumstances of this death, particularly as it relates to the victim presenting to the police station, her interaction with civilian staff and the assessment and action taken regarding threats that had been made.   
2019-18The victim was a 44-year-old man who was murdered by his 32-year-old common-law spouse. Both the victim and perpetrator had a history of alcohol abuse and domestic violence.  In many instances, the victim had been the instigator of the violence. There were six risk factors for intimate partner homicide identified.No recommendations.
2019-EX-01This case involves the homicide of 24-year-old female victim by her 23-year-old former boyfriend. There were three risk factors for intimate partner homicide identified.No recommendations.
2019-EX-02This case involved the death of 28-year-old female victim by her 41-year-old male acquaintance. The victim and the perpetrator described their relationship as like “brother and sister.” The perpetrator indicated that he had wanted to pursue a relationship, the victim was not receptive. There were seven risk factors for intimate partner homicide identified.No recommendations.