Executive summary

During 2018, nine deaths by suicide occurred among serving and retired police officers in the province of Ontario. This number was thought to be unprecedented^{footnote *[*]}.  Soon after the year ended, the Office of the Chief Coroner initiated an expert panel review process. The eight-member panel began its work in June 2019.  The experts on the panel understood that world research on suicide prevention has demonstrated that any specific death by suicide is difficult to predict or prevent, given that the known risk indicators for suicide also exist in large numbers of people who never attempt or die by suicide.  Despite this, however, there are a number of evidence-based risk indicators for suicide, which when taken together, provide a list of factors known to be present in the majority of cases of completed suicide.  Therefore, these points of risk can be used as potential targets for intervention when dealing with a vulnerable individual, and for the panel’s purpose, these points of risk could serve as a method for organizing and understanding the information obtained on the nine deceased police officers.  These risk indicators and potential targets for intervention to prevent suicide are described in Part One of our report.

These risk patterns were clearly evident in all nine of our subject officers' lives.  In Part Two, we identify several characteristics unique to policing that may place all police members at greater risk, including the presence of mental health challenges, whether mild, moderate or severe.  Given the presence of a diagnosable mental disorder (often Depression) in over 90% of those who die by suicide, the panel interpreted its mandate to extend beyond preventing deaths by suicide, to include a focus on improving mental health outcomes for all police members.

In Part Three of our report, we introduce and discuss seven pathways to better outcomes.  The first of these, and perhaps the most vital, is the normalization of mental health issues.  We call for deliberate steps to introduce a more open culture that will support earlier and continuing visibility of mental health conditions, better and sustained access to care, treatment and recovery, and an end to the isolating social disconnections that can often carry these conditions to their extremes.  In a cross cutting manner, the six remaining themes build upon other aspects of this culture to strengthen organizational and clinical supports, to protect the strong sense of identity that police members value deeply, to more actively inform and engage police members' families and outside supports, and to better unify and align the tremendous efforts at improvement that are already underway across the policing and mental health systems.  Alongside this discussion, we also feature in a running sidebar a number of specific observations on the strengths and weaknesses in the current police and mental health ecosystem.  In Part Four, these themes are consolidated into a broader legacy.

Assembled under 14 main recommendations in Part Five of this report, our panel outlines a total of 36 actions and specifications, most of which include proposed roles and responsibilities, and all of which reflect a continuing theme of collaboration.  First among these is a call for the formation of an Ontario Police Members Mental Health Collaborative (OPMMHC) to serve as a standing body that will initiate, guide, monitor and report on an urgent and comprehensive plan of action in Ontario.

The panel members are named in the Appendix, and we are all grateful to Dr. Dirk Huyer for his leadership in assembling this expert panel and for inviting us to serve in this important work.  We also extend our thanks to the staff in the Office of the Chief Coroner for their valued guidance throughout our process.

Statistically, it is much higher than reported rates in the general public.  Anecdotally, it may reflect increases in mental health issues across the policing sector. 

For the panel, for police services and police association officials, for health professionals, and most notably for the surviving families, it is an alarming and unacceptable number.